[Retrospective evaluation of electronically recorded patient questionnaires of a university outpatient pain clinic with the painDETECT® questionnaire]

BACKGROUND AND OBJECTIVE

Psychometric tests can provide important information for diagnostics and progression in chronic pain patients. Between 2008 and 2018, the electronic system painDETECT® was used in the outpatient pain clinic of the Hannover Medical School (MHH). The aim of this retrospective study was to evaluate the pain symptomatology data recorded using painDETECT® and the treatment procedures used in the patient cohort examined over a period of 15 months.

MATERIAL AND METHODS

A statistical analysis of baseline and follow-up data was performed. The analysis comprised pain-related parameters recorded by use of the painDETECT® system as well as outpatient records.

RESULTS

Baseline data of 459 patients (66% women) could be evaluated. The most common clinical pictures were spinal pain, headache, facial pain, and somatoform disorders, mostly with many years of previous treatment. Approximately 40% showed evidence of neuropathic pain components or central sensitization. With a mean pain intensity of VAS 6 (0-10), a predominantly high degree of chronicity was present. Approximately one third showed a high degree of pain-related functional impairment. Slightly more than half showed evidence of clinically relevant depression. Approximately 80% showed clinically relevant sleep disturbances. Follow-up data were available for 145 patients (31.6%). The proportion of patients receiving a nonpharmacological form of treatment increased by 44.1% (physical therapy) and by 24.1% (psychotherapeutic procedures) during the observation period. The use of co-analgesics increased by approximately 30% over the course.

CONCLUSION

In the outpatient setting, an extension of treatment can be successful for high-grade chronic pain patients. Close structural networking with the clinics for rehabilitation medicine and for psychosomatics and psychotherapy at the MHH can be a favorable prerequisite for this.

The interplay of chronic stress and genetic traits discriminates between patients suffering from multisomatoform disorder with pain as the leading symptom and matched controls

OBJECTIVE

Somatoform disorders and functional somatic syndromes (FSS) with symptoms that are not sufficiently explained by physical or technical examination are among the most challenging underlying causes. Many different somatoform disorders and FSS have overlapping symptoms, often with pain as the most prevalent one, leading to a high burden of disease. The concept of multisomatoform disorder (MSD) has been developed to acknowledge that fact. We analyzed a group of 151 patients and 149 matched controls to identify interactions of genetic and environmental factors with a possible influence on the development of MSD.

DESIGN

In a retrospective case-control study, we performed a statistical analysis on 151 patients and 149 matched controls using logistic regression and a Classification and Regression Tree (CART) analysis.

RESULTS

The logistic regression analysis of genes and environmental factors demonstrated significant differences in the results of the Trier Inventory of Chronic Stress (TICS) questionnaire, the single nucleotide polymorphism rs1800955 of the dopamine receptor D4 and the single nucleotide polymorphism rs4818 of the enzyme catechol-O-methyltransferase between patients with MSD and healthy controls. The resulting decision tree of the CART analysis determined that the TICS questionnaire was able to differentiate patients and controls most accurately, followed by certain genotypes of the 5-hydroxytryptamine receptor 2A and a single nucleotide polymorphism of the enzyme catechol-O-methyltransferase.

CONCLUSIONS

The results of the statistical analysis identified a gene-environmental interaction possibly leading to MSD. The resulting identifiers could be used as a reference to inform diagnostic algorithms to easier identify patients suffering from MSD.

[Evaluation of outpatient medical pain management in Germany : Results of an internet-based cross-sectional survey among pain specialists in outpatient departments]

Hintergrund

Nach den Kriterien der Qualitätssicherungsvereinbarung Schmerztherapie (QSV) nahmen zum Stichtag 31.12.2016 1206 Ärztinnen und Ärzte an der ambulanten Versorgung chronischer Schmerzpatienten teil. Bei in weiten Teilen bestehender Unterversorgung chronischer Schmerzpatienten fehlen Daten zur Einschätzung der ambulanten Schmerztherapie durch die Schmerztherapeuten selbst.

Methoden

In einem Hybrid-Delphi-Verfahren wurde ein Fragebogen zur inhaltlichen, strukturellen und persönlichen Bewertung der ambulanten Schmerztherapie in Deutschland entwickelt.

Mit diesem Instrument wurde eine internetbasierte Querschnittsbefragung von 281 QSV-Schmerzmedizinern aus vier Bundesländern (Berlin, Niedersachsen, Sachsen, Baden-Württemberg) und aller universitären Schmerzambulanzleiter (n = 36) in Deutschland durchgeführt.

