Efficacy and safety of tibial nerve stimulation using a wearable device for overactive bladder

OBJECTIVE

To evaluate the efficacy and safety of a wearable, smartphone-controlled, rechargeable transcutaneous tibial nerve stimulation (TTNS) device in patients with overactive bladder (OAB).

PATIENTS AND METHODS

This multicentre, prospective, single-blind, randomised clinical trial included eligible patients with OAB symptoms who were randomly assigned to the stimulation group or sham group. The primary efficacy outcome was change from baseline in voiding frequency/24 h after 4 weeks of treatment. The secondary efficacy outcomes included changes in bladder diary outcomes (urgency score/void, nocturia episodes/day, micturition volume/void, and incontinence episodes/day), questionnaires on Overactive Bladder Symptom Score (OABSS), Patient Perception of Bladder Condition (PPBC), and American Urological Association Symptom Index Quality of Life Score (AUA-SI-QoL) at baseline and after 4 weeks of treatment. Device-related adverse events (AEs) were also evaluated.

RESULTS

In the full analysis set (FAS), the mean (sd) change of voiding frequency/24 h in the stimulation group and sham group at 4 weeks were -3.5 (2.9) and -0.6 (2.4), respectively (P < 0.01). Similar results were obtained in the per-protocol set (PPS): -3.5 (2.9) vs -0.4 (2.3) (P < 0.01). In the FAS and PPS, micturition volume/void significantly improved at 4 weeks (P = 0.01 and P = 0.02). PPBC improvement almost reached significance in the FAS (P = 0.05), while it was significant in the PPS (P = 0.02). In the FAS and PPS, AUA-SI-QoL significantly improved at 4 weeks in the two groups (P < 0.01 and P < 0.01), whereas there were no significant differences in urgency score/void, nocturia episodes/day or OABSS between the groups. Also, no device-related serious AEs were reported.

CONCLUSIONS

The non-invasive neuromodulation technique using the novel ambulatory TTNS device is effective and safe for treating OAB. Its convenience and easy maintenance make it a new potential home-based treatment modality. Future studies are warranted to confirm its longer-term efficacy.

Wireless Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Chemotherapy-Induced Peripheral Neuropathy (CIPN): A Proof-of-Concept Randomized Clinical Trial

Chemotherapy-induced peripheral neuropathy (CIPN) affects approximately 30 to 60% of people who receive neurotoxic chemotherapy. CIPN is associated with impaired quality of life and function and has few effective treatments. This 6-site, subject and assessor-blinded randomized clinical trial (RCT) was designed to assess 1) preliminary efficacy (ie, alpha pre-specified at .2) of a wearable, app-controlled, transcutaneous electrical nerve stimulation (TENS) device for chronic CIPN and 2) feasibility of conducting a confirmatory trial within the National Cancer Institute Community Oncology Research Program (NCORP) (NCT04367480). The primary outcome was the EORTC-CIPN20. The main secondary outcomes were individual symptoms assessed daily (via 0-10 numeric rating scales). The primary analysis was an analysis of covariance (outcome: EORTC-CIPN20, fixed effect: arm, covariates: baseline EORTC-CIPN20 and site). Secondary analyses used a similar analysis of covariance models (excluding site) for each symptom on subgroups of subjects with ≥4 out of 10 for that symptom at baseline. 142 eligible subjects were randomized and received a device; 130 (91%) completed the study. The difference between groups in the EORCT-CIPN20 at the endpoint (placebo-active) was 1.05 (95% Confidence Interval: -.56, 2.67; P = .199). The difference between groups for the individual symptoms was as follows: hot/burning pain: 1.37 (-.33, 3.08; P = .112), sharp/shooting pain: 1.21 (-.37, 2.79; P = .128), cramping: 1.35 (-.32, 3.02; P = .110), tingling: .23 (-.61, 1.08; P = .587), numbness: .27 (-.51, 1.05; P = .492). An RCT of an app-controlled TENS device for chronic CIPN with excellent retention is feasible in the NCORP. Preliminary efficacy evidence suggests that TENS is promising for pain and cramping from CIPN. A confirmatory RCT of TENS for painful CIPN is highly warranted. PERSPECTIVE: Daily, home-based TENS therapy demonstrates promising efficacy for painful CIPN symptoms in this proof-of-concept randomized clinical trial. Future confirmatory trial is warranted.

Output of Electronic Muscle Stimulators: Physical Therapy and Police Models Compared

INTRODUCTION

Both physical therapists and police officers use electrical muscle stimulation. The typical physical therapist unit is attached with adhesive patches while the police models use needle-based electrodes to penetrate clothing. There have been very few papers describing the outputs of these physical therapy EMS (electrical muscle stimulator) units.

METHODS

We purchased 6 TENS/EMS units at retail and tested them with loads of 500 Ω, 2 kΩ, and 10 kΩ.

RESULTS

For the typical impedance of 500 Ω, the EMS units delivered the most current followed by the electrical weapons; TENS units delivered the least current. At higher im-pedances (> 2 kΩ) the electrical weapons delivered more current than the EMS units, which is explained by the higher voltage-compliance of their circuits. Some multi channel EMS units deliver more calculated muscle stimula tion than the multi-channel weapons.

CONCLUSION

Present therapeutic electrical muscle stimula-tors can deliver more current than present law-enforcement muscle stimulators.

Stretchable, Fully Polymeric Electrode Arrays for Peripheral Nerve Stimulation

There is a critical need to transition research level flexible polymer bioelectronics toward the clinic by demonstrating both reliability in fabrication and stable device performance. Conductive elastomers (CEs) are composites of conductive polymers in elastomeric matrices that provide both flexibility and enhanced electrochemical properties compared to conventional metallic electrodes. This work focuses on the development of nerve cuff devices and the assessment of the device functionality at each development stage, from CE material to fully polymeric electrode arrays. Two device types are fabricated by laser machining of a thick and thin CE sheet variant on an insulative polydimethylsiloxane substrate and lamination into tubing to produce pre-curled cuffs. Device performance and stability following sterilization and mechanical loading are compared to a state-of-the-art stretchable metallic nerve cuff. The CE cuffs are found to be electrically and mechanically stable with improved charge transfer properties compared to the commercial cuff. All devices are applied to an ex vivo whole sciatic nerve and shown to be functional, with the CE cuffs demonstrating superior charge transfer and electrochemical safety in the biological environment.

