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Pritzlaff SG, Latif U, Rosenow JM, Chae J, Wilson RD, Huffman WJ, Crosby ND, Boggs JW. A review of prospective studies regarding percutaneous peripheral nerve stimulation treatment in the management of chronic pain. Pain Manag 2024; 14:209-222. [PMID: 38939963 DOI: 10.1080/17581869.2024.2352398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/03/2024] [Indexed: 06/29/2024] Open
Abstract
Conventionally, peripheral nerve stimulation (PNS) for treatment of chronic pain has involved a two-stage process: a short-term (e.g., 7 days) trial and, if significant pain relief is achieved, a permanent PNS system is implanted. A percutaneous PNS treatment is now available where a coiled lead may be implanted for up to 60 days with the goal of producing sustained relief. In the present review, published prospective trials using percutaneous PNS treatment were identified and synthesized. The collected evidence indicates that percutaneous PNS treatment for up to 60 days provides durable clinically significant improvements in pain and pain interference. Similar efficacy across diverse targets and etiologies supports the broad applicability for use within the chronic pain population using this nonopioid technology.
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Affiliation(s)
- Scott G Pritzlaff
- Department of Anesthesiology & Pain Medicine, University of California Davis Health, Sacramento, CA 95817, USA
| | - Usman Latif
- Department of Anesthesiology, Pain & Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS 66103, USA
| | - Joshua M Rosenow
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - John Chae
- MetroHealth Rehabilitation Institute, The MetroHealth System, Cleveland, OH 44109 ,USA
- Department of Physical Medicine & Rehabilitation, Case Western Reserve University, Cleveland, OH 44109, USA
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Richard D Wilson
- MetroHealth Rehabilitation Institute, The MetroHealth System, Cleveland, OH 44109 ,USA
- Department of Physical Medicine & Rehabilitation, Case Western Reserve University, Cleveland, OH 44109, USA
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Arulkumar S, Neuchat EE, Ly E, Ly AI, Fahimipour K, Desai MJ. Peripheral Nerve Stimulation of the Shoulder: A Technical Primer. J Pain Res 2024; 17:1725-1733. [PMID: 38751996 PMCID: PMC11095401 DOI: 10.2147/jpr.s446901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
Scapulalgia or shoulder pain accounts for 16% of all musculoskeletal complaints in the healthy adult population and becomes more common as we age. When this pain exceeds 3 months in duration, it is deemed to be chronic, and typically treated in an escalating manner. Spanning a continuum of conservative and non-conservative measures, chronic shoulder pain treatments range from rest and physical therapy to surgery. Since each patient presents with a unique spectrum of symptoms a customized treatment plan is often required. Over the lifetime of many of these patients, a variety of treatment options are required. One of these treatment options, peripheral nerve stimulation (PNS), is a minimally invasive procedure in which an electrical impulse is delivered through a percutaneously implanted, small caliber electrode to a peripheral nerve proximal to the lesion which interferes with the pain signals. Over the past several years, significant growth of PNS in the treatment of chronic neuropathic pain has been observed. However, the procedural techniques have not been well described. The foundation of long-term, minimally invasive percutaneous PNS in patients with chronic shoulder pain, and procedural techniques for stimulating the suprascapular and axillary nerves using fluoroscopy or ultrasonography will be described in this report.
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Affiliation(s)
- Sailesh Arulkumar
- Department of Anesthesiology, SSM Health, St. Anthony’s Hospital, Oklahoma City, OK, USA
| | - Elisa E Neuchat
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | - Eric Ly
- Department of Anesthesiology, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Austin Ingwei Ly
- The University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
| | - Kiana Fahimipour
- Department of Anesthesiology; Louisiana State University Health Sciences Center at New Orleans, New Orleans, LA, USA
| | - Mehul J Desai
- International Spine Pain & Performance Center, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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3
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Osman H, Siu R, Makowski NS, Knutson JS, Cunningham DA. Neurostimulation After Stroke. Phys Med Rehabil Clin N Am 2024; 35:369-382. [PMID: 38514224 DOI: 10.1016/j.pmr.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Neural stimulation technology aids stroke survivors in regaining lost motor functions. This article explores its applications in upper and lower limb stroke rehabilitation. The authors review various methods to target the corticomotor system, including transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and vagus nerve stimulation. In addition, the authors review the use of peripheral neuromuscular electrical stimulation for therapeutic and assistive purposes, including transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, and functional electrical stimulation. For each, the authors examine the potential benefits, limitations, safety considerations, and FDA status.
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Affiliation(s)
- Hala Osman
- MetroHealth Center for Rehabilitation Research, 4229 Pearl Dr, Cleveland, OH 44109, USA; APT Center, 10701 East Boulevard, Cleveland, OH 44106, USA
| | - Ricardo Siu
- MetroHealth Center for Rehabilitation Research, 4229 Pearl Dr, Cleveland, OH 44109, USA; Department of Physical Medicine and Rehabilitation, Case Western Reserve University, 9501 Euclid Avenue, Cleveland, OH 44106, USA
| | - Nathan S Makowski
- MetroHealth Center for Rehabilitation Research, 4229 Pearl Dr, Cleveland, OH 44109, USA; APT Center, 10701 East Boulevard, Cleveland, OH 44106, USA; Department of Physical Medicine and Rehabilitation, Case Western Reserve University, 9501 Euclid Avenue, Cleveland, OH 44106, USA
| | - Jayme S Knutson
- MetroHealth Center for Rehabilitation Research, 4229 Pearl Dr, Cleveland, OH 44109, USA; Department of Physical Medicine and Rehabilitation, Case Western Reserve University, 9501 Euclid Avenue, Cleveland, OH 44106, USA; Cleveland FES Center, 10701 East Boulevard, Cleveland, OH 44106, USA
| | - David A Cunningham
- MetroHealth Center for Rehabilitation Research, 4229 Pearl Dr, Cleveland, OH 44109, USA; Department of Physical Medicine and Rehabilitation, Case Western Reserve University, 9501 Euclid Avenue, Cleveland, OH 44106, USA; Cleveland FES Center, 10701 East Boulevard, Cleveland, OH 44106, USA.
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4
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Zakel J, Chae J, Wilson RD. Innovations in Stroke Recovery and Rehabilitation: Poststroke Pain. Phys Med Rehabil Clin N Am 2024; 35:445-462. [PMID: 38514229 DOI: 10.1016/j.pmr.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Pain can be a significant barrier to a stroke survivors' functional recovery and can also lead to a decreased quality of life. Common pain conditions after stroke include headache, musculoskeletal pain, spasticity-related pain, complex regional pain syndrome, and central poststroke pain. This review investigates the evidence of diagnostic and management guidelines for various pain syndromes after stroke and identifies opportunities for future research to advance the field of poststroke pain.
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Affiliation(s)
- Juliet Zakel
- MetroHealth Rehabilitation Institute, MetroHealth System, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA.
| | - John Chae
- MetroHealth Rehabilitation Institute, MetroHealth System, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
| | - Richard D Wilson
- MetroHealth Rehabilitation Institute, MetroHealth System, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
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Xiong F, Shen P, Li Z, Huang Z, Liang Y, Chen X, Li Y, Chai X, Feng Z, Li M. Bibliometric Analysis of Post-Stroke Pain Research Published from 2012 to 2021. J Pain Res 2023; 16:1-20. [PMID: 36636268 PMCID: PMC9830001 DOI: 10.2147/jpr.s375063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023] Open
Abstract
Background and Purpose Pain is one of the most common symptoms in patients after stroke. It is a distressing experience that affects patients' quality of life, and it is highly prevalent in clinical practice. The pathogenesis mechanisms of PSP are not so clear, and there is currently a lack of effective medical treatments, hence it is necessary to establish a sufficient understanding of this disease. Limited number of studies have applied bibliometric methods to systematically analyze studies on post-stroke pain. This study aimed to systematically analyze scientific studies conducted worldwide on post-stroke pain from 2012 to 2021 to evaluate global trends in this field using a bibliometric analysis. Methods Publications related to post-stroke pain from 2012 to 2021 were obtained from the Web of Science Core Collection database. Bibliometrics Biblioshiny R-package software was used to analyze the relationship of publication year with country, institution, journals, authors, and keywords and to generate variant visual maps to show annual publications, most relevant countries, authors, sources, keywords, and top-cited articles. Results In this study, 5484 papers met the inclusion criteria. The annual growth rate of publications was 5.13%. The USA had the highest number of publications (1381, 25.2%) and citations (36,395), and the University of Toronto had the highest number of papers (156, 2.8%). "Stroke", "management", "pain", "risk", "prevalence", "ischemic stroke", "risk factors", "disease", "diagnosis" and "therapy" are the top 10 keywords. Conclusion The global research interest regarding PSP has maintained growing over the past ten years. Both central post stroke pain and hemiplegic shoulder pain are the hottest research subjects. Further investigations are needed in order to reveal the mystery of the pathophysiologic mechanisms of CPSP, and high-quality well-designed trials of potential treatments of CPSP and HSP are also needed.
