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The direct neural stimulation of peripheral or central nervous systems has been shown as an effective tool to treat neurological conditions. The electrical activation of the nervous sensory pathway can be adopted to restore the artificial sense of touch and proprioception in people suffering from sensory-motor disorders. The modulation of the neural stimulation parameters has a direct effect on the electrically induced sensations, both when targeting the somatosensory cortex and the peripheral somatic nerves. The properties of the artificial sensations perceived, as their location, quality and intensity are strongly dependent on the direct modulation of pulse width, amplitude and frequency of the neural stimulation. Different sensory encoding schemes have been tested in patients showing distinct effects and outcomes according to their impact on the neural activation. Here, I reported the most adopted neural stimulation strategies to artificially encode somatosensation into the peripheral nervous system. The real-time implementation of these strategies in bionic devices is crucial to exploit the artificial sensory feedback in prosthetics. Thus, neural stimulation becomes a tool to directly communicate with the human nervous system. Given the importance of adding artificial sensory information to neuroprosthetic devices to improve their control and functionality, the choice of an optimal neural stimulation paradigm could increase the impact of prosthetic devices on the quality of life of people with sensorimotor disabilities., (© 2022 The Author. European Journal of Neuroscience published by Federation of European Neuroscience Societies and John Wiley & Sons Ltd.)

Aim: This case report documents the use of peripheral nerve stimulation in the setting of entrapment of the anterior cutaneous branches of the intercostal nerves, with pain rated by the patient as severe during exacerbation episodes. Materials & methods: Under ultrasound guidance, two permanent leads were implanted caudad to cephalad, along and superficial to the lateral aspect of the rectus abdominis, distal to the umbilicus (1 lead per side). Results: At the 6 month follow-up, the patient reported near complete resolution of baseline pain, as well as fewer, sporadic pain exacerbation episodes, rated as mild-to-moderate. Conclusion: This case report suggests that peripheral nerve stimulation might be a valuable treatment option for previously intractable abdominal pain due to entrapment of the anterior cutaneous branches.

Peripheral nerve stimulation is an established treatment modality for chronic neuropathic pain. Over the last decade, with the advent of innovative devices and delivery platforms, peripheral nerve stimulation has evolved from invasive open surgeries to image-guided, minimally invasive percutaneous procedures. The authors hereby present a novel device, the Nalu™ Neurostimulation System (Nalu Medical, CA, USA), which has established its advantages in providing predictable and reliable peripheral nerve stimulation therapy for chronic neuropathic pain management. This novel device is effective in treating chronic pain conditions such as post-herniorrhaphy pain syndrome, intercostal neuralgia, post-laminectomy syndrome, and complex regional pain syndrome and holds great promise for the treatment of peripheral neuropathic pain.

Although neuromodulation is well established for the treatment of non-neurogenic lower urinary tract symptoms, recent literature supports its use in the patient having LUTS associated with a neurologic condition. Sacral neuromodulation, in particular, may see new use as a modality to facilitate neurologic remodeling in spinal cord injured patients as well as children. As a therapeutic option, sacral neuromodulation and dorsal genital nerve stimulation may one day become more effective and more efficient utilizing the concept of closed- loop feedback, where electro-neurogram and bladder pressure data are incorporated into stimulation routines. In addition, some older therapies are reviewed that have recently demonstrated success in this patient population. [ABSTRACT FROM AUTHOR]

Paired Associative Stimulation (PAS) has come to prominence as a potential therapeutic intervention for the treatment of brain injury/disease, and as an experimental method with which to investigate Hebbian principles of neural plasticity in humans. Prototypically, a single electrical stimulus is directed to a peripheral nerve in advance of transcranial magnetic stimulation (TMS) delivered to the contralateral primary motor cortex (M1). Repeated pairing of the stimuli (i.e., association) over an extended period may increase or decrease the excitability of corticospinal projections from M1, in manner that depends on the interstimulus interval (ISI). It has been suggested that these effects represent a form of associative long-term potentiation (LTP) and depression (LTD) that bears resemblance to spike-timing dependent plasticity (STDP) as it has been elaborated in animal models. With a large body of empirical evidence having emerged since the cardinal features of PAS were first described, and in light of the variations from the original protocols that have been implemented, it is opportune to consider whether the phenomenology of PAS remains consistent with the characteristic features that were initially disclosed. This assessment necessarily has bearing upon interpretation of the effects of PAS in relation to the specific cellular pathways that are putatively engaged, including those that adhere to the rules of STDP. The balance of evidence suggests that the mechanisms that contribute to the LTP- and LTD-type responses to PAS differ depending on the precise nature of the induction protocol that is used. In addition to emphasizing the requirement for additional explanatory models, in the present analysis we highlight the key features of the PAS phenomenology that require interpretation. [ABSTRACT FROM AUTHOR]

