Complex regional pain syndrome of the foot and its management using spinal cord stimulation

Background: This article discusses neuropathic foot pain with particular reference to complex regional pain syndrome. It provides recommendations for the clinical evaluation of complex regional pain syndrome and highlights the value of spinal cord stimulation in its management. The aim is to review neuropathic foot pain in complex regional pain syndrome and outline its management using spinal cord stimulation. It is important for Podiatrists managing such patients to have an understanding of this treatment modality. Methods: A narrative literature review was undertaken using English language medical databases combining search strategies for complex regional pain syndrome and spinal cord stimulation. Results: Spinal cord stimulation improves the subjective symptoms of the neuropathic foot pain of complex regional pain syndrome, enables objective functional improvement and reduces analgesic consumption. Conclusion: Recent technical developments in spinal cord stimulation have led to improved stimulation patterns adapted to the patients’ needs. Careful preoperative diagnosis, robust patient selection and frequent follow-up are vital for the success of this method

Use of spinal cord stimulation in managing neuropathic foot pain: an observational pilot case series study

Objective: In cases of complex regional pain syndrome where conservative treatment is unsuccessful in controlling neuropathic foot pain spinal cord stimulation may be considered. To our knowledge there have been no such cases reported in the foot & ankle literature. The aim of the study was to establish useful information that may supplement our understanding of this complex multifactorial problem and help toinform future management of similar cases. Methods: A pilot observational case series study was undertaken to investigate the use of spinal cord stimulation in the management of neuropathic foot pain using five cases with complex regional pain syndrome (type I). Results: Reduced pain following spinal cord stimulation was reported. The interval between diagnosis and commencement of spinal cord stimulation was variable between cases and maybe responsible for differing levels and timing of pain relief experienced. Conclusion: Careful preoperative diagnosis, robust patient selection and close postoperative monitoring are vital for a successful outcome. The small sample size and potential for bias, limit the generalizability to a larger population. A larger study is therefore indicated to expand upon preliminary findings

Intrathecal drug delivery systems for the management of chronic non-cancer pain : a systematic review of economic evaluations

Background: Intrathecal drug delivery (ITDD) systems are one of a limited number of management options for chronic non-cancer pain, cancer pain and spasticity. Concerns over their effectiveness and high initial costs led NHS England to decommission ITDD for patients with chronic non-cancer pain. However, the extent to which this decision is in line with existing economic evidence is unclear. The aim of this systematic review is to identify and review the existing evidence on the cost-effectiveness of ITDD for chronic non-cancer pain. Methods: Full and partial economic evaluations on ITDD were identified through systematic searches in MEDLINE, EMBASE, Web of Science and the National Health Service Centre for Reviews and Dissemination databases. Database searches were complemented by hand searching of reference lists of relevant studies and searches of grey literature. Study selection was carried out by two assessors, independently. Study quality assessment was performed to inform critical appraisal of health economics studies. Data were extracted using a data extraction form developed for this study. Results: 4464 unique studies were identified, of which seven met the inclusion criteria. With the exception of one study, the studies found ITDD to be either cost-saving or cost-effective compared to conventional medical management. ITDD becomes cost-ineffective in one further study following price year adjustment to 2016. Conclusions: Study findings show ITDD as not cost-effective only in extremely conservative scenarios. There is limited evidence on the effectiveness of ITDD in non-cancer pain; however, the available economic evidence controverts arguments to refute the treatment on economic grounds

Intrathecal drug delivery for the management of pain and spasticity in adults: an executive summary of the British Pain Society’s recommendations for best clinical practice

This article provides a summary of the updated British Pain Society Guidance on Intrathecal Drug Delivery for the management of pain and spasticity in adults. We aim to highlight the areas of the guidance that have been updated and to provide a concise summary

Analysis of psychological characteristics impacting spinal cord stimulation treatment outcomes:a prospective assessment

