Non-pharmacological interventions for chronic pain in people with spinal cord injury

BACKGROUND

Chronic pain is frequent in persons living with spinal cord injury (SCI). Conventionally, the pain is treated pharmacologically, yet long-term pain medication is often refractory and associated with side effects. Non-pharmacological interventions are frequently advocated, although the benefit and harm profiles of these treatments are not well established, in part because of methodological weaknesses of available studies.

OBJECTIVES

To critically appraise and synthesise available research evidence on the effects of non-pharmacological interventions for the treatment of chronic neuropathic and nociceptive pain in people living with SCI.

SEARCH METHODS

The search was run on the 1st March 2011. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), four other databases and clinical trials registers. In addition, we manually searched the proceedings of three major scientific conferences on SCI. We updated this search in November 2014 but these results have not yet been incorporated.

SELECTION CRITERIA

Randomised controlled trials of any intervention not involving intake of medication or other active substances to treat chronic pain in people with SCI.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias in the included studies. The primary outcome was any measure of pain intensity or pain relief. Secondary outcomes included adverse events, anxiety, depression and quality of life. When possible, meta-analyses were performed to calculate standardised mean differences for each type of intervention.

MAIN RESULTS

We identified 16 trials involving a total of 616 participants. Eight different types of interventions were studied. Eight trials investigated the effects of electrical brain stimulation (transcranial direct current stimulation (tDCS) and cranial electrotherapy stimulation (CES); five trials) or repetitive transcranial magnetic stimulation (rTMS; three trials). Interventions in the remaining studies included exercise programmes (three trials); acupuncture (two trials); self-hypnosis (one trial); transcutaneous electrical nerve stimulation (TENS) (one trial); and a cognitive behavioural programme (one trial). None of the included trials were considered to have low overall risk of bias. Twelve studies had high overall risk of bias, and in four studies risk of bias was unclear. The overall quality of the included studies was weak. Their validity was impaired by methodological weaknesses such as inappropriate choice of control groups. An additional search in November 2014 identified more recent studies that will be included in an update of this review.For tDCS the pooled mean difference between intervention and control groups in pain scores on an 11-point visual analogue scale (VAS) (0-10) was a reduction of -1.90 units (95% confidence interval (CI) -3.48 to -0.33; P value 0.02) in the short term and of -1.87 (95% CI -3.30 to -0.45; P value 0.01) in the mid term. Exercise programmes led to mean reductions in chronic shoulder pain of -1.9 score points for the Short Form (SF)-36 item for pain experience (95% CI -3.4 to -0.4; P value 0.01) and -2.8 pain VAS units (95% CI -3.77 to -1.83; P value < 0.00001); this represented the largest observed treatment effects in the included studies. Trials using rTMS, CES, acupuncture, self-hypnosis, TENS or a cognitive behavioural programme provided no evidence that these interventions reduce chronic pain. Ten trials examined study endpoints other than pain, including anxiety, depression and quality of life, but available data were too scarce for firm conclusions to be drawn. In four trials no side effects were reported with study interventions. Five trials reported transient mild side effects. Overall, a paucity of evidence was found on any serious or long-lasting side effects of the interventions.

AUTHORS' CONCLUSIONS

Evidence is insufficient to suggest that non-pharmacological treatments are effective in reducing chronic pain in people living with SCI. The benefits and harms of commonly used non-pharmacological pain treatments should be investigated in randomised controlled trials with adequate sample size and study methodology.

[MR relaxation time measurements with and without selective fat suppression (SPIR) in endocrine orbitopathy]

PURPOSE

To determine the value and utility of relaxation time measurements with magnetic resonance (MR) imaging in patients with Graves' ophthalmopathy (G.O.).

MATERIALS AND METHODS

20 orbits were studied in control subjects and 58 orbits in patients with G.O. T2 relaxation times of extraocular muscles and retrobulbar fat tissue were calculated. The thickness of the eye muscles was correlated with the calculated T2 times. 18 orbits were measured before and after retro-orbital radiation therapy.