Noninvasive Neuroprosthesis Promotes Cardiovascular Recovery After Spinal Cord Injury

Spinal cord injury (SCI) leads to severe impairment in cardiovascular control, commonly manifested as a rapid, uncontrolled rise in blood pressure triggered by peripheral stimuli-a condition called autonomic dysreflexia. The objective was to demonstrate the translational potential of noninvasive transcutaneous stimulation (TCS) in mitigating autonomic dysreflexia following SCI, using pre-clinical evidence and a clinical case report. In rats with SCI, we show that TCS not only prevents the instigation of autonomic dysreflexia, but also mitigates its severity when delivered during an already-triggered episode. Furthermore, when TCS was delivered as a multisession therapy for 6 weeks post-SCI, the severity of autonomic dysreflexia was significantly reduced when tested in the absence of concurrent TCS. This treatment effect persisted for at least 1 week after the end of therapy. More importantly, we demonstrate the clinical applicability of TCS in treatment of autonomic dysreflexia in an individual with cervical, motor-complete, chronic SCI. We anticipate that TCS will offer significant therapeutic advantages, such as obviating the need for surgery resulting in reduced risk and medical expenses. Furthermore, this study provides a framework for testing the potential of TCS in improving recovery of other autonomic functions such lower urinary tract, bowel, and sexual dysfunction following SCI.

Long-Term Non Anesthetic Preclinical Study Available Extra-Cranial Brain Activator (ECBA) System for the Future Minimally Invasive Human Neuro Modulation

In recent years, electroceuticals have been spotlighted as an emerging treatment for various severe chronic brain diseases, owing to their intrinsic advantage of electrical interaction with the brain, which is the most electrically active organ. However, the majority of research has verified only the short-term efficacy through acute studies in laboratory tests owing to the lack of a reliable miniaturized platform for long-term animal studies. The construction of a sufficient integrated system for such a platform is extremely difficult because it requires multi-disciplinary work using state-of-the-art technologies in a wide range of fields. In this study, we propose a complete system of an implantable platform for long-term preclinical brain studies. Our proposed system, the extra-cranial brain activator (ECBA), consists of a titanium-packaged implantable module and a helmet-type base station that powers the module wirelessly. The ECBA can also be controlled by a remote handheld device. Using the ECBA, we performed a long-term non-anesthetic study with multiple canine subjects, and the resulting PET-CT scans demonstrated remarkable enhancement in brain activity relating to memory and sensory skills. Furthermore, the histological analysis and high-temperature aging test confirmed the reliability of the system for up to 31 months. Hence, the proposed ECBA system is expected to lead a new paradigm of human neuromodulation studies in the near future.

Design and Implementation of an Intelligent Analgesic Bracelet Based on Wrist-ankle Acupuncture

A flexible, multifunctional, and intelligent analgesic bracelet was proposed in this article to alleviate symptoms of pain. Based on the theory of wrist-ankle acupuncture in traditional Chinese medicine, transcutaneous electrical nerve stimulation is the technical basis of the method. A set of targeted circuit system capable of generating adjustable electrical stimulation signals to simulate filamentary acupuncture was designed. The system architecture includes a wireless communication module, a signal control module, a stimulus signal generation module, and a wearable, flexible bracelet. In addition, a pain assessment interface with a visual analog scale was designed to assess pain levels. Two comparative experiments were designed, involving a custom pain assessment scale and hand-held dolorimeter that were performed before and after wearing the bracelet to verify the analgesic effect of the bracelet. The results showed that the wrist-worn analgesic bracelet is significantly effective in alleviating pain in various parts of the human body.

Update on noninvasive neuromodulation for migraine treatment-Vagus nerve stimulation

Noninvasive neurostimulation methods are particularly suited for migraine treatment thanks to their most favorable adverse event profile. Among them, noninvasive vagus nerve stimulation (nVNS) has raised great hope because of the role the vagus nerve is known to play in pain modulation, inflammation and brain excitability. We will critically review the clinical studies performed for migraine attack treatment and migraine prevention with the GammaCore® device, which allows cervical vagus nerve stimulation. nVNS is effective for the abortive treatment of migraine attacks, although the effect size is modest and numbers-to-treat appear not superior to those of other noninvasive neurostimulation methods, and inferior to those of oral triptans. The effect of nVNS with the GammaCore® in migraine prevention is not superior to sham stimulation, except possibly in patients with high adherence to the treatment. Both in acute and preventive trials, nVNS was characterized by an outstanding tolerance and safety profile, like the other noninvasive neurostimulation techniques. In physiological animal and human studies, cervical nVNS was shown to generate somatosensory evoked responses, to modulate pain perception and several areas of the cerebral pain network, and to inhibit experimental cortical spreading depression, which are relevant effects for migraine therapy.

A Wide Dynamic Range Neural Data Acquisition System With High-Precision Delta-Sigma ADC and On-Chip EC-PC Spike Processor

A high-performance, wide dynamic range, fully-integrated neural interface is one key component for many advanced bidirectional neuromodulation technologies. In this paper, to complement the previously proposed frequency-shaping amplifier (FSA) and high-precision electrical microstimulator, we will present a proof-of-concept design of a neural data acquisition (DAQ) system that includes a 15-bit, low-power Delta-Sigma analog-to-digital converter (ADC) and a real-time spike processor based on one exponential component-polynomial component (EC-PC) algorithm. High-precision data conversion with low power consumption and small chip area is achieved by employing several techniques, such as opamp-sharing, multi-bit successive approximation (SAR) quantizer, two-step summation, and ultra-low distortion data weighted averaging (DWA). The on-chip EC-PC engine enables low latency, automatic detection, and extraction of spiking activities, thus supporting closed-loop control, real-time data compression and /or neural information decoding. The prototype chip was fabricated in a 0.13  μm CMOS process and verified in both bench-top and In-Vivo experiments. Bench-top measurement results indicate the designed ADC achieves a peak signal-to-noise and distortion ratio (SNDR) of 91.8 dB and a dynamic range of 93.0 dB over a 10 kHz bandwidth, where the total power consumption of the modulator is only 20  μW at 1.0 V supply, corresponding to a figure-of-merit (FOM) of 31.4fJ /conversion-step. In In-Vivo experiments, the proposed DAQ system has been demonstrated to obtain high-quality neural activities from a rat's motor cortex and also greatly reduce recovery time from system saturation due to electrical microstimulation.

Flexible Body-Conformal Ultrasound Patches for Image-Guided Neuromodulation

The paper presents the design and validation of body-conformal active ultrasound patches with integrated imaging and modulation modalities for image-guided neural therapy. A mechanically-flexible linear 64-element array of piezoelectric transducers with a resonance frequency of 5 MHz was designed for nerve localization. A second 8-element array using larger elements was integrated on the wearable probe for low intensity focused ultrasound neuromodulation at a resonance frequency of 1.3 MHz. Full-wave simulations were used to model the flexible arrays and estimate their generated pressure profiles. A focal depth of 10-20 mm was assumed for beamforming and focusing to support modulation of the vagus, tibial, and other nerves. A strain sensor integrated on the probe provides patient-specific feedback information on array curvature for real-time optimization of focusing and image processing. Each patch also includes high voltage (HV) multiplexers, transmit/receive switches, and pre-amplifiers that simplify connectivity and also improve the signal-to-noise ratio (SNR) of the received echo signals by  ∼ 5 dB. Experimental results from a flexible prototype show a sensitivity of 80 kPa/V with  ∼ 3 MHz bandwidth for the modulation and 20 kPa/V with  ∼ 6 MHz bandwidth for the imaging array. An algorithm for accurate and automatic localization of targeted nerves based on using nearby blood vessels (e.g., the carotid artery) as image markers is also presented.