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Affiliation(s)
- Feng Xiong
- Rehabilitation Medicine Department, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Peng Shen
- Rehabilitation Medicine Department, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Zhenhui Li
- Children Health Care Department, Longyan First Hospital Affiliated to Fujian Medical University, Longyan, People’s Republic of China
| | - Ziyi Huang
- Rehabilitation Medicine Department, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Ying Liang
- Rehabilitation Medicine Department, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Xiwen Chen
- Rehabilitation Medicine Department, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Yutong Li
- First School of Clinical Medicine, Nanchang University, Nanchang, People’s Republic of China
| | - Xinping Chai
- First School of Clinical Medicine, Nanchang University, Nanchang, People’s Republic of China
| | - Zhen Feng
- Rehabilitation Medicine Department, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Moyi Li
- Rehabilitation Medicine Department, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China,Correspondence: Moyi Li; Zhen Feng, Rehabilitation Medicine Department, The First Affiliated Hospital of Nanchang University, No. 17, Yong Wai Zheng Jie, Nanchang, Jiangxi, 330006, People’s Republic of China, Tel +86 15806031050; +86 13970038111, Email ;
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Peripheral Nerve Stimulation for the Treatment of Phantom Limb Pain: A Case Series. Case Rep Anesthesiol 2023; 2023:1558183. [PMID: 36923017 PMCID: PMC10010869 DOI: 10.1155/2023/1558183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/01/2023] [Accepted: 02/11/2023] [Indexed: 03/08/2023] Open
Abstract
This case series aims to highlight the efficacy of peripheral nerve stimulation (PNS) in the treatment of phantom limb pain, as well as provide an alternative method for the treatment of this pain syndrome. In this report, we describe three amputee patients with severe phantom limb pain who obtained substantial analgesia and improvement in physical functionality after implantation of a temporary PNS device. Future studies should assess predictors of successful response or poor response to PNS therapy, such as mental health, environmental stressors, coping skills, and procedural factors. These factors may facilitate an individualized approach for each patient to ensure appropriate candidacy for PNS and better prognosis. Considering that patients in our cohort did not achieve long-lasting benefit after removal of temporary PNS, future research should assess if patients with phantom limb pain would benefit from permanent PNS, rather than temporary PNS.
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Layne-Stuart CM, Carpenter AL. Chronic Pain Considerations in Patients with Cardiovascular Disease. Anesthesiol Clin 2022; 40:791-802. [PMID: 36328629 DOI: 10.1016/j.anclin.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Cardiovascular disease affects close to half of the United States population and many of these patients will develop chronic pain syndromes as a result of their disease process. This article provides an overview of several pain syndromes that result, directly or indirectly, from cardiovascular disease including peripheral arterial disease, angina, thoracic outlet syndrome, postamputation pain, complex regional pain syndrome, and poststroke pain. Psychological and medical comorbidities that affect the medical decision-making process in the treatment of chronic pain associated with cardiovascular disease are also discussed.
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Affiliation(s)
- Corinne M Layne-Stuart
- Department of Anesthesiology, Division of Chronic Pain Medicine, Center for Integrative Pain Management, West Virginia University, 1075 Van Voorhis Road, Morgantown, WV 26505, USA.
| | - Anna L Carpenter
- Department of Anesthesiology, Division of Chronic Pain Medicine, Center for Integrative Pain Management, West Virginia University, 1075 Van Voorhis Road, Morgantown, WV 26505, USA
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8
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Yaccarino V, Jin MY, Abd-Elsayed A, Kraemer JM, Sehgal N. Peripheral Nerve Stimulation in Painful Conditions of the Upper Extremity-An Overview. Biomedicines 2022; 10:2776. [PMID: 36359295 PMCID: PMC9687108 DOI: 10.3390/biomedicines10112776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 08/01/2023] Open
Abstract
Our objective is to present a brief history of the evolution of peripheral nerve stimulation, the current understanding of peripheral nerve stimulation mechanisms in chronic pain, peripheral nerve stimulation applications in upper extremity chronic pain conditions, and complications of peripheral nerve stimulation. The evolution of peripheral nerve stimulation from the early ages to the current status has been facilitated by discoveries in neurobehavioral mechanisms of pain, advances in technology and percutaneous lead development, and the availability of high-quality portable ultrasound units. Peripheral nerve stimulation application in managing upper extremity pain of amputated limbs, post-stroke shoulder pain, complex regional pain syndrome (CRPS), and median, ulnar, and radial neuropathies are discussed. Finally, we describe complications of peripheral nerve stimulation. The availability of ultrasound-guided peripheral nerve stimulation techniques and superior peripheral nerve stimulation technology have opened up new and minimally invasive treatment options for chronic intractable neuropathic pain of the upper extremity. Additionally, the ability to place peripheral nerve stimulation leads percutaneously without open peripheral nerve surgery expands the pool of implanting physicians, while simultaneously decreasing the risks and complications that are associated with open surgery.
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Affiliation(s)
- Vincent Yaccarino
- Department of Orthopedics & Rehabilitation, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, USA
| | - Max Y. Jin
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53792, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53792, USA
| | | | - Nalini Sehgal
- Department of Orthopedics & Rehabilitation, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, USA
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9
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Strand N, D'Souza RS, Hagedorn JM, Pritzlaff S, Sayed D, Azeem N, Abd-Elsayed A, Escobar A, Huntoon MA, Lam CM, Deer TR. Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain. J Pain Res 2022; 15:2483-2504. [PMID: 36039168 PMCID: PMC9419727 DOI: 10.2147/jpr.s362204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/29/2022] [Indexed: 12/17/2022] Open
Abstract
The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.
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Affiliation(s)
- Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Scott Pritzlaff
- Department of Anesthesiology and Pain Medicine, Division of Pain Medicine, University of California-Davis, Sacramento, CA, USA
| | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | - Nomen Azeem
- Florida Spine & Pain Specialists, Bradenton, FL, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | | | - Mark A Huntoon
- Department of Anesthesiology, Virginia Commonwealth University, Henrico, VA, USA
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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10
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Chitneni A, Hasoon J, Urits I, Viswanath O, Berger A, Kaye A. Peripheral Nerve Stimulation for Chronic Shoulder Pain Due to Rotator Cuff Pathology. Orthop Rev (Pavia) 2022; 14:37494. [DOI: 10.52965/001c.37494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chronic shoulder pain affects millions of patients each year. Various conditions can result in shoulder pain ranging from rotator cuff injury, subacromial impingement, post-surgical pain, bursitis, adhesive capsulitis, and osteoarthritis. Typically, rotator cuff pathology is diagnosed by physical exam maneuvers along with advanced imaging modalities. Initial treatment for rotator cuff injury typically consists of physical therapy, NSAIDs, and possible injections depending on the extent of the injury. If conservative measures fail or the injury is too substantial, surgery is typically the appropriate treatment for healthy patients. For patients who are not surgical candidates or refuse surgery, peripheral nerve stimulation (PNS) can be considered. With the use of PNS, the suprascapular and axillary nerves can be targeted to provide pain relief for a variety of chronic shoulder pain issues. We describe the use of PNS in 2 patients with significant rotator cuff pathology who were not surgical candidates.
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Affiliation(s)
- Ahish Chitneni
- Department of Physical Medicine & Rehabilitation, New York-Presbyterian (Columbia/Cornell), New York, NY
| | - Jamal Hasoon
- UTHealth McGovern Medical School, Department of Anesthesia and Pain Medicine, Houston, TX
| | - Ivan Urits
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Omar Viswanath
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Amnon Berger
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alan Kaye
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA
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11
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Harte LM, Rick T, Bisson LJ, Inglis S, Marzo JM. Clinical implications of the distinct anatomy and innervation of the long head biceps tendon. J Anat 2022; 241:453-460. [PMID: 35578947 DOI: 10.1111/joa.13685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 01/14/2023] Open
Abstract
The proximal long head of the biceps tendon (LHBT) has been recognized as a well-known cause of anterior shoulder pain. Previous studies have identified a heterogeneous distribution of nerve fibers in the tendon, with a higher abundance of fibers in the proximal and distal thirds of the tendon. This suggests that the proximal portion of the long head biceps tendon may have a different source of innervation than the distal portion. The purpose of this study was to review the innervation of the superior shoulder and identify the proximal source of sensory innervation of the LHBT. The relevant hypothesis was that the suprascapular nerve (SSN) was the proximal source of sensory innervation to the LHBT. Gross and microdissection of eight fresh human cadaver shoulders were performed, with a focus on the distal articular branches of suprascapular nerve (SSN). Utilizing 3.5× magnification loupes, the medial subacromial branch (MSAb), lateral subacromial branch (LSAb), and posterior glenohumeral branch (PGHb) were identified and followed distally to their terminal branches. In all specimens, terminal branches of the lateral subacromial branch supplied the proximal LHBT and the superior labrum. Terminal branches of the posterior glenohumeral branch supplied the posterosuperior labrum and, to a lesser extent, the labral attachment of the LHBT. These findings confirm branches of the suprascapular nerve as the proximal source of sensory innervation to the LHBT. Identification of the suprascapular nerve as a source of proximal innervation of the LHBT may influence clinical decisions related to nonsurgical and surgical intervention, nerve blocks, and nerve ablation procedures.
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Affiliation(s)
- Lauren M Harte
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Taylor Rick
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Leslie J Bisson
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Stuart Inglis
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - John M Marzo
- Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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12
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Pingree MJ, Hurdle MF, Spinner DA, Valimahomed A, Crosby ND, Boggs JW. Real-world evidence of sustained improvement following 60-day peripheral nerve stimulation treatment for pain: a cross-sectional follow-up survey. Pain Manag 2022; 12:611-621. [PMID: 35510333 DOI: 10.2217/pmt-2022-0005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: This study presents real-world data from a cross-sectional follow-up survey of patients who previously received 60-day peripheral nerve stimulation (PNS) treatment for pain. Materials & methods: A survey including validated pain and other related outcome measures was distributed to patients who previously underwent implantation of temporary PNS leads for 60-day PNS treatment. Results: Among survey respondents who were at least 3 months from the start of treatment, most reported sustained clinically significant improvements in pain and/or quality of life, with the length of follow-up at the time of survey completion ranging from 3 to 30 months. Conclusion: These real-world data support recent prospective studies indicating that 60-day percutaneous PNS provides significant and sustained relief across a wide range of pain conditions.
