There is a lack of consensus on the role of selective cannabinoids for the treatment of neuropathic pain (NP). Guidelines from national and international pain societies have provided contradictory ...recommendations. The primary objective of this systematic review and meta-analysis (SR-MA) was to determine the analgesic efficacy and safety of selective cannabinoids compared to conventional management or placebo for chronic NP.
We reviewed randomized controlled trials that compared selective cannabinoids (dronabinol, nabilone, nabiximols) with conventional treatments (eg, pharmacotherapy, physical therapy, or a combination of these) or placebo in patients with chronic NP because patients with NP may be on any of these therapies or none if all standard treatments have failed to provide analgesia and or if these treatments have been associated with adverse effects. MEDLINE, EMBASE, and other major databases up to March 11, 2016, were searched. Data on scores of numerical rating scale for NP and its subtypes, central and peripheral, were meta-analyzed. The certainty of evidence was classified using the Grade of Recommendations Assessment, Development, and Evaluation approach.
Eleven randomized controlled trials including 1219 patients (614 in selective cannabinoid and 605 in comparator groups) were included in this SR-MA. There was variability in the studies in quality of reporting, etiology of NP, type and dose of selective cannabinoids. Patients who received selective cannabinoids reported a significant, but clinically small, reduction in mean numerical rating scale pain scores (0-10 scale) compared with comparator groups (-0.65 points; 95% confidence interval, -1.06 to -0.23 points; P = .002, I = 60%; Grade of Recommendations Assessment, Development, and Evaluation: weak recommendation and moderate-quality evidence). Use of selective cannabinoids was also associated with improvements in quality of life and sleep with no major adverse effects.
Selective cannabinoids provide a small analgesic benefit in patients with chronic NP. There was a high degree of heterogeneity among publications included in this SR-MA. Well-designed, large, randomized studies are required to better evaluate specific dosage, duration of intervention, and the effect of this intervention on physical and psychologic function.
Neuropathic pain (NeP), redefined as pain caused by a lesion or a disease of the somatosensory system, is a disabling condition that affects approximately two million Canadians.
To review the ...randomized controlled trials (RCTs) and systematic reviews related to the pharmacological management of NeP to develop a revised evidence-based consensus statement on its management.
RCTs, systematic reviews and existing guidelines on the pharmacological management of NeP were evaluated at a consensus meeting in May 2012 and updated until September 2013. Medications were recommended in the consensus statement if their analgesic efficacy was supported by at least one methodologically sound RCT (class I or class II) showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment were based on the degree of evidence of analgesic efficacy, safety and ease of use.
Analgesic agents recommended for first-line treatments are gabapentinoids (gabapentin and pregabalin), tricyclic antidepressants and serotonin noradrenaline reuptake inhibitors. Tramadol and controlled-release opioid analgesics are recommended as second-line treatments for moderate to severe pain. Cannabinoids are now recommended as third-line treatments. Recommended fourth-line treatments include methadone, anticonvulsants with lesser evidence of efficacy (eg, lamotrigine, lacosamide), tapentadol and botulinum toxin. There is support for some analgesic combinations in selected NeP conditions.
These guidelines provide an updated, stepwise approach to the pharmacological management of NeP. Treatment should be individualized for each patient based on efficacy, side-effect profile and drug accessibility, including cost. Additional studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics, long-term outcomes and treatment of pediatric, geriatric and central NeP.
To provide family physicians with a practical clinical summary of the Canadian Pain Society (CPS) revised consensus statement on the pharmacologic management of neuropathic pain.
A multidisciplinary ...interest group within the CPS conducted a systematic review of the literature on the current treatments of neuropathic pain in drafting the revised consensus statement.
Gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are the first-line agents for treating neuropathic pain. Tramadol and other opioids are recommended as second-line agents, while cannabinoids are newly recommended as third-line agents. Other anticonvulsants, methadone, tapentadol, topical lidocaine, and botulinum toxin are recommended as fourth-line agents.
Many pharmacologic analgesics exist for the treatment of neuropathic pain. Through evidence-based recommendations, the CPS revised consensus statement helps guide family physicians in the management of patients with neuropathic pain.