Chronic migraine is a disabling disorder that is costly to individuals and society. Occipital nerve stimulation has been used to treat refractory cases of primary headache disorders including drug-resistant chronic cluster headaches and chronic migraine. The Food and Drug Administration (FDA) off-labeled application of equipment used for peripheral nerve (occipital) stimulation is borrowed from FDA-labeled spinal cord stimulation. Manufacturer-sponsored randomized trials include a feasibility study (ONSTIM-Medtronic) and a safety and efficacy study (St Jude). A non-industry sponsored prospective, randomized crossover study by Serra and Marchiotretto suggests improved quality of life and a significant reduction in medication use. Though preliminary studies suggest occipital nerve stimulation is safe and efficacious in treating chronic migraine headache, complication rates, including lead migration, lead fracture, and surgical site infections remain high. Further studies are needed to demonstrate long-term outcomes, while improved surgical techniques and site-specific equipment are needed to minimize complications. [ABSTRACT FROM AUTHOR]

The effects of unilateral afferent inputs induced by electrical peripheral nerve stimulation (ES) at three different frequencies (1, 2, and 3 Hz) on ipsilateral primary motor cortex excitability (ipsi-M1) were investigated using transcranial magnetic stimulation (TMS). In experiment 1, ES was applied to the left ulnar nerve at 1, 2, or 3 Hz, followed by TMS, which was delivered to the left M1 at inter-stimulus interval (ISI) of 25, 35, 65, or 150 ms, to reveal the suitable conduction time. In experiment 2, we investigated whether the interventional 600 ES burst at 1, 2, or 3 Hz provoked plastic changes in the ipsi-M1. ISI of 35 ms was found to provoke the greatest change in ipsi-M1 excitability that depended on frequency of ES. Ipsi-M1 excitability seen in 2 Hz condition was significantly reduced as compared with that seen in the 1 and 3 Hz conditions. The interventional 600 ES burst was able to produce plastic changes in ipsi-M1 excitability. In particular, Ipsi-M1 excitability seen in the 2 Hz condition was significantly reduced as compared with that seen in 1 and 3 Hz conditions. The unilateral afferent inputs at different frequencies modulated ipsi-M1 excitability that were dependent on their frequencies. [ABSTRACT FROM AUTHOR]

Background: Chronic radicular pain can be effectively treated with spinal cord stimulation, but this therapy is not always sufficient for chronic back pain. Subcutaneous nerve stimulation (SQS) refers to the placement of percutaneous leads in the subcutaneous tissue within the area of pain. Case series data show that failed back surgery syndrome (FBSS) patients experience clinically important levels of pain relief following SQS and may also reduce their levels of analgesic therapy and experience functional well-being. However, to date, there is no randomized controlled trial evidence to support the use of SQS in FBSS. Methods/Design: The SubQStim study is a multicenter randomized controlled trial comparing SQS plus optimized medical management ('SQS arm') versus optimized medical management alone ('OMM arm') in patients with predominant back pain due to FBSS. Up to 400 patients will be recruited from approximately 33 centers in Europe and Australia and will be randomized 1:1 to the SQS or OMM arms. After 9 months, patients who fail to reach the primary outcome will be allowed to switch treatments. Patients will be evaluated at baseline (prior to randomization) and at 1, 3, 6, 9, 12, 18, 24, and 36 months after randomization. The primary outcome is the proportion of patients at 9 months with a ⩾50% reduction in back pain intensity compared to baseline. The secondary outcomes are: back and leg pain intensity score, functional disability, health-related quality of life, patient satisfaction, patient global impression of change, healthcare resource utilization/costs, cost-effectiveness analysis and adverse events. Outcomes arms will be compared between SQS and OMM arms at all evaluation points up to and including 9 months. After the 9-month assessment visit, the main analytic focus will be to compare within patient changes in outcomes relative to baseline. Discussion: The SubQStim trial began patient recruitment in November 2012. Recruitment is expected to close in late 2014. Trial registration: ClinicalTrials.gov NCT01711619 [ABSTRACT FROM AUTHOR]