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Affiliation(s)
- Matthew J Pingree
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55901, USA
| | - Mark Fb Hurdle
- Pain Medicine & Spine Care, Mayo Clinic, Jacksonville, FL 32224, USA
| | - David A Spinner
- Rehabilitation Medicine, Mount Sinai Health System, New York, NY 10029, USA
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13
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Peripheral Nerve Stimulation for Chronic Pain and Migraine. Phys Med Rehabil Clin N Am 2022; 33:379-407. [DOI: 10.1016/j.pmr.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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14
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Naidu R, Li S, Desai MJ, Sheth S, Crosby ND, Boggs JW. 60-Day PNS Treatment May Improve Identification of Delayed Responders and Delayed Non-Responders to Neurostimulation for Pain Relief. J Pain Res 2022; 15:733-743. [PMID: 35310895 PMCID: PMC8932923 DOI: 10.2147/jpr.s349101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Conventional neurostimulation typically involves a brief (eg, ≤10-day) trial to assess presumed effectiveness prior to permanent implantation. Low trial conversion rates and high explant rates due to inadequate pain relief highlight the need for improved patient identification strategies. The development of a 60-day percutaneous peripheral nerve stimulation (PNS) system enables evaluation of outcomes following an extended temporary treatment period of up to 60 days, that may obviate or validate the need for permanent implant. The present study provides the first real-world evidence regarding patient response throughout a 60-day PNS treatment period. Methods Anonymized data listings were compiled from patients who underwent implantation of temporary percutaneous leads and opted-in to provide real-world data to the device manufacturer during routine interactions with device representatives throughout the 60-day treatment. Results Overall, 30% (222/747) of patients were early responders (≥50% pain relief throughout treatment). Another 31% (231/747) of patients initially presented as non-responders but surpassed 50% pain relief by the end of treatment. Conversely, 32% (239/747) of patients were non-responders throughout treatment. An additional 7% (55/747) of patients initially presented as responders but fell below 50% relief by the end of the treatment period. Conclusion An extended, 60-day PNS treatment may help identify delayed responders, providing the opportunity for sustained relief and improving access to effective PNS treatment. Compared to a conventionally short trial of ≤10 days, a longer 60-day PNS treatment may also help reduce explant rates by identifying delayed non-responders unlikely to benefit long-term. These scenarios support the importance of an extended 60-day temporary PNS stimulation period to help inform stepwise treatment strategies that may optimize outcomes and cost-effectiveness.
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Affiliation(s)
- Ramana Naidu
- California Orthopedics & Spine, Larkspur, CA, USA
- Correspondence: Ramana Naidu, California Orthopedics & Spine, 2 Bon Air Road #120, Larkspur, CA, 94939, USA, Tel +1 608-695-7266, Email
| | - Sean Li
- Premier Pain Centers, Shrewsbury, NJ, USA
| | - Mehul J Desai
- International Spine Pain & Performance Center, Washington, DC, USA
- George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Samir Sheth
- Sutter Roseville Pain Management, Roseville, CA, USA
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Beltrá P, Ruiz-Del-Portal I, Ortega FJ, Valdesuso R, Delicado-Miralles M M, Velasco E. Sensorimotor effects of plasticity-inducing percutaneous peripheral nerve stimulation protocols. Eur J Pain 2022; 26:1039-1055. [PMID: 35191131 DOI: 10.1002/ejp.1928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 02/14/2022] [Accepted: 02/20/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Electrical stimulation of skin afferents can induce somatosensory plasticity in humans. Nevertheless, it is unknown if this is possible to do through percutaneous stimulation of a peripheral nerve, which will allow for regional anaesthesia interventions. Furthermore, potentiation protocols applied over mainly non-nociceptive fibers inhibit nociception in rodents, but this has not been tested in humans. OBJECTIVE to determine whether a protocol aiming to depress the nociceptive circuit and another aiming to potentiate non-nociceptive circuits produce regional hypoalgesia and changes in motor function, applied through percutaneous peripheral nerve stimulation (pPNS), and to assess which of them is more promising for pain relief, immediately and 24 hours after intervention. METHODS PT-cLF protocol aims to depress the nociceptive pathway through Pain Threshold, continuous Low Frequency stimulation and ST-bHF aims to produce potentiation of the non-nociceptive pathway, through Sensory Threshold burst stimulation at High Frequency. All subjects (n=29) went through both protocols and a control condition in a randomized and blinded crossover design. RESULTS Compared to control, ST-bHF induced distal hypoalgesia, towards electrical (p=0.04) and mechanical stimuli (p=0.02) and produced mechanical hypoesthesia (p=0.02). Contrarily, hypoalgesia was not observed after PT-cLF (p>0.05) but increased electrical motor threshold (p=0.04), reduced motor recruitment (p=0.03), and the subjects reported feeling reduced strength (p<0.01). CONCLUSION This works provides evidence that is possible to induce antinociceptive plasticity in a wide territory using pPNS. Moreover, it demonstrates for the first time in humans that a protocol aiming to produce long-term potentiation applied predominantly over non-nociceptive afferents induces hypoesthesia and hypoalgesia.
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Affiliation(s)
- P Beltrá
- Physical therapy and advanced rehabilitation clinic RehAv Elche, 03203, Elche, Spain
| | - I Ruiz-Del-Portal
- Physical therapy and advanced rehabilitation clinic RehAv Elche, 03203, Elche, Spain
| | - F J Ortega
- Physical therapy and advanced rehabilitation clinic RehAv Elche, 03203, Elche, Spain.,Physical therapy department, CEU-Cardenal Herrera University, 03204, Elche, Spain
| | - R Valdesuso
- Physical therapy and advanced rehabilitation clinic RehAv Elche, 03203, Elche, Spain.,Physical therapy department, CEU-Cardenal Herrera University, 03204, Elche, Spain
| | - M Delicado-Miralles M
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, 03550, San Juan de Alicante, Spain
| | - E Velasco
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, 03550, San Juan de Alicante, Spain
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16
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Stewart CM, Qadri MYJ, Daly CA. Upper-Extremity Peripheral Nerve Stimulators. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 5:121-125. [PMID: 36704375 PMCID: PMC9870788 DOI: 10.1016/j.jhsg.2021.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/15/2021] [Indexed: 01/29/2023] Open
Abstract
Chronic pain conditions are some of the most challenging problems upper-extremity surgeons face and often require a multimodal approach including neuromodulation. Peripheral nerve stimulation (PNS) is one of these modalities, delivering electrical stimulation to peripheral axons to modulate the spinal cord and block out nociceptive signals from the extremity. This blockade leads to long-lasting effects in both the peripheral and central nervous systems. Not only does PNS decrease peripheral pain signals but it also decreases the peripheral inflammatory response and assists with central nervous system plasticity for long-term pain control. Although PNS was initially developed in the 1960s, it has been underrepresented in the literature largely due to the advent of spinal cord stimulation and the lack of Food and Drug Administration-approved hardware for PNS. However, for upper-extremity pain, PNS provides notable benefits over spinal cord stimulation devices, as PNS allows for safer, more specific, and often more effective pain control. As clinicians attempt to limit narcotic use, therapies such as PNS have been revisited and are gaining popularity. We present a narrative review of PNS; discuss its mechanism of action, indications, and surgical technique; and provide a summary of the available literature for the upper-extremity surgeon. Peripheral nerve stimulation offers a solution for chronic, debilitating pain recalcitrant to other treatment modalities.
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Affiliation(s)
| | | | - Charles A. Daly
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA,Corresponding author: Charles A. Daly, MD, Department of Orthopaedic Surgery, Emory University, 21 Ortho Lane, Atlanta, GA 30324.
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17
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Helm S, Shirsat N, Calodney A, Abd-Elsayed A, Kloth D, Soin A, Shah S, Trescot A. Peripheral Nerve Stimulation for Chronic Pain: A Systematic Review of Effectiveness and Safety. Pain Ther 2021; 10:985-1002. [PMID: 34478120 PMCID: PMC8586061 DOI: 10.1007/s40122-021-00306-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 12/01/2022] Open
Abstract
Peripheral nerve stimulation (PNS) was the first application of neuromodulation. Widespread application of PNS was limited by technical concerns. Recent advances now allow the percutaneous placement of leads with ultrasound or fluoroscopic guidance, while the transcutaneous powering of these leads removes the need for leads to cross major joints. This systematic review was written to assess the current status of high-quality evidence supporting the use of PNS for pain conditions treated by interventional pain physicians. The available literature on PNS, limited to conditions treated by interventional pain physicians, was reviewed and the quality assessed. Literature from 1966 to June 2021 was reviewed. The outcome measures were pain relief and functional improvement. One hundred and two studies were identified. Five randomized controlled trials (RCT) and four observational studies, all case series, met the inclusion criteria. One RCT was of high quality and four were of moderate quality; all four case series were of moderate quality. Three of the RCTs and all four case series evaluated peripheral nerve neuropathic pain. Based upon these studies, there is level II evidence supporting the use of PNS to treat refractory peripheral nerve injury. One moderate-quality RCT evaluated tibial nerve stimulation for pelvic pain, providing level III evidence for this indication. One moderate-quality RCT evaluated surgically placed cylindrical leads for cluster headaches, providing level III evidence for this indication. The evidence suggests that approximately two-thirds of patients with peripheral neuropathic pain will have at least 50% sustained pain relief. Adverse events from PNS are generally minor. A major advantage of PNS over spinal cord stimulation is the absence of any risk of central cord injury. The study was limited by the paucity of literature for some indications. No studies dealt with joint-related osteoarthritic pain.