Ergebnisse

Die Befragung erzielte eine bereinigte Rücklaufquote von insgesamt 35,9 %. Bei den Schmerzambulanzleitern antworteten 66,7 %. Bei 91 % der Befragten lag der Anteil an chronisch Schmerzkranken in der Praxis bei über 70 %. 67,3 % geben an, mit ihrer Praxissituation zufrieden zu sein, auf der anderen Seite äußern 63,4 % ihre Unzufriedenheit mit der aktuellen Organisation der Schmerzmedizin in Deutschland insgesamt. Diese Unzufriedenheit zeigt sich vor allem in Bezug auf die Budgetregelungen (69,3 %), die Kooperation mit Psychotherapeuten (69,3 %) und die interdisziplinäre Vernetzung (50,5 %). Als gute Vorbereitung für den späteren Beruf werden die einjährige Weiterbildung bei einem Weiterbildungsbefugten (87,1 %) und die Teilnahme an dem Kurs „Psychosomatische Grundversorgung“ (90,1 %) bewertet. Vielfältige Freitextkommentare weisen darauf hin, dass die Ausbildung zu kurz und nicht ausreichend sei. Die Mehrheit der Befragten hält es sowohl aus Arztsicht (61,4 %) wie auch aus Patientensicht (54,5 %) für sinnvoll, einen Facharzt für Schmerzmedizin als Versorgungsmodell zu etablieren. 70,8 % der Schmerzambulanzleiter sprechen sich für eigenständige Strukturen mit eigenem Budget aus, 75,0 % geben an, dass ihre Ambulanz unter den aktuellen Bedingungen nicht kostendeckend arbeitet. In Bezug auf die aktuelle Ausbildungssituation berichten nur 39,7 % der QSV-Schmerztherapeuten in der Niederlassung, dass sie auch Ärzte ausbilden, 57,6 % von ihnen planen zudem, ihre Tätigkeit innerhalb der nächsten 10 Jahre aufzugeben.

Schlussfolgerungen

Die mangelnde Eigenständigkeit der Schmerzmedizin und die unzureichend ausgebauten ambulanten Versorgungsnetzwerke tragen dazu bei, dass Schmerztherapeuten mit vielen Aspekten ihrer Tätigkeit unzufrieden sind. Die Etablierung eines Facharztes für Schmerztherapie wird als eine gute Lösung für eine bessere schmerzmedizinische Versorgung und für die Nachwuchsproblematik gesehen.

Autoantibodies against P29ING4 are associated with complex regional pain syndrome

INTRODUCTION

Complex regional pain syndrome (CRPS) is a complication following trauma or surgery and may be difficult to diagnose since biomarkers are lacking. Using protein array technology, we found antibodies binding to p29ING4, which we further characterized using ELISA.

METHODS

Thirty-six sera of early-stage type 1 CRPS, 66 sera of rheumatoid arthritis (RA), 53 sera of axial spondyloarthritis (axSpA), 29 sera of psoriatic arthritis (PsA), 22 sera of patients after radial fractures (trauma control), and 100 sera of blood donors (BD) were analyzed for anti-p29ING4. We established ELISAs with 7 different antigens and using different secondary antibodies binding to IgG, IgG1, IgG2, IgG3, IgG4, IgA, and IgM, and 2 different tests to detect immune complexes (IC) of p29ING4 and IgG or IgG1.

RESULTS

The highest likelihood ratios versus CRPS and trauma control were observed considering the A1-23 (sensitivity 19%, specificity 100%, LR > 19) using IgG as a secondary antibody, the A120-165 (sensitivity 17%, specificity 100%, LR = 17) using IgG as a secondary antibody and the A120-165 (sensitivity 31%, specificity 95%, LR = 6.2) using IgA as a secondary antibody. IC of p29ING4 and IgG were present in 11/36 (31%) CRPS sera, 17/64 (27%) RA sera, 13/53 (25%) SpA sera, 5/29 (17%) PsA sera, 1/22 (5%) trauma control sera, and 4/100 (4%) sera of BD. IC of p29ING4 and IgG1 were present in 14/36 (39%) CRPS sera, 19/64 (30%) RA sera, 13/53 (25%) SpA, 1/29 (3%) PsA, 2/22 (9%) trauma control, and 4/100 (4%) of the BD sera.

CONCLUSION

Due to the lack of other biomarkers of type 1 CRPS, P29ING4 autoantibodies could be helpful in its diagnostic work-up.

