Percutaneous electrical nerve stimulation: a novel analgesic therapy for diabetic neuropathic pain. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis Efficacy of two cannabis based medicinal extracts for relief of central neuropathic pain from brachial plexus avulsion: results of a randomised controlled trial Acupuncture and amitriptyline for pain due to HIV-related peripheral neuropathy: a randomized controlled trial. Terry Beirn Community Programs for Clinical Research on AIDS. Diabetic Peripheral Neuropathy: Amelioration of Pain With Transcutaneous Electrostimulation St. John's wort has no effect on pain in polyneuropathy The use of complementary and alternative medicines by patients with peripheral neuropathy [Therapeutic effect of deep acupuncture at local acupoints on trigeminal neuralgia]. Transcutaneous Electrical Nerve Stimulation for Neuropathic Pain Impact of low frequency transcutaneous electrical nerve stimulation on symptomatic diabetic neuropathy using the new Salutaris device.
OBJECTIVE To evaluate the use of percutaneous electrical nerve stimulation ( PENS ) in the management of patients with painful diabetic peripheral neuropathy . RESEARCH DESIGN AND METHODS A total of 50 adult patients with type 2 diabetes and peripheral neuropathic pain of > 6 months duration involving the lower extremities were r and omly assigned to receive active PENS ( needles with electrical stimulation at an alternating frequency of 15 and 30 Hz ) and sham ( needles only ) treatments for 3 weeks . Each series of treatments was administered for 30 min three times a week according to a st and ardized protocol . After a 1-week washout period , all patients were subsequently switched to the other modality . A 10-cm visual analog scale ( VAS ) was used to assess pain , physical activity , and quality of sleep before each session . The changes in VAS scores and daily requirements for oral analgesic medication were determined during each 3-week treatment period . Patients completed the MOS 36-Item Short-Form Health Survey ( SF-36 ) , the Beck Depression Inventory ( BDI ) , and the Profile of Mood States ( POMS ) before and after completion of each treatment modality . At the end of the crossover study , a patient preference question naire was used to compare the effectiveness of the two modalities . RESULTS Compared with the pain VAS scores before active ( 6.2 + /- 1.0 ) and sham ( 6.4 + /- 0.9 ) treatments , pain scores after treatment were reduced to 2.5 + /- 0.8 and 6.3 + /- 1.1 , respectively . With active PENS treatment , the VAS activity and sleep scores were significantly improved from 5.2 + /- 1.0 and 5.8 + /- 1.3 to 7.9 + /- 1.0 and 8.3 + /- 0.7 , respectively . The VAS scores for pain , activity , and sleep were unchanged from baseline values after the sham treatments . Patients ' daily oral nonopioid analgesic requirements decreased by 49 and 14 % after active and sham PENS treatments , respectively . The post-treatment physical and mental components of the SF-36 , the BDI , and the POMS all showed a significantly greater improvement with active versus sham treatments . Active PENS treatment improved the neuropathic pain symptoms in all patients . CONCLUSIONS PENS is a useful nonpharmacological therapeutic modality for treating diabetic neuropathic pain . In addition to decreasing extremity pain , PENS therapy improved physical activity , sense of well-being , and quality of sleep while reducing the need for oral nonopioid analgesic medication & NA ; Complex regional pain syndrome type 1 ( CRPS1 ) involves cortical abnormalities similar to those observed in phantom pain and after stroke . In those groups , treatment is aim ed at activation of cortical networks that subserve the affected limb , for example mirror therapy . However , mirror therapy is not effective for chronic CRPS1 , possibly because movement of the limb evokes intolerable pain . It was hypothesised that preceding mirror therapy with activation of cortical networks without limb movement would reduce pain and swelling