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Affiliation(s)
- Standiford Helm
- Department of Anesthesiology and Pain Management, University of California, Irvine, Orange, CA, USA.
| | - Nikita Shirsat
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | | | - Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Management, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | - Shalini Shah
- Department of Anesthesiology and Pain Management, University of California, Irvine, Orange, CA, USA
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18
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Hasoon J, Dalal S, Berger AA, Orhurhu V, Kaye AD. Peripheral Nerve Stimulation for the Treatment of Hemiplegic Shoulder Pain. Orthop Rev (Pavia) 2021; 13:27362. [PMID: 34745486 DOI: 10.52965/001c.27362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/30/2021] [Indexed: 11/06/2022] Open
Abstract
Hemiplegic shoulder pain (HSP) is a common comorbidity affecting stroke survivors. It can lead to chronic pain in a significant portion of patients. Prompt recognition and treatment may lead to improved outcomes, though it can be very challenging to treat. Peripheral nerve stimulation (PNS) has shown significant promise as a treatment modality for HSP. We present an interesting case of a patient with debilitating HSP that was unresponsive to a variety of medications and prior neuromodulation therapies. We report our experience utilizing the SPRINT PNS system and our outcomes treating a patient with refractory HSP.
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Affiliation(s)
- Jamal Hasoon
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School; Pain Specialists of America
| | | | - Amnon A Berger
- Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Vwaire Orhurhu
- Massachusetts General Hospital and Harvard Medical School
| | - Alan D Kaye
- Louisiana State University Health Sciences Center
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19
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Gilmore CA, Desai MJ, Hopkins TJ, Li S, DePalma MJ, Deer TR, Grace W, Burgher AH, Sayal PK, Amirdelfan K, Cohen SP, McGee MJ, Boggs JW. Treatment of chronic axial back pain with 60-day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study. Pain Pract 2021; 21:877-889. [PMID: 34216103 PMCID: PMC9290596 DOI: 10.1111/papr.13055] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/01/2021] [Accepted: 06/24/2021] [Indexed: 12/18/2022]
Abstract
Background The objective of this prospective, multicenter study is to characterize responses to percutaneous medial branch peripheral nerve stimulation (PNS) to determine if results from earlier, smaller single‐center studies and reports were generalizable when performed at a larger number and wider variety of centers in patients recalcitrant to nonsurgical treatments. Materials & Methods Participants with chronic axial low back pain (LBP) were implanted with percutaneous PNS leads targeting the lumbar medial branch nerves for up to 60 days, after which the leads were removed. Participants were followed long‐term for 12 months after the 2‐month PNS treatment. Data collection is complete for visits through end of treatment with PNS (primary end point) and 6 months after lead removal (8 months after start of treatment), with some participant follow‐up visits thereafter in progress. Results Clinically and statistically significant reductions in pain intensity, disability, and pain interference were reported by a majority of participants. Seventy‐three percent of participants were successes for the primary end point, reporting clinically significant (≥30%) reductions in back pain intensity after the 2‐month percutaneous PNS treatment (n = 54/74). Whereas prospective follow‐up is ongoing, among those who had already completed the long‐term follow‐up visits (n = 51), reductions in pain intensity, disability, and pain interference were sustained in a majority of participants through 14 months after the start of treatment. Conclusion Given the minimally invasive, nondestructive nature of percutaneous PNS and the significant benefits experienced by participants who were recalcitrant to nonsurgical treatments, percutaneous PNS may provide a promising first‐line neurostimulation treatment option for patients with chronic axial back pain.
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Affiliation(s)
| | - Mehul J Desai
- International Spine, Pain, and Performance Center, Washington, DC, USA
| | | | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | | | - Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, West Virginia, USA
| | - Warren Grace
- The Spine and Nerve Centers of the Virginias, Charleston, West Virginia, USA
| | | | - Puneet K Sayal
- International Spine, Pain, and Performance Center, Washington, DC, USA
| | | | - Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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20
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Yang A, Nadav D, Legler A, Chen GH, Hingula L, Puttanniah V, Gulati A. An Interventional Pain Algorithm for the Treatment of Postmastectomy Pain Syndrome: A Single-Center Retrospective Review. PAIN MEDICINE 2021; 22:677-686. [PMID: 33155049 DOI: 10.1093/pm/pnaa343] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Breast cancer is the most common female malignancy worldwide. Breast surgery and adjuvant oncological therapies are often required to increase survival. Treatment-related pain may persist and evolve into postmastectomy pain syndrome (PMPS) in a significant subset of breast cancer survivors. In this retrospective investigation, we will present our experience in applying an interventional algorithmic approach to treat PMPS. DESIGN A retrospective study. SETTING An academic cancer hospital. SUBJECTS Adult females with PMPS diagnosis. METHODS We reviewed 169 records with the diagnosis of PMPS from 2015 to 2019 within our health system. Pre- and post-injection pain scores, relief duration, and medication usage changes were collected. The decision to perform each procedure was based on the anatomic location of the painful area with the corresponding peripheral sensory innervation. Decision-making flow diagrams were created to present our experience in managing PMPS beyond peripheral nerve blocks. RESULTS Ultrasound-guided peripheral nerve block results (n=350) were analyzed. The mean baseline pain score was 7, compared with the post-treatment mean score of 3 (95% confidence interval: 3.58 to 3.98, P = 0.0001). Among the responders, the mean pain relief duration was 45 days, with a median of 84 days. Opioid medication consumption was reduced by 11% (t = 0.72, P = 0.47). CONCLUSIONS Ultrasound-guided nerve blocks of this area could be performed safely and effectively after breast surgeries. We also present our proposed algorithm to provide a stepwise application for selecting the appropriate therapies in the management of more complex PMPS.
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Affiliation(s)
- Ajax Yang
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.,The Spine and Pain Institute of New York, New York, USA
| | - Danielle Nadav
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Aron Legler
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Grant H Chen
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lee Hingula
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay Puttanniah
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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21
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Percutaneous Electrical Nerve Stimulation (PENS) as a Rehabilitation Approach for Reducing Mixed Chronic Pain in Patients with Musculoskeletal Disorders. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11094257] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
“Mixed pain” is a term recently introduced to define the overlapping of nociceptive, neuropathic and nociplastic pain. To date, it has been reported that pharmacological treatments might have a modest effectiveness on patients affected by mixed chronic pain, with detrimental consequences in terms of disability, physical function and health-related quality of life. In this scenario, Percutaneous Electrical Nerve Stimulation (PENS), a mini-invasive neuromodulation technique, has been recently suggested as a promising approach for the complex management of mixed pain in musculoskeletal disorders. Albeit PENS showed to be effective in reducing unspecified pain in several chronic pain conditions, there is still a lack of evidence in the literature about its role in the management of neuropathic or mixed pain not responsive to pharmacological treatments. Therefore, by the present scoping review, we portray the potential effects of PENS in the multidisciplinary and multidimensional management of mixed chronic pain in patients with musculoskeletal disorders.
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22
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Moman RN, Olatoye OO, Pingree MJ. Temporary, Percutaneous Peripheral Nerve Stimulation for Refractory Occipital Neuralgia. PAIN MEDICINE 2021; 23:415-420. [PMID: 33823015 DOI: 10.1093/pm/pnab128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Rajat N Moman
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Oludare O Olatoye
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew J Pingree
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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23
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Jung MJ, Pritzlaff SG. Peripheral Nerve Stimulation of Complex Upper Extremity Amputation Pain May Be Variable. A A Pract 2021; 15:e01441. [PMID: 33793432 DOI: 10.1213/xaa.0000000000001441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michael J Jung
- Department of Anesthesiology and Pain Medicine, University of California, Davis (UC Davis) Medical Center, Sacramento, California,
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24
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Deer TR, Gilmore CA, Desai MJ, Li S, DePalma MJ, Hopkins TJ, Burgher AH, Spinner DA, Cohen SP, McGee MJ, Boggs JW. Percutaneous Peripheral Nerve Stimulation of the Medial Branch Nerves for the Treatment of Chronic Axial Back Pain in Patients After Radiofrequency Ablation. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:548-560. [PMID: 33616178 PMCID: PMC7971467 DOI: 10.1093/pm/pnaa432] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Lumbar radiofrequency ablation is a commonly used intervention for chronic back pain. However, the pain typically returns, and though retreatment may be successful, the procedure involves destruction of the medial branch nerves, which denervates the multifidus. Repeated procedures typically have diminishing returns, which can lead to opioid use, surgery, or implantation of permanent neuromodulation systems. The objective of this report is to demonstrate the potential use of percutaneous peripheral nerve stimulation (PNS) as a minimally invasive, nondestructive, motor-sparing alternative to repeat radiofrequency ablation and more invasive surgical procedures. DESIGN Prospective, multicenter trial. METHODS Individuals with a return of chronic axial pain after radiofrequency ablation underwent implantation of percutaneous PNS leads targeting the medial branch nerves. Stimulation was delivered for up to 60 days, after which the leads were removed. Participants were followed up to 5 months after the start of PNS. Outcomes included pain intensity, disability, and pain interference. RESULTS Highly clinically significant (≥50%) reductions in average pain intensity were reported by a majority of participants (67%, n = 10/15) after 2 months with PNS, and a majority experienced clinically significant improvements in functional outcomes, as measured by disability (87%, n = 13/15) and pain interference (80%, n = 12/15). Five months after PNS, 93% (n = 14/15) reported clinically meaningful improvement in one or more outcome measures, and a majority experienced clinically meaningful improvements in all three outcomes (i.e., pain intensity, disability, and pain interference). CONCLUSIONS Percutaneous PNS has the potential to shift the pain management paradigm by providing an effective, nondestructive, motor-sparing neuromodulation treatment.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
| | | | - Mehul J Desai
- International Spine Pain and Performance Center, George Washington University, School of Medicine, Washington, DC, USA
| | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | | | | | | | | | - Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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25
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Deer TR, Eldabe S, Falowski SM, Huntoon MA, Staats PS, Cassar IR, Crosby ND, Boggs JW. Peripherally Induced Reconditioning of the Central Nervous System: A Proposed Mechanistic Theory for Sustained Relief of Chronic Pain with Percutaneous Peripheral Nerve Stimulation. J Pain Res 2021; 14:721-736. [PMID: 33737830 PMCID: PMC7966353 DOI: 10.2147/jpr.s297091] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/26/2021] [Indexed: 12/23/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is an effective tool for the treatment of chronic pain, although its efficacy and utilization have previously been significantly limited by technology. In recent years, purpose-built percutaneous PNS devices have been developed to overcome the limitations of conventional permanently implanted neurostimulation devices. Recent clinical evidence suggests clinically significant and sustained reductions in pain can persist well beyond the PNS treatment period, outcomes that have not previously been observed with conventional permanently implanted neurostimulation devices. This narrative review summarizes mechanistic processes that contribute to chronic pain, and the potential mechanisms by which selective large diameter afferent fiber activation may reverse these changes to induce a prolonged reduction in pain. The interplay of these mechanisms, supported by data in chronic pain states that have been effectively treated with percutaneous PNS, will also be discussed in support of a new theory of pain management in neuromodulation: Peripherally Induced Reconditioning of the Central Nervous System (CNS).
