Blog International House of Pain

Nevro SCS for Extremity pain from MS Spinal Cord Injury!

This fine young gentleman has been chasing treatment and amelioration of his multiple sclerosis pain for years. He’s had an exceptionally successful trial with the Nevro HF 10 Senza spinal cord stimulator and so today he undergoes a permanent implant.

 

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Knee Pain

Knee Pain: Genicular Nerve Ablation.

Here is a recent study on GNB:

Knee Pain: 

Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial., Choi WJ1, Hwang SJ, Song JG, Leem JG, Kang YU, Park PH, Shin JW., Pain. 2011 Mar;152(3):481-7. doi: 10.1016/j.pain.2010.09.029. Epub 2010 Nov 4.

Radiofrequency (RF) neurotomy is a therapeutic alternative for chronic pain. We investigated whether RF neurotomy applied to articular nerve branches (genicular nerves) was effective in relieving chronic OA knee joint pain. The study involved 38 elderly patients with (a) severe knee OA pain lasting more than 3 months, (b) positive response to a diagnostic genicular nerve block and (c) no response to conservative treatments. Patients were randomly assigned to receive percutaneous RF genicular neurotomy under fluoroscopic guidance (RF group; n=19) or the same procedure without effective neurotomy (control group; n=19). Visual analogue scale (VAS), Oxford knee scores, and global perceived effect on a 7-point scale were measured at baseline and at 1, 4, and 12weeks post-procedure. VAS scores showed that the RF group had less knee joint pain at 4 (p<0.001) and 12 (p<0.001) weeks compared with the control group. Oxford knee scores showed similar findings (p<0.001). In the RF group, 10/17 (59%), 11/17 (65%) and 10/17 (59%) achieved at least 50% knee pain relief at 1, 4, and 12 weeks, respectively. No patient reported a post-procedure adverse event during the follow-up period. RF neurotomy of genicular nerves leads to significant pain reduction and functional improvement in a subset of elderly chronic knee OA pain, and thus may be an effective treatment in such cases. Further trials with larger sample size and longer follow-up are warranted.

Genicular nerve ablation is a promising new treatment approach to chronic knee pain. The knee pain can be either knee pain that is chronic after a failed knee replacement or knee pain that has no other reasonable surgical or treatment solution.

If the patient is adverse to surgery, or if the surgical risks are too great then this is a consideration.

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Degenerative Disc Disease Pain

Degenerative Disc Disease

Degenerative Disc Disease

Degenerative Disc Disease:

In this video we discuss the current and possible future treatments for “Degenerative Disc Disease:” discogenic low back pain. This is pain from degenerative disc disease a very common cause of low back pain and neck pain

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Knee Pain: Genicular Nerve Ablation.

Knee Pain: Genicular Nerve Ablation.

Here is a recent study on GNB:

Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial., Choi WJ1, Hwang SJ, Song JG, Leem JG, Kang YU, Park PH, Shin JW., Pain. 2011 Mar;152(3):481-7. doi: 10.1016/j.pain.2010.09.029. Epub 2010 Nov 4.

Radiofrequency (RF) neurotomy is a therapeutic alternative for chronic pain. We investigated whether RF neurotomy applied to articular nerve branches (genicular nerves) was effective in relieving chronic OA knee joint pain. The study involved 38 elderly patients with (a) severe knee OA pain lasting more than 3 months, (b) positive response to a diagnostic genicular nerve block and (c) no response to conservative treatments. Patients were randomly assigned to receive percutaneous RF genicular neurotomy under fluoroscopic guidance (RF group; n=19) or the same procedure without effective neurotomy (control group; n=19). Visual analogue scale (VAS), Oxford knee scores, and global perceived effect on a 7-point scale were measured at baseline and at 1, 4, and 12weeks post-procedure. VAS scores showed that the RF group had less knee joint pain at 4 (p<0.001) and 12 (p<0.001) weeks compared with the control group. Oxford knee scores showed similar findings (p<0.001). In the RF group, 10/17 (59%), 11/17 (65%) and 10/17 (59%) achieved at least 50% knee pain relief at 1, 4, and 12 weeks, respectively. No patient reported a post-procedure adverse event during the follow-up period. RF neurotomy of genicular nerves leads to significant pain reduction and functional improvement in a subset of elderly chronic knee OA pain, and thus may be an effective treatment in such cases. Further trials with larger sample size and longer follow-up are warranted.