in patients with chronic CRPS1 . Thirteen chronic CRPS1 patients were r and omly allocated to a motor imagery program ( MIP ) or to ongoing management . The MIP consisted of two weeks each of a h and laterality recognition task , imagined h and movements and mirror therapy . After 12 weeks , the control group was crossed‐over to MIP . There was a main effect of treatment group ( F(1,11)=57 , P<0.01 ) and an effect size of ∼25 points on the Neuropathic pain scale . The number needed to treat for a 50 % reduction in NPS score was ∼2 . The effect of treatment was replicated in the crossed‐over control subjects . The results uphold the hypothesis that a MIP initially not involving limb movement is effective for CRPS1 and support the involvement of cortical abnormalities in the development of this disorder . Although the mechanisms of effect of the MIP are not clear , possible explanations are sequential activation of cortical pre‐motor and motor networks , or sustained and focussed attention on the affected limb , or both Background : Central pain in multiple sclerosis ( MS ) is common and often refractory to treatment . Methods : We conducted a single-center , 5-week ( 1-week run-in , 4-week treatment ) , r and omized , double-blind , placebo-controlled , parallel-group trial in 66 patients with MS and central pain states ( 59 dysesthetic , seven painful spasms ) of a whole-plant cannabis-based medicine ( CBM ) , containing delta-9-tetrahydrocannabinol : cannabidiol ( THC : CBD ) delivered via an oromucosal spray , as adjunctive analgesic treatment . Each spray delivered 2.7 mg of THC and 2.5 of CBD , and patients could gradually self-titrate to a maximum of 48 sprays in 24 hours . Results : Sixty-four patients ( 97 % ) completed the trial , 34 received CBM . In week 4 , the mean number of daily sprays taken of CBM ( n = 32 ) was 9.6 ( range 2 to 25 , SD = 6.0 ) and of placebo ( n = 31 ) was 19.1 ( range 1 to 47 , SD = 12.9 ) . Pain and sleep disturbance were recorded daily on an 11-point numerical rating scale . CBM was superior to placebo in reducing the mean intensity of pain ( CBM mean change −2.7 , 95 % CI : −3.4 to −2.0 , placebo –1.4 95 % CI : −2.0 to −0.8 , comparison between groups , p = 0.005 ) and sleep disturbance ( CBM mean change –2.5 , 95 % CI : −3.4 to −1.7 , placebo –0.8 , 95 % CI : −1.5 to −0.1 , comparison between groups , p = 0.003 ) . CBM was generally well tolerated , although more patients on CBM than placebo  reported dizziness , dry mouth , and somnolence . Cognitive side effects were limited to long-term memory storage . Conclusions : Cannabis-based medicine is effective in reducing pain and sleep disturbance in patients with multiple sclerosis related central neuropathic pain and is mostly well tolerated & NA ; The objective was to investigate the effectiveness of cannabis‐based medicines for treatment of  chronic pain associated with brachial plexus root avulsion . This condition is an excellent human model of central neuropathic pain as it represents an unusually homogenous group in terms of anatomical location of injury , pain descriptions and patient demographics . Forty‐eight patients with at least one avulsed root and baseline pain score of four or more on an 11‐point ordinate scale participated in a r and omised , double‐blind , placebo‐controlled , three period crossover study . All patients had intractable symptoms regardless of current analgesic therapy . Patients entered a baseline period of 2 weeks , followed by three , 2‐week treatment periods during each of which they received one of three oromucosal spray preparations . These were placebo and two whole plant extracts of Cannabis sativa L. : GW‐1000‐02 ( Sativex ® ) , containing Δ9tetrahydrocannabinol (THC):cannabidiol ( CBD ) in an approximate 1:1 ratio and GW‐2000‐02 , containing primarily THC . The primary outcome measure was the mean pain severity score during the last 7 days of treatment . Secondary outcome measures included pain related quality of life assessment s. The primary outcome