The aim of this study was to examine whether single-pulse transcranial magnetic stimulation (spTMS) affects the pattern of corticospinal activity once voluntary drive has been restored after spTMS-induced EMG silence. We used fractal dimension (FD) to explore the 'complexity' of the electromyography (EMG) signal, and median frequency of the spectra (MDF) to examine changes in EMG spectral characteristics. FD and MDF of the raw EMG epochs immediately before were compared with those obtained from epochs after the EMG silence. Changes in FD and MDF after spTMS were examined with three levels of muscle contraction corresponding to weak (20-40 %), moderate (40-60 %) and strong (60-80 % of maximal voluntary contraction) and three intensities of stimulation set at 10, 20 and 30 % above the resting motor threshold. FD was calculated using the Higuchi fractal dimension algorithm. Finally, to discern the origin of FD changes between the CNS and muscle, we compared the effects of spTMS with the effects of peripheral nerve stimulation (PNS) on FD and MDF. The results show that spTMS induced significant decrease in both FD and MDF of EMG signal after stimulation. PNS did not have any significant effects on FD nor MDF. Changes in TMS intensity did not have any significant effect on FD or MDF after stimulation nor had the strength of muscle contraction. However, increase in contraction strength decreased FD before stimulation but only between weak and moderate contraction. The results suggest that the effects of spTMS on corticospinal activity, underlying voluntary motor output, outlast the TMS stimulus. It appears that the complexity of the EMG signal is reduced after spTMS, suggesting that TMS alters the dynamics of the ongoing corticospinal activity most likely temporarily synchronizing the neural network activity. Further studies are needed to confirm whether observed changes after TMS occur at the cortical level. [ABSTRACT FROM AUTHOR]

The effect of whole body vibration ( WBV) on reflex responses is controversially discussed in the literature. In this study, three different modalities of reflex activation with increased motor complexity have been selected to clarify the effects of acute WBV on reflex activation: (1) the electrically evoked H-reflex, (2) the mechanically elicited stretch reflex, and (3) the short-latency response ( SLR) during hopping. WBV-induced changes of the H-reflex, the stretch reflex, and the SLR during hopping were recorded in the soleus and gastrocnemius muscles and were analyzed before, during (only the H-reflex), immediately after, 5 min and 10 min after WBV. The main findings were that (1) the H-reflexes were significantly reduced during and at least up to 5 min after WBV, (2) the stretch reflex amplitudes were also significantly reduced immediately after WBV but recovered to their initial amplitudes within 5 min, and (3) the SLR during hopping showed no vibration-induced modulation. With regard to the modalities with low motor complexities, the decreased H- and stretch reflex responses are assumed to point toward a reduced Ia afferent transmission during and after WBV. However, it is assumed that during hopping, the suppression of reflex sensitivity is compensated by facilitatory mechanisms in this complex motor task. [ABSTRACT FROM AUTHOR]

Purpose: To report on the use of the laparoscopic implantation of neuroprosthesis (LION) procedure on the sensitive branches of the lumbar plexus for the treatment of refractory postherniorrhaphy neuropathic inguinodynia. Methods: Laparoscopic exposure and implantation of an electrode to the different nerves is undertaken by the transumbilical transperitoneal approach. The genitofemoral nerve is identified on the anterior surface of the psoas major muscle, the ilioinguinal, iliohypogastric, and of the lateral femoral cutaneous nerves on the anterior surface of the quadratus lumborum muscle behind the kidney and colon. A quadripolar electrode is placed laparoscopically in direct contact with the injured nerve(s). Results: All patients included in this series had reported failure of all previous treatments. Twenty-three consecutive patients were included in this series. Success, defined as visual analog scale (VAS) reduction >50%, was obtained in 19 patients. To date (mean follow-up 28.61 months [±16.2; min. 6 months to max. 68 months]), 11 patients report a reduction of the mean VAS of more than 80% and eight report a reduction of between 50 and 80%; the mean VAS score could be reduced, so far, from 8.1 (±8.1; range 6-10) preoperatively to 3.1 (±2.8; range 0-5) postoperatively ( P < 0.001). Conclusions: The presented technique of laparoscopic implantation permits a selective implantation and neuromodulation of all sensitive branches of the lumbar plexus. These preliminary results suggest that the technique described is effective, safe, minimally invasive, and must be indicated in patients after failure of all other treatments. [ABSTRACT FROM AUTHOR]

