The Doctor's Channel - Alternative Medicine

Magnetic stimulation shows promise for migraine with aura

2010-03-08T19:29:41+00:00

NEW YORK (Reuters Health) – A portable magnetic stimulation device is a promising noninvasive, drug-free treatment for acute migraine with aura, according to a March 4th online report in The Lancet Neurology.

However, although the single-pulse transcranial magnetic stimulation (TMS) was more effective than sham treatment, most patients still had some pain, the report indicates.

Transcranial magnetic stimulation has been “tested in individuals with migraine based on the hypothesis that a fluctuating magnetic field…applied to the back of the head, would induce electrical current and disrupt cortical spreading depression,” lead author Dr. Richard B. Lipton, from Albert Einstein College of Medicine, Bronx, New York, and co-researchers explain.

In the current study, Dr. Lipton’s team assessed response rates in 201 patients with migraine with aura who took home the hand-held Cerena Transcranial Magnetic Stimulator for TMS, or an identical sham device.

Over the 3-month study period, patients treated up to three migraine attacks while experiencing aura. Thirty-seven participants did not treat a migraine attack and were excluded from further analysis.

The main outcome -- no pain 2 hours after the first attack – occurred in 39% of TMS patients and 22% of sham treatment patients (p = 0.0179). Rates of sustained pain-free response at 24 hours were 29% vs. 16% and at 48 hours, 27% vs. 13% (p < 0.05 for both).

Non-inferiority analysis indicated that TMS was at least as effective as sham treatment in combating nausea, photophobia, and phonophobia.

No serious device-related events occurred, and the rate and severity of events was comparable in each patient group.

“For patients who commonly have aura as a signal of an impending migraine, treatment with single-pulse TMS may abort progression of the attack and abate disabling pain and other symptoms,” the authors conclude.

Because there is evidence of cortical spreading depression in migraine without aura, it is possible that TMS may be an effective treatment for these headaches as well, they add.

In an editorial, Dr. Hans-Christoph Diener of University Hospital Essen in Germany writes that with more research, “the use of TMS could be a major step forward in the treatment of migraine with aura, particularly in patients in whom presently available drug treatment is ineffective, poorly tolerated, or contraindicated.”

Reference:
Lancet Neurol 2010.

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High-flow oxygen therapy effective for cluster headache

2009-12-11T16:23:55+00:00

NEW YORK (Reuters Health) – High-flow inhaled oxygen is an effective treatment for cluster headache attacks, investigators said in the Journal of the American Medical Association for December 9.

In a crossover study, patients with acute cluster headache alternated therapies at the start of attacks: either they breathed high-flow oxygen, or air, without knowing which treatment they were using.

With oxygen, patients were significantly more likely to be pain-free at 15 minutes, Dr. Peter J. Goadsby, from the University of California, San Francisco, and colleagues found.

“The great advantage of oxygen is that it has no established adverse effects, can be readily combined with other treatments, and can be used several times daily,” they note.

As the authors report in their paper, 109 adults with episodic or chronic cluster headache were treated through 4 cluster headache attacks alternatively with 15 minutes of high-dose, high-flow oxygen (100%, 12 L/min by face mask) at attack onset or high-flow air. The final analysis was based on 57 patients with episodic cluster headache and 19 patients with chronic cluster headache.

According to Dr. Goadsby and colleagues, 78% of patients reported being pain-free or having adequate relief within 15 minutes after oxygen treatment, compared to 20% of patients after breathing air (p < 0.001).

In addition, "oxygen was numerically superior to air” for the secondary end points: pain-free at 30 minutes, reduction in pain up to 60 minutes, need for rescue medication 15 minutes after treatment, overall response to the treatment and overall functional disability, and effect on associated symptoms.

For example, 72% of patients were pain-free 30 minutes after oxygen treatment, but only 24% were pain-free 30 minutes after breathing air.

Similarly, more patients had reduction in pain at 60 minutes after breathing oxygen (92%) than after breathing air (59%).

There were no serious adverse events related to the treatments.

“This work," the investigators conclude, "paves the way for further studies to optimize the administration of oxygen and its more widespread use as an acute treatment in cluster headache, offering an evidence-based alternative to those who cannot take triptan agents.”

Reference:
JAMA 2009;302:2451-2457.

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Transcranial magnetic stimulation – who benefits?

2009-12-07T17:20:56+00:00

Ian A Cook, MD, Director, Unipolar Depression Research, UCLA David Geffen School of Medicine, discusses a new depression treatment using gentle brain stimulation called TMS, or transcranial magnetic stimulation, and describes new research which uses EEG to determine early response to treatment which is thought to be predictive of treatment outcomes.