The best from East and West? Acupuncture and medical training therapy as monotherapies or in combination for adult patients with episodic and chronic tension-type headache: study protocol for a randomized controlled trial

BACKGROUND

This study aims to evaluate the feasibility and efficacy of a complex health intervention, based on the combination of conventional Western medicine and traditional Chinese medicine (TCM), in an outpatient department of a university hospital for patients with frequent episodic or chronic tension-type headaches.

METHODS/DESIGN

This is a prospective randomized controlled pilot study with four balanced treatment arms (usual care, acupuncture, training, and training plus acupuncture). Each arm will have 24 patients. After the initial screening examination and randomization, a 6-week treatment period follows, with treatment frequencies decreasing at 2-week intervals. After completion of the intervention, two follow-up evaluations will be performed 3 and 6 months after the start of treatment. At predefined times, the various outcomes (pain intensity, health-related quality of life, pain duration, autonomic regulation, and heart rate variability) as well as the participants' acceptance of the complex treatment will be evaluated with valid assessment instruments (Migraine Disability Assessment, PHQ-D, GAD-7, and SF-12) and a headache diary. The acupuncture treatment will be based on the rules of TCM, comprising a standardized combination of acupuncture points and additional points selected according to individual pain localization. The training therapy comprises a combination of strength training, endurance training, and training to improve flexibility and coordination. Besides descriptive analyses of the samples, their comparability will be assessed using an analysis of variance (ANOVA) or chi-squared tests. Analyses will be performed on an intention-to-treat basis. Potential interaction effects will be calculated using a repeated-measures ANOVA to test the primary and secondary hypotheses. In supplementary analyses, the proportion of treatment responders (those with a 50% reduction in the frequency of pain episodes) will be determined for each treatment arm.

DISCUSSION

This trial may provide evidence for the additive effects of acupuncture and medical training therapy as a combination treatment and may scientifically support the implementation of this complex health intervention.

TRIAL REGISTRATION

Registered on 11 Feburary 2019. German Clinical Trials Register, DRKS00016723.

[Anonymize or personalize? : Does social desirability influence the response behavior of chronic pain patients?]

BACKGROUND

The subjective state of health with respect to pain and psyche was surveyed utilizing validated pain questionnaires in patients undergoing special pain therapy and represents the basis for targeted treatment measures.

OBJECTIVE

The purpose of this study was to investigate the possible distortion of answers due to social desirability of responses in chronic pain patients.

MATERIAL AND METHODS

During two survey periods assessing patient satisfaction using both anonymized and personalized questionnaires, the effects arising from socially desirable response patterns were analyzed. The sample consisted of chronic pain patients being treated in an inpatient therapy setting.

RESULTS

In both periods of observation no significant impact on the response behavior of chronic pain patients was found in personalized or anonymized questionnaires.

CONCLUSION

The results of the study suggest that the responses of chronic pain patients with respect to their subjective state of health are not influenced by social desirability. Thus, scoring systems such as the German pain questionnaire will not be influenced by social desirability in chronic pain patients and can therefore be used as a part of diagnostics and therapy planning.

The beta-adrenergic receptor agonist, terbutaline, reduces UVB-induced mechanical sensitization in humans

OBJECTIVES

Previously, we found in cultures of primary neurons and in animals that sensitized primary neurons can be desensitized by treatment with e.g. beta-adrenergic receptor agonists. We now tested whether also in human sensitization such as UVB-radiation induced sunburn-like hyperalgesia can be reduced by intradermal injection of the beta-adrenergic receptor agonist terbutaline.

METHODS

In our prospective randomized study, 17 participants received an individual UVB dose to cause a defined local sunburn-like erythema at four locations, two on each forearm. Twenty-four hours later, the sensitized four areas were injected intradermally with terbutaline pH 4.3, terbutaline pH 7.0, saline pH 4.3 or saline pH 7.0, respectively. Pain thresholds were examined before and after induction of UVB-sensitization, and 15, 30 and 60 min after injection of the respective solution. Mechanical pain thresholds of the skin and of deeper tissues were determined by pinprick and pressure algometer measurements, respectively.

RESULTS

UVB-irradiation decreased mechanical pain thresholds for pinprick and pressure algometer measurements demonstrating a successful sunburn-like sensitization. Intradermal injection of terbutaline pH 7.0 into the sensitized skin reduced the sensitization for all measured timepoints as determined by pinprick measurements. Pinprick measurements of sensitization were not reduced by injection of terbutaline pH 4.3, saline solution pH 7.0 or saline solution pH 4.3. Also, sensitization of deeper tissue nociceptors were not altered by any of the injections as measured with the pressure algometer.