Headaches (cephalgias) are a common reason for patients to seek medical care. There are groups of patients with recurrent headache and craniofacial pain presenting with malignant course of their disease that becomes refractory to pharmacotherapy and other medical management options. Neuromodulation can be a viable treatment modality for at least some of these patients. We review the available evidence related to the use of neuromodulation modalities for the treatment of medically refractory craniofacial pain of different nosology based on the International Classification of Headache Disorders, 2nd edition (ICHD-II) classification. This article also reviews the scientific rationale of neuromodulation application in management of cephalgias. [ABSTRACT FROM AUTHOR]

Objective To describe a new approach to block the femoral nerve and to evaluate the distribution of a dye injected into the psoas compartment using a new femoral nerve block approach; to assess its clinical application, when combined with a sciatic nerve block, for surgical anaesthesia/analgesia of the pelvic limb in dogs. Study design Prospective anatomical, research and clinical study. Animals Two dog cadavers; two dogs that had to be euthanized for reasons unrelated to this study, and 15 dogs undergoing pelvic limb orthopaedic surgery. Methods Phase 1: anatomical dissections were performed to determine a simple method to approach the femoral nerve within the psoas compartment. Phase 2: 0.1 mL kg−1 of a lidocaine-new methylene blue solution was injected bilaterally after successful electrolocation of the femoral nerve in two anaesthetized dogs. Colorant spread was evaluated through femoral nerve dissections after euthanasia. Phase 3: in 15 dogs undergoing pelvic limb orthopaedic surgery under light general anaesthesia with isoflurane, intra-operative analgesic effect (cardiovascular responses) and early post-operative pain score, of the novel femoral nerve block combined with a sciatic nerve block as the sole analgesic protocol, were evaluated. Results Phase 1: a needle inserted from the lateral aspect of the lumbar muscles, cranially to the iliac crest and with a 30-45° caudo-medial direction, reaches the femoral nerve in the caudal portion of the psoas compartment. Phase 2: Four femoral nerves were stained >2 cm. Phase 3: this novel lateral pre-iliac approach, combined with the sciatic nerve block, blunted the intra-operative cardiovascular response to surgical stimulation in 13 out of 15 anaesthetized dogs. In addition, rescue analgesia was not required in the early post-operative 2-hour period. Conclusion and clinical relevance The lateral pre-iliac femoral nerve block technique may provide adequate intra- and early post-operative pain relief in dogs undergoing pelvic limb surgery. [ABSTRACT FROM AUTHOR]

A headache is a common neurological disorder, and large numbers of patients suffer from intractable headaches including migraine, tension headache and cluster headache, etc., with no clear therapeutic options. Despite the advances made in the treatment of headaches over the last few decades, subsets of patients either do not achieve adequate pain relief or cannot tolerate the side effects of typical migraine medications. An electrical stimulation of the peripheral nerves via an implantable pulse generator appears to be good alternative option for patients with treatment-refractory headaches. A number of clinical trials show considerable evidence supporting the use of peripheral nerve stimulator (PNS) for headaches not responding to conservative therapies. However, the mechanism by which PNS improves headaches or predicts who will benefit from PNS remains uncertain. The decision to use PNS should be individualized based on patient suffering and disability. Hence, further work is imperative. Here, we discuss the mechanism, indication, efficacy, implant technique, and complications of PNS. [ABSTRACT FROM AUTHOR]

Interventional pain procedures are critical in the diagnosis and management of a variety of facial pain conditions. Trigeminal neuralgia (TN) is the most frequent diagnosis for facial pain, with a reported prevalence 10 times greater than persistent idiopathic facial pain (PIFP). Although pharmacological treatments and psychological interventions benefit many patients with these diagnoses, the pain remains disabling for a significant portion of others. Percutaneous interventions targeting the gasserian ganglion and its branches have proven effective in the management of TN, while there is also supportive evidence for treating the sphenopalatine ganglion in PIFP. [ABSTRACT FROM AUTHOR]