Reading:
Rábago CA, Lancaster JL, Narayana S, Zhang W, Fox PT. Automated-parameterization of the motor evoked potential and cortical silent period induced by transcranial magnetic stimulation. Clin Neurophysiol. 2009 Aug;120(8):1577-87. Epub 2009 Jun 25.
Padberg F, George MS. Repetitive transcranial magnetic stimulation of the prefrontal cortex in depression. Exp Neurol. 2009 Sep;219(1):2-13. Epub 2009 May 4. Review.
Siebner HR, Hartwigsen G, Kassuba T, Rothwell JC. How does transcranial magnetic stimulation modify neuronal activity in the brain? Implications for studies of cognition. Cortex. 2009 Oct;45(9):1035-42. Epub 2009 Mar 3.

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Treating depression without drugs

2009-12-07T17:17:00+00:00

Ian A Cook, MD, Director, Unipolar Depression Research, UCLA David Geffen School of Medicine, discusses a new depression treatment using gentle brain stimulation and TMS, or transcranial magnetic stimulation, rather than ECT or medication. The treatment was approved by the FDA in 2008.

Reading:
Kim DR, Pesiridou A, O'Reardon JP. Transcranial magnetic stimulation in the treatment of psychiatric disorders. Curr Psychiatry Rep. 2009 Dec;11(6):447-52.
Fitzgerald PB, McQueen S, Herring S, Hoy K, Segrave R, Kulkarni J, Daskalakis ZJ. A study of the effectiveness of high-frequency left prefrontal cortex transcranial magnetic stimulation in major depression in patients who have not responded to right-sided stimulation. Psychiatry Res. 2009 Aug 30;169(1):12-5. Epub 2009 Jul 23.
Demitrack MA, Thase ME. Clinical significance of transcranial magnetic stimulation (TMS) in the treatment of pharmacoresistant depression: synthesis of recent data. Psychopharmacol Bull. 2009;42(2):5-38.
Herbsman T, Avery D, Ramsey D, Holtzheimer P, Wadjik C, Hardaway F, Haynor D, George MS, Nahas Z. More lateral and anterior prefrontal coil location is associated with better repetitive transcranial magnetic stimulation antidepressant response. Biol Psychiatry. 2009 Sep 1;66(5):509-15. Epub 2009 Jul 9.

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Laser therapy effective for acute and chronic neck pain

2009-11-17T15:10:15+00:00

NEW YORK (Reuters Health) - Low-level laser therapy (LLLT) provides rapid relief of acute neck pain as well as sustained improvements in chronic neck pain, a meta-analysis has shown. Exactly how it works, though, is still a bit of a mystery.

Medications have only limited efficacy in treating neck pain, a common and costly problem, Dr. Roberta T. Chow, from the University of Sydney, Australia, and colleagues note. Although a number of studies have looked at LLLT as a treatment for neck pain, its efficacy remains unclear.

Searching various computerized databases, Dr. Chow's team identified 16 randomized controlled trials (with 820 patients) that compared LLLT with placebo or with active control as a treatment for acute or chronic neck pain.

According to their report in the November 13th online issue of The Lancet, data from two of the trials showed that LLLT was 69% more likely than placebo to improve acute neck pain.

In five trials looking at chronic neck pain and reporting categorical data, LLLT was roughly four times more likely than placebo to improve pain. In 11 trials that evaluated changes in visual analogue scale, LLLT was associated with a mean drop in pain intensity of 19.86 mm.

Data from seven trials, with up to 22 weeks of follow-up, showed persistent pain relief for up to 6 months, with a mean reduction in pain intensity of 22.07 mm.

LLLT was well tolerated and side effects were comparable to what was seen with placebo, the report indicates.

The evidence from this analysis that LLLT is effective for neck pain "is more solid than that for many current interventions," Dr. Jaime Guzman, from the University of British Columbia, Vancouver, Canada, writes in an editorial.

"Although the mechanisms of action and effects on function and occupational outcomes are not clearly understood and warrant further impartial study, LLLT is an option worthy of consideration for management of non-specific neck pain," the researcher concludes.

Reference:
Lancet 2009.

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Shock-wave therapy as good as surgery for long-bone nonunions

2009-11-10T13:59:27+00:00

NEW YORK (Reuters Health) – New research suggests that extracorporeal shock-wave therapy (ESWT) is a viable alternative to surgery for long-bone hypertrophic nonunions.