measure failed to fall by the two points defined in our hypothesis . However , both this measure and measures of sleep showed statistically significant improvements . The study medications were generally well tolerated with the majority of adverse events , including intoxication type reactions , being mild to moderate in severity and resolving spontaneously . Studies of longer duration in neuropathic pain are required to confirm a clinical ly relevant , improvement in the treatment of this condition CONTEXT Peripheral neuropathy is common in persons infected with the human immunodeficiency virus ( HIV ) but few data on symptomatic treatment are available . OBJECTIVE To evaluate the efficacy of a st and ardized acupuncture regimen ( SAR ) and amitriptyline hydrochloride for the relief of pain due to HIV-related peripheral neuropathy in HIV-infected patients . DESIGN R and omized , placebo-controlled , multicenter clinical trial . Each site enrolled patients into 1 of the following 3 options : ( 1 ) a modified double-blind 2 x 2 factorial design of SAR , amitriptyline , or the combination compared with placebo , ( 2 ) a modified double-blind design of an SAR vs control points , or ( 3 ) a double-blind design of amitriptyline vs placebo . SETTING Terry Beirn Community Programs for Clinical Research on AIDS ( HIV primary care providers ) in 10 US cities . PATIENTS Patients with HIV-associated , symptomatic , lower-extremity peripheral neuropathy . Of 250 patients enrolled , 239 were in the acupuncture comparison ( 125 in the factorial option and 114 in the SAR option vs control points option ) , and 136 patients were in the amitriptyline comparison ( 125 in the factorial option and 11 in amitriptyline option vs placebo option ) . INTERVENTIONS St and ardized acupuncture regimen vs control points , amitriptyline ( 75 mg/d ) vs placebo , or both for 14 weeks . MAIN OUTCOME MEASURE Changes in mean pain scores at 6 and 14 weeks , using a pain scale ranging from 0.0 ( no pain ) to 1.75 ( extremely intense ) , recorded daily . RESULTS Patients in all 4 groups showed reduction in mean pain scores at 6 and 14 weeks compared with baseline values . For both the acupuncture and amitriptyline comparisons , changes in pain score were not significantly different between the 2 groups . At 6 weeks , the estimated difference in pain reduction for patients in the SAR group compared with those in the control points group ( a negative value indicates a greater reduction for the " active " treatment ) was 0.01 ( 95 % confidence interval [ CI ] , -0.11 to 0.12 ; P=.88 ) and for patients in the amitriptyline group vs those in the placebo group was -0.07 ( 95 % CI , -0.22 to 0.08 ; P=.38 ) . At 14 weeks , the difference for those in the SAR group compared with those in the control points group was -0.08 ( 95 % CI , -0.21 to 0.06 ; P=.26 ) and for amitriptyline compared with placebo was 0.00 ( 95 % CI , -0.18 to 0.19 ; P=.99 ) . CONCLUSIONS In this study , neither acupuncture nor amitriptyline was more effective than placebo in relieving pain caused by HIV-related peripheral neuropathy OBJECTIVE To evaluate the efficacy of transcutaneous electrotherapy for chronic painful peripheral neuropathy in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS Thirty-one patients with symptoms and signs of peripheral neuropathy were r and omized to the electrotherapy or sham treatment ( control ) group . The electrostimulation was given by a portable unit ( H-Wave machine ) than generated a biphasic , exponentially decaying waveform ( pulse width 4 ms , 25–35 V , ≥ 2 Hz ) . Patients treated each of their lower extremities for 30 min daily for 4 weeks at home . Nine patients from the sham-treatment group participated for a second period , during which all of them received the active electrotherapy . Patient 's degree of pain and discomfort was grade d on a scale of 0 to 5 . RESULTS In the sham-treated group ( n = 13 ) , the neuropathic symptoms improved in five ( 38 % ) patients , and the pain score declined from 2.92 ± 0.13 to 2.38 ± 0.26 ( P < 0.04 ) , suggesting a procedure-related placebo effect . In the electrotherapy group ( n = 18 ) , symptomatic improvement was seen in 15 ( 83 % ) cases , 3 of which were completely asymptomatic ; the pain score declined from 3.17 ± 0.12 to 1.44 ± 0.25 ( P < 0.01 ) and the posttreatment pain scores were considerably lower ( P < 0.03 ) , indicating a substantial treatment effect over and above any placebo influence . Patients in the electrotherapy group reported greater reduction in symptoms ( 52 ± 7 % vs. 27 ± 10 % in control subjects , P < 0.05 ) on an analog scale . Moreover , the electrotherapy decreased pain scores ( from 3.0 ± 0.62 to 1.56 ± 0.32 , P < 0.02 ) in nine patients who had received sham treatment earlier . CONCLUSIONS A form of transcutaneous electrotherapy ameliorated the pain and discomfort associated with peripheral neuropathy . This novel modality offers a potential non-pharmacological treatment option & NA ; Tricyclic antidepressants are the mainstay of treatment of painful polyneuropathy but can not be used in a substantial number of patients . St. John 's wort is a herbal antidepressant , which may act via mechanisms similar to the tricyclics . The aim of this study was to test if St. John 's wort would relieve  painful polyneuropathy . The study design was r and omized , double‐blind , placebo‐controlled and cross‐over . Fifty‐four patients were assigned to one of the two treatment sequences . The daily dose of St. John 's wort was three tablets each containing 900 & mgr;g totalhypericin . During the two treatment periods of 5 weeks duration , patients rated constant pain , lancinating pain paroxysms , touch‐evoked pain and pain on pressure by use of 0–10 point numeric rating scales . Forty‐seven patients – 18 diabetics and 29 non‐diabetics – completed the study . There was a trend of lower total pain score ( sum of the individual pain scores ) on St. John 's wort than on placebo ( median 14 vs. 15 , P=0.05 ) . None of the individual pain ratings were significantly changed by St. John 's wort as compared to placebo ( P=0.09–0.33 ) . Complete , good or moderate pain relief was experienced by nine patients with St. John 's wort and two with placebo ( P=0.07 ) . In conclusion , St. John 's wort has no significant effect on pain in polyneuropathy Complementary and alternative medicine ( CAM ) therapies have become increasingly popular and are used regularly by patients with chronic neurological disorders . The prevalence and characteristics of CAM use by patients with peripheral neuropathy is unknown . We performed a prospect i ve , question naire-based study to determine the prevalence and patterns of use of CAM therapies in 180 consecutive out patients with peripheral neuropathy . The use of CAM was reported by 77 patients ( 43 % ) with neuropathy . The most frequent were megavitamins ( 35 % ) , magnets ( 30 % ) , acupuncture ( 30 % ) , herbal remedies ( 22 % ) , and chiropractic manipulation ( 21 % ) ; 37 ( 48 % ) tried more than one form of alternative treatment . Seventeen respondents ( 27 % ) thought their neuropathy symptoms improved with these approaches . Those who used CAM were slightly younger ( mean age 62 vs. 65 years , p = 0.05 ) and more often college educated ( 39 % vs. 24 % , p = 0.03 ) compared to CAM nonusers . They also more often reported burning neuropathic pain ( 62 % vs. 44 % , p = 0.01 ) . Patients with diabetic neuropathy used CAM  more frequently than others ( p = 0.03 ) . The most common reason for using CAM was inadequate pain control ( 32 % ) . Almost half of patients did not consult a physician before starting CAM . We conclude that there is a high prevalence of  CAM  use in our patients with neuropathy , and one-quarter reported that their symptoms improved . CAM users were better educated than nonusers , but most did not discuss CAM treatments with their physician . Neuropathic pain was substantially more common in CAM users , and lack of pain control was the most common reason for CAM use OBJECTIVE To