Objective: Previous studies demonstrated the efficacy of Intramuscular Nerve (IMN) therapy with a 4-lead percutaneous, peripheral nerve stimulation (PNS) system in reducing hemiplegic shoulder pain (HSP). This case series investigates the feasibility of a less complex, single-lead approach in reducing HSP. Methods: Eight participants received one percutaneous intramuscular lead in the hemiparetic deltoid muscle and were then treated 6 hours/day for 3 weeks. The primary outcome measure was the Brief Pain Inventory (Short-Form) Question 3 (BPI3), which queries worst pain in the last week on a 0 to 10 numeric rating scale. Secondary outcomes included pain interference (BPI9) and Medical Outcomes Study Short-Form 36 (SF-36v2). Primary and secondary outcomes were assessed at the end of treatment (EOT) and 1 and 4 weeks after the EOT. Results: All participants tolerated the treatment well with 96% compliance. All leads remained infection-free and were removed intact at the EOT. On average, participants exhibited 70% reduction in BPI3 at the EOT and 61% reduction at 4 weeks after the EOT. All participants satisfied the success criterion of at least a 2-point reduction in BPI3 at the EOT. Longitudinal analysis revealed significant treatment effect for BPI3 ( F = 14.0, P < 0.001), BPI9 ( F = 5.9, P < 0.01), and the bodily pain domain of SF-36v2 ( F = 12.8, P < 0.001). Conclusion: This case series demonstrates the feasibility of a single-lead, 3-week IMN therapy for the treatment of chronic HSP. Additional studies are needed to further demonstrate safety, efficacy, and long-term benefit, define optimal prescriptive parameters and dose, and expand clinical indications. [ABSTRACT FROM AUTHOR]

Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from - unfortunately, there is no consensus on which treatments are "better" and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option., Competing Interests: CWH is a consultant for Abbott, Averitas, Biotronik, Boston Scientific, Mainstay, Nalu, PainTEQ, Saluda, SKK, Vivex. Funded Research by Abbott, Boston Scientific, Discgenics, Mesoblast, Saluda, TissueGene, Vivex. Grants from Saluda, PainTEQ, and Mainstay, outside the submitted work. TRD is a consultant/Research Investigator for Abbott, Avanos, Medtronic, Boston Scientific, Saluda, Nalu, Cornorloc, PainTEQ, Spinal Simplicity, Mainstay Medical, Ethos, Spinethera, SPR Therapeutic, Tissue Tech and Vertos Medical. Funded Research by Abbott, Boston Scientific, Nalu and PainTEQ. In addition, Dr TDR has a patent Abbott pending to DRG Surgical Leads and stock options from Vertos Medical, SpineThera, Saluda Medical, Nalu Medical, Cornerloc, SPR Therapeutic, PainTEQ and Spinal Simplicity; Common stock in Ethos. TD is a consultant for Abbott and Vivex. Funded Research by Discgenics, Mesoblast, TissueGene, Vivex. Research Support, OA Knee Study from Biostar, Kolon Tissuegene and Xalud, outside the submitted work. MFE is a consultant for Abbott, Boston Scientific, Flowonix, Medtronic, Nevro and Stimwave, outside the submitted work. JHG is a consultant for Abbott and Saluda, reports personal fees from Abbott, Stratus Medical, Research Support from SPR Therapeutics and Mainstay Medical, outside the submitted work. Funded Research for Saluda. SP is a consultant for Abbott. JSW is a consultant for Abbott and reports personal fees from Medtronic, Saluda, Biotronik, and SI Bone, during the conduct of the study. AC reports consultant from Arthrex and Zimmer Biomet, outside the submitted work. DB is a consultant for Discgenics, Mesoblast, Vivex, Medtronic, Spineology, Merit Medical, Johnson and Johnson, IZI, Techlamed, Peterson Enterprises, Medical Metrics, Radius Pharmaceuticals, Avanos, Boston Scientific, Sollis Pharmaceuticals, Simplify Medical, Stryker, Lenoss Medical, Spine BioPharma, Piramal, ReGelTec, Nanofuse, Spinal Simplicity, Pain Theory, Spark Biomedical, Micron Medical Corp, Bronx Medical, Smart Soft, Tissue Tech, Kahtnu Surgical, RayShield, Stayble, Thermaquil, Stratus Medical, Genesys, Abbott, Eliquence, SetBone Medical, Amber Implants, Cerapedics, Neurovasis, outside the submitted work. DS is a consultant for Boston Scientific, Neuralace, Nevro, PainTEQ, and Saluda. Funded Research by Neuralace, Nevro, PainTEQ, and Saluda. NS is a consultant for Abbott, Nimbus, Saluda, and Nevro. The authors report no other conflicts of interest in this work., (© 2022 Hunter et al.)