  • Genicular Nerve AblationGenicular Nerve Ablation for chronic knee pain following total knee arthroplasty.

Genicular nerve ablation is a promising new treatment approach to chronic knee pain. The knee pain can be either knee pain that is chronic after a failed knee replacement or knee pain that has no other reasonable surgical or treatment solution.

If the patient is adverse to surgery, or if the surgical risks are too great then this is a consideration.

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Intradiscal (Inside the Disc) “Stem Cell” Injection

Intradiscal (Inside the Disc) “Stem Cell” Injection

Intradiscal Stem Cell Injection (Autologous “self”) “Auto-ISCI”

 

Auto-ISCI is quite different from “Allogenic” stem cell injection.  At-ISCI involves taking either fat or bone marrow harvest from the same patient who is receiving the cells and then separating the stem cells from the harvested tissue and re-injecting the stem cells into the spinal discs.  This approach and procedure is FDA approved as long as any manipulation of the cells occurs at the point of injection. Presently we do Auto-ISCI for painfully degenerative lumbar discs.

Allogenic “Allo-ISCI” is very different (NOT FDA APPROVED)

It involves taking already prepared stem cells from a foreign tissue donor and then injecting those stem cells into the patient’s discs.  Often the cells are manipulated, cultured or tissue expanded (multiplied without specific tissue expression) before they are injected. (See Mesoblast website.)

 

Post Procedure Protocol:

 

Day (0-3) (Harvest and Injection day+ next two days): Try to stay horizontal as much as possible. Start taking your antibiotics the day of the procedure.  If vertical (either standing or sitting) limit it to maximum of ten minutes.  Lying on back or in recliner is best.  Do pressure reliefs if vertical.   A pressure relief is anything that takes the weight off the spine for 1-2 minutes, either lying down, sitting in a chair and suspending your self by pushing down on the arms of the chair.  Another method would be to lean over on a counter on your folded arms and suspending your legs off the floor.

 

Week 1:  May sit or stand for no greater than 10 minutes without a pressure relief.

Week 2:  May sit or stand for no greater than 20 minutes without a pressure relief.

Week 3:  May sit or stand for no greater than 30 minutes without a pressure relief.

Week 4:  May sit or stand for no greater than 40 minutes without a pressure relief.

 

This can be challenging but good compliance with the protocol does seem to predict success with the intradiscal injection. Flying and driving can be difficult especially in the first week or two, but you can use the arms of the seat to help with pressure relief.

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Peripheral Neuromodulation for Chronic Knee pain following surgery

Peripheral Neuromodulation for Chronic Knee pain following surgery

 

Novel approach for peripheral subcutaneous field stimulation for the treatment of severe, chronic knee joint pain after total knee arthroplasty.

www.neuromodulationjournal.com © 2009 International Neuromodulation Society Neuromodulation 2010; 13: 131–136

William Porter McRoberts, MD, Martin Roche, MD

Objective: The objective of this study is to present a novel approach for the treatment of severe, chronic knee joint pain following total knee arthroplasty utilizing peripheral subcutaneous field stimulation and discuss the role of this treatment modality in patients with symptoms that are refractory to conventional pharmacologic, surgical, and physical therapies.

Materials and Methods: Presented are two case reports of patients with chronic intractable knee pain where peripheral nerve stimulation via a permanent neurostimulating implant was introduced successfully. Both patients presented with persistent knee pain, for greater than one year, after having had total knee arthroplasty. The patients’ symptoms failed to be alleviated by a variety of interventions including non-steroidal anti-inflammatory drugs (NSAIDS), oral antidepressants, membrane stabilizers, opioids, physical therapy, surgical revisions, manipulation under anesthesia, local anesthetic patches, and transcutaneous electrical nerve stimulation. In each case, direct stimulation of the knee was achieved utilizing a peripheral nerve stimulator via a periarticular approach.

Results: Neuromodulation daily has produced both significant pain relief and functional improvement. Significant decreases in pain visual analog scale (VAS) scores and improvement in functional capacity were observed during the stimulation trial and during the follow-up after permanent implantation. The mean VAS score changed dramatically.

Conclusions: Introduction of a peripheral subcutaneous field stimulation directly to the painful knee area is a novel and simple procedure that was extremely effective for the relief of pain and may provide a breakthrough in the treatment of chronic intractable knee pain following total knee arthroplasty. The periarticular approach has several advantages, including only small incisions over the lateral and medial knee, proximal thigh and abdomen resulting in minimal strain on the lead array with flexion and extension contributing to overall stability of this system.