CONCLUSIONS

Similar to our cellular observations, also in humans beta-adrenergic agonists such as terbutaline can reduce the sensitization of primary neurons in the skin.

SIGNIFICANCE

We previously showed in model systems that beta-adrenergic stimulation can not only sensitize but also desensitize nociceptors. Our study shows that also in humans beta-adrenergic agonists desensitize if injected into UVB-sensitized skin. This indicates an analgesic activity of adrenergic agonists in addition to their vasoconstrictory function.

Venous thromboembolic complications with and without intermittent intraoperative and postoperative pneumatic compression in patients with glioblastoma multiforme using intraoperative magnetic resonance imaging. A retrospective study

OBJECTIVE

To evaluate the effectiveness of intraoperative and postoperative intermittent pneumatic compression (IPC) as a method used to decrease the incidence of deep venous thrombosis (DVT), in comparison to the standard use of graduated compression stockings, low-molecular weight heparin (LMWH) and physiotherapy during the hospital stay. All patients in this study underwent intracranial surgery for glioblastoma multiforme (GBM) using intraoperative magnetic resonance imaging (MRI) guidance.

PATIENTS AND METHODS

We performed a single center retrospective study of a cohort of 153 patients who underwent surgery for GBM aided by intraoperative MRI from October of 2009 to January of 2015 at the International Neuroscience Institute (INI), Hannover, Germany. Out of all patients, 75 in comparison to 78 were operated with and without the additional use of IPC, respectively. Both groups received graduated compression stockings, LMWH and physiotherapy postoperatively as a basic thromboprophylaxis. Postoperatively the patients were screened for DVT by Doppler ultrasonography of the limbs and pulmonary embolism (PE) by CT-scan of the chest.

RESULTS

DVTs were found in 6 patients with IPC and in 3 patients without IPC. The incidence of developing DVTs was therefore not significantly increased with the application of IPC from 3.9% to 8% (P-value: 0.33). No statistically significant differences were found in the probability of occurrence of pulmonary embolism (PE) with a reduction from 2.6% to 1.3% (P-value: 0.59).

CONCLUSION

Our results demonstrate, that the surgical intervention and the subsequent patient immobilization, as well as the thromboprophylactic techniques used have a relatively low influence on the occurrence of thromboembolic complications than we expected. Our findings might be attributed to the overall low number of these complications in a glioblastoma multiforme patient population expected to be at a high risk for coagulopathy. In other words, in order to produce statistically significant results, we would need to increase the patient cohort. By doing so we may better detect a positive therapeutic effect. Alternatively, because of the multitude of possible complex risk-factors leading to coagulopathy in a glioblastoma patient population it might be the case that IPC has little or no effect and that there is a different underlying mechanism responsible for the observed coagulopathy.

An international expert survey on acupuncture in randomized controlled trials for low back pain and a validation of the low back pain acupuncture score

BACKGROUND

Acupuncture is a promising treatment approach in patients with chronic low back pain (cLBP) but little is known about the quality of acupuncture in randomized controlled trials (RCT) of acupuncture cLBP. -

OBJECTIVE

To determine how international experts (IES) rate the quality of acupuncture in RCTs of cLBP; independent international validation of the Low Back Pain Acupuncture Score (LBPAS).

METHODOLOGY

Fifteen experts from 9 different countries outside China were surveyed (IES). They were asked to read anonymized excerpts of 24 RCTs of cLBP and answer a three-item questionnaire on how the method of acupuncture conformed to 1) Chinese textbook standards, 2) the expert?s personally preferred style, and 3) how acupuncture is performed in the expert?s country. Likert scale rating, calculation of the mode for each answer, and Spearman?s rank correlation coefficient between all three answers and the LBPAS were calculated.

RESULTS

On comparison with Chinese textbook standards (question 1), 6 RCTs received a good rating, 8 trials a fair and 10 trials a poor or very poor rating. 5 of the 6 trials rated good, received at least a good rating also in question 2 or 3. We found a high correlation of 0.85 (p<0.0001) between the IES and LBPAS ratings for question 1 and question 2, and a correlation of 0.66 (p<0.0001) for question 3.

CONCLUSION

The international expert survey (IES) revealed that only 6 out of 24 (25%) RCTs of acupuncture for cLBP were rated "good" in respect to Chinese textbook acupuncture standards. There were only small differences in how the acupuncture quality was rated in comparison to Chinese textbook acupuncture, personally preferred and local styles of acupuncture. The rating showed a high correlation with the Low Back Pain Acupuncture Score LBPAS.