search for an effective method for increasing therapeutic effect on trigeminal neuralgia . METHODS Ninety cases of primary trigeminal neuralgia were r and omly divided into a  deep needling group  and a  routine needling group  , 45 cases in each group . The routine needling group were treated by shallow acupuncture at local acupoints and distal acupoints along the H and and Foot-Yangming Channels , and the deep needling group were treated by acupuncture at the above acupoints and deeply needling at the local acupoints to nerve stem for 3 courses . RESULTS In the deep needling group 12 cases were clinical ly cured , 24 cases were markedly effective , 7 cases improved and 2 cases were ineffective , with a total effective rate of 95.6 % ; and in the routine needling group , the corresponding figures were 7 , 15 , 12 , 11 , 75.6 % . The therapeutic effect in the deep needling group was better than that in the routine needling group ( P<0.05 ) . CONCLUSION Deeply needling local acupoints plus acupuncture at distal acupoints along the H and and Foot-Yangming Channels can increase significantly the therapeutic effect on trigeminal neuralgia This study examined the clinical effectiveness of high-frequency transcutaneous electrical nerve stimulation for reducing  hypersensitivity of the h and . Nineteen patients suffering from h and hypersensitivity were r and omly assigned into either a treatment or a placebo group . A visual analogue scale and the Downey H and Centre H and Sensitivity Test were used to measure the tactile tolerance of the h and . Grip strength was assessed by a grip dynamometer . Daily applications of electrical stimulation were provided for 2 weeks . Significantly lower pain scores were found in the treatment group than in the placebo group by Day 7 and Day 11 . The ranking of ten dowel textures of the Downey H and Centre H and Sensitivity Test in the treatment group was significantly higher than in the placebo group by Day 7 and Day 11 . However , no significant intergroup difference was found in grip strength In a double blind , r and omised study , 19 patients suffering from mild-to-moderate symptomatic diabetic neuropathy ( Total Symptom Score , NTSS 4 - 16 ) received either treatment with the new transcutaneous electrical nerve stimulation ( TENS ) device " Salutaris " ( verum group ) or a placebo treatment with an identical but electrically inactive device ( placebo group ) . Stimulation pads were placed at the anatomical localisation of the peroneal nerve and stimulation was performed using a low frequency mode . At baseline ( V1 ) , after 6 ( V2 ) , and 12 ( V3 ) wk of treatment , the patients ' symptoms were registered using the new total symptom score ( NTSS-6 ) and a visual analogue scale ( VAS ) . In addition , sensory nerve thresholds ( temperature , vibration , pain ) and microvascular function were measured at the lower limb at baseline and after 12 wk of treatment . Active TENS-treatment result ed in a significant improvement in NTSS-6 score after 6 wk ( -42 % ) and after 12 wk ( -32 % ) of treatment ( baseline : 10.0+/-3.3 , 6 wk : 5.8+/-5.0 , p<0.05 ; 12 wk : 6.8+/-3.9 , p=0.05 ; placebo group : baseline : 7.6+/-3.1 ; 6 wk : 8.1+/-5.1 , n.s . ; 12 wk : 6.5+/-6.1 , n.s . ) . Sub analysis of the different qualities of the NTSS-score revealed an improvement in numbness ( 2.2+/-1.0 to 1.6+/-1.3 ; p<0.03 ) ; lancinating pain ( 1.6+/-1.1 to 0.6+/-0.9 ; p<0.02 ) and allodynia ( 1.4+/-1.6 to 0.5+/-1.0 ; p<0.05 ) . Also , a significant improvement in the VAS rating was found after 6 wk of TENS therapy ( 19.8+/-5.0 to 14.4+/-9.6 ; p<0.05 ) , while no change was observed in the placebo arm . In conclusion , our study indicates that the new TENS device " Salutaris " is a convenient , non-pharmacological option for primary or adjuvant treatment of painful diabetic neuropathy
OBJECTIVE To assess the evidence from rigorous clinical trials , systematic review s , and meta-analyses of complementary and alternative therapies for treating  neuropathic and neuralgic pain .