Combined effect of laser acupuncture and electroacupuncture in knee osteoarthritis patients: A protocol for a randomized controlled trial

BACKGROUND

Knee osteoarthritis (KOA) is a common degenerative joint disorder that affects 250 million people globally. KOA can lead to disability and is often associated with cardiovascular disease, poor quality of life, and mortality. The most common treatment for KOA is non-steroidal anti-inflammatory drug administration. However, the analgesic effect is limited and often accompanied by multiple side effects. Hence, many KOA patients opt for complementary and alternative medicine. Acupuncture is one of the most popular complementary treatments with great analgesic effect and minimal side effect. Electroacupuncture (EA) and laser acupuncture (LA) have been known to reduce pain in KOA patients. However, to date, no study has assessed the benefits of combining these two therapies.

METHODS

Fifty participants diagnosed with KOA, aged 50 years or older, and with consistent knee pain for more than 3 months were recruited and randomly assigned to the treatment group (EA plus LA) or control group (EA plus sham LA without laser output). All subjects in the treatment group will undergo a combined EA and LA treatment thrice a week for 4 weeks. The acupuncture will be performed on GB33, GB34, SP9, SP10, and ST36 sites. The treatment group will receive acupuncture with a transcutaneous electrical nerve stimulator at GB33, GB34, SP9, and SP10 sites and with LA at EX-LE5, ST35, and BL40 sites. The subjects in the control group will undergo the same treatment modality as the treatment group, except these subjects will not be exposed to laser output. Outcome measurements will include visual analog scale, Western Ontario McMaster Universities Osteoarthritis Index, Knee injury and osteoarthritis outcome, body composition analysis, knee range of motion, quadriceps muscle stiffness, one-leg standing with eyes open test, and the 30-s chair stand test before and after 4 weeks of intervention.

OBJECTIVES

This protocol aims to investigate the combined effect of EA and LA in KOA patients.

Different electrode positioning for transcutaneous electrical nerve stimulation in the treatment of urgency in women: a study protocol for a randomized controlled clinical trial

BACKGROUND

Urgency is a complaint of sudden, compelling desire to pass urine, which is difficult to defer, caused by involuntary contraction of the detrusor muscle during the bladder-filling stage. To enable detrusor inhibition, electrotherapy resources such as transcutaneous tibial nerve stimulation (TTNS) and parasacral transcutaneous electrical stimulation (PTES) have been used. The objective this study is to publish the study protocol that aims to investigate whether urgency decreases after treatment with both of the techniques.

METHODS

This randomized controlled clinical trial will include 99 women, aged more than 18 years old, with urgency (score ≥ 8 in the Overactive Bladder-Validated 8-Question Awareness Tool [OAB-V8]). Women will be randomly allocated into three groups: TTNS, PTES, and placebo. The following questionnaires will be applied: the Anamnesis Record, the Incontinence Questionnaire Overactive Bladder, the King's Health Questionnaire, the 24-Hour Voiding Diary, and the OAB-V8, at four different time points: at baseline prior to the first session, at the 6th session, the 12th session and at follow-up. The current used for the transcutaneous electrical stimulation will be a symmetrical balanced biphasic pulsed current, for 12 sessions, twice a week, for 20 minutes. Qualitative variables will be displayed as frequency and percentage, quantitative variables as mean and standard deviation. Comparison of urgency severity among groups will be performed with a repeated measures ANOVA, considering the effect of the three groups and the four evaluations, and interactions among them.

DISCUSSION

The present study aims to contribute evidence for a more in-depth discussion on electrode positioning for electrostimulation used in urgency treatment. It should be emphasized that, based on the possibility of confirming the hypothesis that urgency will decrease in a similar way after both treatments (TTNS and PTES), the PTES will be used as an option for positioning the electrodes alternatively to the tibial nerve region in special populations, such as amputees or people with severe lower limb sensory impairment.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC) ID: RBR-9rf33n, date of registration: 17 May 2018.

New Technologies and Applications in Sacral Neuromodulation: An Update

Recently rechargeable devices have been introduced for sacral neuromodulation (SNM) with conditional safety for full-body magnetic resonance imaging (MRI). Currently a recharge-free SNM device represents the standard implant; however, it is only approved for MRI head scans. As further new technologies with broader MRI capabilities are emerging, the advantages as well as disadvantages of both rechargeable versus recharge-free devices will be briefly discussed in this commentary from the perspective of patients, healthcare professionals, and providers.

Effects of transcutaneous electrical nervous stimulation (TENS) associated with vocal therapy on musculoskeletal pain of women with behavioral dysphonia: A randomized, placebo-controlled double-blind clinical trial

Recently, electrical stimulation in vocal rehabilitation has been the subject of studies. This treatment has shown promising results regarding the decrease of vocal/laryngeal symptoms, pain and the improvement of vocal tension. In addition to decreasing pain symptoms, TENS treatments may lead to muscle relaxation. There is no data on the effects of this resource as a vocal therapy in women with behavioral dysphonia. Research in this area may provide evidence to assist the clinical decision related to the treatment of women with complaints of behavioral dysphonia and musculoskeletal pain.

OBJECTIVE

To verify the effects of low-frequency TENS in association with vocal therapy on musculoskeletal pain in women with behavioral dysphonia.

METHODS

Participants included 27 women with vocal nodules randomized into two groups. The experimental group (EG) - 13 women received 12 sessions of TENS (pulse of 200 μs, frequency at 10 Hz, in motor threshold) with electrodes placed bilaterally on the trapezius muscle and submandibular area for 20 min followed by 30 min of vocal therapy, and the control group (CG) - 14 women received 12 sessions of 20 min of a placebo TENS followed by 30 min of vocal therapy. We investigated the frequency and intensity of the musculoskeletal pain in several body regions, as well as the intensity of pain at rest and in the application of pressure with an algometer applied to the descending fibers of the trapezius muscle. The pressure-pain threshold (PPT) was also investigated. All evaluations occurred before, immediately after, and at one and three months after treatment in both groups.

RESULTS

We observed a reduction in the frequency of pain in the larynx after treatment of both groups, but only the EG showed a decrease in pain intensity in this region. It was verified with an algometer to the trapezius muscle that the electrical stimulation associated with the vocal therapy decreased the intensity of pain during the application of pressure and increased the PPT. There were no significant differences with regard to variables investigated in the comparison between the interventions. On the other hand, there was decreased pain in the trapezius muscle for the EG in comparison to the pre- and post-intervention.