High-affinity blockade of voltage-operated skeletal muscle and neuronal sodium channels by halogenated propofol analogues

BACKGROUND AND PURPOSE

Voltage-operated sodium channels constitute major target sites for local anaesthetic-like action. The clinical use of local anaesthetics is still limited by severe side effects, in particular, arrhythmias and convulsions. These side effects render the search for new local anaesthetics a matter of high interest.

EXPERIMENTAL APPROACH

We have investigated the effects of three halogenated structural analogues of propofol on voltage-operated human skeletal muscle sodium channels (Na(V)1.4) and the effect of one compound (4-chloropropofol) on neuronal sodium channels (Na(V)1.2) heterologously expressed in human embryonic kidney cell line 293.

KEY RESULTS

4-Iodo-, 4-bromo- and 4-chloropropofol reversibly suppressed depolarization-induced whole-cell sodium inward currents with high potency. The IC(50) for block of resting channels at -150 mV was 2.3, 3.9 and 11.3 microM in Na(V)1.4, respectively, and 29.2 microM for 4-chloropropofol in Na(V)1.2. Membrane depolarization inducing inactivation strongly increased the blocking potency of all compounds. Estimated affinities for the fast-inactivated channel state were 81 nM, 312 nM and 227 nM for 4-iodopropofol, 4-bromopropofol and 4-chloropropofol in Na(V)1.4, and 450 nM for 4-chloropropofol in Na(V)1.2. Recovery from fast inactivation was prolonged in the presence of drug leading to an accumulation of block during repetitive stimulation at high frequencies (100 Hz).

CONCLUSIONS AND IMPLICATIONS

Halogenated propofol analogues constitute a novel class of sodium channel-blocking drugs possessing almost 100-fold higher potency compared with the local anaesthetic and anti-arrhythmic drug lidocaine. Preferential drug binding to inactivated channel states suggests that halogenated propofol analogues might be especially effective in suppressing ectopic discharges in a variety of pathological conditions.

[Above elbow amputation due to acupuncture treatment?]

Opinions of acupuncture experts should always be sought in any lawsuit or claim for compensation involving sequelae of acupuncture treatment. Overall,--in the hands of experienced acupuncturists--acupuncture is very safe but not without minor adverse events. However, serious adverse events are extremely rare, especially the risk of a serious vascular lesion. In contrast, inflammatory bowel disease is an independent and disease specific risk factor for thromboembolism, especially if the disease is highly active.

[The endogenous cannabinoid system. Therapeutic implications for neurologic and psychiatric disorders]

For about 5,000 years, cannabis has been used as a therapeutic agent. There has been growing interest in the medical use of cannabinoids. This is based on the discovery that cannabinoids act with specific receptors (CB1 and CB2). CB1 receptors are located in specific brain areas (e.g. cerebellum, basal ganglia, and hippocampus) and CB2 receptors on cells of the immune system. Endogenous ligands of the cannabinoid receptors were also discovered (e.g. anandamids). Many physiologic processes are modulated by the two subtypes of cannabinoid receptor: motor functions, memory, appetite, and pain. These innovative neurobiologic/pharmacologic findings could possibly lead to the use of synthetic and natural cannabinoids as therapeutic agents in various areas. Until now, cannabinoids were used as antiemetic agents in chemotherapy-induced emesis and in patients with HIV-wasting syndrome. Evidence suggests that cannabinoids may prove useful in some other diseases, e.g. movement disorders such as Gilles de la Tourette's syndrome, multiple sclerosis, and pain. These new findings also explain the acute adverse effects following cannabis use.

[Accidental intraartrial injection of diacethylmorphine (heroin) in drug addicts -- three case reports]

Accidental intrarterial injections are not uncommon in medical treatments. This is also true for uncontrolled injections by drug-addicts. Since 2002 a number of 600 heavy opiate addicts in Germany are substituted in a country-wide study with pure diacetylmorphine (Heroine). We report the course and outcome of three cases of accidental intraarterial injections of pure diacetylmorphine under controlled conditions. After initial symptoms of vasospasms, all cases were without symptoms within one hour and no obvious loss of tissue was observed. After discussing the literature about medical literature and treatment options in intraarterial injections it is concluded, that the cause of major complications after intraarterial injections may not be the pure diacetylmorphine but additional substances in impure "street-heroin" samples.

Transdermal fentanyl: little absorption in two patients with systemic sclerosis?