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Steven M Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Marc A Huntoon
- Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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26
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Xu J, Sun Z, Wu J, Rana M, Garza J, Zhu AC, Chakravarthy KV, Abd-Elsayed A, Rosenquist E, Basi H, Christo P, Cheng J. Peripheral Nerve Stimulation in Pain Management: A Systematic Review. Pain Physician 2021; 24:E131-E152. [PMID: 33740342 PMCID: PMC8897810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. OBJECTIVES To assess the clinical evidence of PNS in the treatment of acute or chronic pain. STUDY DESIGN A systematic review of the efficacy and safety of PNS in managing acute or chronic pain. METHODS Data sources were PubMed, Cochrane Library, Scopus, CINAHL Plus, Google Scholar, and reference lists. The literature search was performed up to December 2019. Study selection included randomized trials, observational studies, and case reports of PNS in acute or chronic pain. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data syntheses: 227 studies met inclusion criteria and were included in qualitative synthesis. RESULTS Evidence synthesis based on randomized controlled trials (RCTs) and observational studies showed Level I and II evidence of PNS in chronic migraine headache; Level II evidence in cluster headache, postamputation pain, chronic pelvic pain, chronic low back and lower extremity pain; and Level IV evidence in peripheral neuropathic pain, and postsurgical pain. Peripheral field stimulation has Level II evidence in chronic low back pain, and Level IV evidence in cranial pain. LIMITATIONS Lack of high-quality RCTs. Meta-analysis was not possible due to wide variations in experimental design, research protocol, and heterogeneity of study population. CONCLUSIONS The findings of this systematic review suggest that PNS may be effective in managing chronic headaches, postamputation pain, chronic pelvic pain, and chronic low back and lower extremity pain, with variable levels of evidence in favor of this technique.
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Affiliation(s)
- Jijun Xu
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Anesthesiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Zhuo Sun
- Department of Anesthesiology and Perioperative Medicine, Augusta University Medical Center, Medical College of Georgia, Augusta, GA
| | - Jiang Wu
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
| | - Maunak Rana
- Department of Anesthesiology and Critical Care, The University of Chicago, Chicago, IL
| | - Joshua Garza
- Department of Anesthesiology and Critical Care, The University of Chicago, Chicago, IL
| | - Alyssa C. Zhu
- Department of Anesthesiology and Pain Medicine, University of California San Diego, VA San Diego Healthcare System, La Jolla, CA
| | - Krishnan V. Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego, VA San Diego Healthcare System, La Jolla, CA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ellen Rosenquist
- Center for Spine Health and Pain Management, Cleveland Clinic, Cleveland, OH
| | - Hersimren Basi
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Paul Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jianguo Cheng
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
- Department of Neuroscience, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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27
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Dyer S, Mordaunt DA, Adey-Wakeling Z. Interventions for Post-Stroke Shoulder Pain: An Overview of Systematic Reviews. Int J Gen Med 2020; 13:1411-1426. [PMID: 33324087 PMCID: PMC7732168 DOI: 10.2147/ijgm.s200929] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 01/08/2023] Open
Abstract
Background Shoulder pain following stroke leads to poorer quality of life and daily functioning. Whilst many treatment approaches exist, there is currently no systematic overview of the evidence base for these. This review addressed the question “What is the evidence for interventions for treating hemiplegic shoulder pain?” Methods An overview of systematic reviews was performed according to PROSPERO protocol (CRD42020140521). Five electronic databases including Cochrane, MEDLINE, Embase and EmCare were searched to June 2019. Included systematic reviews were those of comparative trials of interventions for hemiplegic shoulder pain in adults, reporting pain outcomes using a validated pain scale. Review quality was assessed with AMSTAR2 and those considered at high risk of bias for four or more items were excluded. The most recent, comprehensive review for each intervention category was included. Outcomes of function and quality of life were also extracted. Results Seven systematic reviews of 11 interventions were included, with varied quality. Reviews showed significant benefits in terms of pain reduction for many interventions including acupuncture (conventional 19 trials, electroacupuncture 5 trials, fire needle 2 trials, warm needle 1 trial and bee venom 3 trials), orthoses (1 trial), botulinum toxin injection (4 trials), electrical stimulation (6 trials) and aromatherapy (1 trial). However, the majority of trials were small, leading to imprecise estimates of effect. Findings were often inconsistent across outcome measures or follow-up times. Outcomes from trials of acupuncture were heterogenous with likely publication bias. Conclusion A number of systematic reviews indicate significant reductions in pain, with a wide range of treatments appearing promising. However, significant limitations mean the clinical importance of these findings are uncertain. Due to complex etiology, practitioners and health systems must consider the range of potential interventions and tailor their approach to individual presentation, guided by their local circumstances, expert opinion and the growing literature base.
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Affiliation(s)
- Suzanne Dyer
- Rehabilitation, Aged and Extended Care, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Dylan A Mordaunt
- Rehabilitation, Aged and Extended Care, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Department of Rehabilitation Medicine, Southern Adelaide Local Health Network, Bedford Park, South Australia, Australia
| | - Zoe Adey-Wakeling
- Rehabilitation, Aged and Extended Care, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Department of Rehabilitation Medicine, Southern Adelaide Local Health Network, Bedford Park, South Australia, Australia
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Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain. Anesthesiology 2020; 133:1127-1149. [PMID: 32898231 DOI: 10.1097/aln.0000000000003532] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.
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Deer TR, Esposito MF, McRoberts WP, Grider JS, Sayed D, Verrills P, Lamer TJ, Hunter CW, Slavin KV, Shah JM, Hagedorn JM, Simopoulos T, Gonzalez DA, Amirdelfan K, Jain S, Yang A, Aiyer R, Antony A, Azeem N, Levy RM, Mekhail N. A Systematic Literature Review of Peripheral Nerve Stimulation Therapies for the Treatment of Pain. PAIN MEDICINE 2020; 21:1590-1603. [DOI: 10.1093/pm/pnaa030] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AbstractObjectiveTo conduct a systematic literature review of peripheral nerve stimulation (PNS) for pain.DesignGrade the evidence for PNS.MethodsAn international interdisciplinary work group conducted a literature search for PNS. Abstracts were reviewed to select studies for grading. Inclusion/exclusion criteria included prospective randomized controlled trials (RCTs) with meaningful clinical outcomes that were not part of a larger or previously reported group. Excluded studies were retrospective, had less than two months of follow-up, or existed only as abstracts. Full studies were graded by two independent reviewers using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsPeripheral nerve stimulation was studied in 14 RCTs for a variety of painful conditions (headache, shoulder, pelvic, back, extremity, and trunk pain). Moderate to strong evidence supported the use of PNS to treat pain.ConclusionPeripheral nerve stimulation has moderate/strong evidence. Additional prospective trials could further refine appropriate populations and pain diagnoses.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | | | | | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Jay M Shah
- SamWell Institute for Pain Management, Colonia, New Jersey
| | | | - Tom Simopoulos
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | - Sameer Jain
- Pain Treatment Centers of America, Little Rock, Arkansas
| | - Ajax Yang
- Mt. Sinai Hospital, New York, New York
| | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry Faculty, Henry Ford Health System, Detroit, Michigan
| | - Ajay Antony
- University of Florida College of Medicine, Jacksonville, Florida
| | - Nomen Azeem
- Florida Spine & Pain Specialists, Bradenton, Florida
| | - Robert M Levy
- Director of Neurosurgical Services, Director of Clinical Research, Anesthesia Pain Care Consultants, Tamarac, Florida
| | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, Ohio, USA
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Mansfield JT, Desai MJ. Axillary Peripheral Nerve Stimulation for Painful End-Stage Primary Osteoarthritis of the Shoulder: A Case Report. Neuromodulation 2020; 23:878-880. [DOI: 10.1111/ner.13089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/22/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022]
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Cohen SP, Gilmore CA, Rauck RL, Lester DD, Trainer RJ, Phan T, Kapural L, North JM, Crosby ND, Boggs JW. Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Pain Following Amputation. Mil Med 2020; 184:e267-e274. [PMID: 31111898 PMCID: PMC6614808 DOI: 10.1093/milmed/usz114] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/02/2019] [Accepted: 04/18/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction Chronic pain and reduced function are significant problems for Military Service members and Veterans following amputation. Peripheral nerve stimulation (PNS) is a promising therapy, but PNS systems have traditionally been limited by invasiveness and complications. Recently, a novel percutaneous PNS system was developed to reduce the risk of complications and enable delivery of stimulation without surgery. Materials and Methods Percutaneous PNS was evaluated to determine if stimulation provides relief from residual and phantom limb pain following lower-extremity amputation. PNS leads were implanted percutaneously to deliver stimulation to the femoral and/or sciatic nerves. Patients received stimulation for up to 60 days followed by withdrawal of the leads. Results A review of recent studies and clinical reports found that a majority of patients (18/24, 75%) reported substantial (≥50%) clinically relevant relief of chronic post-amputation pain following up to 60 days of percutaneous PNS. Reductions in pain were frequently associated with reductions in disability and pain interference. Conclusions Percutaneous PNS can durably reduce pain, thereby enabling improvements in quality of life, function, and rehabilitation in individuals with residual or phantom limb pain following amputation. Percutaneous PNS may have additional benefit for Military Service members and Veterans with post-surgical or post-traumatic pain.