Keywords: Chronic intractable pain, knee joint pain, neuromodulation, peripheral nerve field neuromodulation (PSFS), peripheral subcutaneous field stimulation, peripheral subcutaneous implant, subcutaneous targeted neuromodulation (STN), total knee arthroplasty

Conflict of interest: The authors reported no conflicts of interest.

 

COMMENTS:

 

Peripheral neuromodulation is gaining wider acceptance either in the form of peripheral subcutaneous field stimulation or targeted periph- eral nerve stimulation for intractable chronic pain states of various etiologies. This is a very good work that adds to the already extensive applications of peripheral neuromodulation. Although it includes just two patients, this series opens a new mode of treatment for patients who derive insufficient pain relief from conventional treatments and it is less invasive than dorsal column stimulation. The authors have given a very good account of knee innervation and why peripheral field neurostimulation would be effective. Only long term follow up will tell us how stable the leads would be in their implanted position. Certainly more work is needed to recommend it as an alternative and I am sure we will read more about this application in future. All in all a very good effort and is worth disseminating to colleagues already into peripheral neuromodulation as well as others not aware of this mode of pain relief.

Dr. Riaz Khan Khyshza

Consultant in Anesthesia and Pain Management Royal Free Hospital London, United Kingdom

 

This article shows still another application of the new and growing field of Peripheral Subcutaneous Field Stimulation. Intractable pain following total knee arthroplasty is a difficult condition to treat. The pain is usually severe and it substantially impairs the ambulatory capabilities of the affected individual. Neurostimulation options until now included spinal cord stimulation or intraspinal nerve root stimulation. Both require electrode placement in the spinal canal. The authors have successfully reduced the pain in two patients who had undergone arthroplasty by placing the leads in the subcutaneous tissues around the knee. The stimulation of the small peripheral nerve fibers resulted in a significant reduction of the pain. This modality, if proven to have good results in a larger number of patients, could become the preferred neuromodulation option in patients with “failed” knee arthroplasty.

 

Giancarlo Barolat, MD

Director Barolat Neuroscience Presbyterian/St. Luke’s Medical Center Denver, Colorado, USA

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Achilles Tendinitis

Achilles Tendinitis

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No brain, No pain!

No brain, No pain!

The above post is reprinted from materials provided by Manchester UniversityNote: Materials may be edited for content and length.

Scientists at The University of Manchester have shown for the first time that the numbers of opiate receptors in the brain increases to combat severe pain in arthritis sufferers.

Chronic pain — pain which lasts for more than six months — is a real problem for many people with approximately 46% of the UK population estimated to suffer from it (comprising 20% of consultations in general practice). However, some people seem to cope better than others with pain, and knowing more about how these coping mechanisms work might help to develop new ways of treating this distressing symptom.

It has been known for a long time that we have receptors in our brains that respond to natural painkilling opiates such as endorphins, but the researchers in Manchester have now shown that these receptors increase in number to help cope with long-term, severe pain.

By applying heat to the skin using a laser stimulator, Dr Christopher Brown and his colleagues showed that the more opiate receptors there are in the brain, the higher the ability to withstand the pain.

The study used Positron Emission Tomography (PET) imaging on 17 patients with arthritis and nine healthy controls to show the spread of the opioid receptors.

This suggests that the increase in opiate receptors in the brain is an adaptive response to chronic pain, allowing people to deal with it more easily.

Dr Brown said: “As far as we are aware, this is the first time that these changes have been associated with increased resilience to pain and shown to be adaptive.

“Although the mechanisms of these adaptive changes are unknown, if we can understand how we can enhance them, we may find ways of naturally increasing resilience to pain without the side effects associated with many pain killing drugs.”

Professor Anthony Jones is the director of the Manchester Pain Consortium which is focused on improving the understanding and treatment of chronic pain. He said: “This is very exciting because it changes the way we think about chronic pain.

“There is generally a rather negative and fatalistic view of chronic pain. This study shows that although the group as a whole are more physiologically vulnerable, the whole pain system is very flexible and that individuals can adaptively upregulate their resilience to pain.

“It may be that some simple interventions can further enhance this natural process, and designing smart molecules or simple non-drug interventions to do a similar thing is potentially attractive.”

