Innovations In Clinical Neuroscience

Pain Management August 2016

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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researchers sought to determine if lack of complete pain relief despite unlimited access to opioid therapy was related specifically to the study or represented a phenomenon among chronic cancer pain sufferers in general. The investigators systemically reviewed all published opioid trials in chronic cancer pain patients to assess pain scores and determine if pain free status was achieved. Inclusion criteria comprised opioid therapy, cancer pain, clinical trial, and pain scores (NPS, VAS only) and exclusion criteria comprised non- malignant pain, studies that did not have unlimited access to PRN opioids, and pain measures like Likert, Faces scale, observer rating, and categorical. The primary outcome measures were VAS or NPS scores before and after intervention. Additional data collected were gender, age, opioid type, dose, patient satisfaction, and study types. The researchers found 62 published papers of clinical trials of opioid therapy for the treatment of chronic cancer pain for a total of 5,251 patients, with a weighted mean pain score at the start of 5.4 (0=no pain; 10=worst possible pain) and a weighted mean pain score at the end of 2.7. Their analysis revealed that cancer patients with chronic pain do not titrate themselves to 0/10 relief despite unlimited access to opioids, and that the mean pain score was close to the moderate-severe rating, which is higher than what most providers would suggest is reasonable and recommended. The researchers hypothesized that patients may be balancing analgesia with unwanted opioid adverse effects, which may be why any final pain score greater than 0, i.e., ≥1/10 (0 being the goal of most practitioners) was not being achieved. ÎPoster #867 Development of a Milestones Based Chronic Pain Curriculum with Pain-centric Assessment Tools Mordechai Bronner, Melissa Davidson, and Clarence Ivie Summary: Chronic Pain Management (CPM) rotation is an Accreditation Council for Graduate Medical Education (ACGME) requirement for anesthesiology residency. Through a literature search, these presenters found a lack of validated tools to assess performance in CPM, and thus developed a set of tools for use in the first CPM rotation. In this review, the authors describe the process of a) revising rotation objectives, and b) creating tools with focus on pain-centric history and physical (H&P) and procedural skills in interventional pain management. The authors postulate that since residents get 1 to 2 months of CPM exposure, these tools will eventually help determine the average number of procedures and patient interview observations needed to attain competency. ÎPoster #921 Anodal Transcranial Direct Current Stimulation for Treatment-resistant Chronic Foot Pain: A Pilot Study Anaida Abagyan, Bahaa Amer, Dhaval Patel, Erato Giokas, Michael Paula, Tyrone Mayorga, Yasmin Sarraf, and Fortunato Battaglia from New York College of Podiatric Medicine Summary: Here researchers investigated the effect of primary motor cortex (M1) anodal transcranial direct current stimulation (tDCS) treatment on pain intensity, pain-related anxiety, depression, and disability in patients with chronic lower extremities pain in 10 elderly patients with symptomatic treatment- resistant plantar fasciitis. Using a pair of saline-soaked surface sponge electrodes to transfer the tDCS, the anode electrode was placed over the leg motor area contralateral to the symptomatic foot and the cathode electrode was placed over the supraorbital area contralateral to the stimulated motor cortex. Investigators administered a constant current of 2mA intensity 20 minutes daily for five consecutive days. They obtained outcome measures at baseline (T0), at the end of the tDCS protocol (T1), after a follow-up period of one week (T2) and four weeks (T3) and assessed effect of tDCS on pain intensity and on foot functions using the Visual Analog Scale (VAS) for pain and the Foot Function Index (FFI). They administered Pain Anxiety Symptoms Scale-20 (PASS-20) for the evaluation of the anxiety responses specific to pain and assessed depressive symptoms with the Hamilton Depression Rating Scale 17 items (HDRS). They asked patients to keep a pain medication use diary. Researchers found that anodal tDCS treatment was associated with a significant decrease in pain intensity (p<0.0001), FFI (p<0.0001), and PASS-20 (p<0.0001) scores, which lasted up to four weeks after treatment. They also saw a significant decrease in pain medication intake(p<0.0001); however, there was no significant effect on depressive symptoms. The researchers postulate that through a change to the state of local cortical excitability, the reduction of the pain intensity after this treatment might be related to an up- regulation of motor cortex activity, and that modulation of the N-methyl-D-aspartate receptors and neuroplasticity might be involved in the therapeutic neuromodulation of pain perception. They conclude anodal tDCS of the primary motor cortex in elderly patients with chronic lower extremity pain may be a safe and effective treatment to control pain intensity and psychiatry comorbidity. ÎPoster #1022 The Endocannabinoid System: Current Knowledge and Future Directions Dennis Gray with University of Texas Medical Branch Summary: Here, the presenter reviewed endocannabinoid system and its importance in pain medicine now and into the future. Mechanisms of action, downstream effects, peripheral and central distribution, endogenous ligands, and metabolism of such ligands of endocannabinoids are discussed. Manipulation of the endocannabinoid system to provide novel targets for drug discovery that will minimize central psychiatric side-effects while suppressing pain signaling at almost every level of nociceptive processing are reviewed. D Hot Topics in Pain Management [August 2016] 8 14 th Annual Pain Medicine Meeting Selected Poster Highlights

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