CONCLUSION

The vocal therapyprogram reduced the frequency and intensity of the musculoskeletal pain in the regions proximal to the larynx of women with behavioral dysphonia. In addition, TENS followed by vocal therapy increased the threshold of sensitivity to muscular pain in the trapezius, demonstrating that it is a good resource to use in conjunction with traditional vocal therapy in cases of behavioral dysphonia associated with pain and muscle tension.

[Neuromodulation of lower urinary tract dysfunction]

Neuromodulative procedures such as transcutaneous electrical nerve stimulation (TENS), transcutaneous/percutaneous tibial nerve stimulation (TTNS/PTNS), and sacral neuromodulation (SNM) are promising second-line treatments for refractory lower urinary tract dysfunction. Using these therapies, both storage and voiding disorders but also bowel dysfunction might be successfully treated. Although the mechanism of action of neuromodulation is not well understood, it seems to involve modulation of spinal cord reflexes and brain networks by peripheral afferents (genital/rectal, tibial and sacral afferents in the case of TENS, TTNS/PTNS, and SNM, respectively). Neuromodulative procedures might also be highly effective in the most desperate situations and further relevant developments are expected so that these innovative techniques will most likely become even more important in urology.

Medical Devices; Neurological Devices; Classification of the Thermal Vestibular Stimulator for Headache. Final order

The Food and Drug Administration (FDA or we) is classifying the thermal vestibular stimulator for headache into class II (special controls). The special controls that apply to the device type are identified in this order and will be part of the codified language for the thermal vestibular stimulator for headache's classification. We are taking this action because we have determined that classifying the device into class II (special controls) will provide a reasonable assurance of safety and effectiveness of the device. We believe this action will also enhance patients' access to beneficial innovative devices, in part by reducing regulatory burdens.

Overcoming the Challenges of Experimental Research: Lessons From a Criminal Justice Case Study Involving TASER Exposure

OBJECTIVE

To provide guidance to criminologists for conducting experiments in light of two common discouraging factors: the belief that they are overly time-consuming and the belief that they can compromise the ethical principles of human subjects' research.

METHOD

A case study approach is used, based on a large-scale randomized controlled trial experiment in which we exposed participants to a 5-s TASER shock, to describe how the authors overcame ethical, methodological, and logistical difficulties.

RESULTS

We derive four pieces of advice from our experiences carrying out this experimental trial: (1) know your limitations, (2) employ pilot testing, (3) remain flexible and patient, and (4) "hold the line" to maintain the integrity of the research and the safety of human subjects.

CONCLUSIONS

Criminologists have an obligation to provide the best possible evidence regarding the impact and consequences of criminal justice practices and programs. Experiments, considered by many to be the gold standard of empirical research methodologies, should be used whenever possible in order to fulfill this obligation.

Effectiveness of percutaneous neuromuscular electrical stimulation for neck pain relief in patients with cervical spondylosis

BACKGROUND

This study aimed to evaluate the effectiveness and safety of percutaneous neuromuscular electrical stimulation (PNMES) for treating neck pain in patients with cervical spondylosis (CS).

METHODS

One hundred and twenty four patients with neck pain of CS were included, and then they were randomly divided into a PNMES group and a control group in a ratio of 1:1. All patients received PNMES or sham PNMES 30 minutes daily, 3 times weekly for 12 weeks. The primary outcome was assessed by the visual analog scale (VAS). The secondary outcomes were evaluated by the cervical range of motion (ROM), neck disability index (NDI) score, as well as the adverse events (AEs). All outcome measurements were measured at the end of 12-week treatment, and 4-week follow-up after treatment.

RESULTS

At the end of the 12-week treatment, and 4-week follow-up, the patients receiving PNMES exhibited more decrease in the mean VAS (P < .01), and NDI (P < .01) respectively, compared with the patients receiving sham PNMES. Additionally, the increase in the mean ROM was also significantly higher in the PNMES group than that in the sham PNMES group at the end of the 12-week treatment, and 4-week follow-up, respectively (P < .01). No AEs were found in either group.

CONCLUSIONS

The results of this study demonstrated that PNMES is more effective than Sham PNMES for neck pain relief in patients with CS.

Medical Devices; Neurological Devices; Classification of the Percutaneous Nerve Stimulator for Substance Use Disorders. Final order

The Food and Drug Administration (FDA or we) is classifying the percutaneous nerve stimulator for substance use disorders into class II (special controls). The special controls that apply to the device type are identified in this order and will be part of the codified language for the percutaneous nerve stimulator for substance use disorders' classification. We are taking this action because we have determined that classifying the device into class II (special controls) will provide a reasonable assurance of safety and effectiveness of the device. We believe this action will also enhance patients' access to beneficial innovative devices, in part by reducing regulatory burdens.

Transcutaneous electrical nerve stimulator of 5000 Hz frequency provides better analgesia than that of 100 Hz frequency in mice muscle pain model

Transcutaneous electrical nerve stimulators (TENSs) have been proved to be effective in muscle pain management for several decades. However, there is no consensus for the optimal TENS program. Previous research demonstrated that a 100 Hz TENS (L-TENS) provided better analgesia than a conventional TENS (< 5 Hz). However, no research compared a higher-frequency (> 100 Hz) TENS with a 100 Hz TENS. We used a 5000 Hz (5 kHz) frequency TENS (M-TENS) and an L-TENS to compare analgesic effect on a mice skin/muscle incision retraction model. Three groups of mice were used (sham, L-TENS, and M-TENS) and applied with different TENS programs on Day 4 after the mice skin/muscle incision retraction model; TENS therapy was continued as 20 min/d for 3 days. Mice analgesic effects were measured via Von Frey microfilaments with the up-down method. After therapy, mice spinal cord dorsal horn and dorsal root ganglion (DRG) were harvested for cytokine evaluation (tumor necrosis factor-α and interleukin-1β) with the Western blotting method. Our data demonstrated that the M-TENS produced better analgesia than the L-TENS. Cytokine in the spinal cord or DRG all expressed lower than that of the sham group. However, there is no difference in both cytokine levels between TENSs of different frequencies in the spinal cord and DRG. We concluded that the M-TENS produced faster and better mechanical analgesia than the L-TENS in the mice skin/muscle incision retraction model. Those behavior differences were not in accordance with cytokine changes in the spinal cord or DRG.

Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature

OBJECTIVE

Spinal cord and peripheral neurostimulation techniques have been practiced since 1967 for the relief of pain, and some techniques are also used for improvement in organ function. Neuromodulation has recognized complications, although very rarely do these cause long-term morbidity. The aim of this article is to present a review of complications observed in patients treated with neurostimulation techniques.

METHODS

A review of the major recent publications in the literature on the subjects of spinal cord, occipital, sacral, and peripheral nerve field stimulation was conducted.

RESULTS

The incidence of complications reported varies from 30% to 40% of patients affected by one or more complications. Adverse events can be subdivided into hardware-related complications and biological complications. The commonest hardware-related complication is lead migration. Other lead related complications such as failure or fracture have also been reported. Common biological complications include infection and pain over the implant. Serious biological complications such as dural puncture headache and neurological damage are rarely observed.