Two patients suffering from systemic sclerosis (SSc) were treated with the 25 micro/hr transdermal fentanyl patch for pain from either deltoid muscle tendinitis of the left arm or from ischemia of the left-hand thumb. When the medication was changed to either oral morphine or oral methadone, the effects did not correspond to the drug conversion table. These findings suggest that patients with SSc and other systemic skin diseases may be at risk for limited absorption of transdermal fentanyl. In contrast, no restriction of the absorption of transdermal testosterone was observed.

Effect of acupuncture on the neutrophil respiratory burst: a placebo-controlled single-blinded study

OBJECTIVES

Little is known about the influence of acupuncture treatment on the phagocytic immune system. This trial was performed to examine whether multiple acupuncture treatment affects the respiratory burst (RB) of neutrophils, a recognised measure of their cytotoxicity.

DESIGN

Placebo-controlled single-blinded study.

INTERVENTIONS

Eleven volunteers were treated bilaterally with standard needles (real) at acupoint LI11, 11 volunteers with placebo needles (placebo) at the same point. Treatments were performed for 30 min each twice a week for 4 weeks, eight times in all. The standard needles were manipulated until needle sensation (DEQI) developed. Before the treatment course (baseline), 48 h after the fourth (follow-up 1) and 48 h after the last treatment (follow-up 2) blood samples were drawn.

MAIN OUTCOME MEASURES

RB and plasma beta-endorphin at each time point.

RESULTS

In the real group there was a highly significant increase in the RB at follow-ups 1 (P=0.004) and 2 (P=0.007). Beta-endorphin levels decreased, but not significantly. In the placebo group there was a significant increase in the RB at follow-up 2 (P=0.048). In addition, at follow-up 2 a significant drop in beta-endorphin levels was observed (P=0.015).

CONCLUSIONS

The RB of neutrophils is significantly activated by a course of several acupuncture treatments. In addition, psychological effects and a placebo that was not totally inert may contribute to the findings in the placebo group which may be mediated by the opiate endorphin system.

Chronic epicondylitis: effects of real and sham acupuncture treatment: a randomised controlled patient- and examiner-blinded long-term trial

OBJECTIVE

The clinical long-term effectiveness of real and sham acupuncture treatment on differentiated pain measurement was evaluated in chronic lateral epicondylitis, an example of a tendomyotic disorder.

METHODS

Randomised, examiner- and patient-blinded controlled clinical study.

OUTCOME MEASUREMENT

pain at rest, pain on movement, pain on exertion, frequency and duration of pain. Real acupuncture (n = 23) was tested versus invasive sham acupuncture (n = 22). Ten treatments were given (2 treatments/week). Patients were examined at baseline (E1) as well as 2 weeks (E2), 2 months (E3) and 1 year (E4) after the end of treatment. In the treatment with real acupuncture, acupuncture points were selected and mechanically stimulated while in the sham group non-acupuncture points were selected.

RESULTS

There was no significant difference between the groups at baseline for any outcome parameter. Two weeks, 2 months and 1 year after the end of treatment there were significant reductions in all pain variables compared to baseline. At the first follow-up, significant group differences were registered for pain on motion and pain on exertion in favour to the real acupuncture group. These differences in pain intensity between the groups were no longer significant at the 2 months and 12 months follow-ups.

CONCLUSION

The results suggest that, in the treatment of chronic epicondylitis, the selection of so-called real acupuncture points gives better results than invasive sham acupuncture at early follow-up. This additional effect can be interpreted as a specific effect of real acupuncture.

Acupuncture in chronic epicondylitis: a randomized controlled trial

OBJECTIVE

To evaluate the clinical efficacy of acupuncture in the treatment of chronic lateral epicondylitis.

METHODS

In a randomized, investigator- and patient-blinded, controlled clinical study, 23 patients were treated with real acupuncture and 22 patients received sham acupuncture. Patients each received 10 treatments, with two treatments per week. The primary outcome variables were maximal strength, pain intensity (verbal rating scale) and disability scale (Disabilities of the Arm, Shoulder and Hand questionnaire). Patients were examined at baseline (1 week before the start of treatment) and at follow-up 2 weeks and 2 months after the end of treatment.

RESULTS

There was no significant difference between the groups at baseline for any outcome parameter. Two weeks and 2 months after the end of treatment, there were significant reductions in pain intensity and improvements in the function of the arm and in maximal strength in both treatment groups. At the 2-week follow-up these differences were significantly greater for all outcome parameters in the group treated with real acupuncture. At 2 months the function of the arm was still better in this group than in the sham acupuncture group; however, the differences in pain intensity and maximal strength between the groups were no longer significant.

