Few empirical studies have explored how different types of knowledge are associated with diverse objectivities and moral economies. Here, we examine these associations through an empirical ...investigation of the public policy debate in Israel around medical cannabis (MC), which may be termed a contested medicine because its therapeutic effects, while subjectively felt by users, are not generally recognized by the medical profession. Our findings indicate that beneath the MC debate lie deep-seated issues of epistemology, which are entwined with questions of ethics and morality. Whereas some stakeholder groups viewed evidence-based medicine and mechanical objectivity as the only valid knowledge base, others called for recognition of a particular experience-based knowledge, championing regulatory, administrative, or strong objectivity. Stakeholders’ interpretations of what should be considered as ethical courses of (in)action corresponded to their epistemological views, with most criticizing the regulators for relying on regulatory subjectivity instead of objectivity. Our in-depth mapping of this arena allowed us not only to shed light on the emergence of the new entity called “medical cannabis” but also to reexamine the link between epistemology, ethics, and action and to elucidate how heterogeneous groups view the validity and objectivity of knowledge and the interface between medicine, science, and policy.
Background
Although studied in a few randomized controlled trials, the efficacy of medical cannabis (MC) for chronic pain remains controversial. Using an alternative approach, this multicentre, ...questionnaire‐based prospective cohort was aimed to assess the long‐term effects of MC on chronic pain of various aetiologies and to identify predictors for MC treatment success.
Methods
Patients with chronic pain, licensed to use MC in Israel, reported weekly average pain intensity (primary outcome) and related symptoms before and at 1, 3, 6, 9 and 12 months following MC treatment initiation. A general linear model was used to assess outcomes and identify predictors for treatment success (≥30% reduction in pain intensity).
Results
A total of 1,045 patients completed the baseline questionnaires and initiated MC treatment, and 551 completed the 12‐month follow‐up. At 1 year, average pain intensity declined from baseline by 20% −1.97 points (95%CI = −2.13 to −1.81; p < 0.001). All other parameters improved by 10%–30% (p < 0.001). A significant decrease of 42% reduction of 27 mg; (95%CI = −34.89 to 18.56, p < 0.001) from baseline in morphine equivalent daily dosage of opioids was also observed. Reported adverse effects were common but mostly non‐serious. Presence of normal to long sleep duration, lower body mass index and lower depression score predicted relatively higher treatment success, whereas presence of neuropathic pain predicted the opposite.
Conclusions
This prospective study provides further evidence for the effects of MC on chronic pain and related symptoms, demonstrating an overall mild‐to‐modest long‐term improvement of the tested measures and identifying possible predictors for treatment success.
Abstract Differential diagnosis is a crucial aspect of medical practice, as it guides clinicians to accurate diagnoses and effective treatment plans. Traditional resources, such as medical books and ...services like UpToDate, are constrained by manual curation, potentially missing out on novel or less common findings. This paper introduces and analyzes two novel methods to mine etiologies from scientific literature. The first method employs a traditional Natural Language Processing (NLP) approach based on syntactic patterns. By using a novel application of human-guided pattern bootstrapping patterns are derived quickly, and symptom etiologies are extracted with significant coverage. The second method utilizes generative models, specifically GPT-4, coupled with a fact verification pipeline, marking a pioneering application of generative techniques in etiology extraction. Analyzing this second method shows that while it is highly precise, it offers lesser coverage compared to the syntactic approach. Importantly, combining both methodologies yields synergistic outcomes, enhancing the depth and reliability of etiology mining.
Muscles and the deep fascia surrounding them have been suggested to play an important role in various musculoskeletal pain conditions including low back pain. Both have been shown to host rich ...nociceptive innervation and to undergo changes in individuals with chronic pain. However, evidence for the respective contribution of muscle and fascia sensitization in humans with myofascial pain syndrome is lacking. Here, we studied the sensitization of muscle and fascia in individuals with myofascial low back pain. Twenty individuals with acute (5) and chronic (15) myofascial low back pain of the quadratus lumborum muscle and a matched control group of twenty healthy individuals were recruited and clinically evaluated. All participants underwent ultrasound-guided needling of their subcutaneous tissue, deep fascia and quadratus lumborum muscle. Reported pain intensity and episodes of muscle twitching were recorded and analyzed. Among pain patients, both muscles and deep fascia demonstrated pain hypersensitivity, but muscles were significantly more sensitized than the deep fascia. No difference between acute- or chronic-pain patients was observed. Results of this study suggest that while both deep fascia and muscle show pain sensitization in both early and chronic stages of low back pain, muscles are more sensitized than fascia.
The energy crisis hypothesis, which is a widely accepted model for the pathogenesis of myofascial pain, has been corroborated by experimental observations. However, the nature of the insult leading ...to the energy crisis remains elusive. A commonly cited model for this insult is the Cinderella hypothesis, suggesting that hierarchical recruitment of motor units leads to a disproportional load on small units, thus driving them towards an energy crisis. New findings cast doubt on this model, showing that in postural muscles motor units are recruited in rotation, rather than in a hierarchical order, precluding the formation of the so-called Cinderella units.
To explore the influence of common myofascial predisposing factors such as muscle load and muscle strength on the relaxation time of postural muscle motor units, assuming they are recruited in rotation.
