The effect of stimulus frequency on the analgesic response to percutaneous electrical nerve stimulation in patients with chronic low back pain. Frequency and Characteristics of Side Effects of Spinal Manipulative Therapy The prevalence and characteristics of fibromyalgia in the general population. Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica Pain epidemiology and health related quality of life in chronic non-malignant pain patients referred to a Danish multidisciplinary pain center Nonsteroidal antiinflammatory drugs and acute renal failure in elderly persons. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. Electroacupuncture in fibromyalgia: results of a controlled trial. Central nervous pathway for acupuncture stimulation: localization of processing with functional MR imaging of the brain--preliminary experience. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Measuring physical function in community-dwelling older persons: a comparison of self-administered, interviewer-administered, and performance-based measures. Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study. Attention and somatic awareness in chronic pain Care‐Seeking Among Individuals With Chronic Low Back Pain Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists Depression and the Experience of Chronic Back Pain: A Study of Related Variables and Age Differences
UNLABELLED Low back pain ( LBP ) is one of the most common medical problems in our society . Increasingly , patients are turning to nonpharmacologic analgesic therapies such as percutaneous electrical nerve stimulation ( PENS ) . We design ed this sham-controlled study to compare the effect of three different frequencies of electrical stimulation on the analgesic response to PENS therapy .  Sixty-eight consenting patients with LBP secondary to degenerative lumbar disc disease were treated with PENS therapy at 4 Hz , alternating 15 Hz and 30 Hz ( 15/30 Hz ) , and 100 Hz , as well as sham-PENS ( 0 Hz ) , according to a r and omized , cross-over study design . Each treatment was administered for a period of 30 min three times per week for 2 wk . The pre- and posttreatment assessment s included the health status survey short form and visual analog scales for pain , physical activity , and quality of sleep . After receiving all four treatments , patients completed a global assessment question naire . The sham-PENS treatments failed to produce changes in the degree of pain , physical activity , sleep quality , or daily intake of oral analgesic medications . In contrast , 4-Hz , 15/30-Hz , and 100-Hz stimulation all produced significant decreases in the severity of pain , increases in physical activity , improvements in the quality of sleep , and decreases in oral analgesic requirements ( P < 0.01 ) . Of the three frequencies , 15/30 Hz was the most effective in decreasing pain , increasing physical activity , and improving the quality of sleep ( P < 0.05 ) . In the global assessment , 40 % of the patients reported that 15/30 Hz was the most desirable therapy , and it was also more effective in improving the patient 's sense of well-being . We conclude that the frequency of electrical stimulation is an important determinant of the analgesic response to PENS therapy . Alternating stimulation at 15-Hz and 30-Hz frequencies was more effective than either 4 Hz or 100 Hz in improving outcome measures in patients with LBP . IMPLICATION S The frequency of electrical stimulation seems to be an important determinant of the analgesic efficacy of percutaneous electrical nerve stimulation . Mixed low- and high-frequency stimulation was more effective than either low or high frequencies alone in the treatment of patients with low back pain Study Design . A prospect i ve clinic‐based survey . Objectives . To study the type , frequency , and characteristics of unpleasant side effects after spinal manipulative therapy . Summary of Background Data . Spinal manipulative therapy is a commonly used treatment , but there is little knowledge of its side effects . Methods . Information regarding unpleasant reactions after spinal manipulative therapy was collected after 4712 treatments on 1058 new patients by 102 Norwegian chiropractors ( response rate , 70 % ) through structured interviews . Results . At least one reaction was reported by 55 % of the patients some time during the course of a maximum of six treatments . Of the reported reactions , the most common were local discomfort ( 53 % ) , headache ( 12 % ) , tiredness ( 11 % ) , or radiating discomfort ( 10 % ) . Reactions were mild or moderate in 85 % of patients . Sixty‐four percent of reactions appeared within 4 hours of treatment , and 74 % had disappeared within 24 hours . Uncommon reactions