Introduction: Current external peripheral nerve stimulation devices stimulate only one nerve. This prospective, randomized, double-blind, sham-controlled trial assessed efficacy, safety, and tolerability of a novel external combined occipital and trigeminal neurostimulation (eCOT-NS) device as a self-administered home treatment for migraine (Relivion ® MG, Neurolief Ltd; Netanya, Israel)., Methods: Episodic and chronic migraine subjects (N = 55) were randomized to receive active (n = 27) or sham (n = 28) treatment. Subjects received eCOT-NS devices and performed 60 ± 20-min home treatments within 45 min of migraine episode onset. The primary endpoint was relative (percent) change in mean baseline VAS pain scores 1 h after treatment initiation. Treatment outcomes assessed at 1-, 2-, and 24-h post-treatment initiation were pain reduction and proportion of pain-free subjects and treatment responders, defined as ≥ 50% pain reduction. Categorical pain ratings (none, mild, moderate, and severe pain) were also analyzed., Results: Active stimulation was significantly more effective than sham stimulation for decreasing pain intensity at 1 h (53% vs. 10%), 2 h (52% vs. 17%), and 24 h (71% vs. 34%). Pain-free ratings were greater for the active treatment arm at 1 h (29.2% vs. 16%), 2 h (41.7% vs. 20%), and 24 h (65.2% vs. 40%). The number of subjects with baseline moderate or severe migraine pain who were pain-free at 2 h was significantly greater among active treatment subjects (43% vs. 10.5%). The responder rate was significantly higher among the active treatment group at 1 h (67% vs. 20%), 2 h (66.7% vs. 32%,), and 24 h (78.3% vs. 48%). Overall headache relief was significantly higher in the active treatment group at 1 h (67% vs. 26%) and 2 h (76% vs. 31.6%). Mild adverse events, reported by a minority of subjects, resolved spontaneously., Conclusions: eCOT-NS provides superior clinically meaningful relief and freedom from migraine pain, offering an effective and safe therapy for acute treatment of migraine., Trial Registration: ClinicalTrials.gov Identifier NCT03398668., (© 2022. The Author(s).)

The use of regional anesthesia is key to a successful approach to improving postoperative analgesia, which involves local anesthetic deposition either around peripheral nerves or within a fascial plane. Unfortunately, the realistic duration even with continuous peripheral nerve blocks usually does not match the duration of surgical pain, comprising a major limitation. Here, the use of 2 interventional modalities-ultrasound-guided percutaneous cryoneurolysis and peripheral nerve stimulation-is discussed, both of which may be used to treat acute and subacute pain and may therefore have a positive impact on the incidence and severity of chronic pain development., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Chronic shoulder pain affects millions of patients each year. Various conditions can result in shoulder pain ranging from rotator cuff injury, subacromial impingement, post-surgical pain, bursitis, adhesive capsulitis, and osteoarthritis. Typically, rotator cuff pathology is diagnosed by physical exam maneuvers along with advanced imaging modalities. Initial treatment for rotator cuff injury typically consists of physical therapy, NSAIDs, and possible injections depending on the extent of the injury. If conservative measures fail or the injury is too substantial, surgery is typically the appropriate treatment for healthy patients. For patients who are not surgical candidates or refuse surgery, peripheral nerve stimulation (PNS) can be considered. With the use of PNS, the suprascapular and axillary nerves can be targeted to provide pain relief for a variety of chronic shoulder pain issues. We describe the use of PNS in 2 patients with significant rotator cuff pathology who were not surgical candidates.

Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and painful condition in patients who have received chemotherapy. The role of neuromodulation therapy in treating pain and improving neurological function in CIPN remains unclear and warrants evidence appraisal. In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review to assess change in pain intensity and neurological function after implementation of any neuromodulation intervention for CIPN. Neuromodulation interventions consisted of dorsal column spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), or peripheral nerve stimulation (PNS). In total, 15 studies utilized SCS (16 participants), 7 studies utilized DRG-S (7 participants), and 1 study utilized PNS (50 participants). Per the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria, there was very low-quality GRADE evidence supporting that dorsal column SCS, DRG-S, and PNS are associated with a reduction in pain severity from CIPN. Results on changes in neurological function remained equivocal due to mixed study findings on thermal sensory thresholds and touch sensation or discrimination. Future prospective, well-powered, and comparative studies assessing neuromodulation for CIPN are warranted.

