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Crohn's disease is a chronic inflammatory bowel condition causing symptoms, notably pain, due to ongoing intestinal inflammation or complications like abscesses, strictures, and fistulas, which are common in IBD patients. Abdominal pain affects up to 60 % of IBD patients, irrespective of disease severity, prompting medical attention. Various medications like NSAIDs, antidepressants, antispasmodics, anticonvulsants, and opioids are used to manage pain, but they have limited effectiveness and potential side effects, even during remission. In this case, a 20-year-old Caucasian female college student [height 5'4″, weight 120lbs (54.4 kg)] with juvenile idiopathic arthritis and Crohn's disease experienced severe daily abdominal pain, negatively impacting her life. Despite a multimodal regimen, including gabapentin, nortriptyline, duloxetine, and acetaminophen, her pain persisted, significantly affecting her appetite, sleep, mood, activity level, and overall quality of life (QOL). To address this, dorsal root ganglion (DRG) stimulation was considered. The patient aimed for a 20 % pain reduction and improved QOL. Trial leads were placed along the T10 and T12 DRG, resulting in a 25 % pain reduction (8-6 out of 10) and substantial QOL improvement. She could eat, sleep without interruptions, walk longer distances, and be more active. The T12 lead was more effective than the T10, targeting upper abdomen stimulation. The patient and her mother were highly satisfied and opted for permanent implantation for the T11 and T12 DRG. While DRG stimulation was approved in 2016 for chronic pain, to our knowledge, this is the first reported case of its use in a patient with debilitating Crohn's disease.

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OBJECTIVES: Spinal cord stimulation (SCS) has been challenged by the lack of neurophysiologic data to guide therapy optimization. Current SCS programming by trial-and-error results in suboptimal and variable therapeutic effects. A novel system with a physiologic closed-loop feedback mechanism using evoked-compound action potentials enables the optimization of physiologic neural dose by consistently and accurately activating spinal cord fibers. We aimed to identify neurophysiologic dose metrics and their ranges that resulted in clinically meaningful treatment responses. MATERIALS AND METHODS: Subjects from 3 clinical studies (n = 180) with baseline back and leg pain ≥60 mm visual analog scale and physical function in the severe to crippled category were included. Maximal analgesic effect (MAE) was operationally defined as the greatest percent reduction in pain intensity or as the greatest cumulative responder score (minimal clinically important differences [MCIDs]) obtained within the first 3 months of SCS implant. The physiologic metrics that produced the MAE were analyzed. RESULTS: We showed that a neural dose regimen with a high neural dose accuracy of 2.8µV and dose ratio of 1.4 resulted in a profound clinical benefit to chronic pain patients (MAE of 79 ± 1% for pain reduction and 12.5 ± 0.4 MCIDs). No differences were observed for MAE or neurophysiological dose metrics between the trial phase and post-implant MAE visit. CONCLUSION: For the first time, an evidence-based neural dose regimen is available for a neurostimulation intervention as a starting point to enable optimization of clinical benefit, monitoring of adherence, and management of the therapy.

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BACKGROUND/IMPORTANCE: Chronic pain affects many people globally, requiring alternative management strategies. Psilocybin is gaining attention for its potential in chronic pain management despite being classified as Schedule I. OBJECTIVE: This systematic review critically evaluates the evidence for psilocybin, a Schedule I substance, in the treatment of chronic pain. The exact purpose of the review is to assess the impact of psilocybin on chronic pain relief, focusing on dosing protocols, treated conditions, and patient outcomes. EVIDENCE REVIEW: A comprehensive review of PubMed, CINAHL, Web of Science, Cochrane Library, and EMBASE was conducted up to January 2024. Eligibility criteria included studies evaluating psilocybin for chronic pain management. The risk of bias was assessed using the MASTER (MethodologicAl STandards for Epidemiological Research) scale, and the strength of evidence was graded using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). FINDINGS: The review identified 28 relevant studies focusing on dosing, treated conditions, and outcomes. The majority of the included studies (76.2%) were of low or very low quality. Several studies with moderate-to-low-quality evidence utilized a 0.14 mg/kg dosing protocol. The findings suggest promise for the use of psilocybin in chronic pain relief, though the quality of evidence is generally low. CONCLUSIONS: The current research shows potential for psilocybin as a treatment option for chronic pain relief. However, methodological issues and a lack of high-quality evidence underscore the need for further investigations with standardized protocols. Despite these limitations, the potential for psilocybin in chronic pain management is encouraging. PROSPERO REGISTRATION NUMBER: CRD42023493823.