CONCLUSION

In the treatment of chronic epicondylopathia lateralis humeri, acupuncture in which real acupuncture points were selected and stimulated was superior to non-specific acupuncture with respect to reduction in pain and improvement in the functioning of the arm. These changes are particularly marked at early follow-up.

Credibility of a newly designed placebo needle for clinical trials in acupuncture research

OBJECTIVE

To test the credibility of a newly designed placebo needle for acupuncture research.

DESIGN

Analysis of data on credibility of true and placebo interventions of a randomised, placebo-controlled, patient- and evaluator-blind clinical trial.

PATIENTS AND SETTING

The study was carried out at a university department for physical medicine and rehabilitation. 68 patients (age 48.1 +/- 14.1 years, mean +/- SD) fulfilling the criteria of the International Headache Society for tension-type headache were enrolled into the study.

INTERVENTIONS

Group 1 (treatment) was assigned to traditional needle placement and manipulation, whereas in group 2 (control) a new placebo device was used.

OUTCOME PARAMETERS

After the first treatment with real or placebo acupuncture, patients were asked to fill in a questionnaire on credibility. In addition, after 3 or 4 treatments, patients were asked for the feeling of needle insertion and deqi.

RESULTS

No difference between real and placebo acupuncture was detected with respect to the credibility of the treatment (p > 0.05). Needle insertion was recognised in all patients in the real acupuncture group and in all but 4 patients of the placebo group (p < 0.05). deqi was reported by 84% of patients in the real acupuncture group and by 34% of patients in the placebo group (p < 0.001).

CONCLUSION

Acupuncture with the placebo needle device described here is of high credibility, and does not differ from that of real acupuncture treatment. However, to achieve comparable prick sensations in both treatment conditions, careful training with the placebo needle is needed. Furthermore, from these results arise new questions with respect to the placebo response of placebo needles. Further investigations are warranted to test if placebo needles are active controls.

Botulinum toxin type A and EMG: a key to the understanding of chronic tension-type headaches?

BACKGROUND

The pathogenesis of chronic tension-type headache remains unclear, and the role of muscle tension is especially controversial. Botulinum toxin type A, a potent inhibitor of muscle tone, has been used to treat chronic tension-type headache.

OBJECTIVE

To determine whether clinical response to treatment of chronic tension-type headache with Botox A parallels changes in resting muscle activity recorded through serial electromyography (EMG).

METHODS

We randomly assigned eight patients with chronic tension-type headache to pericranial injection of 500 MU Botox A versus placebo (isotonic saline).

RESULTS

At 6 and 12 weeks following treatment, there were no significant differences in clinical outcome between the placebo and the Botox A groups. This occurred despite EMG evidence of a reduction in resting muscle activity in the Botox A-treated patients.

CONCLUSION

These results support the hypothesis that peripheral mechanisms such as increased muscle tone play, at most, a minor role in the pathophysiology of chronic tension-type headache.

Needle acupuncture in tension-type headache: a randomized, placebo-controlled study

A study with needle acupuncture was performed in tension-type headache employing a new placebo acupuncture

METHOD

Sixty-nine patients (mean age 48.1 years, SD = 14.1) fulfilling the International Headache Society criteria for tension-type headache were randomly assigned to verum or placebo condition. No significant differences between placebo and verum with respect to visual analogue scale and frequency of headache attacks could be observed immediately, 6 weeks and 5 months after the end of treatment. There was a significant but weak improvement in quality of life parameters (clinical global impressions, Nottingham Health Profile) after verum treatment. In decision tree analyses, the changes in clinical global impressions and headache frequency depended significantly on primary headache frequency with a limit value of 24.5 days headache per month. High values in the von Zerssen Depression Score resulted in high mean visual analogue scale values.

Computerized tomography-guided epidural blood patch in the treatment of spontaneous low cerebrospinal fluid pressure headache

A 54-year-old woman suffering from migraine for 35 years was referred to the pain clinic with a changed pattern of headache that had developed over the last 6 weeks. The pain was located in the central forehead region; aggravation in the prone and immediate relief in the supine position led to the hypothesis of a spontaneous low cerebrospinal fluid (CSF) pressure headache. Cisternography revealed a cyst-like formation in the cervico-thoracic region, indicating cerebrospinal fluid leakage. Magnetic resonance imaging (MRI) myelography confirmed ventral leakage but failed to locate the exact site. Computerized tomography (CT)-guided epidural blood patching between T1 and T2 completely relieved the headache.