RESULTS

Upper limits of determined normal T2 values were 60 ms in extraocular eye muscles and 40 ms in retrobulbar fat tissue. 89% (17/19) of the patients with G.O. had prolonged T2 times in extraocular eye muscles. The retrobulbar fat tissue in 5 of 38 orbits revealed minimal edema with the use of fat saturated sequences. T2 relaxation times decreased significantly (p < 10(-4)) after 10 Gy radiation therapy. No correlation was found between enlargement and T2 relaxation times in extraocular eye muscles (r = 0.44 in patients before radiation therapy).

CONCLUSION

In patients with G.O. the determination of the enlargement of extraocular eye muscles in computed tomography is not a sufficient parameter for an antiinflammatory therapy, since CT cannot visualise eye muscle edema. T2 relaxation time measurements with MR imaging allow differentiation between edematous and fibrotic changes. This is the diagnostic method of choice in patients with Graves' ophthalmopathy.

Scintimammography with Tc-99m MIBI in patients with suspicion of primary breast cancer

The aim of the study was to evaluate the diagnostic accuracy of scintimammography with Tc-99m MIBI for the detection of breast cancer. Patients with a suspicious lesion detected by palpation or mammography were included in the study. Excisional biopsy was performed on all patients. Mammography was performed within 3 weeks prior to scintigraphy. All patients received 740 MBq Tc-99m MIBI intravenously in the arm contralateral to the suspicious breast and were subsequently examined in a prone position. At 5 to 10 min postinjection, planar images were obtained in lateral and anterior views, with an acquisition time of 10 min each. After planar imaging, a SPECT study was performed using a two-head camera. Breast cancer was confirmed in 29 out of 68 patients. The tumor size ranged from 6 to 90 mm in diameter. For scintigraphic studies, the overall sensitivity and specificity was 83% and 84%, respectively. However, sensitivity for palpable lesions was 100%. The smallest detectable tumor measured 9 mm in diameter and could be visualized only in the planar scintigram. Using Tc-99m MIBI, axillary lymph node metastases could be detected with a sensitivity of 82%. Scintigraphy with Tc-99m MIBI has a high diagnostic accuracy for the detection of primary breast cancer in patients with a palpable mass. Scintimammography may be used as a complementary method to mammography and help to decrease the number of unnecessary breast biopsies.

Attempted protection of spermatogenesis from irradiation in patients with seminoma by D-Tryptophan-6 luteinizing hormone releasing hormone

Possible protective effects of D-Tryptophan-6 luteinizing hormone releasing hormone (D-Trp-6-LH-RH) against irradiation-induced testicular damage were investigated for the first time in patients with seminoma. After unilateral orchiectomy 12 men were allocated to receive the long-acting gonadotropin releasing hormone (GnRH) agonist D-Trp-6-LH-RH prior to and for the duration of radiotherapy. Eight patients with the same disease served as a control group. In contrast to several trials to protect spermatogenesis from chemotherapy by GnRH agonists, we first suppressed the pituitary-testicular axis before starting the treatment. As a new schedule this adjuvant GnRH agonist treatment was combined with cyproterone acetate for the first 20 days to diminish the amount and the duration of the initial stimulation of gonadotropins and testosterone. Irradiation started after suppression of the pituitary-gonadal axis. In all patients luteinizing hormone and testosterone were completely suppressed throughout the treatment compared to the controls, whereas the initial suppression of follicle-stimulating hormone was not completely maintained until radiotherapy was completed. At the follow-up at 18 months after completion of therapy, all patients reached their initial concentration of gonadotropins, testosterone, and motile spermatozoa independently of D-Trp-6-LH-RH treatment. With the dose and schedule investigated, the GnRH agonist showed no protective effects against testicular damage caused by radiotherapy.

Primary melanoma of urinary bladder

The fourth case of primary melanoma of the bladder is presented together with a review of the previously reported cases and the relevant literature on malignant melanoma in urology. The criteria for classification of the bladder lesion as the primary site are discussed. The eighty-one-year-old female patient was felt not to be suitable for extensive surgery and was successfully treated with a combination of radiation and immunotherapy with recombinant alpha 2 interferon. After previous monthly recurrences of the tumor the patient is in complete remission fifteen months after initiation of therapy. It appears that this form of treatment might be a valuable alternative to radical surgery in elderly patients.

