Peripheral Nerve Stimulation for the Treatment of Postamputation Pain—A Case Report

Many amputees suffer from postamputation pain, which can be extremely debilitating, decrease quality of life, increase the risk of depression, and negatively affect interpersonal relationships and the ability to work. Present methods of treatment, including medications, are often unsatisfactory in reducing postamputation pain. Electrical stimulation of the nerve innervating the painful area could reduce the pain, but peripheral nerve stimulation is rarely used to treat postamputation pain because present methods require invasive surgical access and precise placement of the leads in close proximity (≤ 2 mm) with the nerve. The present study investigated a novel approach to peripheral nerve stimulation in which a lead was placed percutaneously a remote distance (> 1 cm) away from the femoral nerve in a patient with severe residual limb pain (RLP) 33 years following a below‐knee amputation. Electrical stimulation generated ≥ 75% paresthesia coverage, reduced RLP by > 60%, and improved quality of life outcomes as measured by the pain interference scale of the Brief Pain Inventory‐Short Form (100% reduction in pain interference), Pain Disability Index (74% reduction in disability), and the Patient Global Impression of Change (very much improved) during a 2‐week home trial. There were no adverse events. The ability to generate significant paresthesia coverage and pain relief with a single lead inserted percutaneously and remotely from the target nerve holds promise for providing relief of postamputation pain.     

Neurostimulation for Postsurgical Analgesia: A Novel System Enabling Ultrasound‐Guided Percutaneous Peripheral Nerve Stimulation

While neurostimulation—stimulation of the nervous system using electrical current—has been used to treat chronic pain, its use treating postsurgical pain has been limited. Here, we report on the clinical application of a novel investigational lead to provide analgesia following total knee arthroplasty. In 5 subjects, leads were inserted percutaneously using ultrasound guidance within 0.5 to 3.0 cm of the femoral and/or sciatic nerve(s). With the delivery of current, pain decreased an average of 63% at rest, with 4 of 5 subjects having relief of > 50%. During passive and active knee flexion, pain decreased an average of 14% and 50%, with 0/3 and 1/2 subjects attaining > 50% relief, respectively. Ultrasound‐guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postsurgical pain.     

Peripheral Subcutaneous Stimulation for the Treatment of Intractable Postherpetic Neuralgia: Two Case Reports and Literature Review

Postherpetic neuralgia (PHN) is a common cause of chronic pain in the elderly. Antidepressants, anticonvulsants, and opioids may reduce discomfort in many patients, while others have pain intractable to all forms of therapy. We present a novel treatment approach for intractable PHN utilizing percutaneous peripheral nerve stimulation. Two cases are described in which an 80-year-old man and a 67-year-old woman with intractable PHN, lasting 2 and 10 years, respectively, were effectively treated with implantation of two octapolar leads in the lateral thoracic region. These cases suggest that peripheral nerve stimulation may offer an alternative treatment option for intractable pain associated with PHN especially in the elderly where treatment options are limited because of existing comorbidities.     

Peripheral Nerve Field Stimulation for Intractable Post‐Thoracotomy Scar Pain not Relieved by Conventional Treatment

Peripheral nerve field stimulation (PNFS) is being applied in individual cases where conventional treatments have failed to control pain localized to limited dermatomal distribution. We applied PNFS for unrelieved post‐thoracotomy scar pain. Although spinal cord stimulation may have resulted in good coverage in the same dermatomal distribution, we chose the more peripheral approach to minimize the risk of complications, avoiding the potential neurologic sequelae associated with stimulation of the spinal cord. In summary, PNFS was effective in relieving post‐thoractomy pain refractory to conventional pain management suggesting great potential of PNFS as a treatment option for chronic surgical‐scar pain.     

Transcutaneous Electrical Nerve Stimulation Reduces Acute Low Back Pain during Emergency Transport

Background: Patients with acute low back pain may require emergency transport because of pain and immobilization. Transcutaneous electrical nerve stimulation (TENS) is a nonpharmaceutical therapy for patients with low back pain. Objective: To evaluate the efficacy of paramedic‐administered TENS in patients with acute low back pain during emergency transport. Methods: This was a prospective, randomized study involving 74 patients transported to hospital. The patients were randomly assigned to two groups: group 1 (n= 36) was treated with true TENS, while group 2 (n= 36) was treated with sham TENS. The authors recorded pain and anxiety as the main outcome variables using a visual analog scale (VAS). Results: The authors recorded a significant (p < 0.01) pain reduction (mean ± standard deviation) during transport in group 1 (79.2 ± 6.5 mm VAS to 48.9 ± 8.2 mm VAS), whereas pain scores remained unchanged in group 2 (75.9 ± 16.4 mm VAS and 77.1 ± 11.2 mm VAS). Similarly, the scores for anxiety were significantly reduced (p < 0.01) in group 1 (81.7 ± 7.9 mm VAS to 69.2 ± 12.1 mm VAS) after treatment. No significant change was noted (84.5 ± 5.8 mm VAS and 83.5 ± 8.9 mm VAS, respectively) in group 2. Conclusions: TENS was found to be effective and rapid in reducing pain during emergency transport of patients with acute low back pain and should be considered due to its ease of use and lack of side effects in the study population.     