were dizziness , nausea , hot skin , or " other " complaints , each accounting for 5 % or less of reactions . It was unusual that symptoms commenced later than on the day of or the day after treatment , were of long duration ( not gone at the latest on the day after onset ) , described as severe , or that they result ed in reduced activities of daily living . There were no reports of serious complications in this study . Conclusions . Profiles now are described of common and uncommon reactions to spinal manipulative therapy and their latency , duration , and severity OBJECTIVE To determine the prevalence and characteristics of fibromyalgia in the general population . METHODS A r and om sample of 3,006 persons in Wichita , KS , were characterized according to the presence of no pain , non-widespread pain , and widespread pain . A sub sample of 391 persons , including 193 with widespread pain , were examined and interviewed in detail . RESULTS The prevalence of fibromyalgia was 2.0 % ( 95 % confidence interval [ 95 % CI ] 1.4 , 2.7 ) for both sexes , 3.4 % ( 95 % CI 2.3 , 4.6 ) for women , and 0.5 % ( 95 % CI 0.0 , 1.0 ) for men . The prevalence of the syndrome increased with age , with highest values attained between 60 and 79 years ( > 7.0 % in women ) . Demographic , psychological , dolorimetry , and symptom factors were associated with fibromyalgia . CONCLUSION Fibromyalgia is common in the population , and occurs often in older persons . Characteristic features of fibromyalgia -- pain threshold and symptoms -- are similar in community and clinic population s , but overall severity , pain , and functional disability are more severe in the clinic population Sciatica is a common pain problem and current pharmacologic therapies have proven inadequate for many patients . The objective of this sham-controlled investigation was to compare a novel non-pharmacologic technique , percutaneous electrical nerve stimulation ( PENS ) , to transcutaneous electrical nerve stimulation ( TENS ) in the management of the radicular pain associated with sciatica . Sixty-four consenting patients with sciatica due to lumbar disc herniation were treated with PENS , TENS and sham-PENS according to a r and omized , single-blinded , cross-over study . All patients had been maintained on a stable oral non-opioid analgesic regimen for at least 6 weeks prior to entering the study . Each treatment modality was administered for a period of 30 min three times per week for 3 weeks , with 1 week ' off ' between each modality . Both PENS and TENS treatments were administered using a stimulation frequency of 4 Hz . The pre-treatment assessment included the health status survey short form ( SF-36 ) , as well as visual analog scales ( VAS ) for radicular pain , physical activity and quality of sleep . The pain VAS was also repeated after each treatment session . At the end of each 3-week treatment block , the SF-36 was repeated . After receiving all three treatment modalities , a global assessment question naire was completed . Both PENS ( 42 % ) and TENS ( 23 % ) were significantly more effective than the sham ( 8 % ) treatments in decreasing VAS pain scores . The daily oral analgesic requirements were also significantly reduced compared to the pre-treatment values with PENS ( P<0.01 ) and TENS ( P<0.05 ) . However , PENS was significantly more effective than TENS ( and sham-PENS ) in improving physical activity and quality of sleep . The SF-36 evaluation confirmed the superiority of PENS ( versus TENS and sham-PENS ) with respect to post-treatment functionality . In the overall assessment , 73 % of the patients reported that PENS was the most desirable modality ( versus 21 % for TENS and 6 % for sham-PENS ) . Finally , 71 % of the patients stated that they would be willing to pay extra to receive PENS therapy compared to 22 % and 3 % for TENS and sham-PENS , respectively . In this sham-controlled study , we concluded that PENS was more effective than TENS when administered at a stimulation frequency of 4 Hz in providing short-term pain relief and improved functionality in patients with sciatica & NA ; This paper presents the results of a detailed study of the pain epidemiology and health related quality of life ( HRQL ) in 150 chronic non‐malignant pain patients consecutively referred to a Danish multidisciplinary pain center . Mean pain severity was 71.6 ( SD=18.5 ) on the VAS scale . Forty‐two percent reported poor quality of sleep . HRQL was evaluated with the Medical Outcome Study ‐Short Form ( SF‐36 ) , the Hospital Anxiety and Depression scale ( HAD ) and the Psychological General Well‐Being Scale ( PGWB ) . Compared with the normal population ( NP ) both SF‐36 scores and PGWB scores were significantly