[Radiation therapy of nasopharyngeal carcinoma. Retrospective study for the assessment of long-term results]

During the years from 1967 to 1986, 90 patients with nasopharyngeal carcinomas were irradiated at the Radiologic Hospital of Bonn University. The median overall survival time was 4.3 years which corresponded to 23% of the statistical life expectancy of the patients. 66% were still alive after two years and 46.5% after five years. Compared to the overall group, the prognosis was significantly worse in case of highly differentiated, keratinizing squamous cell carcinomas, penetration of the primary tumor into the base of the skull, or certain symptoms as ophthalmo-neurologic troubles, headaches, loss of body weight, night sweat, or fever. After partial tumor excision performed prior to irradiation or complete remission following to radiotherapy, the therapy results were better than the average with median survival times of about eleven years.

[Therapeutic results in small-cell bronchial carcinoma after ACO II chemotherapy and adjuvant radiation]

During the period from 1980 through 1984, 67 patients suffering from small-cell bronchial carcinomas were submitted to a complete ACO II treatment scheme combined with adjuvant irradiation. The complete remission rate was 12%, the partial remission rate 74%. Half of the patients with limited disease survived 12.3 months or more. The median survival time of patients with extensive disease was eight months. An irradiation of the tumor core had been found useful in cases where remote hematogenous metastases could not be demonstrated. It was shown that a prophylactic skull irradiation after the second chemotherapy series was applied too early, because persisting primary tumor residues formed late intracerebral metastases.

[Computed tomography and MR tomography before and after radiotherapy of primary and secondary CNS lymphoma]

CT scans were made prior to and following radiotherapy in eleven patients with primary or secondary malignant lymphomas of the CNS. Six patients were additionally submitted to MR tomography with calculated T1 and T2 images. Radiotherapy induced a very rapid regression of the lymphomas. A measurable quantitative influence of the irradiation could thus not be visualized in the MR scans. The survival curve of our patients was calculated, too. The median survival after radiotherapy is 17.4 months.

[Primary radiotherapy of esophageal carcinoma: a therapeutic alternative?]

The authors present the results of primary radiotherapy in 73 patients with esophagus carcinomas. A subgroup of non-circular squamous-cell carcinomas without remote and lymph node metastases (n = 19) shows a prognosis which is very favorable for this tumor. As local therapy of the esophagus carcinoma can only aim at a tolerable course of the disease until the appearance of metastases, the results achieved give occasion to doubt the priority of surgery in case of operable tumors. The question arises if primary radiotherapy wouldn't be an effective and not very risky alternative for patients presenting these favorable criteria.

[Mammographically distinguishable parenchymal patterns and their significance in estimating breast cancer risk]

A retrospective study of the mammograms of 11020 women was carried out; amongst these, 490 had carcinomas, including 51 so-called interval carcinomas. An attempt was made to test the suggestion advanced by Wolfe that certain dense types of parenchymal pattern on the mammogram are associated with a significantly increased carcinoma risk. We were unable to confirm Wolfe's suggestion. There is a slightly higher risk for pattern P2-DY, which cannot be used as the basis for future management of the patient. Attention is drawn to the risk of missing many carcinomas of the breast, if the suggestions made by Wolfe are followed.

[Radiologic diagnosis and therapy of the viscerocranial extramedullary plasmocytoma]

A report is given about ten patients with an extramedullary plasmocytoma situated in the head/neck region. The diagnostic possibilities, the spontaneous development and the effect of radiotherapy with or without surgical treatment are evaluated. Ablation and subsequent irradiation with a focal dose of at least 50 Gy offer the best changes to achieve a recovery without recurrences. In case of osseous destruction, especially if the primary tumor is localized in the maxillary sinuses, it is very difficult to attain a permanent remission. If only soft tissues, are affected, a combined surgical and radiologic treatment is possible even in case of an affection of regional lymph nodes.