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Affiliation(s)
- Steven P Cohen
- Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | | | - Richard L Rauck
- Center for Clinical Research, 145 Kimel Park Dr, Suite 330, Winston-Salem, NC
| | - Denise D Lester
- Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA
| | - Robert J Trainer
- Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA
| | - Thomas Phan
- Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA
| | - Leonardo Kapural
- Center for Clinical Research, 145 Kimel Park Dr, Suite 330, Winston-Salem, NC
| | - James M North
- Center for Clinical Research, 145 Kimel Park Dr, Suite 330, Winston-Salem, NC
| | - Nathan D Crosby
- SPR Therapeutics, 22901 Millcreek Blvd, Suite 110, Cleveland, OH
| | - Joseph W Boggs
- SPR Therapeutics, 22901 Millcreek Blvd, Suite 110, Cleveland, OH
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Cleland T, Jain NB, Chae J, Hansen KM, Hisel TZ, Gunzler DD, Whitehair VC, Kim CH, Wilson RD. The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain. Trials 2020; 21:248. [PMID: 32143732 PMCID: PMC7059286 DOI: 10.1186/s13063-020-4174-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population. METHODS This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist. DISCUSSION This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population. TRIAL REGISTRATION Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.
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Affiliation(s)
- Travis Cleland
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Nitin B. Jain
- Vanderbilt University Medical Center, 3319 West End Ave, Nashville, TN 37203 USA
| | - John Chae
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Kristine M. Hansen
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Terri Z. Hisel
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Douglas D. Gunzler
- Center for Healthcare Research and Policy, MetroHealth System, 2500 MetroHealth Dr., Cleveland, OH 44109 USA
| | - Victoria C. Whitehair
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Chong H. Kim
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Richard D. Wilson
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
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Percutaneous and Implanted Peripheral Nerve Stimulation for the Management of Pain: Current Evidence and Future Directions. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-019-00256-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mansfield JT, Desai MJ. Axillary Peripheral Nerve Stimulation for Chronic Shoulder Pain: A Retrospective Case Series. Neuromodulation 2020; 23:812-818. [PMID: 31930660 DOI: 10.1111/ner.13096] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/08/2019] [Accepted: 12/11/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study was to determine the effect of axillary peripheral nerve stimulation (PNS) on pain reduction in patients with chronic shoulder pain. Chronic shoulder pain was defined as pain greater than six months originating from any of the following and not the result of a stroke: subacromial impingement syndrome/rotator cuff pathology, glenohumeral joint arthritis, acromioclavicular joint arthritis, adhesive capsulitis, or biceps tendinopathy. MATERIALS AND METHODS Eight adult patients with chronic shoulder pain, as defined above, who either did not respond to surgical intervention or who were deemed not ideal surgical candidates underwent permanent axillary PNS therapy. Follow-up ranged from 44 to 733 days (avg 445 days). The primary outcome was percent pain reduction, determined by the change in average numerical pain rating scale (NPRS). Additionally, secondary outcome measures were the change in opioid requirements and satisfaction rate. RESULTS Based on the ≥50% pain reduction for treatment success, 88% (7/8) were "responders." Overall average pain reduction was 67% and 70% among responders; 62.5% (5/8) of patients reported that they used opioids prior to axillary PNS therapy for pain relief. Among these patients, 100% reported decreased opioid use after axillary PNS implant, with an average reduction of 88% (based on self-reported reductions). Additionally, 100% (8/8) of patients reported that they would recommend this therapy to other patients suffering from chronic pain. CONCLUSIONS This retrospective case series provides level IV evidence supporting the use of axillary PNS therapy for the management of chronic shoulder pain. Additional, higher-level studies are required to further support its use.
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Affiliation(s)
- John Taylor Mansfield
- International Spine Pain & Performance Center, Washington, DC, USA.,Department of Rehabilitation Medicine, MedStar Georgetown University, Washington, DC, USA
| | - Mehul J Desai
- International Spine Pain & Performance Center, Washington, DC, USA.,School of Medicine and Health Sciences, George Washington University, Washington, DC, USA.,Virginia Hospital Center, Director of Pain Medicine Division, Arlington, VA, USA
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Gilmore CA, Kapural L, McGee MJ, Boggs JW. Percutaneous Peripheral Nerve Stimulation for Chronic Low Back Pain: Prospective Case Series With 1 Year of Sustained Relief Following Short-Term Implant. Pain Pract 2019; 20:310-320. [PMID: 31693791 PMCID: PMC7079182 DOI: 10.1111/papr.12856] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/16/2022]
Abstract
Introduction Percutaneous peripheral nerve stimulation (PNS) provides an opportunity to relieve chronic low back pain and reduce opioid analgesic consumption as an alternative to radiofrequency ablation and permanently implanted neurostimulation systems. Traditionally, the use of neurostimulation earlier in the treatment continuum has been limited by its associated risk, invasiveness, and cost. Methods Percutaneous PNS leads (SPRINT MicroLead) were placed bilaterally to target the medial branches of the dorsal rami nerves under image guidance. The percutaneous leads were connected to miniature wearable stimulators (SPRINT PNS System) for the 1‐month therapy period, after which the leads were removed. Pain and disability were assessed long‐term up to 12 months after lead removal. Results Substantial, clinically significant reductions in average pain intensity (≥50% reduction as measured by the Brief Pain Inventory Short Form) were experienced by a majority of subjects (67%) at end of treatment compared to baseline (average 80% reduction among responders; P < 0.05, analysis of variance; n = 9). Twelve months after the end of PNS treatment, a majority of subjects who completed the long‐term follow‐up visits experienced sustained, clinically significant reductions in pain and/or disability (67%, n = 6; average 63% reduction in pain intensity and 32‐point reduction in disability among responders). No serious or unanticipated adverse events were reported. Conclusions This study challenges the long‐held notion that a positive trial of PNS should be followed by a permanent implant in responders. Percutaneous PNS may serve as an effective neurostimulation therapy for patients with chronic low back pain and should be considered earlier in the treatment continuum as a motor‐sparing means of avoiding opioids, denervation, and permanently implanted neurostimulation systems.
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Affiliation(s)
- Christopher A Gilmore
- Center for Clinical Research, Carolinas Pain Institute, Winston Salem, North Carolina, U.S.A
| | - Leonardo Kapural
- Center for Clinical Research, Carolinas Pain Institute, Winston Salem, North Carolina, U.S.A
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36
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Gilmore CA, Ilfeld BM, Rosenow JM, Li S, Desai MJ, Hunter CW, Rauck RL, Nader A, Mak J, Cohen SP, Crosby ND, Boggs JW. Percutaneous 60-day peripheral nerve stimulation implant provides sustained relief of chronic pain following amputation: 12-month follow-up of a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med 2019; 45:rapm-2019-100937. [PMID: 31740443 DOI: 10.1136/rapm-2019-100937] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/03/2019] [Accepted: 10/27/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Peripheral nerve stimulation (PNS) has historically been used to treat chronic pain, but generally requires implantation of a permanent system for sustained relief. A recent study found that a 60-day PNS treatment decreases post-amputation pain, and the current work investigates longer-term outcomes out to 12 months in the same cohort. METHODS As previously reported, 28 traumatic lower extremity amputees with residual and/or phantom limb pain were randomized to receive 8 weeks of PNS (group 1) or 4 weeks of placebo followed by a crossover 4 weeks of PNS (group 2). Percutaneous leads were implanted under ultrasound guidance targeting the femoral and sciatic nerves. During follow-up, changes in average pain and pain interference were assessed using the Brief Pain Inventory-Short Form and comparing with baseline. RESULTS Significantly more participants in group 1 reported ≥50% reductions in average weekly pain at 12 months (67%, 6/9) compared with group 2 at the end of the placebo period (0%, 0/14, p=0.001). Similarly, 56% (5/9) of participants in group 1 reported ≥50% reductions in pain interference at 12 months, compared with 2/13 (15%, p=0.074) in group 2 at crossover. Reductions in depression were also statistically significantly greater at 12 months in group 1 compared with group 2 at crossover. CONCLUSIONS This work suggests that percutaneous PNS delivered over a 60-day period may provide significant carry-over effects including pain relief, potentially avoiding the need for a permanently implanted system while enabling improved function in patients with chronic pain. TRIAL REGISTRATION NUMBER NCT01996254.