Objective: To describe the team approach of an interventional pain management practice, with particular emphasis on advanced practice providers (APPs), in the selection, education, care, and management of peripheral nerve stimulation (PNS) patients., Materials and Methods: We devised an APP guide to PNS based on an in-depth search of multiple databases for studies on neuromodulation, pain management, and APPs., Results: Of 65 articles captured in the search strategy, three articles were pertinent to the topic of APP involvement in neuromodulation. More specifically, only one of the three publications on neuromodulation discussed APP involvement in PNS. This single publication was from 1995 and focused on electrical stimulation of the trigeminal ganglion using a permanent percutaneously placed electrode., Conclusion: PNS is growing in clinical indication and use for both acute and chronic pain conditions. With the increasing need for APPs in both general and specialty medicine, it is imperative that APPs are well educated on PNS. Here, we have outlined ways in which APPs can optimize the care of PNS patients and how the skillset of the APP in a PNS practice can potentially improve patient outcomes., Competing Interests: CMH provides general consulting for SPR Therapeutics and Nalu Medical. RSD has an investigator-initiated grant with Nevro Corp. JMH is a consultant for Abbott, Boston Scientific, Medtronic, Nevro, and Saluda. He has funded research with Abbott, Medtronic, and Saluda., (© 2022 Hoffmann et al.)

Background: The most common presentation of cluneal neuropathy is ipsilateral low back and gluteal pain. Cluneal neuralgia has been described historically in surgical contexts, with much of the description and treatment related to entrapment and decompression, respectively. Treatment options for addressing axial low back pain have evolved with advancements in the field of interventional pain medicine, though clinical results remain inconsistent. Recent attention has turned toward peripheral nerve stimulation. Nonsurgical interventions targeting the superior and medial cluneal nerve branches have been performed in cases of low back and buttock pain, but there is no known review of the resulting evidence to support these practices., Objectives: In this manuscript we provide a robust exploration and analysis of the available literature regarding treatment options for cluneal neuropathy. We provide clinical manifestations and recommendations for future study direction., Study Design: Narrative review., Methods: This was a systematic, evidence-based narrative, performed after extensive review of the literature to identify all manuscripts associated with interventional treatment of the superior and medial cluneal nerves., Results: Eleven manuscripts fulfilled inclusion criteria. Interventional treatment of the superior and middle cluneal nerves includes blockade with corticosteroid, alcohol neurolysis, peripheral nerve stimulation, radiofrequency neurotomy, and surgical decompression., Limitations: The supportive evidence for interventions in cluneal neuropathy is largely lacking due to small, uncontrolled, observational studies with multiple confounding factors. There is no standardized definition of cluneal neuropathy., Conclusion: Limited studies promote beneficial effects from interventions intended to target cluneal neuropathy. Despite increased emphasis and treatment options for this condition, there is little consensus on the diagnostic criteria, endpoints, and measures of therapeutics, or procedural techniques for blocks, radiofrequency, and neuromodulation. It is imperative to delineate pathology associated with the cluneal nerves and perform rigorous analysis of associated treatment options.

Background: Wireless percutaneous nerve stimulation (PNS) for chronic pain is rapidly evolving in the ever expanding neuromodulation paradigm. Safety and lower risks with a potential of long-term analgesia cannot be over emphasised especially with the ongoing opioid pandemic. PNS with an implanted pulse generator (IPG) has also been shown to provide good benefit, without often unpleasant widespread paraesthesia from conventional spinal cord stimulators., Aim and Methods: We retrospectively extracted data on all wireless PNS implants in our highly specialised pain neuromodulation centre since initiation of wireless PNS service in August 2019. Patient demographics, pain history, analgesic intake and details on implant follow-up data within 1 year post-implant including pain relief, EuroQol-5 Dimension (EQ-5D) and Patients' Global Impression of Change (PGIC) scores were extracted. The cases are presented in a narrative format., Result: A total of five patients were implanted with wireless (Stimwave ® ) PNS from August 2019 to February 2020. Neuropathic pain was the most common presenting diagnosis. All patients showed >50% pain relief at 3 months. EQ-5D and PGIC did not show any improvement in the subjects. Two of the patients managed to decrease their analgesics after implantation. Similar sustained benefits could not be demonstrated after 1 year., Discussion: PNS can provide analgesia in appropriately selected cases. Naivety of the technique and procedure might cause some degree of uncertainty. External pulse generator with wireless transmission avoids IPG and tunnelling related side effects, but requires individualised special wearable technology to power the lead. Minimally invasive nature of the technique might be attractive and preferable for patients with complex medical issues, nickel allergy and poor general health who may otherwise be unsuitable for Spinal Cord Stimulation (SCS) with conventional hardware. Robust prospective controlled studies and RCTs in future might provide further insights on utility in other neuropathic pain diagnosis, long-term outcomes and acceptability compared to conventional SCS., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Peripheral nerve stimulation (PNS) is rapidly increasing in use. This interventional pain treatment modality involves modulating peripheral nerves for a variety of chronic pain conditions. This review evaluated its use specifically in the context of chronic lower extremity pain. Studies continue to elucidate the utility of PNS and better define indications, contraindications, as well as short- and long-term benefits of the procedure for the lower extremity. While large, prospective evidence is still lacking, the best available evidence suggests that improvements may be seen in pain scores, functionality, and opioid consumption. Overall, evidence synthesis suggests that PNS for the lower extremities may be a viable option for patients with chronic lower extremity pain.