A stochastic model of a postural skeletal muscle was developed which integrates the energy crisis model and motor unit rotation patterns observed in postural muscles. Postulating that adequate relaxation time is essential for the energetic replenishment of motor units, we explored the influence of different parameters on the relaxation time of individual motor units under varying conditions of muscle loads and muscle strengths.
The motor unit relaxation/contraction time ratio decreases with elevated muscle loads and with decreased total muscle strength.
In a model of a postural muscle, in which motor units are recruited in rotation, common predisposing factors of myofascial pain, such as increased muscle load and decreased muscle force, lead to shortened motor unit relaxation periods.
In this review we provide the updates on last years’ advancements in basic science, imaging methods, efficacy, and safety of dry needling of myofascial trigger points (MTrPs). The latest studies ...confirmed that dry needling is an effective and safe method for the treatment of MTrPs when provided by adequately trained physicians or physical therapists. Recent basic studies have confirmed that at the site of an active MTrP there are elevated levels of inflammatory mediators, known to be associated with persistent pain states and myofascial tenderness and that this local milieu changes with the occurrence of local twitch response. Two new modalities, sonoelastography and magnetic resonance elastography, were recently introduced allowing noninvasive imaging of MTrPs. MTrP dry needling, at least partially, involves supraspinal pain control via midbrain periaqueductal gray matter activation. A recent study demonstrated that distal muscle needling reduces proximal pain by means of the diffuse noxious inhibitory control. Therefore, in a patient too sensitive to be needled in the area of the primary pain source, the treatment can be initiated with distal needling.
Back Pain with Leg Pain Vulfsons, Simon; Bar, Negev; Eisenberg, Elon
Current pain and headache reports,
07/2017, Letnik:
21, Številka:
7
Journal Article
Recenzirano
Purpose of Review
The clinical diagnostic dilemma of low back pain that is associated with lower limb pain is very common. In relation to back pain that radiates to the leg, the International ...Association for the Study of Pain (IASP) states: “Pain in the lower limb should be described specifically as either referred pain or radicular pain. In cases of doubt no implication should be made and the pain should be described as pain in the lower limb.”
Recent Findings
Bogduks’ editorial in the journal
PAIN
(2009) helps us to differentiate and define the terms somatic referred pain, radicular pain, and radiculopathy. In addition, there are other pathologies distal to the nerve root that could be relevant to patients with back pain and leg pain such as plexus and peripheral nerve involvement. Hence, the diagnosis of back pain with leg pain can still be challenging.
Summary
In this article, we present a patient with back and leg pain. The patient appears to have a radicular pain syndrome, but has no neurological impairment and shows signs of myofascial involvement. Is there a single diagnosis or indeed two overlapping syndromes? The scope of our article encompasses the common diagnostic possibilities for this type of patient. A discussion of treatment is beyond the scope of this article and depends on the final diagnosis/diagnoses made.
Background:
Little research has tested associations of pain and MC use after long-term treatment and through methods that have external validity outside experimental settings. The study examined ...associations of pain, associated painful experiences, and long-term medical cannabis (MC) use in chronic pain (CP) patients using a naturalistic daily diary study that provided novel and externally valid data.
Methods:
Data were obtained from 78 MC users with CP three times daily over a 10-day period (n
observations
= 1,688). Mixed-effects models were used to test the associations between MC use and momentary experiences of pain, affect, and fatigue.
Results:
Within persons, elevated experiences of pain intensity were associated with greater intention to use MC within the next hour. No evidence was found that the time lapse since last MC use was associated with pain levels, negative affect, or fatigue.
Conclusions:
The results imply that after long-term use, CP patients intend to use MC in response to pain experiences. Yet, they may not actually achieve the pain relief. More research is needed to examine whether continued MC use despite lack of pain relief is related to relief of other symptoms (e.g., dependence, withdrawal) or positive benefits (e.g., general sense of well-being) or tolerance.
Over the past decade the phenomenon of cannabis as a legitimate form of treatment for pain has overwhelmed the medical community, especially in the field of pain. From a status of a schedule 1 ...substance having no currently accepted medical use and being considered to have high potential for abuse, its use has mushroomed to over 50,000 legal medical users per year in Israel alone. There appear to be many reasons behind this phenomenon-medical, sociological, and economical. Thus, what is cannabis? An abusive substance or a medication? Should it be incorporated into current biomedical practice, and how should it be administered? Finally, what is the evidence for the beneficial and detrimental effects of cannabis? This article reviews and discusses the current literature regarding the beneficial and the detrimental effects of medical cannabis in the treatment of pain. We further discuss the problems and challenges facing the medical community in this domain and offer a practical approach to deal with these challenges.
Imperforate hymen in an adolescent usually presents with cyclic abdominal pain or with pelvic mass associated with primary amenorrhea. We present a 13-year-old girl with chronic lower back pain of 6 ...months' duration as the only complaint. On physical examination, multiple trigger points were detected in the quadratus lumborum and gluteus medius muscles bilaterally. Abdominal ultrasound revealed hematometrocolpos secondary to an imperforate hymen. Hymenectomy was performed, with complete resolution of the back pain. Myofascial pain syndrome with a viscerosomatic reflex is a possible explanation for the clinical presentation of our patient.
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