“When we examined patients and compared their outcomes at 3 and 6 months, initially those who received ESWT actually felt better than those who had surgery,” lead author Dr. Angelo Cacchio said in a statement. “When we examined patients at 12 and 24 months, there were not significant differences in terms of healing.”

The findings, reported in The Journal of Bone and Joint Surgery for November, stem from a study of 126 patients who were randomized to undergo surgery or to receive four ESWT treatments at one of two energy flux densities (0.40 or 0.70 mJ/millimeters-squared). The main outcome measure was fracture healing assessed with radiography.

At 6 months, the percentage of patients with healed fractures in each group was nearly the same, hovering closely around 71%, Dr. Cacchio, from San Salvatore Hospital of L’Aquila, Italy, and associates report.

At both 3 and 6 months, pain and function scores were significantly better in the ESWT groups than in the surgical group. By 12 months, the differences had largely disappeared with the exception of the ESWT groups continuing to have better scores on the Disabilities of the Arm, Shoulder, and Hand questionnaire.

“The results of this randomized controlled trial strongly suggest that ESWT is a simple and safe alternative to surgical treatment of hypertrophic long-bone nonunions,” the authors conclude.

However, they add, the findings need to be verified, and “different treatment protocols as well as treatment parameters should be investigated; these include the number of shock waves used, the energy levels applied and the frequency of application.”

Reference:
J Bone Joint Surg 2009.

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Omega-3 does not boost response to antidepressant therapy

2009-10-23T14:43:54+01:00

NEW YORK (Reuters Health) – Omega-3 fatty acid supplements do not improve the response to sertraline in heart disease patients with major depression, according to results of a randomized controlled study.

The findings, reported in the Journal of the American Medical Association for October 21, run contrary to prior studies showing that certain omega-3 supplements augment the efficacy of standard antidepressant therapy, Dr. Robert M. Carney, from Washington University School of Medicine, St. Louis, and colleagues point out.

“At the present time, there is no evidence that omega-3, at least the type and dosage of omega-3 used in this study, improves the effectiveness of antidepressants in patients with heart disease,” Dr. Carney noted in email to Reuters Health.

After a 2-week run-in period, the investigators had 122 patients with major depression and coronary heart disease (CHD) start sertraline at a dose of 50 mg/day, at which point patients were randomized to one of two arms: treatment with 2 g/day of omega-3 acid ethyl esters (930 mg EPA and 750 mg DHA), or corn oil placebo capsules.

During the study, which lasted for 10 weeks, medication adherence was high in both groups (97% or more), the researchers report.

Dr. Carney said that while patients in both groups responded to treatment, “there was no difference in improvement between those who got omega-3 and those who received the corn oil placebo.”

In both groups, estimated weekly Beck Depression Inventory (BDI-II) scores showed that depressive symptoms improved over time at comparable rates, and the placebo and omega-3 groups did not differ at 10 weeks with regard to depression or anxiety.

Moreover, there was no significant difference in the rate of remission between the placebo group and the omega-3 group (27.4% vs 28.3%; respectively, odds ratio 0.96) or response to treatment (49.0% vs 47.7%; respectively, odds ratio 1.06).

“We expected depression symptoms in patients taking both sertraline and omega-3 to improve more than in those taking the antidepressant drug and the corn oil placebo,” Dr. Carney said.

The findings are “disappointing," he added, "in light of the fact that depression is a significant risk factor for cardiac mortality and we are in need of more effective treatments for depression in these patients."

“Whether higher doses of omega-3 or sertraline, a different ratio of EPA to DHA, longer treatment, or omega-3 monotherapy can improve depression in patients with CHD remains to be determined," Dr. Carney and colleagues note in their report.

Reference:
JAMA 2009;302:1651-1657.

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Oxygen therapy relieves headache pain in the ED, cuts length of stay, drug use

2009-10-09T15:32:48+01:00

NEW YORK (Reuters Health) - Giving high-flow oxygen therapy for 15 minutes to emergency department patients with headaches provides rapid relief and reduces hospital stays, use of CT scans, and headache pharmacotherapy, according to a pilot study.

Dr. Boris Veysman of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School reported the results on Monday at the annual meeting of the American College of Emergency Physicians in Boston.

"Very often, when a patient comes to the emergency department with one complaint being headache, they're uncomfortable and symptomatic and they have to wait for a workup before anyone can determine the cause. A diagnosis may not even be made in the emergency department," Dr. Veysman told Reuters Health. "So we approached it from a different perspective and asked, 'What if therapy were the first thing you did (for a headache) before attempting to find a cause?' And so we tried giving oxygen therapy, because it's so widespread and safe."