Recent neurophysiological evidence attests to the validity of fibromyalgia (FM), a chronic pain condition that affects >2% of the population.
To present the evidence-based guidelines for the ...diagnosis, management and patient trajectory of individuals with FM.
A needs assessment following consultation with diverse health care professionals identified questions pertinent to various aspects of FM. A literature search identified the evidence available to address these questions; evidence was graded according to the standards of the Oxford Centre for Evidence-Based Medicine. Drafted recommendations were appraised by an advisory panel to reflect meaningful clinical practice.
The present recommendations incorporate the new clinical concepts of FM as a clinical construct without any defining physical abnormality or biological marker, characterized by fluctuating, diffuse body pain and the frequent symptoms of sleep disturbance, fatigue, mood and cognitive changes. In the absence of a defining cause or cure, treatment objectives should be patient-tailored and symptom-based, aimed at reducing global complaints and enhancing function. Healthy lifestyle practices with active patient participation in health care forms the cornerstone of care. Multimodal management may include nonpharmacological and pharmacological strategies, although it must be acknowledged that pharmacological treatments provide only modest benefit. Maintenance of function and retention in the workforce is encouraged.
The new Canadian guidelines for the treatment of FM should provide health professionals with confidence in the complete care of these patients and improve clinical outcomes.
Neuropathic pain (NeP), generated by disorders of the peripheral and central nervous system, can be particularly severe and disabling. Prevalence estimates indicate that 2% to 3% of the population in ...the developed world suffer from NeP, which suggests that up to one million Canadians have this disabling condition. Evidence-based guidelines for the pharmacological management of NeP are therefore urgently needed. Randomized, controlled trials, systematic reviews and existing guidelines focusing on the pharmacological management of NeP were evaluated at a consensus meeting. Medications are recommended in the guidelines if their analgesic efficacy was supported by at least one methodologically sound, randomized, controlled trial showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment are based on degree of evidence of analgesic efficacy, safety, ease of use and cost-effectiveness. Analgesic agents recommended for first-line treatments are certain antidepressants (tricyclics) and anticonvulsants (gabapentin and pregabalin). Second-line treatments recommended are serotonin noradrenaline reuptake inhibitors and topical lidocaine. Tramadol and controlled-release opioid analgesics are recommended as third-line treatments for moderate to severe pain. Recommended fourth-line treatments include cannabinoids, methadone and anticonvulsants with lesser evidence of efficacy, such as lamotrigine, topiramate and valproic acid. Treatment must be individualized for each patient based on efficacy, side-effect profile and drug accessibility, including cost. Further studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics, long-term outcomes, and treatment of pediatric and central NeP.
Catastrophizing is recognized as a key psychosocial factor associated with pain-related negative outcomes in individuals with chronic pain. Longitudinal studies are needed to better understand the ...temporal relationship between these constructs. The aim of this study was to determine if changes in catastrophizing early in treatment predicted subsequent changes in pain intensity and interference later in treatment, or alternately, if early changes in pain intensity and interference predicted subsequent changes in catastrophizing. A total of 538 patients with neuropathic pain were recruited from 6 multidisciplinary pain clinics across Canada. Study participants were asked to complete measures of catastrophizing, pain intensity, and interference when first seen in the clinic and then again at 3- and 6-month follow-ups. Cross-lagged panel analyses were used to determine the temporal associations among the study variables. The results showed that decreases in catastrophizing early in treatment prospectively predicted improvement in both pain intensity and interference later in treatment. Converse temporal relationships were also found, where a reduction in pain intensity and interference early in treatment predicted a subsequent diminishing of catastrophizing. All 4 unique cross-lagged correlations significantly accounted for an additional 4% to 7% of the total variance. The findings are consistent with theoretical models hypothesizing a causal impact of catastrophizing on pain, suggesting a mutual causation between these factors. The results support that treatments targeting catastrophizing may influence other pain-related outcomes, and conversely that treatments aiming to reduce pain could potentially influence catastrophizing. There may therefore be multiple paths to positive outcomes.