CONCLUSIONS

Spinal cord and peripheral neurostimulation techniques are safe and reversible therapies. Hardware-related complications are more commonly observed than biological complications. Serious adverse events such as neurological damage are rare.

Acupuncture and PC6 stimulation for the prevention of postoperative nausea and vomiting in patients undergoing elective laparoscopic resection of colorectal cancer: a study protocol for a three-arm randomised pilot trial

INTRODUCTION

This study aims to assess the feasibility of acupuncture and a Pericardium 6 (PC6) wristband as an add-on intervention of antiemetic medication for the prevention of postoperative nausea and vomiting (PONV) in patients undergoing elective laparoscopic colorectal cancer resection.

METHODS AND ANALYSIS

A total of 60 participants who are scheduled to undergo elective laparoscopic resection of colorectal cancer will be recruited. An enhanced recovery after surgery protocol using standardised antiemetic medication will be provided for all participants. Participants will be equally randomised into acupuncture plus PC6 wristband (Acupuncture), PC6 wristband alone (Wristband), or no acupuncture or wristband (Control) groups using computer-generated random numbers concealed in opaque, sealed, sequentially numbered envelopes. For the acupuncture combined with PC6 wristband group, the embedded auricular acupuncture technique for preoperative anxiolysis and up to three sessions of acupuncture treatments with manual and electrical stimulation within 48 hours after surgery will be provided by qualified Korean medicine doctors. The PC6 wristband will be applied in the Acupuncture and Wristband groups, beginning 1 hour before surgery and lasting 48 hours postoperatively. The primary outcome will be the number of participants who experience moderate or severe nausea, defined as nausea at least 4 out of 10 on a severity numeric rating scale or vomiting at 24 hours after surgery. Secondary outcomes, including symptom severity, participant global assessments and satisfaction, quality of life, physiological recovery, use of medication and length of hospital stay, will be assessed. Adverse events and postoperative complications will be measured for 1 month after surgery.

ETHICS AND DISSEMINATION

All participants will provide written informed consent. The study has been approved by the institutional review board (IRB). This pilot trial will inform a full-scale randomised trial of acupuncture combined with PC6 stimulation for the prevention of PONV in patients undergoing elective laparoscopic colorectal cancer surgery.

TRIAL REGISTRATION NUMBER

NCT02509143.

[Not Available]

Zusammenfassung. Die überaktive Harnblase ist definiert durch einen imperativen Harndrang mit oder ohne Drang-Inkontinenz und ist meist assoziiert mit einer Pollakisurie am Tag und in der Nacht, ohne dass ein Harnwegsinfekt oder eine andere offensichtliche Pathologie zugrunde liegt. Die Prävalenz der überaktiven Harnblase beträgt ab dem 40sten Lebensjahr ca. 17% und nimmt mit steigendem Alter zu. Die damit verbundenen Gesundheitskosten sind enorm. Meist ist die Lebensqualität erheblich eingeschränkt und oft führt die Standard-Therapie mit Antimuskarinika/Beta3-Adrenozeptor-Agonisten zu keiner relevanten Beschwerdebesserung. Doch es gibt neue therapeutische Möglichkeiten: Mit neuromodulativen Verfahren (wie der transkutanen elektrischen Nervenstimulation, der transkutanen oder perkutanen tibialen Nervenstimulation oder der sakralen Neuromodulation) oder Onabotulinumtoxin A-Injektionen in den Detrusor kann auch in aussichtslos scheinenden Situationen oft eine erstaunliche Wirkung erzielt werden.

Auto-Targeted Neurostimulation Is Not Superior to Placebo in Chronic Low Back Pain: A Fourfold Blind Randomized Clinical Trial

BACKGROUND

Myofascial trigger points (MTrPs) are common in people with musculoskeletal pain and may play a role in chronic nonspecific low back pain (CLBP). One of the potential treatments of MTrPs is the Nervomatrix Soleve® auto-targeted neurostimulation device, providing targeted transcutaneous electrical nerve stimulation (TENS) to MTrPs in the lower back muscles. To date, no controlled studies have evaluated the effectiveness of this device for the pain management of this population.

OBJECTIVE

To examine whether the Nervomatrix Soleve® auto-targeted neurostimulation device is superior over placebo for the treatment of CLBP.

STUDY DESIGN

A fourfold-blind randomized controlled trial was conducted.

SETTING

Brussels University Hospital, health care centers and pharmacies around Belgium.

METHODS

Participants with CLBP for at least 3 months were randomly assigned to the experimental (the Nervomatrix Soleve® auto-targeted neurostimulation device providing TENS-stimulation and mechanical pressure) or placebo group (the Nervomatrix Soleve® auto-targeted neurostimulation device providing mechanical pressure alone without current). The treatment protocol in both groups consisted of 6 treatment sessions per patient. Participants were evaluated at baseline prior to the intervention, immediately following treatment, and at one month follow-up. Pain and pain behavior (steps climbed) were assessed as primary outcome measures. Secondary outcome measures were pain functioning, health beliefs, symptoms of central sensitization, pain catastrophizing, and kinesiophobia.

RESULTS

In total, 39 participants were included in the study. Participants in both groups improved significantly for pain and functioning, but no significant differences were observed between groups. These improvements were not clinically meaningful for any of the reported measures. The health beliefs changed significantly in both groups (P < 0.05), with superior results at follow-up in the placebo group.

LIMITATIONS

The follow-up period is limited to one month.

CONCLUSIONS

Treatment of MTrPs with the Nervomatrix Soleve® auto-targeted neurostimulation device in patients with CLBP does not result in a better outcome than placebo-treatment in terms of pain, pain behavior, functioning, central sensitization, pain catastrophizing, and health beliefs.

A Multicenter Trial of a Footdrop Stimulator Controlled by a Tilt Sensor

Objectives. To test the efficacy and acceptance of a footdrop stimulator controlled by a tilt sensor. Methods. A nonrandomized, test-retest study of 26 subjects with footdrop of more than 1 year’s duration, resulting from various central nervous system disorders, was performed in 4 centers for at least 3 months. Speed of walking in a straight line, speed around a figure of 8, and physiological cost index (PCI) were measured with and without the device. Hours/day and steps/day using the device were recorded. Results.All but 2 subjects used the tilt sensor at home, rather than a foot switch. Walking speed increased by 15% after 3 months ( n = 26; P < 0.01), 32% after 6 months ( n = 16; P < 0.01), and 47% after 12 months ( n = 8; P < 0.05), while PCI decreased. The number of steps taken per day of use increased significantly over time, and increased speed was directly correlated with usage. Walking speed also increased with the stimulator off, but to a lesser extent, indicating a training effect. Subject feedback from a questionnaire indicated satisfaction with the stimulator. Conclusions. Both efficacy and acceptance of the stimulator were good in a population of subjects with chronic footdrop.