Background: Psychological factors are recognised as influencing the outcome of spinal cord stimulation (SCS) although there is currently no consensus as to which factors impact upon SCS efficacy. Objective: To identify psychological characteristics that may impact the efficacy of SCS. Study Design: Prospective evaluation. Setting: Single secondary care center in Dudley, United Kingdom. Methods: Patients: Seventy-five patients were initially recruited and 56 patients (31 women and 25 men) were followed-up for 12-months. Intervention: SCS for the management of chronic non-cancer pain. Main Outcome Measures: Outcome measures assessed at baseline, 6 months, and 12 months following SCS implantation included the visual analogue scale (VAS), Oswestry disability index (ODI), hospital anxiety and depression (HAD) scale, and the pain coping strategies questionnaire (PCSQ). Results: Statistically significant improvements were observed for the VAS (P < 0.001), ODI (P = 0.011), anxiety (P = 0.042), and depression (P = 0.010) in the HAD scale and for the subscales reinterpreting pain sensation (P = 0.018), control over pain (P = 0.001), and ability to decrease pain (P < 0.001) of the PCSQ. We observed that depression and autonomous coping (control over pain, ability to reduce pain, and catastrophizing) may impact sensory aspects such as pain intensity and disability scores affecting the outcome of SCS treatment. Age at time of implant and duration of pain prior to implant were also found to impact SCS efficacy. Limitations: It has been reported that loss of analgesia may be experienced within 12 to 24 months following SCS implantation and therefore, it would be of interest to follow patients over a longer period. Conclusions: This study demonstrates that psychological aspects such as depression and autonomous coping may impact SCS treatment. Addressing these issues prior to SCS implantation may improve SCS long-term outcome. © 2015, American Society of Interventional Pain Physicians. All Rights Reserved

The Effectiveness and Cost-Effectiveness of Spinal Cord Stimulation for Refractory Angina (RASCAL Study): A Pilot Randomized Controlled Trial

Background: Patients with “refractory angina” (RA) unsuitable for coronary revascularization experience high levels of hospitalization and poor health‐related quality of life. Randomized trials have shown spinal cord stimulation (SCS) to be a promising treatment for chronic stable angina and RA; however, none has compared SCS with usual care (UC). The aim of this pilot study was to address the key uncertainties of conducting a definitive multicenter trial to assess the clinical and cost‐effectiveness of SCS in RA patients, i.e., recruitment and retention of patients, burden of outcome measures, our ability to standardize UC in a UK NHS setting. Methods: RA patients deemed suitable were randomized in a 1:1 ratio to SCS plus UC (SCS group) or UC alone (UC group). We sought to assess: recruitment, uptake, and retention of patients; feasibility and acceptability of SCS treatment; the feasibility and acceptability of standardizing UC; and the feasibility and acceptability of the proposed trial outcome measures. Patient outcomes were assessed at baseline (prerandomization) and three and six months postrandomization. Results: We failed to meet our planned recruitment target (45 patients) and randomized 29 patients (15 SCS group, 14 UC group) over a 42‐month period across four sites. None of the study participants chose to withdraw following consent and randomization. With exception of two deaths, all completed evaluation at baseline and follow‐up. Although the study was not formally powered to compare outcomes between groups, we saw a trend toward larger improvements in both primary and secondary outcomes in the SCS group. Conclusions: While patient recruitment was found to be challenging, levels of participant retention, outcome completion, and acceptability of SCS therapy were high. A number of lessons are presented in order to take forward a future definitive pragmatic randomized trial

Same Performance Changes after Live High-Train Low in Normobaric vs. Hypobaric Hypoxia.