reduced ( P<0.001 ) indicating that physical , psychological and social well‐being were severely reduced . On the HAD scale 58 % were found to have a depressive or anxiety disorder . Statistically significant but modest correlations were found between pain severity and HRQL . Psychological and social well‐being was closely correlated . Sixty‐three percent of the referred patients had neurogenic pain conditions . Of these , only 25 % were treated with antidepressants or anticonvulsants at referral . Seventy‐three percent were treated with opioids at referral . Mean opioid consumption was 64 mg of morphine per day ( range 1–280 mg ) . Compared with the NP the chronic pain patients had used the health care system five times more often in the years prior to referral ( P<0.001 ) . The study confirms the severe multidimensional impact of chronic pain and demonstrates that HRQL of chronic non‐malignant pain patients is among the lowest observed for any medical condition Renal prostagl and in inhibition by nonsteroidal antiinflammatory drugs ( NSAIDs ) may decrease renal function , especially under conditions of low effective circulating volume . To evaluate the risk of important deterioration of renal function due to this effect , the authors performed a nested case-control study using Tennessee Medicaid enrollees aged > or = 65 years in 1987 - 1991 . Cases were patients who had been hospitalized with community-acquired acute renal failure ; they were selected on the basis of medical record review of Medicaid enrollees with selected discharge diagnoses . Information on the timing , duration , and dose of prescription NSAIDs used , demographic factors , and comorbidity was gathered from computerized Medicaid-Medicare data files . Of the 1,799 patients with acute renal failure ( 4.51 hospitalizations per 1,000 person-years ) , 18.1 % were current users of prescription NSAIDs  as compared with 11.3 % of 9,899 r and omly selected population controls . After control for demographic factors and comorbidity , use of NSAIDs increased the risk of acute renal failure 58 % ( adjusted odds ratio = 1.58 ; 95 % confidence interval ( CI ) : 1.34 , 1.86 ) . For ibuprofen , which accounted for 35 % of NSAID use , odds ratios associated with dosages of < or = 1,200 mg/day , > 1,200-<2,400 mg/day , and > or = 2,400 mg/day were 0.94 ( 95 % CI : 0.58 , 1.51 ) , 1.89 ( 95 % CI : 1.34 , 2.67 ) , and 2.32 ( 95 % CI : 1.45 , 3.71 ) , respectively ( test for linear trend : p = 0.009 ) . Prescription NSAID use result ed in an estimated 25 excess hospitalizations associated with renal failure per 10,000 years of use . Thus , NSAIDs represent a relatively uncommon but avoidable cause of acute renal failure in frail elderly persons CONTEXT A prior national survey documented the high prevalence and costs of  alternative medicine use in the United States in 1990 . OBJECTIVE To document trends in alternative medicine use in the United States between 1990 and 1997 . DESIGN Nationally representative r and om household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997 , respectively . PARTICIPANTS A total of 1539 adults in 1991 and 2055 in 1997 . MAIN OUTCOMES MEASURES Prevalence , estimated costs , and disclosure of alternative therapies to physicians . RESULTS Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8 % in 1990 to 42.1 % in 1997 ( P < or = .001 ) . The therapies increasing the most included herbal medicine , massage , megavitamins , self-help groups , folk remedies , energy healing , and homeopathy . The probability of users visiting an alternative medicine practitioner increased from 36.3 % to 46.3 % ( P = .002 ) . In both surveys alternative therapies were used most frequently for chronic conditions , including back problems , anxiety , depression , and headaches . There was no significant change in disclosure rates between the 2 survey years ; 39.8 % of alternative therapies were disclosed to physicians in 1990 vs 38.5 % in 1997 . The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 ( 64.0 % ) and 1997 ( 58.3 % ) ( P=.36 ) . Extrapolations to the US population suggest a 47.3 % increase in total visits to alternative medicine practitioners , from 427 million in 1990 to 629 million in 1997 , thereby exceeding total visits to all US primary care physicians . An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and /or high-dose vitamins ( 18.4 % of all prescription users ) . Estimated expenditures for alternative medicine professional services increased 45.2 % between 1990 and 1997 and were conservatively estimated at $ 21.2 billion in 1997 , with at least $ 12.2 billion paid out-of-pocket . This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations . Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $ 27.0 billion , which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services . CONCLUSIONS  Alternative medicine use and expenditures increased substantially between 1990 and 1997 , attributable primarily to an increase in the proportion of the population seeking alternative therapies , rather than increased visits per patient OBJECTIVE --To determine the efficacy of electroacupuncture in patients with fibromyalgia , a syndrome of unknown origin causing diffuse musculoskeletal pain . DESIGN --Three weeks ' r and omised study with blinded patients and evaluating physician . SETTING --University divisions of physical medicine and rehabilitation and rheumatology , Geneva . PATIENTS --70 patients ( 54 women ) referred to the division for fibromyalgia as defined by the American College of Rheumatology . INTERVENTIONS -- Patients were r and omised to electroacupuncture ( n = 36 ) or a sham procedure ( n = 34 ) by means of an electronic numbers generator . MAIN OUTCOME MEASURES --Pain threshold , number of analgesic tablets used , regional pain score , pain recorded on visual analogue scale , sleep quality , morning stiffness , and patient 's and evaluating physician 's appreciation . RESULTS --Seven of the eight outcome parameters showed a significant improvement in the active treatment group whereas none were improved in the sham treatment group . Differences between the groups were significant for five of the eight outcome measures after treatment . CONCLUSIONS --Electroacupuncture is effective in relieving symptoms of fibromyalgia . Its potential in long term management should now be studied PURPOSE To characterize the central nervous system ( CNS ) pathway for acupuncture stimulation in the human brain by using functional magnetic resonance ( MR ) imaging . MATERIAL S AND METHODS Functional MR imaging of the whole brain was performed in two groups of nine healthy subjects during four stimulation paradigms : real acupuncture at acupoints ST.36 ( on the leg ) and LI.4 ( on the h and ) and control stimulations ( minimal acupuncture and superficial pricking on the leg ) . Stimulations were performed in semir and omized , balanced order nested within two experiments . Psychophysical responses ( pain , De-Qi effect [ characteristic acupuncture effect of needle-manipulation sensation ] , anxiety , and unpleasantness ) and autonomic responses were assessed . Talairach coordinates-transformed imaging data were averaged for a group analysis . RESULTS Acupuncture at LI.4 and ST.36 result ed in significantly higher scores for De-Qi and in substantial bradycardia .  Acupuncture at both acupoints result ed in activation of the hypothalamus and nucleus accumbens and deactivation of the rostral part of the anterior cingulate cortex , amygdala formation , and hippocampal complex ; control stimulations did not result in such activations and deactivations . CONCLUSION Functional MR imaging can demonstrate the CNS pathway for acupuncture stimulation . Acupuncture at ST.36 and LI.4 activates structures of descending antinociceptive pathway and deactivates multiple limbic areas subserving pain association . These findings may shed light on the CNS mechanism of acupuncture analgesia and form a basis for future investigations of endogenous pain modulation circuits in the human brain BACKGROUND Because the value of popular forms of alternative care for chronic back pain remains uncertain , we compared the effectiveness of acupuncture , therapeutic massage , and self-care education for persistent back pain . METHODS We r and omized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture ( n = 94 ) , therapeutic massage  ( n = 78 ) , or self-care educational material s  ( n = 90 ) . Up to 10 massage or acupuncture visits were permitted over 10 weeks . Symptoms ( 0 - 10 scale ) and dysfunction ( 0 - 23 scale ) were assessed by telephone interviewers masked to treatment group . Follow-up was available for 95 % of patients after 4 , 10 , and 52 weeks , and none withdrew for adverse effects . RESULTS Treatment groups were compared after adjustment for prer and omization covariates using an intent-to-treat analysis . At 10 weeks , massage was superior to self-care on the symptom scale ( 3.41 vs 4.71 , respectively ; P = .01 ) and the disability scale ( 5.88 vs 8.92 , respectively ; P<.001 ) . Massage was also superior to acupuncture on the disability scale ( 5.89 vs 8.25 , respectively ; P = .01 ) . After 1 year , massage was not better than self-care but was better than acupuncture ( symptom scale : 3.08 vs 4.74 , respectively ; P = .002 ; dysfunction scale : 6.29 vs 8.21 , respectively ; P = .05 ) . The massage group used the least medications ( P<.05 ) and had the lowest costs