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Affiliation(s)
| | - Brian M Ilfeld
- Anesthesiology, University of California, San Diego, La Jolla, California, USA
| | - Joshua M Rosenow
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | - Mehul J Desai
- International Spine, Pain, and Performance Center, Washington, District of Columbia, USA
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York City, New York, USA
| | - Richard L Rauck
- Center for Clinical Research, Winston-Salem, North Carolina, USA
| | - Antoun Nader
- Department of Anesthesiology, Northwestern University, Chicago, Illinois, USA
| | - John Mak
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | - Steven P Cohen
- Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Cohen S, Gilmore C, Kapural L, Hanling S, Plunkett A, McGee M, Boggs J. Percutaneous Peripheral Nerve Stimulation for Pain Reduction and Improvements in Functional Outcomes in Chronic Low Back Pain. Mil Med 2019; 184:537-541. [PMID: 30901473 DOI: 10.1093/milmed/usy310] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/16/2018] [Indexed: 11/12/2022] Open
Abstract
Chronic low back pain represents one of the most common sources of disability and a significant healthcare burden for the U.S. military. Present treatments for chronic back pain are often ineffective, poorly tolerated, invasive, destructive, and/or associated with complications and lead to the progression to invasive surgical procedures. There have been multiple calls for the development of a minimally invasive system that is effective without the risks or complications of existing surgical therapies, which could prevent the need for surgery and the recurrence of pain. The goal of this study was to evaluate a novel, minimally invasive approach using a percutaneous peripheral nerve stimulation (PNS) system designed to provide pain relief without surgery, to reduce complications, and provide a less-invasive treatment option. In nine subjects, percutaneous PNS improved participants' function, as evidenced by clinically and statistically significant reductions in pain, disability, and pain interference. Subjects also experienced reductions in opioid and non-opioid analgesic medication usage and reported improvements in quality of life with treatment. There were no serious or unanticipated adverse events. These results demonstrate the potential of percutaneous PNS as a non-surgical therapy to treat chronic back pain without opioids.
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Affiliation(s)
- Steven Cohen
- Department of Anesthesiology, Pain Management Center, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD.,Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, MD
| | - Christopher Gilmore
- Center for Clinical Research, 145 Kimel Park Drive, Suite 330, Winston Salem, NC
| | - Leonardo Kapural
- Center for Clinical Research, 145 Kimel Park Drive, Suite 330, Winston Salem, NC
| | - Steven Hanling
- Anesthesiology and Perioperative Medicine, Augusta University, 1120 15th Street, BA 2188, Augusta, GA
| | - Anthony Plunkett
- Department of Anesthesiology, Womack Army Medical Center, 2817 Reilly Road, Fort Bragg, NC
| | - Meredith McGee
- SPR Therapeutics, 308 W. Rosemary Street, Suite 201, Chapel Hill, NC
| | - Joseph Boggs
- SPR Therapeutics, 308 W. Rosemary Street, Suite 201, Chapel Hill, NC
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Ilfeld BM, Ball ST, Cohen SP, Hanling SR, Fowler IM, Wongsarnpigoon A, Boggs JW. Percutaneous Peripheral Nerve Stimulation to Control Postoperative Pain, Decrease Opioid Use, and Accelerate Functional Recovery Following Orthopedic Trauma. Mil Med 2019; 184:557-564. [PMID: 30901395 DOI: 10.1093/milmed/usy378] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/14/2018] [Indexed: 11/13/2022] Open
Abstract
Orthopedic trauma is a significant military problem, causing several of the most disabling conditions with high rates of separation from duty and erosion of military readiness. The objective of this report is to summarize the findings of case series of a non-opioid therapy-percutaneous peripheral nerve stimulation (PNS) - and describe its potential for postoperative analgesia, early opioid cessation, and improved function following orthopedic trauma. Percutaneous PNS has been evaluated for the treatment of multiple types of pain, including two case series on postoperative pain following total knee replacement (n = 10 and 8, respectively) and a case series on postamputation pain (n = 9). The orthopedic trauma induced during TKR is highly representative of multiple types of orthopedic trauma sustained by Service members and frequently produces intense, prolonged postoperative pain and extended opioid use following surgery. Collectively, the results of these three clinical studies demonstrated that percutaneous PNS can provide substantial pain relief, reduce opioid use, and improve function. These outcomes suggest that there is substantial potential for the use of percutaneous PNS following orthopedic trauma.
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Affiliation(s)
- Brian M Ilfeld
- University of California San Diego, 200 W Arbor Drive, San Diego, CA
| | - Scott T Ball
- University of California San Diego, 200 W Arbor Drive, San Diego, CA
| | - Steven P Cohen
- Johns Hopkins School of Medicine, Department of Anesthesiology and Critical Care Medicine, 1800 Orleans Street, Baltimore, MD
| | - Steven R Hanling
- Medical College of Georgia, Department of Anesthesiology & Perioperative Medicine, BIW-2144 1120 15th Street, Augusta, GA
| | - Ian M Fowler
- Naval Medical Center San Diego, Department of Anesthesiology, 34800 Bob Wilson Dr, San Diego, CA
| | | | - Joseph W Boggs
- SPR Therapeutics, 22901 Millcreek Boulevard, Suite 110, Cleveland, OH
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40
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Ilfeld BM, Finneran JJ, Gabriel RA, Said ET, Nguyen PL, Abramson WB, Khatibi B, Sztain JF, Swisher MW, Jaeger P, Covey DC, Meunier MJ, Hentzen ER, Robertson CM. Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the suprascapular nerve and brachial plexus for postoperative analgesia following ambulatory rotator cuff repair. A proof-of-concept study. Reg Anesth Pain Med 2019; 44:310-318. [PMID: 30770421 DOI: 10.1136/rapm-2018-100121] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/04/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period. METHODS Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14-28. RESULTS Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1-14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported. CONCLUSIONS This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture. TRIAL REGISTRATION NUMBER NCT02898103.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA .,The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA.,The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA.,The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Patrick L Nguyen
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Matthew W Swisher
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA.,The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Pia Jaeger
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA.,The Outcomes Research Consortium, Cleveland, Ohio, USA.,Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dana C Covey
- Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA
| | - Matthew J Meunier
- Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA
| | - Eric R Hentzen
- Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA
| | - Catherine M Robertson
- Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA
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Deer TR, Jain S, Hunter C, Chakravarthy K. Neurostimulation for Intractable Chronic Pain. Brain Sci 2019; 9:E23. [PMID: 30682776 PMCID: PMC6406470 DOI: 10.3390/brainsci9020023] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/15/2019] [Accepted: 01/21/2019] [Indexed: 12/20/2022] Open
Abstract
The field of neuromodulation has seen unprecedented growth over the course of the last decade with novel waveforms, hardware advancements, and novel chronic pain indications. We present here an updated review on spinal cord stimulation, dorsal root ganglion stimulation, and peripheral nerve stimulation. We focus on mechanisms of action, clinical indications, and future areas of research. We also present current drawbacks with current stimulation technology and suggest areas of future advancements. Given the current shortage of viable treatment options using a pharmacological based approach and conservative interventional therapies, neuromodulation presents an interesting area of growth and development for the interventional pain field and provides current and future practitioners a fresh outlook with regards to its place in the chronic pain treatment paradigm.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, VA 25301, USA.
| | - Sameer Jain
- Pain Treatment Centers of America, Little Rock, AR 72205, USA.
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY 10022, USA.
| | - Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA 92037, USA.
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Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Sciatic Nerve for Postoperative Analgesia Following Ambulatory Foot Surgery, a Proof-of-Concept Study. Reg Anesth Pain Med 2019; 43:580-589. [PMID: 29905630 PMCID: PMC6092098 DOI: 10.1097/aap.0000000000000819] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain the day following knee surgery. However, it remains unknown if this analgesic technique may be used in ambulatory subjects following foot procedures beginning within the recovery room immediately following surgery, and with only short series of patients reported to date, the only available data are derived from strictly observational studies. The purposes of this proof-of-concept study were to demonstrate the feasibility of using percutaneous sciatic nerve PNS to treat postoperative pain following ambulatory foot surgery in the immediate postoperative period and provide the first available data from a randomized controlled study design to provide evidence of analgesic effect. METHODS Preoperatively, an electrical lead (SPRINT; SPR Therapeutics, Inc, Cleveland, Ohio) was percutaneously inserted posterior to the sciatic nerve between the subgluteal region and bifurcation with ultrasound guidance. Following hallux valgus osteotomy, subjects received 5 minutes of either stimulation or sham in a randomized, double-masked fashion followed by a 5-minute crossover period and then continuous stimulation until lead removal on postoperative days 14 to 28. RESULTS During the initial 5-minute treatment period, subjects randomized to stimulation (n = 4) experienced a downward trajectory in their pain over the 5 minutes of treatment, whereas those receiving sham (n = 3) reported no such change until their subsequent 5-minute stimulation crossover. During the subsequent 30 minutes of stimulation, pain scores decreased to 52% of baseline (n = 7). Three subjects (43%) used a continuous popliteal nerve block for rescue analgesia during postoperative days 0 to 3. Overall, resting and dynamic pain scores averaged less than 1 on the numeric rating scale, and opioid use averaged less than 1 tablet daily with active stimulation. One lead dislodged, 2 fractured during use, and 1 fractured during intentional withdrawal. CONCLUSIONS This proof-of-concept study demonstrates that percutaneous sciatic nerve PNS is feasible for ambulatory foot surgery and suggests that this modality provides analgesia and decreases opioid requirements following hallux valgus procedures. However, lead dislodgement and fracture are concerns. CLINICAL TRIAL REGISTRATION This study was registered at Clinicaltrials.gov, identifier NCT02898103.