PURPOSE: We investigated the changes in physiological and performance parameters after a Live High-Train Low (LHTL) altitude camp in normobaric (NH) or hypobaric hypoxia (HH) to reproduce the actual training practices of endurance athletes using a crossover-designed study. METHODS: Well-trained triathletes (n = 16) were split into two groups and completed two 18-day LTHL camps during which they trained at 1100-1200 m and lived at 2250 m (P i O2 = 111.9 ± 0.6 vs. 111.6 ± 0.6 mmHg) under NH (hypoxic chamber; FiO2 18.05 ± 0.03%) or HH (real altitude; barometric pressure 580.2 ± 2.9 mmHg) conditions. The subjects completed the NH and HH camps with a 1-year washout period. Measurements and protocol were identical for both phases of the crossover study. Oxygen saturation (S p O2) was constantly recorded nightly. P i O2 and training loads were matched daily. Blood samples and VO2max were measured before (Pre-) and 1 day after (Post-1) LHTL. A 3-km running-test was performed near sea level before and 1, 7, and 21 days after training camps. RESULTS: Total hypoxic exposure was lower for NH than for HH during LHTL (230 vs. 310 h; P &lt; 0.001). Nocturnal S p O2 was higher in NH than in HH (92.4 ± 1.2 vs. 91.3 ± 1.0%, P &lt; 0.001). VO2max increased to the same extent for NH and HH (4.9 ± 5.6 vs. 3.2 ± 5.1%). No difference was found in hematological parameters. The 3-km run time was significantly faster in both conditions 21 days after LHTL (4.5 ± 5.0 vs. 6.2 ± 6.4% for NH and HH), and no difference between conditions was found at any time. CONCLUSION: Increases in VO2max and performance enhancement were similar between NH and HH conditions

Validation of a sea lice dispersal model : principles from ecological agent-based models applied to aquatic epidemiology

Sea lice are one of the most economically costly and ecologically concerning problems facing the salmon farming industry. Here, we validated a coupled biological and physical model that simulated sea lice larvae dispersal from salmon farms in the Broughton Archipelago (BA), British Columbia, Canada. We employed a concept from ecological agent-based modeling known as ‘pattern matching’, which identifies similar emergent properties in both the simulated and observed data to confirm that the simulation contained sufficient complexity to recreate the emergent properties of the system. One emergent property from the biophysical simulations was the existence of sub-networks of farms. These were also identified in the observed sea lice count data in this study using a space−time scan statistic (SaTScan) to identify significant spatio-temporal clusters of farms. Despite finding support for our simulation in the observed data, which consisted of over a decade’s worth of monthly sea lice abundance counts from salmon farms in the BA, the validation was not entirely straightforward. The complexities associated with validating this biophysical dispersal simulation highlight the need to further develop validation techniques for agent-based models in general, and biophysical simulations in particular, which often result in patchiness in their dispersal fields. The methods utilised in this validation could be adopted as a template for other epidemiological dispersal models, particularly those related to aquaculture, which typically have robust disease monitoring data collection plans in place

Similar Hemoglobin Mass Response in Hypobaric and Normobaric Hypoxia in Athletes

Purpose: To compare hemoglobin mass (Hbmass) changes during an 18-day live high-train low (LHTL) altitude training camp in normobaric hypoxia (NH) and hypobaric hypoxia (HH). Methods: Twenty-eight well-trained male triathletes were split into three groups (NH: n = 10, HH: n = 11, control (CON): n = 7) and participated in an 18-day LHTL camp. NH and HH slept at 2250 m while CON slept and all groups trained at altitudes 0.08) and remained unchanged in CON (+0.2%, P = 0.89). Conclusion: HH and NH evoked similar Hbmass increases for the same hypoxic dose and after 18-day LHTL. The wide variability in individual Hbmass responses in HH and NH emphasize the importance of individual Hbmass evaluation of altitude training.This study was financially supported by the Federal Office of Sport (FOSPO; Switzerland) and by the Ministère des Sports, de la Jeunesse, de l’Education Populaire et de la Vie Associative (MSJEPVA)/Institut National du Sport, de l’Expertise et de la Performance (INSEP, France)