of subsequent care . CONCLUSIONS Therapeutic massage was effective for persistent low back pain , apparently providing long-lasting benefits . Traditional Chinese Medical acupuncture was relatively ineffective . Massage might be an effective alternative to conventional medical care for persistent back pain PURPOSE To compare two self-administered , one interviewer-administered , and one performance-based measure of physical function in community-based older persons . METHODS Eighty-three subjects were recruited from meal sites , senior recreation centers , and senior housing units for a comprehensive geriatric assessment program . At the time of screening , study participants self-administered the Functional Status Question naire ( FSQ ) and were administered the Katz Activities of Daily Living ( ADL ) and the Older Americans Re sources and Services Instrumental Activities of Daily Living ( OARS-IADL ) instruments by interview . Participants also completed the Physical Performance Test ( PPT ) and were given the  Medical Outcomes Study SF-36 to self-administer on site or at home and return by mail . RESULTS All 83 subjects completed FSQ , Katz ADL , OARS-IADL , and PPT ; 72 returned SF-36 forms . Correlations between the two self-administered physical function measures ( FSQ and SF-36 ) were higher than between self-administered and interviewer-assessed ( ADL and OARS-IADL ) or performance-based ( PPT ) measures . When assessed for construct validity , the self-administered , OARS , and PPT measures had comparable correlations with role limitations as a result of physical health problems , but relationships between physical functional status measures and other SF-36 measures of health were inconsistent . CONCLUSION The relationships between commonly used self-administered , interviewer-administered , and performance-based measures of physical function were inconsistent and weak , suggesting that these instruments are not measuring the same construct CONTEXT Low back pain ( LBP ) contributes to considerable disability and lost wages in the United States . Commonly used opioid and nonopioid analgesic drugs produce adverse effects and are of limited long-term benefit in the management of this patient population . OBJECTIVE To compare the effectiveness of a novel nonpharmacologic pain therapy , percutaneous electrical nerve stimulation ( PENS ) , with transcutaneous electrical nerve stimulation ( TENS ) and flexion-extension exercise therapies in patients with long-term LBP . DESIGN A r and omized , single-blinded , sham-controlled , crossover study from March 1997 to December 1997 . SETTING An ambulatory pain management center at a university medical center . PATIENTS Twenty-nine men and 31 women with LBP secondary to degenerative disk disease . INTERVENTIONS Four therapeutic modalities ( sham-PENS , PENS , TENS , and exercise therapies ) were each administered for a period of 30 minutes 3 times a week for 3 weeks . MAIN OUTCOME MEASURES Pretreatment and posttreatment visual analog scale ( VAS ) scores for pain , physical activity , and quality of sleep ; daily analgesic medication usage ; a global patient assessment question naire ; and Health Status Survey Short Form ( SF-36 ) . RESULTS PENS was significantly more effective in decreasing VAS pain scores after each treatment than sham-PENS , TENS , and exercise therapies ( after-treatment mean + /- SD VAS for pain , 3.4+/-1.4 cm , 5.5+/-1.9 cm , 5.6+/-1.9 cm , and 6.4+/-1.9 cm , respectively ) . The average + /- SD daily oral intake of nonopioid analgesics ( 2.6+/-1.4 pills per day ) was decreased to 1.3+/-1.0 pills per day with PENS ( P<.008 ) compared with 2.5+/-1.1 , 2.2+/-1.0 , and 2.6+/-1.2 pills per day with sham-PENS , TENS , and exercise , respectively . Compared with the other 3 modalities , 91 % of the patients reported that PENS was the most effective in decreasing their LBP . The PENS therapy was also significantly more effective in improving physical activity , quality of sleep , and sense of well-being ( P<.05 for each ) . The SF-36 survey confirmed that PENS improved posttreatment function more than sham-PENS , TENS , and exercise . CONCLUSIONS In this sham-controlled study , PENS was more effective than TENS or exercise therapy in providing short-term pain relief and improved physical function in patients with long-term LBP Abstract Empirical methods are used to explore the relationship between chronic pain , somatic awareness and attention . Using a primary task paradigm , 46 chronic pain patients performed an attentionally dem and ing task . Patients were classified according to self reported pain intensity and the extent of their reporting of the perception of bodily sensations ( somatic awareness ) . Results