We report on neutron diffraction experiments performed on organogels prepared from triarylamine tris-amide (TATA), as well as on their ternary thermoreversible gels made up with polyvinyl chloride ...(PVC). Three different solvents together with their deuterated counterparts have been used; tetrachloroethane, wherein TATA fibrils display ohmic conductivity, bromobenzene and
o
-dichlorobenzene. The TATA crystal structure differs in the three solvents. Most importantly, the difference in the diffraction patterns whether hydrogenous solvents or deuterated solvents are used demonstrate the occurrence of molecular compounds. Tentative unit cells are presented. These results are also discussed in the light of the current views on the solvent role in the gelation process.
We report on neutron diffraction experiments performed on organogels prepared from triarylamine tris-amide (TATA), as well as on their ternary thermoreversible gels made up with polyvinyl chloride (PVC).
•The coda wave is very sensitive for detection.•The technology is rather new in the application of fouling detection.•This method of detection is non-invasive, so it can be applied on-line in the ...industry.•The cost of the detection by coda waves is low.
Fouling in heat exchangers is the buildup of deposits on the solid surfaces. These deposits reduce the eco-efficiency of the processing equipment and increase the risk of subsequent surface contamination with the formation of biofilms. In the agro-food and water supplier sectors, which are our main concern, fouling on the hot walls of processing heat exchangers is a common occurrence and requires frequent cleaning cycles to ensure hygiene requirements are met. This results in a considerable ecological footprint. Sensors and diagnostic tools for monitoring fouling are thus of utmost importance to ensure the rational validation of the cleaning end-point and to decrease the environmental impact of the cleaning cycles.
In this paper, a non-destructive ultrasonic monitoring technique using coda waves and the associated signal processing was tested to monitor the evolution over time of a deposit layer on a solid wall during cleaning. To ascertain the feasibility of the method, a piece of wax of controlled thickness was deposited to simulate the initial fouling state and a cleaning cycle was launched. The decorrelation coefficient was used as an indicator to monitor fouling. This article presents the principle of this unprecedented technique for measuring the degree of fouling.
The results of the experiments show that this non-destructive monitoring technology is sensitive to changes in fouling and that the decorrelation coefficient curves are in agreement with the cleaning kinetics captured using a video camera, thus ascertaining the pertinence of the diagnostic tool proposed.
OBJECTIVES:Several tools have been developed to screen for neuropathic pain. This study examined the sensitivity of the Douleur Neuropathique en 4 Questions (DN4) in screening for various neuropathic ...pain syndromes.
MATERIALS AND METHODS:This prospective observational study was conducted in 7 Canadian academic pain centers between April 2008 and December 2011. All newly admitted patients (n=2199) were approached and 789 eligible participants form the sample for this analysis. Baseline data included demographics, disability, health-related quality of life, and pain characteristics. Diagnosis of probable or definite neuropathic pain was on the basis of history, neurological examination, and ancillary diagnostic tests.
RESULTS:The mean age of study participants was 53.5 years and 54.7% were female; 83% (n=652/789) screened positive on the DN4 (≥4/10). The sensitivity was highest for central neuropathic pain (92.5%, n=74/80) and generalized polyneuropathies (92.1%, n=139/151), and lowest for trigeminal neuralgia (69.2%, n=36/52). After controlling for confounders, the sensitivity of the DN4 remained significantly higher for individuals with generalized polyneuropathies (odds ratio OR=4.35; 95% confidence interval CI2.15, 8.81), central neuropathic pain (OR=3.76; 95% CI1.56, 9.07), and multifocal polyneuropathies (OR=1.72; 95% CI1.03, 2.85) compared with focal neuropathies.
DISCUSSION:The DN4 performed well; however, sensitivity varied by syndrome and the lowest sensitivity was found for trigeminal neuralgia. A positive DN4 was associated with greater pain catastrophizing, disability and anxiety/depression, which may be because of disease severity, and/or these scales may reflect magnification of sensory symptoms and findings. Future research should examine how the DN4 could be refined to improve its sensitivity for specific neuropathic pain conditions.
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