A Review of Duloxetine 60 mg Once‐Daily Dosing for the Management of Diabetic Peripheral Neuropathic Pain,Fibromyalgia, and Chronic Musculoskeletal Pain Due to Chronic Osteoarthritis Pain and Low Back Pain

Background: Duloxetine is a selective dual neuronal serotonin (5‐Hydroxytryptamine, 5‐HT) and norepinephrine reuptake inhibitor (SSNRI). It is indicated in the United States for treatment of major depressive disorder (MDD), generalized anxiety disorder (GAD), and several chronic pain conditions, including management of diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain due to chronic osteoarthritis (OA) pain and chronic low back pain (LBP). Its use for antidepressant and anxiolytic actions has been extensively reviewed previously. We here review the evidence for the efficacy of 60 mg once‐daily dosing of duloxetine for chronic pain conditions. Method: The literature was searched for clinical trials in humans conducted in the past 10 years involving duloxetine. Results: There were 199 results in the initial search. Studies not in the English language were excluded. We then included only studies of diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain (OA and LBP). Studies of painful symptoms reported in mental health studies were excluded. This resulted in 32 studies. Articles that did not include a 60 mg/day daily dose as a study arm were excluded. This resulted in 30 studies, broken down as follows: 12 for diabetic peripheral neuropathy, 9 for fibromyalgia, 6 for LBP, and 3 for OA pain. Conclusions: The studies reviewed report that duloxetine 60 mg once‐daily dosing is an effective option for the management of diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain due to chronic OA pain and chronic LBP. As these pains are often comorbid with MDD or GAD, duloxetine might possess the pharmacologic properties to be a versatile agent able to address several symptoms in these patients. With adequate attention to FDA prescribing guidance regarding safety and drug–drug interactions, duloxetine 60 mg once‐daily dosing appears to be an effective option in the appropriate pain patient population.     

Effectiveness of Percutaneous Neuromodulation Therapy for Patients with Chronic and Severe Low Back Pain

Abstract : Percutaneous neuromodulation therapy (PNT) is a minimally invasive approach to the treatment of low back pain (LBP), involving electrical stimulation applied to percutaneous electrodes placed within the lumbar paraspinal tissues during 30-minute treatment sessions. This study reports the effects of PNT on a population of patients with chronic and severe levels of LBP. This study was performed in an outpatient clinical research setting. Thirty-nine patients were enrolled who had stable levels of LBP lasting at least 6 months, with enrollment LBP visual analog scale (VAS) scores of at least 5 on a scale of 10. The patients were treated with PNT 2 times per week for 4 weeks. Baseline VAS scores of LBP, physical activity, sleep, and the Oswestry Questionnaire were recorded. The final assessment was made 48 hours after the last treatment. After 4 sessions, the patients completed a "responder screen" questionnaire whereby, to continue treatment, they had to indicate both a perceived benefit and improvement in LBP and/or activity levels. Thirty-one patients completed the study protocol. Of the 18 patients (58% of 31) who passed the responder screen, 14 (78% of 18, 45% of 31) had ≥30% improvement in LBP and/or activity levels. Mean LBP scores decreased by 37% to 4.5 ± 2.2 from 7.1 ± 1.0 (P=0.0001); activity scores improved by 39% to 4.0 ± 2.1 from 6.7 ± 1.5 (P=0.0005); sleep scores improved by 40% from 6.2 ± 2.6 to 4.0 ± 2.6 (P=0.0003). Oswestry scores improved from 44 ± 12 to 33 ± 15 (P=0.002). In conclusion, for patients with chronic and severe stable levels of low back pain, PNT appears promising for pain level reduction and improvement in function.     

Chronic Low Back Pain: Evidence-Informed Management Considerations for Nurse Practitioners

Chronic low back pain (CLBP) is a condition that commonly consumes many resources and creates economic burden for the health care system. Evidence-informed care is crucial to guide management and prevent unnecessary procedures, including diagnostic imaging. Conservative therapy is currently recommended as the first-line and the most cost-effective treatment. Antibiotic therapy and surgical procedures are considered last resort treatment options for CLBP. The aim of this article is to summarize CLBP options for nurse practitioners (NP).     

疼痛缓解对慢性非特异性腰痛患者步态特征的影响

目的 观察针刺治疗后疼痛缓解对慢性非特异性腰痛(CNLBP)患者的步速、跨步长和地面反作用力(GRF)特征值的影响.方法 2019年5月至12月,网络招募CNLBP受试者28例,随机分为等待治疗组(n=14)和针刺治疗组(n=14).针刺治疗组接受针刺治疗,每次30 min,每周3次,共4周;等待治疗组入组后仅进行健康...