In the placebo-controlled study, 17 patients were randomized to 100% oxygen at 15 L/min for 15 minutes; 14 received high flow air for 15 minutes; and 17 received no intervention prior to standard treatment. Headache intensity was assessed using a 10-point visual analog scale.

Median times to relief were significantly shorter for patients treated with oxygen (40 minutes) compared with those treated with high flow air (110 minutes) or nothing (120 minutes). Median length of stay was also significantly shorter for patients treated with oxygen (57.5 minutes) than for those treated with air (210 minutes) or nothing (180 minutes).

In addition, CT scans were ordered less frequently: for four of 17 patients (24%) who received oxygen; 11 of 14 (79%) who received air; and eight of 17 (47%) who got nothing.

Medication was given to 29% of those who received oxygen, 86% of those who received air, and 82% of those who received no treatment.

Headache intensity was significantly reduced at both 15 minutes and 30 minutes after initiation of treatment, with patients treated with oxygen realizing the greatest reductions.

"It was a small study, and our results are preliminary," Dr. Veysman stressed. "But the medical community is starting to recognize that it's important to treat discomfort even when you don't know what's causing it, as long as you feel confident the treatment won't make the patient worse. In this case, we found more relief with oxygen than with placebo, although the fact that the headache goes away doesn't necessarily mean the patient can go home."

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Radiofrequency treatment plus surgery safe and effective for snoring

2009-10-06T15:39:08+01:00

NEW YORK (Reuters Health) – Radiofrequency tissue volume reduction (RFTVR) of the soft palate combined with partial uvulectomy is a relatively safe and effective treatment for primary snoring, the results of a 3-year study suggest.

“Some studies demonstrated that radiofrequency-surgery of the soft palate leads to a significant improvement of primary snoring and is associated with minimal postoperative pain while postoperative complication rates were low,” lead researcher Dr. Cheng-Yu Lin told Reuters Health. Long-term outcomes of this treatment had not been studied in a large group of patients, however.

The present study involved 60 patients with primary snoring (apnea-hypopnea index <15, body mass index < 30) who received two session of combined RFTVR of the soft palate and underwent partial uvulectomy, Dr. Lin, from Tainan Municipal Hospital, Taiwan, said.

Three-year efficacy and morbidity findings were presented this week at the American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting & OTO EXPO in San Diego, California.

RFTVR plus partial uvulectomy was associated with a statistically significant (p < 0.0001) and clinically relevant improvement in snoring severity. Body mass index and preoperative snoring level were both positive predictors of a treatment response, Dr. Lin said.

Aside from pharyngeal irritation, which was limited but persistent, postoperative sequelae improved during follow-up.

Roughly 72% of patients reported satisfaction with the treatment results on long-term follow-up.

The current findings, Dr. Lin said, support the use of RFTVR plus uvulectomy as a safe and effective treatment for primary snoring.

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Combining drugs improves neuropathic pain relief

2009-10-05T15:34:31+01:00

NEW YORK (Reuters Health) - Given together, nortriptyline and gabapentin are more effective than either agent alone in treating neuropathic pain, according to a report in the September 30th online issue of The Lancet.

"Drugs for neuropathic pain have incomplete efficacy and dose-limiting side-effects when given as monotherapy," Dr. Ian Gilron, from Queen's University, Kingston, Canada, and colleagues note.

With this in mind, the researchers conducted a randomized cross-over study involving 56 patients with neuropathic pain. In a 1:1:1 fashion, patients received one of three sequences of daily oral gabapentin, nortriptyline, or a combination of the two, with each treatment period lasting 6 weeks. Drug doses were titrated towards the maximum tolerated dose.

Forty-seven patients who finished at least two of the three treatment periods were analyzed for their mean daily pain at their maximum tolerated dose, which was the primary outcome.

At baseline, the average daily pain score was 5.4 on a scale of 1 to 10. With gabapentin, nortriptyline, and both drugs, pain scores fell to 3.2, 2.9, and 2.3, respectively. Further analysis showed that combined treatment was significantly more effective than monotherapy with gabapentin (p = 0.001) or nortriptyline (p = 0.02).

The most common side effect at the maximum tolerated dose was dry mouth, seen more often when nortriptyline was given (p < 0.001). No serious adverse events occurred.

In a related editorial, Dr. Troels Staehelin Jensen and Dr. Nanna Brix Finnerup, from Aarhus University Hospital, Denmark, comment that the present study does not answer the question of whether a treatment effect must be established for each drug alone to know if the combination will work. "In clinical practice," they add, "sequential treatment is most common, but in Gilron and colleagues' study, drugs in combination were given simultaneously."

Reference:
Lancet 2009.

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