Minimizing Stimulus Current in a Wearable Pudendal Nerve Stimulator Using Computational Models

After spinal cord injury, functions of the lower urinary tract may be disrupted. A wearable device with surface electrodes which can effectively control the bladder functions would be highly beneficial to the patients. A trans-rectal pudendal nerve stimulator may provide such a solution. However, the major limiting factor in such a stimulator is the high level of current it requires to recruit the nerve fibers. Also, the variability of the trajectory of the nerve in different individuals should be considered. Using computational models and an approximate trajectory of the nerve derived from an MRI study, it is demonstrated in this paper that it may be possible to considerably reduce the required current levels for trans-rectal stimulation of the pudendal nerve compared to the values previously reported in the literature. This was corroborated by considering an ensemble of possible and probable variations of the trajectory. The outcome of this study suggests that trans-rectal stimulation of the pudendal nerve is a plausible long term solution for treating lower urinary tract dysfunctions after spinal cord injury.

Technology for Peripheral Nerve Stimulation

Peripheral nerve stimulation (PNS) has been in use for over 50 years to treat patients suffering from chronic pain who have failed conservative treatments. Despite this long history, the devices being used have changed very little. In fact, current PNS technology was developed specifically for spinal cord stimulation. The use of technology developed for other applications in PNS has led to an unnecessary number of device complications and the limited adoption of this promising therapy. The following chapter provides an overview of PNS technology throughout the years, outlining both the benefits and limitations. We will briefly explore the electrophysiology of PNS stimulation, with an emphasis on technology and indication-specific devices. Finally, design and technical requirements of an ideal PNS device will be discussed.

Management of pain secondary to temporomandibular joint syndrome with peripheral nerve stimulation

BACKGROUND

Temporomandibular joint syndrome, or Costen syndrome, is a clinically diagnosed disorder whose most common symptoms include joint pain and clicking, difficulty opening the mouth, and temporomandibular joint discomfort. The temporomandibular joint (TMJ) is supplied by the auriculotemporal nerve, a collateral branch of the mandibular nerve (the V3 branch of the trigeminal nerve).

OBJECTIVES

The aim of this study is to assess the effectiveness and safety of permanent peripheral nerve stimulation to relieve TMJ pain.

STUDY DESIGN

This case series is a prospective study.

SETTING

Pain Unit of a regional universitary hospital.

METHODS

The study included 6 female patients with temporomandibular pain lasting from 2 to 8 years that did not respond to intraarticular local anesthetic and corticoid injections. After a positive diagnostic block test, the patients were implanted with quadripolar or octapolar leads in the affected preauricular region for a 2-week stimulation test phase, after which the leads were connected to a permanent implanted pulse generator. Results of the visual analog scale, SF-12 Health Survey, Brief Pain Inventory, and drug intake were recorded at baseline and at 4, 12, and 24 weeks after the permanent implant.

RESULTS

Five out of 6 patients experienced pain relief exceeding 80% (average 72%) and received a permanent implant. The SF-12 Health Survey results were very positive for all specific questions, especially items concerning the physical component. Patients reported returning to normal physical activity and rest at night. Four patients discontinued their analgesic medication and 1 patient reduced their gabapentin dose by 50%.

LIMITATIONS

Sample size; impossibility of placebo control.

CONCLUSION

Patients affected with TMJ syndrome who do not respond to conservative treatments may find a solution in peripheral nerve stimulation, a simple technique with a relatively low level of complications.

Decreased low back pain intensity and differential gene expression following Calmare®: results from a double-blinded randomized sham-controlled study

In this double-blinded, randomized controlled trial we evaluated the effects of Calmare®, a non-invasive neurocutaneous electrical pain intervention, on lower back pain intensity as measured by the "worst" pain score and on pain interference using the Brief Pain Inventory-Short Form, on measures of pain sensitivity assessed by quantitative sensory testing, and on mRNA expression of pain sensitivity genes. Thirty participants were randomized to receive up to 10 sessions of Calmare® treatment (n = 15) or a sham treatment (n = 15) using the same device at a non-therapeutic threshold. At 3 weeks after conclusion of treatment, compared with the sham group, the Calmare® group reported a significant decrease in the "worst" pain and interference scores. There were also significant differences in pain sensitivity and differential mRNA expression of 17 pain genes, suggesting that Calmare® can be effective in reducing pain intensity and interference in individuals with persistent low back pain by altering the mechanisms of enhanced pain sensitivity. Further study of long-term pain outcomes, particularly functional status, analgesic use and health care utilization, is warranted.

Medical devices; neurological devices; classification of the transcutaneous electrical nerve stimulator to treat headache. Final order

The Food and Drug Administration (FDA) is classifying the transcutaneous electrical nerve stimulator to treat headache into class II (special controls). The special controls that will apply to the device are identified in this order, and will be part of the codified language for the transcutaneous electrical nerve stimulator to treat headache classification. The Agency is classifying the device into class II (special controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

Percutaneous tibial nerve stimulation: the Urgent PC®device

Lower urinary tract disorders, with its main representative the overactive bladder, are an increasing problem that impact patients' quality of life tremendously. Neuromodulative treatment may fill the gap between conservative measures and invasive surgery. Percutaneous tibial nerve stimulation (Urgent PC) is a neuromodulation technique that is minimally invasive and easy to perform. Stimulation is carried out in 12 weekly sessions of 30 min each, through a percutaneously placed needle cephalad to the medial malleolus. Success can be obtained in approximately two-thirds of patients, but the therapy has the disadvantage of the necessity of maintenance therapy. The development of a small implantable device may be the future next step in the evolution of the technique.

Electrical stimulation with non-implanted electrodes for urinary incontinence in men

BACKGROUND

Electrical stimulation with non-implanted devices is used for patients with different types of urinary incontinence and symptoms of urgency, frequency and nocturia. The current review focused on electrical stimulation with non-implanted devices for the treatment of urinary incontinence in men.

OBJECTIVES

To determine the effectiveness of electrical stimulation with non-implanted devices for men with stress, urgency or mixed urinary incontinence in comparison with no treatment, placebo treatment, or any other 'single' treatment. Additionally, the effectiveness of electrical stimulation with non-implanted devices in combination with another intervention was compared with the other intervention alone. Finally, the effectiveness of one method of electrical stimulation with non-implanted devices was compared with another method.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PreMEDLINE, and handsearching of journals and conference proceedings (searched 21 January 2012). We also searched other electronic and non-electronic bibliographic databases and the reference lists of the included studies as well as contacting researchers in the field to identify other relevant trials.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all the identified trials for eligibility. Risk of bias was assessed using the Cochrane tool for determining bias. Disagreements were resolved by discussion, and a third review author was involved in the case of no consensus. Data were analysed using Cochrane methods.

