Evidence-based pain management: is the concept of integrative medicine applicable?

This article is dedicated to the concept of predictive, preventive, and personalized (integrative) medicine beneficial and applicable to advance pain management, overviews recent insights, and discusses novel minimally invasive tools, performed under ultrasound guidance, enhanced by model-guided approach in the field of musculoskeletal pain and neuromuscular diseases. The complexity of pain emergence and regression demands intellectual-, image-guided techniques personally specified to the patient. For personalized approach, the combination of the modalities of ultrasound, EMG, MRI, PET, and SPECT gives new opportunities to experimental and clinical studies. Neuromuscular imaging should be crucial for emergence of studies concerning advanced neuroimaging technologies to predict movement disorders, postural imbalance with integrated application of imaging, and functional modalities for rehabilitation and pain management. Scientific results should initiate evidence-based preventive movement programs in sport medicine rehabilitation. Traditional medicine and mathematical analytical approaches and education challenges are discussed in this review. The physiological management of exactly assessed pathological condition, particularly in movement disorders, requires participative medical approach to gain harmonized and sustainable effect.

Intramuscular stimulation therapy for healthcare: a systematic review of randomised controlled trials

OBJECTIVE

A systematic review of randomised controlled trials was conducted to evaluate the efficacy and effectiveness of intramuscular stimulation (IMS).

METHODS

Electronic databases including Medline, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, the Cochrane Library, China National Knowledge Infrastructure, KoreaMED, Korean Studies Information Service System, RISS and DBPIA were searched through June, 2012. The Cochrane criteria were used to assess the risk of bias for the individual studies.

RESULTS

A total of 416 publications were initially collected and four studies were included in this review. One study evaluated the efficacy of IMS for chronic tension-type headaches; IMS showed a better effect than the sham (headache index: mean difference (MD) -4.90, 95% CI -9.53 to -0.27). Three studies tested the effectiveness of IMS for various conditions. In the first study no significant difference was observed in a comparison of IMS and meloxicam therapy for chronic shoulder pain (pain-visual analogue scale (VAS): MD -0.05, 95% CI -0.25 to 0.16). The second study in patients with myofascial pain syndrome of the upper trapezius muscle found that IMS had a greater effect than simple dry needling measured by the pain-VAS (MD -2.70, 95% CI -3.77 to -1.63). In the third study, patients with lower back pain who received IMS plus the standard treatment had a better status at discharge than those receiving the standard treatment alone (relative risk 1.63, 95% CI 1.18 to 2.24).

CONCLUSIONS

Despite the positive results of these individual studies, the level of evidence supporting the efficacy and effectiveness of IMS for several conditions remains insufficient because of concerns about a lack of precision and a high risk of bias of the included studies. Rigorous large-scale clinical trials of IMS are needed to evaluate the clinical utility of this technique.

A new method for quantifying the needling component of acupuncture treatments

OBJECTIVES

The highly variable nature of acupuncture needling creates challenges to systematic research. The goal of this study was to test the feasibility of quantifying acupuncture needle manipulation using motion and force measurements. It was hypothesised that distinct needling styles and techniques would produce different needle motion and force patterns that could be quantified and differentiated from each other.

METHODS

A new needling sensor tool (Acusensor) was used to record needling in real time as performed by six New England School of Acupuncture staff from the 'Chinese acupuncture' (style 1) and 'Japanese acupuncture' (style 2) programmes (three from each). Each faculty expert needled 12 points (6 bilateral locations) in 12 healthy human subjects using tonification (technique 1) and dispersal (technique 2). Parameters calculated from the raw needling data were displacement amplitude, displacement frequency, rotation amplitude, rotation frequency, force amplitude and torque amplitude.

RESULTS

Data analysis revealed significant differences in the amplitude of displacement and rotation between needling performed by staff from two different acupuncture styles. Significant overall differences in the frequency of displacement between techniques 1 and 2 that were not dependent of the style of acupuncture being performed were also found. The relationships between displacement and rotation frequencies, as well as between displacement and force amplitudes showed considerable variability across individual acupuncturists and subjects.

CONCLUSIONS

Needling motion and force parameters can be quantified in a treatment-like setting. Needling data can subsequently be analysed, providing an objective method for characterising needling in basic and clinical acupuncture research.

Performing arts medicine - instrumentalist musicians: part III - case histories

In parts I and II of this article series, the basic principles of examining musicians in a healthcare setting were reviewed [Dommerholt, J. Performing arts medicine - instrumentalist musicians: part I: general considerations. J. Bodyw. Mov. Ther., in press-a; Dommerholt, J. Performing arts medicine - instrumentalist musicians: part II: the examination. J. Bodyw. Mov. Ther., in press-b]. Part III describes three case reports of musicians with hand pain, interfering with their ability to play their instruments. The musicians consulted with a performing arts physiotherapist. Neither musician had a correct medical diagnosis if at all, when they first contacted the physiotherapist. Each musician required an individualized approach not only to establish the correct diagnosis, but also to develop a specific treatment program. The treatment programs included ergonomic interventions, manual therapy, trigger point therapy, and patient education. All musicians returned to playing their instruments without any residual pain or dysfunction.

Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points

OBJECTIVES

To investigate the biochemical milieu of the upper trapezius muscle in subjects with active, latent, or absent myofascial trigger points (MTPs) and to contrast this with that of the noninvolved gastrocnemius muscle.

DESIGN

We used a microanalytic technique, including needle insertions at standardized locations in subjects identified as active (having neck pain and MTP), latent (no neck pain but with MTP), or normal (no neck pain, no MTP). We followed a predetermined sampling schedule; first in the trapezius muscle and then in normal gastrocnemius muscle, to measure pH, bradykinin, substance P, calcitonin gene-related peptide, tumor necrosis factor alpha, interleukin 1beta (IL-1beta), IL-6, IL-8, serotonin, and norepinephrine, using immunocapillary electrophoresis and capillary electrochromatography. Pressure algometry was obtained. We compared analyte concentrations among groups with 2-way repeated-measures analysis of variance.

SETTING

A biomedical research facility.

PARTICIPANTS

Nine healthy volunteer subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Preselected analyte concentrations.

RESULTS

Within the trapezius muscle, concentrations for all analytes were higher in active subjects than in latent or normal subjects (P<.002); pH was lower (P<.03). At needle insertion, analyte concentrations in the trapezius for the active group were always higher (pH not different) than concentrations in the gastrocnemius muscle. At all times within the gastrocnemius, the active group had higher concentrations of all analytes than did subjects in the latent and normal groups (P<.05); pH was lower (P<.01).

CONCLUSIONS

We have shown the feasibility of continuous, in vivo recovery of small molecules from soft tissue without harmful effects. Subjects with active MTPs in the trapezius muscle have a biochemical milieu of selected inflammatory mediators, neuropeptides, cytokines, and catecholamines different from subjects with latent or absent MTPs in their trapezius. These concentrations also differ quantitatively from a remote, uninvolved site in the gastrocnemius muscle. The milieu of the gastrocnemius in subjects with active MTPs in the trapezius differs from subjects without active MTPs.