Prospects for the Personalized Multimodal Therapy Approach to Pain Management via Action on NO and NOS

Chronic pain syndromes are an important medical problem generated by various molecular, genetic, and pathophysiologic mechanisms. Back pain, neuropathic pain, and posttraumatic pain are the most important pathological processes associated with chronic pain in adults. Standard approaches to the treatment of them do not solve the problem of pain chronicity. This is the reason for the search for new personalized strategies for the prevention and treatment of chronic pain. The nitric oxide (NO) system can play one of the key roles in the development of peripheral pain and its chronicity. The purpose of the study is to review publications devoted to changes in the NO system in patients with peripheral chronical pain syndromes. We have carried out a search for the articles published in e-Library, PubMed, Oxford Press, Clinical Case, Springer, Elsevier, and Google Scholar databases. The search was carried out using keywords and their combinations. The role of NO and NO synthases (NOS) isoforms in peripheral pain development and chronicity was demonstrated primarily from animal models to humans. The most studied is the neuronal NOS (nNOS). The role of inducible NOS (iNOS) and endothelial NOS (eNOS) is still under investigation. Associative genetic studies have shown that single nucleotide variants (SNVs) of NOS1, NOS2, and NOS3 genes encoding nNOS, iNOS, and eNOS may be associated with acute and chronic peripheral pain. Prospects for the use of NOS inhibitors to modulate the effect of drugs used to treat peripheral pain syndrome are discussed. Associative genetic studies of SNVs NOS1, NOS2, and NOS3 genes are important for understanding genetic predictors of peripheral pain chronicity and development of new personalized pharmacotherapy strategies.

[Positional vertigo variant]

The article describes case history and multiphase treatment of the patient with attacks of vertigo, initially regarded as the onset of Meniere's disease, but later qualified as secondary positional attacks with combined musculoskeletal pathology of the craniovertebral region and temporomandibular joint. Medicinal, local and surgical treatment led to the perfect result. Thus, the team work of neurologist, otolaryngologist, maxillofacial surgeon and orthodontist led to the successful elimination of vertigo attacks.

[Piriformis syndrome. Treatment under control of CT fluoroscopy]

OBJECTIVE

To demonstrate one of the effective methods of treatment of the piriformis syndrome under the control of a highly technological visualization method.

MATERIAL AND METHODS

Eight patients (7 women and 1 man), aged 44 to 63 years, with piriformis syndrome, were studied from 2016 to 2018. The main complaints of the patients were pain in the lumbosacral spine with irradiation to the gluteal region and/or legs. All patients underwent MRI and/or MSCT of the lumbosacral spine, the pelvic ultrasound, according to the results of which 1 patient was diagnosed with uterine myoma, 5 with lesions of intervertebral discs in the L4-L5 and L5-S1 segments of varying severity in combination with changes in posture. For therapeutic purposes, all patients under the control of CT fluoroscopy were administered to xeomin (n=3), dexamethasone (n=1) or betamethasone (n=4).

RESULTS

In all patients, a positive therapeutic effect was observed after 4-12 months for xeomin injections, 2-3 weeks for dexamethasone and up to 3 months for betamethasone. No complications during the manipulations were observed. The authors present a clinical case to describe the botulinum therapy technique under the control of CT fluoroscopy, which allows effective treatment of the piriformis syndrome.

CONCLUSION

In the treatment of the piriformis syndrome it is necessary to apply an integrated approach, the leading of which are methods of local impaction on the suffering muscle. Only a methodologically correct injection can increase the effectiveness of treatment in these patients and reduce the risk of complications.

Evidence for miniscalpel-needle/needle knife in the management of chronic pain related conditions: A protocol for systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review with meta-analysis is to determine the effect of miniscalpel-needle/needle-knife in treatment of chronic pain symptoms.

METHODS

The following electronic databases will be searched by 2 independent reviewers: PubMed, Cochrane Library, EMBASE, Springer, China National Knowledge Infrastructure (CNKI), Wanfang, and Chinese Biomedical Literature Database (CBM). All randomized controlled trials on miniscalpel-needle/need-knife for chronic pain published in electronic databases from inception to August 1, 2019 with language restricted in Chinses and English will be included in the study.Methodologic quality is assessed by 2 blinded reviewers independently screen and score the articles using the Physiotherapy Evidence Database (PEDro) scale and the Cochrane Collaboration risk of bias tool. A meta-analysis was performed when there is sufficient clinical homogeneity in at least 2 studies. The Grading of Recommendations Assessment, Development and Evaluation approach is used to rate the body of evidence in each meta-analysis. When the quantitive evaluation is not available, a qualitative description of the results of single study is provided.

RESULTS

A high-quality synthesis of current evidence of miniscapel-needle/needle-knife treating chronic pain will be illustrated using subjective reports and objective measures of performance. The primary outcomes consisted of pain intensity improvement rate clinically meaningful improvements in pain and disability are also noted. Secondary outcomes involve the short form of McGill Pain Questionnaire score (SF-MPQ) and the side effects.

CONCLUSION

This protocol will present the evidence of whether miniscalpel-needle/needle-knife is an effective intervention for chronic pain.

PROSPERO REGISTRATION NUMBER

CRD42019129076.

Effect of Acupuncture on Chronic Pelvic Pain Secondary to Abdominal Myofascial Syndrome Not Responsive to Local Anesthetic Block: A Pilot Study

Objective: Strong evidence shows that 85% of women with chronic pelvic pain (CPP) have musculoskeletal disorders, such as abdominal myofascial pain syndrome (AMPS). The aim of this research was to assess the efficacy of local acupuncture treatment for women with CPP secondary to AMPS unresponsive to treatment with trigger-point injection. Materials and Methods: This pilot study involved 17 women with moderate-to-severe AMPS-related CPP. Acupuncture treatments were given at abdominal-wall trigger points once per week for 10 consecutive weeks. Pain relief was assessed with a visual analogue scale (VAS), the McGill questionnaire, and pressure dynamometer. Quality of life and psychosocial function (risk for anxiety and depression) were evaluated using the Short-Form-36 questionnaire and the Hospital Anxiety and Depression scale. Assessments were performed at baseline and after 1, 3, and 6 months of treatment. Results: Both the VAS and McGill pain questionnaire showed significantly decreased pain intensity (VAS, P < 0.001; and McGill, P 0.049), and the effects were sustained even at 6 months after treatment. Conclusions: Acupuncture treatment was effective for the women who participated in this study, and the current authors believe that these preliminary results suffice to recommend performing randomized controlled trials.