Rachel Slangen

Spinal Cord Stimulation and Pain Relief in Painful Diabetic Peripheral Neuropathy: A Prospective Two-Center Randomized Controlled Trial

OBJECTIVE Painful diabetic peripheral neuropathy (PDPN) is a common complication of diabetes mellitus. Unfortunately, pharmacological treatment is often partially effective or accompanied by unacceptable side effects, and new treatments are urgently needed. Small observational studies suggested that spinal cord stimulation (SCS) may have positive effects. RESEARCH DESIGN AND METHODS We performed a multicenter randomized clinical trial in 36 PDPN patients with severe lower limb pain not responding to conventional therapy. Twenty-two patients were randomly assigned to SCS in combination with the best medical treatment (BMT) (SCS group) and 14 to BMT only (BMT group). The SCS system was implanted only if trial stimulation was successful. Treatment success was defined as ≥50% pain relief during daytime or nighttime or “(very) much improved” for pain and sleep on the patient global impression of change (PGIC) scale at 6 months. RESULTS Trial stimulation was successful in 77% of the SCS patients. Treatment success was observed in 59% of the SCS and in 7% of the BMT patients (P < 0.01). Pain relief during daytime and during nighttime was reported by 41 and 36% in the SCS group and 0 and 7% in the BMT group, respectively (P < 0.05). Pain and sleep were “(very) much improved” in 55 and 36% in the SCS group, whereas no changes were seen in the BMT group, respectively (P < 0.001 and P < 0.05). One SCS patient died because of a subdural hematoma. CONCLUSIONS Treatment success was shown in 59% of patients with PDPN who were treated with SCS over a 6-month period, although this treatment is not without risks.

Sustained Treatment Effect of Spinal Cord Stimulation in Painful Diabetic Peripheral Neuropathy: 24-Month Follow-up of a Prospective Two-Center Randomized Controlled Trial

Spinal cord stimulation (SCS) has been demonstrated to serve as a successful second-line treatment modality for painful diabetic peripheral neuropathy (PDPN), as documented in two randomized clinical trials (RCTs) (1,2). Besides the fact that these two RCTs demonstrate a pain-relieving effect for a period of 6 months after the start of SCS treatment, only small observational studies suggest a long-term sustained effect in PDPN (3–5). In this article, we present the 24-month follow-up data of our recently published RCT in Diabetes Care (1). Thirty-six patients were enrolled in this study, and after randomization, 22 patients with PDPN in the lower limbs (15 male, mean age 57.1 years [SD 12.4], years of PDPN 6.0 [SD 5.1]) were assigned to the SCS group. A 2-week trial stimulation was performed to evaluate sufficient pain relief. After 6 …

Sustained effect of spinal cord stimulation on pain and quality of life in painful diabetic peripheral neuropathy

References 1 Alper KR, Lotsof HS, Frenken GMN, et al. Treatment of acute opiod withdrawal with ibogaine. Am J Addict 1999; 8: 234–42 2 Mash DC, Kovera CA, Pablo J, et al. Ibogaine: complex pharmacokinetics, concerns for safety and preliminary efficacy measures. Ann N Y Acad Sci 2000; 914: 394–401 3 Hoelen DWM, Spiering W, Valk GD. Long QT syndrome induced by the antiaddiction drug ibogaine. N Engl J Med 2009; 360: 308–9 4 BBC News Magazine, April 2012. Available at http://www.bbc.co. uk/news/magazine-17666589

Increased Contact Heat Evoked Potential Stimulation Latencies in Responders to Spinal Cord Stimulation for Painful Diabetic Polyneuropathy

To analyze sensory characteristics and small nerve fiber function in patients suffering from painful diabetic polyneuropathy (PDP) and compare outcomes in responders and nonresponders to SCS treatment.

Severity of Neuropathy Is Associated With Long-term Spinal Cord Stimulation Outcome in Painful Diabetic Peripheral Neuropathy: Five-Year Follow-up of a Prospective Two-Center Clinical Trial

OBJECTIVE Evidence from prospective studies for long-term treatment efficacy of spinal cord stimulation (SCS) in painful diabetic peripheral neuropathy (PDPN) is not available. We report prospective data on the effect of SCS on pain ratings, treatment success and failure, and complications during a 5-year follow-up in patients with PDPN. RESEARCH DESIGN AND METHODS Patients with PDPN (n = 48) were included in this prospective multicenter study. The Michigan Diabetic Neuropathy Score (MDNS) was used to assess the severity of neuropathy. Numerical rating scale (NRS) score for pain, Patient’s Global Impression of Change (PGIC), and treatment success (50% reduction of NRS score or significant PGIC) during 5 years of follow-up were evaluated. Complications of SCS were reported, and associations between baseline characteristics and SCS trial success or failure during a 5-year follow-up were investigated by using survival analyses. RESULTS Treatment success was observed in 55% of patients after 5 years. Median duration of SCS treatment was 60 months (minimum 1 month, maximum 60 months), and 80% of patients with a permanent implant still used their SCS device after 5 years. Higher MDNS was associated with treatment failure during the 5-year follow-up (hazard ratio 3.9 [95% CI 1.3–11.6]; P = 0.014). CONCLUSIONS SCS is successful in reducing chronic pain symptoms in the lower extremities of patients with PDPN up to 5 years after initiation of treatment. Furthermore, 80% of patients with PDPN still use their SCS device after 5 years. Moreover, the severity of neuropathy is associated with a higher chance of long-term treatment failure during a 5-year follow-up.