showed that , as predicted , disruption of attentional performance was most pronounced in those who reported high pain intensity and high somatic awareness . Further analysis revealed that these patients also reported high negative affect . These findings are discussed in terms of their theoretical implication s for the concept of hypervigilance and their clinical implication s for chronic pain control Study Design . This was a stratified , r and om telephone survey of adults in North Carolina . Objective To determine the prevalance of chronic low back pain and the extent to which treatment is sought for this condition . Summary of Background Data Chronic low back pain is a major problem . Previous studies often have comb ined acute and chronic back pain . Methods Telephone interviews regarding back pain were conducted with 4437 North Caroliona adults during 1992 . Results Chronic back pain affects 3.9 % of the North Carolina population . Thirty-four percent considered themselves permanently disabled and 52 % assessed their overall health as fair or poor . The median number of bed-disability days per year was three . Seventy-three percent saw a health care provider Of those who sought care , 91 % saw a medical doctore , 29 % saw a physical therapist , and 25 % saw a chiropractor , Use of technology was extensive : 37 % received a computed tomography scan , 25 % received a magnetic resonance imaging scan , and 10.4 % underwent surgery . Conclusions Chronic back pain is common , and the level of care-seeking and costs of care among those afflicted are extremely high Acupuncture is increasingly popular , but it is not free from risk for the patient.1 Safety is best established with prospect i ve surveys . Our aim was to ascertain the incidence of adverse events related to acupuncture treatment , as currently practised in Britain by doctors and physiotherapists . Volunteer acupuncture practitioners were recruited through journals circulated to members of the British Medical Acupuncture Society and the Acupuncture Association of Chartered Physiotherapists ( approximately 2750 members).2 A prospect i ve survey was undertaken using forms for intensive event monitoring that had been piloted previously.3 Minor adverse events were defined as “ any ill-effect , no matter how small , that is unintended and non-therapeutic , even if not unexpected . ” These events were reported every month , along with the total number of consultations . Minor or serious events that were considered to be “ significant”—“unusual , novel , dangerous , significantly inconvenient , or requiring further information”—were reported on separate forms when they occurred . Anonymous reporting was accepted . A sample size of Objective : To document the prevalence of depression and examine the relationship between depression and selected pain-related variables associated with chronic back pain among elderly and nonelderly sample s. Design : Survey with mailed question naire . Setting : Patients seeking treatment at a spine diagnostic and treatment center . Patients : Consecutive sample of elderly subjects (n=69).Nonelderly subjects ( n=59 ) were r and omly selected to achieve a sample size comparable to the elderly . Evaluation of depressed mood was determined by Beck Depression Inventory . Main Outcome Measures : Multidimensional Pain Inventory , Pain Disability Index , Pain Duration , Work-Related Disability , Medication Use , and Pain Severity . Results : A high prevalence of dysphoria was found in both age group . No significant differences were found between age and depressed mood . The only significant association between depressed mood and age occurred with pain duration , with the elderly experiencing fewer total hours per day in pain . Combining age groups , multivariate analysis of variance revealed that dysphoric chronic pain patients reported more antidepressant use , greater pain intensity , greater interference due to pain , and less life control than the nondepressed patients . Interference in activities demonstrated the strongest relationship with depressed mood in both age groups . Conclusion : There is a high prevalence of dysphoria in both the elderly and nonelderly with chronic back pain . The relationships between pain-related constructs and depressed mood in chronic back pain patients are similar in the elderly and nonelderly . The impact of the pain experience on the individual 's activities , functioning , and feelings of life control should be considered in theoretical and clinical explanations of the association between pain and depression
OBJECTIVE To review common complementary and alternative treatment modalities for the treatment of persistent musculoskeletal pain in older adults .