Val Derbyshire, a patient with arthritis said: “As a patient who suffers chronic pain from osteoarthritis, I am extremely interested in this research. I feel I have developed coping mechanisms to deal with my pain over the years, yet still have to take opioid medication to relieve my symptoms.

“The fact that this medication has to be increased from time to time concerns me greatly, due to the addictive nature of these drugs. The notion of enhancing the natural opiates in the brain, such as endorphins, as a response to pain, seems to me to be infinitely preferable to long term medication with opiate drugs.

“Anything that can reduce reliance on strong medication must be worth pursuing.”

Professor of Cognitive Neuroscience at the University, Wael El-Deredy said: “Receptor imaging is challenging and requires the co-ordination of a large team to collect and analyse the images. We are very lucky to have this technique in Manchester. There are very few places in the world where this study could have been done.”

The paper, ‘Striatal opioid receptor availability is related to acute and chronic pain perception in arthritis: Does opioid adaptation increase resilience to chronic pain?’, featured in the journal Pain, published by Wolters Kluwer.


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SPINAL CORD STIMULATION FOR WEIGHT LOSS AND OBESITY

SPINAL CORD STIMULATION FOR WEIGHT LOSS AND OBESITY

Spinal Cord Electrical Stimulation for Obesity: A Preliminary Rodent Study (99)

Geng-Qing Song, Veterans Research and Education Foundation, Oklahoma City, OK; Jiande Chen, MD PhD, Veterans Research and Education Foundation, Oklahoma City, OK

Introduction: Spinal cord electrical stimulation (SCS) has been applied for the management of chronic pain . Most studies have revealed a decrease in sympathetic activity with SCS . In this study, we hypothesize that SCS with appropriate parameters and specific locations might increase sympathetic activity (causing an increase in metabolism and thus a decrease in body weight) and inhibited gastrointestinal motility (leading to early satiety with reduced food intake) .

Aims: The aim of this study was to investigate the effect of SCS on heart rates, sympathetic activity, serum norepinephrine, gastric emptying, and food intake in rats .

Methods: Male rats chronically implanted with SCS electrodes at T1/T2 or T5/T6 were studied in three experiments . Experiment 1 was to study the effects of SCS with different parameters and locations on heart rates, sympathetic activity . Experiment 2 was to assess the effect of SCS on serum norepinephrine and gastric emptying . Experiment 3 was to assess the effects of SCS on food intake . The animals received 5 days of either sham-SCS or SCS in a randomized order .

Results: (1) SCS at T1-T2 or T5-T6 of the 90% MT, 0 .1 ms, 100 Hz (but not 20 or 80 Hz) increased heart rates and sympathova- gal balance . Heart rate was 462 .4 ± 8 .2 beats/min or 466 .0 ± 9 .7 beats/min at baseline and increased to 477 .8 ± 9 .5 beats/min
(P = 0 .011, SCS at T1/T2) or 479 .9 ± 9 .8 beats/min (P = 0 .013, SCS at T1/T2), respectively . Similarly, the sympathovagal balance was 0 .43 ± 0 .03 or 0 .46 ± 0 .04 at baseline and increased to 0 .50 ± 0 .06 (P = 0 .018, SCS at T1/T2) or 0 .51 ± 0 .03 (P = 0 .012, SCS at T5/T6) , respectively . (2) SCS at T1-T2 or T5-T6 of the 90% MT, 0 .1 ms, 100 Hz increased serum norepinephrine by 98 .8% or 100 .8%, respectively, in comparison with baseline before SCS . (3) SCS at T5-T6 but not T1-T2 of the 90% MT, 0 .1 ms, 100 Hz de- layed gastric emptying . Gastric emptying was 60 .0% ± 3 .7% in the controls and decreased to 50 .4% ± 4 .8% with SCS at T5-T6 (P = 0 .042, vs . controls) . (4) SCS at T5-T6 of the 90% MT, 0 .1 ms, 100 Hz reduced daily food intake by 17 .8% (P = 0 .046) .

Conclusion: SCS at T5-T6 with appropriate parameters reduces food intake in regular rats and the inhibitory effect may attrib- uted to increased sympathetic activity and reduced gastric emptying . Further studies are warranted to explore the potential of SCS for obesity .

Disclosures: J. Chen: None . G. Song: None .

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fascinating articles

fascinating articles

Understanding pain requires understanding what pain MEANS to a person.

Our fund of knowledge is rapidly changing.

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