Cervical dizziness: the Hautant procedure in normal and whiplash-associated-disorder subjects

Abstract Introduction In general practice, dizziness is one of the most frequently reported complaints. Dizziness, as a part of other clinical syndromes, is found in 16% of patients and is frequently associated with whiplash-associated disorders (WAD). In manual/musculoskeletal medicine the Hautant procedure has been advocated as a test for disturbed neck proprioception. The main aim of the present study was to evaluate in a quantitative way the reproducibility of Hautants procedure in normal subjects. Patients and methods Ten healthy subjects, all women, participated in the reproducibility study with a mean age of 23.3 (range 18–28, SD 3.3). Nine subjects, who were diagnosed with WAD grade II, were included with a mean age of 33 (range 17–42, SD 15.6) and contained four male and five female subjects. Arm motion patterns in combination with a particular head movement were registered with a 3 Space Inside Track HP. A neutral-positioned receiver was attached to the ceiling, which quantified arm motion in the frontal sagittal and transversal planes, y, z, and yaw values, respectively. Results Of the 42 absolute differences in the y, z, and yaw values, 40 were reproducible. No particular motion pattern in combination with a particular head movement was seen, either in normal subjects or WAD II patients. Conclusions Based on our results, the Hautant test, as we performed it, is reproducible. In the original paper, Hautant used his test as a vestibular one and made no relation at all with cervical propriocepsis. Since no differences were found between normal subjects and WAD II patients, in clinical practice the diagnostic value of the Hautant test is very low.

Impact of muscle contraction upon head stabilisation during forward acceleration

Abstract Introduction: The impact of muscle contraction upon head movements induced by a forward acceleration was studied as a model for low impact car-accidents. The purpose of our research is to examine: (i) whether and by which mechanism neck muscle contraction is induced after onset of the movement; and (ii) if voluntary neck muscle contraction prior to the movement affects head motion. Subjects and methods: Eight healthy volunteers (mean age 21.4 years) were included in this study. Volunteers were sitting on a standard car seat mounted on a sled. The computer-controlled, motor-driven sled was forward accelerated with 0.6 g. In test series 1, head and body movement were detected with a standard video camera (20 ms per frame) and accelerometers mounted on the head without interference with muscle activity. Muscle activation was detected by simultaneous measurement of surface EMG of m. splenius capitis, m. trapezius (descending part), m. scalenis medius, m. sternocleido mastoideus, m. digastricus (anterior belly), m. mylohyoideus, m. pectoralis major, m. quadriceps, tibialis anterior and triceps surae. The subjects movements and muscle activity were examined during forward sled acceleration when: (i) the subjects were relaxed and could not anticipate the precise start of sled acceleration; (ii) when they contracted all body muscles for about 4 s prior to and during the sled acceleration; and (iii) when head and trunk were fixed to the chair. The same subjects were accelerated in test series 2, but now head and trunk movements were measured with a better time resolution by use of a high-speed video camera (500 Hz) and accelerometers mounted on the head (bite board), body and sled. Head and body movements were measured under conditions 1 and 2 as described above. Reproducibility was tested by repeating each test condition once, including repositioning of the subjects, the accelerometers and body fixed sell spot markers. Results and conclusions: The current experimental set-up allows a low-cost evaluation of head and body movements induced by low impact velocity impulses. We observed that sudden whole body acceleration induces head accelerations that exceed the acceleration of the impact by a factor of 2–3-fold. After the impact, the head first remains stationary in space while the sled and trunk move forward (relative head and upper trunk translation). Subsequently, head and trunk rotate backwards, ultimately followed by an additional retroflexion of the head alone. Precontraction and anticipation of the impact leads to a faster increase of general muscle tone. It does not affect the initial translation but leads to a reduction of about 30–35% of head rotations and head angular velocities. The muscle contraction is most like a generalised alerting response. It should be noted that the current results were obtained at a loading level of 0.7 g, which is far below the 5–12 g levels observed in rear-end collisions. Since the current study shows only small influences of the muscle contraction, it is assumed that the contraction will not be strong enough to limit the larger head and trunk motion with greater impacts and does not reduce the probability of getting a whiplash injury.