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Crago PE. Neuromodulation by combined sensory and motor stimulation in the peripheral nerve: tendon organ afferent activity. J Neural Eng 2018; 16:016015. [PMID: 30523807 DOI: 10.1088/1741-2552/aaeaa9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Neuromuscular stimulation is a therapeutic approach to treat impairments such as stroke or pain, although the resulting inputs to the nervous system due to the stimulation are not well quantified. Stimulation activates both afferents and efferents, and the resulting neural activity is a mix of the effects of both: the changes in afferent activity due to efferent physiological actions plus the alterations due to afferent stimulation. This study quantitatively describes the resulting Golgi tendon organ Ib afferent activity in response to mixed afferent and efferent stimulation. APPROACH Neural and stimulated action potentials interact by means of collision, neural resetting, and refractory block. We simulated the action potential patterns of Ib afferents in the human first dorsal interosseous during constant voluntary, stimulated, and combined contractions, varying both stimulation rate and location, and both with and without simultaneous Ib stimulation. MAIN RESULTS Efferent stimulation affects the firing rate versus force relationships of individual tendon organs, but the effects on the population mean are very small. In contrast, afferent stimulation changes the firing rate versus force relationship of individual afferents by increasing the firing rate, decreasing the force resolution, broadening the distribution of action potential rates, and temporally phase locking a portion of the action potentials. Force resolution is retained in the population mean. The effects of afferent stimulation change with the stimulation rate and location, and with receptor firing rates. SIGNIFICANCE This is the first quantitative description of the changes in afferent feedback during combined efferent and afferent nerve stimulation. The small effects of efferent stimulation on the population response implies that tendon organs could provide accurate force feedback during stimulated contractions. The effects of afferent stimulation can be altered by choice of stimulus rate and site and are generalizable to other afferents.
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Affiliation(s)
- Patrick E Crago
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, United States of America. Louis Stokes Department of Veterans Affairs Medical Center, Cleveland Functional Electrical Stimulation (FES) Center, Cleveland, OH 44106, United States of America. MetroHealth Rehabilitation Institute, MetroHealth Medical Center, Cleveland, OH 44109, United States of America
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44
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Jain S, Deer TR. New Advances in Neuromodulation. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0298-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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45
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Efficiency of Neuromuscular Electrical Stimulation and Transcutaneous Nerve Stimulation on Hemiplegic Shoulder Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil 2018; 99:1730-1739. [DOI: 10.1016/j.apmr.2018.04.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 01/09/2018] [Accepted: 04/18/2018] [Indexed: 11/20/2022]
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46
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Ilfeld BM, Said ET, Finneran JJ, Sztain JF, Abramson WB, Gabriel RA, Khatibi B, Swisher MW, Jaeger P, Covey DC, Robertson CM. Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Femoral Nerve for Postoperative Analgesia Following Ambulatory Anterior Cruciate Ligament Reconstruction: A Proof of Concept Study. Neuromodulation 2018; 22:621-629. [PMID: 30160335 PMCID: PMC6767389 DOI: 10.1111/ner.12851] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/06/2018] [Accepted: 06/19/2018] [Indexed: 01/08/2023]
Abstract
Objectives The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft. Materials and Methods Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double‐masked fashion followed by a 5‐min crossover period, and then continuous active stimulation until lead removal postoperative Day 14–28. Statistics were not applied to the data due to the small sample size of this feasibility study. Results During the initial 5‐min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5‐min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1–3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet. Conclusions This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Outcomes Research consortium, Cleveland, OH, USA
| | - Engy T Said
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - John J Finneran
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Outcomes Research consortium, Cleveland, OH, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Outcomes Research consortium, Cleveland, OH, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Matthew W Swisher
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Outcomes Research consortium, Cleveland, OH, USA
| | - Pia Jaeger
- Outcomes Research consortium, Cleveland, OH, USA.,Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dana C Covey
- Department of Orthopedic Surgery, University of California, San Diego, San Diego, CA, USA
| | - Catherine M Robertson
- Department of Orthopedic Surgery, University of California, San Diego, San Diego, CA, USA
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Ilfeld BM, Ball ST, Gabriel RA, Sztain JF, Monahan AM, Abramson WB, Khatibi B, Said ET, Parekh J, Grant SA, Wongsarnpigoon A, Boggs JW. A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty. Neuromodulation 2018; 22:653-660. [PMID: 30024078 PMCID: PMC6339601 DOI: 10.1111/ner.12790] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/19/2018] [Accepted: 04/09/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA). METHODS For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total. RESULTS In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported. CONCLUSIONS This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Scott T Ball
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Amanda M Monahan
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Jesal Parekh
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Stuart A Grant
- Duke University Medical Center, Duke University, Durham, NC, USA
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Barber B, Seikaly H, Ming Chan K, Beaudry R, Rychlik S, Olson J, Curran M, Dziegielewski P, Biron V, Harris J, McNeely M, O'Connell D. Intraoperative Brief Electrical Stimulation of the Spinal Accessory Nerve (BEST SPIN) for prevention of shoulder dysfunction after oncologic neck dissection: a double-blinded, randomized controlled trial. J Otolaryngol Head Neck Surg 2018; 47:7. [PMID: 29361981 PMCID: PMC5781293 DOI: 10.1186/s40463-017-0244-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 11/30/2017] [Indexed: 12/02/2022] Open
Abstract
Background Shoulder dysfunction is common after neck dissection for head and neck cancer (HNC). Brief electrical stimulation (BES) is a novel technique that has been shown to enhance neuronal regeneration after nerve injury by modulating the brain-derived neurotrophic growth factor (BDNF) pathways. The objective of this study was to evaluate the effect of BES on postoperative shoulder function following oncologic neck dissection. Methods Adult participants with a new diagnosis of HNC undergoing Level IIb +/− V neck dissection were recruited. Those in the treatment group received intraoperative BES applied to the spinal accessory nerve (SAN) after completion of neck dissection for 60 min of continuous 20 Hz stimulation at 3-5 V of 0.1 msec balanced biphasic pulses, while those in the control group received no stimulation (NS). The primary outcome measured was the Constant-Murley Shoulder (CMS) Score, comparing changes from baseline to 12 months post-neck dissection. Secondary outcomes included the change in the Neck Dissection Impairment Index (ΔNDII) score and the change in compound muscle action potential amplitude (ΔCMAP) over the same period. Results Fifty-four patients were randomized to the treatment or control group with a 1:1 allocation scheme. No differences in demographics, tumor characteristics, or neck dissection types were found between groups. Significantly lower ΔCMS scores were observed in the BES group at 12 months, indicating better preservation of shoulder function (p = 0.007). Only four in the BES group compared to 17 patients in the NS groups saw decreases greater than the minimally important clinical difference (MICD) of the CMS (p = 0.023). However, NDII scores (p = 0.089) and CMAP amplitudes (p = 0.067) between the groups did not reach statistical significance at 12 months. BES participants with Level IIb + V neck dissections had significantly better ΔCMS and ΔCMAP scores at 12 months (p = 0.048 and p = 0.025, respectively). Conclusions Application of BES to the SAN may help reduce impaired shoulder function in patients undergoing oncologic neck dissection, and may be considered a viable adjunct to functional rehabilitation therapies. Trial registration Clinicaltrials.gov (NCT02268344, October 17, 2014).
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Affiliation(s)
- Brittany Barber
- Division of Otolaryngology-Head & Neck Surgery, University of Alberta, Edmonton, Canada
| | - Hadi Seikaly
- Division of Otolaryngology-Head & Neck Surgery, University of Alberta, Edmonton, Canada
| | - K Ming Chan
- Department of Physical Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Rhys Beaudry
- Department of Physical Therapy, University of Texas, Arlington, Texas, USA
| | - Shannon Rychlik
- Division of Otolaryngology-Head & Neck Surgery, University of Alberta, Edmonton, Canada
| | - Jaret Olson
- Division of Plastic Surgery, University of Alberta, Edmonton, Canada
| | - Matthew Curran
- Division of Plastic Surgery, University of Alberta, Edmonton, Canada
| | | | - Vincent Biron
- Division of Otolaryngology-Head & Neck Surgery, University of Alberta, Edmonton, Canada
| | - Jeffrey Harris
- Division of Otolaryngology-Head & Neck Surgery, University of Alberta, Edmonton, Canada
| | - Margaret McNeely
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Daniel O'Connell
- Division of Otolaryngology-Head & Neck Surgery, University of Alberta, Edmonton, Canada.
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49
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Gofeld M, Agur A. Peripheral Nerve Stimulation for Chronic Shoulder Pain: A Proof of Concept Anatomy Study. Neuromodulation 2018; 21:284-289. [DOI: 10.1111/ner.12749] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/25/2017] [Accepted: 11/26/2017] [Indexed: 11/27/2022]
Affiliation(s)
| | - Anne Agur
- University of Toronto; Toronto ON Canada
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50
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Boggs JW, Chae J, Bennett ME. Peripheral Nerve Stimulation for Pain Suppression. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00057-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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