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Cancer pain has a substantial impact on the quality of life and functional capacity with a prevalence of up to 70 % in patients with advanced, metastatic, or terminal disease [1]. The WHO pain ladder has been used in practice to guide cancer pain management. A three-step ladder starts with NSAIDs and non-opioids for mild pain, weak opioids for mild to moderate pain and strong opioids for moderate to severe pain with the use of adjuvant medications such as TCAs and muscle relaxants at any stage for optimization (Fallon et al., Dec 2022) [2] We present a case of a patient with metastatic colon cancer who was admitted for intractable pain crisis and right sided L-5 radiculopathy secondary to epidural metastasis (Figs. 1 and 2). The patient's pain left her bedridden, unable to walk and remained refractory to an escalating intravenous opioid regimen and caudal epidural steroids. The patient subsequently underwent spinal cord stimulation (SCS) trial at level T-7 and achieved >80 % pain relief resulting in a markedly decreased opioid requirement and tremendous recovery of ambulatory function (Fig. 3). After sustained results, a permanent implant was placed at T-8 and patient remains discharged with functional restoration and continued pain improvement (Fig. 4). To our knowledge, this is a novel application of SCS for a refractory pain crisis secondary to a metastatic colon cancer induced radiculopathy presenting with severe functional impairment. As we transition away from opioid use, it is imperative as pain physicians, to investigate the potential of current as an alternative means of cancer pain management: a ubiquitous and challenging clinical conundrum.

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PURPOSE OF REVIEW: The main objective of this review is to appraise the literature on the role of spinal cord stimulation (SCS), cannabinoid therapy, as well as SCS and cannabinoid combination therapy for the management of chronic neuropathic and nociceptive pain. Current research suggests that SCS reduces pain and increases functional status in carefully selected patients with minimal side effects. RECENT FINDINGS: As cannabinoid-based medications become a topic of increasing interest in pain management, data remains limited regarding the clinical efficacy of cannabinoids for pain relief. Furthermore, from a mechanistic perspective, although various pain treatment modalities utilize overlapping pain-signaling pathways, clarifying whether cannabinoids work synergistically with SCS via shared mechanisms remains to be determined. In considering secondary outcomes, the current literature suggests cannabinoids improve quality of life, specifically sleep quality, and that SCS decreases opioid consumption, increases functional capacity, and decreases long-term healthcare costs. These findings, along with the high safety profiles of SCS and cannabinoids overall, incentivize further exploration of cannabinoids as an adjunctive therapy to SCS in the treatment of neuropathic and nociceptive pain.

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ABSTRACT: The COVID-19 pandemic has propelled an unprecedented global implementation of telemedicine and telerehabilitation as well as its integration into the healthcare system. Here, we describe the clinical implementation of the A3E framework for the deployment of telerehabilitation in the inpatient and outpatient rehabilitation continuum by addressing accessibility, adaptability, accountability, and engagement during the COVID-19 pandemic. By using an organized, coordinated, and stratified approach, we increased our telerehabilitation practice from 0 to more than 39,000 visits since the pandemic began. Learning from both the successes and challenges can help address the need to increase access to rehabilitation services even beyond the COVID-19 pandemic.

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BACKGROUND: Radiofrequency neurotomy (RFN) of facet or sacroiliac joints is widely used for the treatment of chronic axial pain and can provide long-term pain relief in well-selected patients. The most common side effect is transient neuropathic pain at the paravertebral level of interest. Pain physicians commonly administer corticosteroid post-neurotomy to reduce the risk of post-neurotomy neuropathic pain, yet it remains unclear if this provides a true reduction in incidence. OBJECTIVES: To determine the efficacy of corticosteroid administration post-lesion in preventing the development of post-neurotomy neuropathic pain after cervical, thoracic, lumbar, and sacroiliac joint radiofrequency denervation. STUDY DESIGN: Randomized, placebo-controlled, double-blind prospective study. SETTING: Ambulatory Surgical Center within a Tertiary Hospital System. METHODS: This trial is registered on ClinicalTrials.gov (NCT03247413). Permission to conduct human research was obtained from the Institutional Review Board. Eligible patients included those with cervical, thoracic, or lumbar facet or sacroiliac joint pain who had positive concordant medial branch blocks (thus scheduled for bilateral RFN), at least 18 years of age, and English-speaking. Patients received dexamethasone vs saline (control) at each lesion site, serving as their own control (with laterality). Follow-ups were completed at 4- and 8-weeks post-intervention to evaluate the incidence of post-procedure pain (questionnaire) and function using the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI). RESULTS: At the time of data analysis, 35/63 patients completed the study protocol. There was a statistically significant reduction in the incidence of post-neurotomy pain in the steroid group vs the control group (20/35 control group vs 3/35 steroid group, P < 0.001). ODI/NDI scores changed differently over time depending on the spinal level of neurotomy, showing statistically significant improvement in ODI/NDI in the cervical subgroup and lumbar subgroup at 4-week (P = 0.05) and 8-week time points (P < 0.01), respectively. There was no improvement of ODI scores in the sacral subgroup. The incidence of post-neurotomy neuropathic pain was not significantly different among patients with different spinal levels of neurotomy. Patients who developed post-neurotomy neuropathic pain did not differ in ODI/NDI scores at any time point. LIMITATIONS: This study has several limitations, most notably the number of patients lost to follow-up, the use of a single corticosteroid, and the use of laterality for incidence reporting. Additionally, all procedures were performed by a single interventionalist using one neurotomy system. CONCLUSIONS: A statistically significant reduction in post-neurotomy pain was observed in the steroid group. This protocol can be feasibly conducted in an effective and resource-efficient manner. Additional research is needed to increase the power of the study.

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