MAIN RESULTS

Six randomized controlled trials (five full papers and one abstract) were included. There was considerable variation in the interventions used, study protocols, types of electrical stimulation parameters and devices, study populations and outcome measures. In total 544 men were included, of whom 305 received some form of electrical stimulation, and 239 a control or comparator treatment. The trials were mostly small and generally there was not sufficient information to assess risk of bias; only two trials used secure methods of randomization.There was some evidence that electrical stimulation (ES) had a short-term effect in reducing incontinence compared with sham treatment (for example risk ratio (RR) at six months 0.38, 95% CI 0.16 to 0.87) but not at 12 months. Four trials evaluated the effect of adding PFMT to ES versus pelvic floor muscle training (PFMT) alone or with biofeedback. There was no evidence of a statistically significant difference in the number of men with urinary incontinence at three months (146/239, 61% for combined treatment versus 98/156, 63% with PFMT alone; RR 0.93, 95% CI 0.82 to 1.06). However, there were more adverse effects with combined treatment (23/139, 17% versus 2/99, 2% with PFMT alone; RR 7.04, 95% CI 1.51 to 32.94) and quality of life also seemed better with PFMT alone. One small trial did not detect statistically significant differences between two methods of administration of transcutaneous electrical stimulation (anal versus perineal) but the quality of life score was lower (better) in the anal stimulation group.

AUTHORS' CONCLUSIONS

There was some evidence that electrical stimulation enhanced the effect of PFMT in the short term but not after six months. There were, however, more adverse effects (pain or discomfort) with electrical stimulation.

Flexible charge balanced stimulator with 5.6 fC accuracy for 140 nC injections

Electrical stimulations of neuronal structures must ensure net injected charges to be zero for biological safety and voltage compliance reasons. We present a novel architecture of general purpose biphasic constant current stimulator that exhibits less than 5.6 fC error while injecting 140 nC charges using 1.4 mA currents. The floating current sources and conveyor switch based system can operate in monopolar or bipolar modes. Anodic-first or cathodic-first pulses with optional inter-phase delays have been demonstrated with zero quiescent current requirements at the analog front-end. The architecture eliminates blocking capacitors, electrode shorting and complex feedbacks. Bench-top and in-vivo measurement results have been presented with emulated electrode impedances (resistor-capacitor network), Ag-AgCl electrodes in saline and in-vivo (acute) peripheral nerve stimulations in anesthetized rats.

[DENAS-Vertebra--an innovative step in transcutaneous electrical neural stimulation in the realm of evidence-based medicine]

Despite data of numerous original investigations giving evidence of the high pain-relieving efficacy of transcutaneous electrical neural stimulation (TENS), the authors of the Cochraine reviews avoid definitive conclusions with respect to this issue. This discrepancy is a result of antagonism between the requirements of maximum possible degree of standardization of the method in question and the principle of necessary personification of preventive measures. Certain technological characteristics of the DENAS-Vertebra apparatus allows the acceptable level of consensus to be reached for the solution of the standardization/personification problem pertinent to TCNS procedures.

Exploring the evidence for using TENS to relieve pain

Transcutaneous electrical nerve stimulation (TENS) has several advantages as it is a non-addictive, non-invasive means of analgesia that is simple to use, portable and can give continuous analgesia for a variety of conditions. This article outlines how it works and examines the evidence on its efficacy and possible uses in clinical practice.

Inhibition of somatosensory evoked potentials during spinal cord stimulation and its possible role in the comprehension of antalgic mechanisms of neurostimulation for neuropathic pain

BACKGROUND

Spinal cord stimulation (SCS) has been widely used for pain relief of patients with neuropathic chronic pain, frequently with only partial efficacy. Further advancements probably need a better understanding of SCS mechanisms, yet largely unknown. Aims of this paper were to answer the question if the lumbar SCS inhibits the tibial nerve somatosensory evoked potentials (SEPs) and to discuss the role of lemniscal afferents modulation in the antalgic mechanism of SCS.

METHODS

Ten consecutive patients successfully treated with implanted SCS devices for chronic pain in the lower limbs (four males, six females, age range 42-72 years) were enrolled. All the patients had an implanted system with an epidural lead connected to a pulse generator. The vertebral level ranged from T9 to T12. The cortical SEPs complex P39-N50-P60 was recorded at the basal (T0) evaluation, during the stimulation (T1) and immediately after the stimulation (T2).

RESULTS

In two of ten patients (20%) the complex P39-N50-P60 became unrelievable at the T1 control (stimulator on). In the remaining eight patients statistical analysis showed a significant reduction of the P39/N50 amplitude at T1 recording. In all patients considered, T0 and T2 recordings were not significantly different, suggesting a fast recovery of the SCS effect on SEPs.

CONCLUSION

The results obtained in the present study show an inhibitory effect of SCS on SEPs and support the hypothesis that in some forms of neuropathic pain the antalgic effect of SCS could be attributed to the collision of action potentials travelling in opposite direction on peripheral large diameter fibres.

A double blind randomised controlled clinical trial on the effect of transcutaneous spinal electroanalgesia (TSE) on low back pain

A double blind randomised controlled clinical trial on the effect of transcutaneous spinal electroanalgesia (TSE) on low back pain was carried out in 58 patients attending a Pain Management Unit. Four TSE instruments, two active and two sham, were used and each patient was assigned randomly to one of these. Low back pain was rated by each patient using a visual analogue scale (VAS) immediately before and immediately after a single 20 min treatment of TSE and also daily for the week prior to, and the week following, the treatment. No significant difference in mean pain score was detected between the active and sham treated groups immediately after treatment or during the subsequent week. The Hospital, Anxiety and Depression scale (HAD) and the General Health Questionnaire (GHQ) were completed by each patient and there was a positive correlation between the scores achieved on these scales and the mean pain scores in both the active and sham treated groups. A post-trial problem was the discovery that the specification of the two active TSE machines differed from the manufacturer's specification. Thus, the output frequencies were either more (+10%) or less (-17%) while the maximum output voltages were both less (-40% and -20%), respectively. However, additional statistical analysis revealed no significant differences between the results obtained with the two active machines.

Implementation of a portable electronic system for providing pain relief to patellofemoral pain syndrome patients

In this study, a portable electromyogram (EMG) system and a stimulator are developed for patellofemoral pain syndrome patients, with the objective of reducing the pain experienced by these patients; the patellar pain is caused by an imbalance between the vastus medialis obliquus (VMO) and the vastus lateralis (VL). The EMG measurement circuit and the electrical stimulation device proposed in this study are specifically designed for the VMO and the VL; they are capable of real-time waveform recording, possess analyzing functions, and can upload their measurement data to a computer for storage and analysis. The system can calculate and record the time difference between the EMGs of the VMO and the VL, as well as the signal strengths of both the EMGs. As soon as the system detects the generation of the EMG of the VL, it quickly calculates and processes the event and stimulates the VMO as feedback through electrical stimulation units, in order to induce its contraction. The system can adjust the signal strength, time length, and the sequence of the electrical stimulation, both manually and automatically. The output waveform of the electrical stimulation circuit is a dual-phase asymmetrical pulse waveform. The primary function of the electrical simulation circuit is to ensure that the muscles contract effectively. The performance of the device can be seen that the width of each pulse is 20-1000 μs, the frequency of each pulse is 10-100 Hz, and current strength is 10-60 mA.