Coping strategies in episodic and chronic tension-type headache

OBJECTIVE

To study the importance of coping with illness strategies in tension-type headache (TTH).

BACKGROUND

The pathophysiology of TTH is complex, and coping with illness strategies might contribute to the transformation to a chronic form.

METHODS

We examined 89 subjects (mean age, 45.6 +/- 14.8 years; range, 18 to 72 years) with episodic (n = 37) and chronic (n = 52) TTH. Patients were required to fill in a Freiburg Questionnaire of Coping with Illness (FQCI), a von Zerssen Depression Scale, quality-of-life questionnaires, and a headache home diary (over 4 weeks). In addition, pressure pain thresholds (temporal muscles) and total tenderness scores were obtained.

RESULTS

Patients with chronic TTH exhibited poorer quality-of-life measures, slightly more depressive symptoms, and significantly stronger avoidance behavior and endurance strategies on FQCI scales F4 and F5 (P< .05). There was no difference between episodic and chronic TTH with respect to measures of muscle tenderness or pain thresholds.

CONCLUSIONS

We conclude that disadvantageous coping with illness strategies might contribute to a transformation to chronic TTH.

Effects of fentanyl and low doses of alcohol on neuropsychological performance in healthy subjects

The effects of the opioid fentanyl and low doses of alcohol on neuropsychological functions in healthy volunteers were measured. Twenty-four healthy male volunteers participated in this study. Two randomised placebo-controlled cross-over trials were conducted. In group 1, 6 subjects received fentanyl (0.2 microgram/kg body weight) in the order of fentanyl/placebo and 6 subjects in the order of placebo/fentanyl. Group 2 received alcohol in a similar procedure by continuous intravenous infusion, leading to a blood alcohol concentration (BAC) of 0.03%. Impairment was measured via different neuropsychological tests. The results indicate that fentanyl in concentrations commonly used in out-patient surgical procedures produces pronounced cognitive impairment (auditory reaction time, signal detection, sustained attention, recognition) in comparison to placebo. After application of low doses of alcohol (BAC 0.03%) only visual reaction time was impaired in comparison to placebo.

Effects of fentanyl on cellular immune functions in man

In order to analyze the effects of the opioid agonist fentanyl on cells of the innate immune system, seven healthy individuals were treated intravenously with the opioid fentanyl and five subjects received a placebo. Respiratory burst of polymorphonuclear cells (PMNC) and phenotypes of peripheral blood lymphocytes (PBL) were analyzed from blood samples drawn before, 15 and 30 min after fentanyl or placebo application. In addition, in vitro effects of fentanyl on natural killer (NK) activity was assessed. Fentanyl administration affected neither superoxide production of PMNC nor circulating numbers of B-and T-lymphocytes. In contrast, NK cell (CD16+/CD56+) numbers significantly increased in response to fentanyl. However, no direct influence of fentanyl on NK cell function in vitro could be detected. These results suggest a transient effect of fentanyl on NK cell circulation which seemed to be centrally mediated rather than a direct effect of this opioid on NK cells.

Treatment of severe injuries caused by attempted suicide: pattern of injury and influence of the psychiatric disorder on the postoperative course

OBJECTIVE

To assess the influence of psychiatric disorders on the treatment and postoperative course of patients severely injured as a result of attempted suicide.

DESIGN

Retrospective case study.

SETTING

University hospital, Germany.

SUBJECTS

36 patients who had multiple injuries after attempting suicide during the five year period 1991-95.

INTERVENTIONS

Operative and psychiatric treatment.

MAIN OUTCOME MEASURE

Functional results assessed with the Trauma Outcome Profile (TOP) score, psychiatric state, and risk of further suicide attempts.

RESULTS

30 of the 36 patients attempted suicide by jumping from a height, and the most common injuries were fractures of the spine (n = 33) and lower limbs (n = 43). All patients had a psychiatric disorder, and 18 had previously attempted suicide at least once though had inflicted only minor injuries. 29 of the 36 were receiving psychiatric care at the time of the suicide attempt. Five patients died. 27 of the 31 survivors were available for follow up and 26 of them had good or excellent functional results. 30 of the 31 underwent psychiatric assessment (one refused) and none was judged to be at risk of a further attempt.

CONCLUSIONS

The functional results were better than we expected. The psychological effect of severe injuries and a long hospital stay seems to reduce the risk of a further attempt, so all treatment (both surgical and psychiatric) is worthwhile.