[Complications of selective retrograde laevocardiography. A survey of 2000 examinations (author's transl)]

The incidence of complications in 2000 selective retrograde laevocardiograms is reported. Seventy-four complications were observed in 69 patients. None of these was fatal. On 39 occasions cardiac, and on three occasions cerebral complications were observed. In 20 patients there were complications at the site of puncture and in four patients sepsis or bacteraemia. Contrast sensitivity or allergy was found in eight patients. The relationship, described in the literature, between intramural contrast deposition and the type of catheter, ventricular size and ventricular wall was confirmed by our own observations, as well as the most frequent situation on the posterior wall of the left ventricle.

[Computer tomographic demonstration of lymph node metastases from malignant testicular tumours. A comparison of lymphography and computer tomography (author's transl)]

Lymphography and computer tomography was performed on 64 patients with malignant testicular tumours in order to demonstrate lymph node metastases. In 60 patients it was possible to confirm the findings by surgery. In 43 patients there was agreement between the findings of the computer tomogram and the lymphogram. In 39 of these patients lymph node metastases had been demonstrated, in three there was a false negative and in one a false positive. Amongst the patients in whom there was a descrepancy between the two types of examination, the CT findings were confirmed histologically in twelve, and the lymphographic findings in nine. In 12.5% CT added significant additional information. Accuracy of lymphography was 73% and of computer tomography 80%. Specificity for each examination was 79%.

[Transfemoral aspiration of a thrombus from a renal artery with an angiographic catheter (author's transl)]

Thrombosis in a renal artery occurred in a 60-year-old woman after regional hypothermia of the kidney for which balloon occlusion of the artery had been used. Perfusion of the kidney was re-established by aspiration and flushing of the thrombus; this was confirmed angiographically and anatomically. Renal function did not recover, however, since removal of the thrombus by means of an angiographic catheter was carried out too late. We regard early aspiration of emboli from major abdominal vessels as a further application of arterial catheterisation by the Seldinger technique.

[The angiographic appearances of liver haemangiomas (author's transl)]

Thirteen cases of cavernous haemangiomas of the liver are described, and the clinical features, diagnosis and treatment are discussed. The purpose of this paper is to show the value of selective coeliac angiography in the differential diagnosis. The most important angiographic findings in cavernous haemangiomas of the liver are: supplying arteries of normal width, prolonged stasis of the contrast medium producing the appearance of spotty contrast depots, frequently, sharp delineation of the tumours; no A-V fistulae and no tumour vessels. Other hypervascular liver tumours must be distinguished from these, particularly hepatocellular carcinomas and sarcomas, as well as the rare haemangioendotheliomas.

[Intravenous injection of thermometer mercury (author's transl)]

The possible complications in two women who had injected themselves intravenously with thermometer mercury with suicidal intent are discussed with reference to the few comparable cases. A manifest pulmonary hypertension due to multiple mercury emboli in the lesser circulation in one patient who developed a dyspnoea on exertion could be excluded by cardiac catheterization. Signs of acute and chronic mercury poisoning could not be demonstrated in our patients, in contrast to some cases reported in the literature. So far, specific therapy has therefore been dispensed with.

[Metastasising carcinoma of the renal pelvis after Thorotrast pyelography]

A carcinoma of the renal pelvis was diagnosed in a female patient 42 years after a retrograde Thorotrast pyelogram. The patient died as a result of the carcinoma at the age of 60. The literature is reviewed. As a result of this case, the need is stressed for early recognition of Thorotrast depositis in the kidney. In this case it was demonstrated by autoradiography. Appropriate treatment is discussed.

[Chylous reflux and chylous ascites in lymphatic dysplasia, with the lymphographic demonstration of mediastinal and retroperitoneal lymphatic cysts]

Two patients with congenital dysplasia of the lymphatic system and with chylous ascites are described. In one 24-year old woman with this rare condition, it was possible to demonstrate for the first time numerous mediastinal lymphatic cysts during lymphangiography. Both patients showed an abnormality of the retroperitoneal lymphatics, consisting of lymphatic dilatation and cysts. In the investigation of chylous ascites, direct lymphangiography must be regarded as a valuable and necessary investigation.