Stimulation of the peripheral nervous system for the painful extremity

Peripheral nerve stimulation and, recently, peripheral nerve field stimulation are excellent options for the control of extremity pain in instances where conventional methods have failed and surgical treatment is ruled inappropriate. New techniques, ultrasound guidance, smaller generators, and task-specific neuromodulatory hardware and leads result in increasingly safe, stable and efficacious treatment of pain in the extremities. Peripheral nerve stimulation has shown to be an increasingly viable option for many painful conditions with neuropathic and possibly nociceptive origins. This chapter focuses on the historical use of neuromodulation in the extremities, technical tasks associated with implant, selection of candidates, and potential pitfalls of and solutions for implanting devices around the peripheral nervous system for extremity pain.

Occipital neuromodulation for refractory headache in the Chiari malformation population

Chronic occipital and suboccipital headache is a common symptom in patients with Chiari I malformation (CMI). These headaches may persist despite appropriate surgical treatment of the underlying pathology via suboccipital decompression, duraplasty and related procedures. Occipital stimulation has been shown to be effective in the treatment of a variety of occipital headache/pain syndromes. We present our series of 18 patients with CMI and persistent occipital headaches who underwent occipital neurostimulator trials and, following successful trials, permanent stimulator placement. Seventy-two percent (13/18) of patients had a successful stimulator trial and proceeded to permanent implant. Of those implanted, 11/13 (85%) reported continued pain relief at a mean follow-up of 23 months. Device-related complications requiring additional surgeries occurred in 31% of patients. Occipital neuromodulation may provide significant long-term pain relief in selected CMI patients with persistent occipital pain. Larger and longer-term studies are needed to further define appropriate patient selection criteria as well as to refine the surgical technique to minimize device-related complications.

Spinal nerve root stimulation

Spinal nerve root stimulation (SNRS) is a neuromodulation technique that is used to treat chronic pain. This modality places stimulator electrode array(s) along the spinal nerve roots, creating stimulation paresthesias within the distribution of the target nerve root(s), thereby treating pain in that same distribution. There are several different forms of spinal nerve root stimulation, depending upon the exact electrode positioning along the nerve roots. SNRS combines the minimally invasive nature, central location, and ease of placement of spinal cord stimulation with the focal targeting of stimulation paresthesias of peripheral nerve stimulation. This hybrid technique may be an effective alternative for patients in whom other forms of neurostimulation are either ineffective or inappropriate.

Peripheral nerve stimulation for chronic neurogenic pain

Peripheral nerve stimulation (PNS) has been used for the treatment of neuropathic pain for more than 40 years. Recent interest in the utilization of this technique stems from the many modifications of the original procedure and the refinement of the available hardware. This rendered the procedure less traumatic and more effective, and thus more widely accepted as a neuromodulation technique for the treatment of various chronic pain syndromes including post-traumatic and postsurgical neuropathy, occipital neuralgia, and complex regional pain syndromes, and in relatively new indications for neuromodulation, such as migraines and daily headaches, cluster headaches. We present a review of the principle and indications for the use of PNS, and review our single institution experience that comprises 24 peripheral nerve stimulators as well as 8 occipital nerve stimulators over 13 years. We review the protocol of our approach including the surgical nuances for our implantation technique. Collaborative efforts in future research will lead to a growth in our clinical experience with the utilization of PNS and will help in identifying the best candidates for it. This, along with the development and refinement of the available hardware would lead to a more specific patient selection for each modality of treatment, increasing the efficacy and success of the intended treatment.

Occipital nerve stimulation: technical and surgical aspects of implantation

Occipital nerve stimulation may provide pain relief for patients with otherwise refractory primary headache disorders. While this treatment modality remains an off-label use of spinal cord stimulator technology, a growing body of literature documents surgical techniques, stimulation parameters, complications, and outcome of this novel form of neuromodulation. This chapter will review occipital nerve stimulation, including surgical techniques and complications noted in the literature. A discussion of stimulation parameters used for occipital stimulation will be included. Prospective, blinded studies of occipital nerve stimulation may clarify the role of occipital stimulation in chronic headache management.

Peripheral neuromodulation for migraine headache

Extremely high prevalence among general population along with the high percentage of treatment-refractory cases makes migraine headaches one of the potentially largest indications for neuromodulation. Cranial peripheral nerve stimulation targeting the occipital nerve(s) alone or in combination with others appears to be both safe and efficacious for the treatment of medically intractable migraine headaches. Although initial reports of occipital nerve stimulation for migraine headaches were very encouraging, this clinical benefit was not clearly confirmed in larger-scale prospective randomized trials. Moreover, the exact mechanism of neuromodulation effect in migraine treatment remains unclear. Significant further investigation needs to be performed to optimize our knowledge concerning patient selection, stimulation targets and parameters and device programming, and further improve clinical results. At present, neurostimulation for migraine headache pain is performed in the United States on an 'off-label' basis, but based upon our experience and the increasing evidence in the medical literature, we look forward to its approval by the FDA in the near future so that patients suffering from severe, medically intractable headache pain may gain access to these potentially important therapies.

[Using transcranial electric stimulation in patients with occupational disorders of the nervous system]

The paper presents the results of transcranial electrical stimulation (TES) in treating patients with vibration disease and occupational lumbosacral radiculopathy. It is shown that the inclusion of TES in the program of rehabilitation therapy gives a more pronounced clinical effect, helps to reduce pain, has psychological correcting antidepressant action significantly, improves the quality of life of patients. The study results enable to recommend TES in the complex medical and rehabilitative measures as an effective and pathogenetically substantiated method of treatment of patients with occupational diseases of the nervous system.

[Technical advantages of ultrasound-guided obturator nerve block compared with the nerve stimulating technique]

BACKGROUND

We investigated the onset time of obturator nerve block and time required for the nerve block comparing two groups in a prospective randomized study.

METHODS

Obturator nerve block was performed in 37 cases by either nerve stimulation guide (NS group) or nerve stimulation and ultrasound guide (US group) with 10 ml of 1.5% lidocaine adding 1:200000 epinephrine.

RESULTS

There was no significant difference between the onset time in the NS group (6.1 min) and that in the US group (5.7 min). The time required for the nerve block (4.2 min vs 1.7 min) was significantly shorter, and the frequency of needle advancement for the optimal position (4.7 vs 1.7) was significantly smaller in the US group than in the NS group (P<0.05).

CONCLUSIONS

Ultrasound imaging facilitated the identification of obturator nerves between adductor muscles. Ultrasound-guided obturator nerve block is a safe, quick and useful technique.