Background: Chronic pelvic pain (CPP) is a complex, heterogeneous condition affecting both female and male patients with significant effects on quality of life. Chronic pelvic pain is a prevalent but often underdiagnosed condition due to the variation in patient presentation, a gap in communication among specialties, under-reporting of the syndrome, and lack of standardized diagnostic criteria with a subsequent delay in diagnosis. The mechanism of CPP is complex due to multifactorial etiologies of pain and its vast anatomy and innervation. Potential causes of pelvic pain include the nerves, muscles, bone, or organs of the reproductive, gastrointestinal, urological, musculoskeletal, vascular, neurological, and psychological systems., Objectives: The objective of this article is to review the anatomy of the pelvis, share current lead placement locations, and discuss the current evidence for neuromodulation in the management of chronic pelvic pain., Study Design: This is a narrative review of current literature on neuromodulation for chronic pelvic pain., Setting: A database review., Methods: A PubMed search was performed to gather literature on neuromodulation for chronic pelvic pain., Results: Traditionally, pelvic pain has been managed with conservative therapies such as physical therapy, pharmacological agents, trigger point injections, botulinum toxin injections, ganglion impar blocks, caudal epidural steroid injections, or superior and inferior hypogastric blocks, but with the evolution of the neuromodulation, there are new advances to incorporate this modality in the management of chronic pelvic pain., Limitations: This review article possesses limitations and includes published data, excluding case reports. For this reason, some applications of neuromodulation for chronic pelvic pain may be missed., Conclusions: Neuromodulation may include spinal cord stimulation, dorsal root ganglion stimulation, and peripheral nerve stimulation. Specifically, neuromodulation utilizes electrical stimulation or pharmacological agents to modulate a nerve and alter pain signals. Currently used locations for lead placement include intracranial, spinal cord, dorsal root ganglion, sacral nerve roots, or at a peripheral nerve. As the field of pelvic pain continues to evolve, continued evidence for neuromodulatory interventions is needed.

Peripheral nerve stimulation (PNS) is a powerful interventional option for the management of otherwise intractable pain. This technique involves the implantation of electrodes to apply electrical stimulation to named peripheral nerves, thereby alleviating pain in the territory of the target nerves. Recent advancements, largely driven by physician-industry relationships, have transformed the therapy into one that is minimally invasive, safe, evidence-based, and effective. Ongoing research has expanded the indications beyond chronic neuropathic pain in a peripheral nerve distribution. This article provides an overview of recent advances in this field., Competing Interests: Conflict of interest disclosure H.P. Fogel has no relevant commercial conflicts of interest to disclose. C.J. Winfree has no relevant commercial conflicts of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: This study presents real-world data from a cross-sectional follow-up survey of patients who previously received 60-day peripheral nerve stimulation (PNS) treatment for pain. Materials & methods: A survey including validated pain and other related outcome measures was distributed to patients who previously underwent implantation of temporary PNS leads for 60-day PNS treatment. Results: Among survey respondents who were at least 3 months from the start of treatment, most reported sustained clinically significant improvements in pain and/or quality of life, with the length of follow-up at the time of survey completion ranging from 3 to 30 months. Conclusion: These real-world data support recent prospective studies indicating that 60-day percutaneous PNS provides significant and sustained relief across a wide range of pain conditions.

Background: Chronic migraine (CM) is a debilitating neurological disorder with few treatment options. Peripheral nerve stimulation (PNS) of the occipital nerves is a potentially promising therapy for CM patients. Methods: In this randomized, controlled multicenter study, patients diagnosed with CM were implanted with a neurostimulation device near the occipital nerves and randomized 2:1 to active (n = 105) or sham (n = 52) stimulation. The primary endpoint was a difference in the percentage of responders (defined as patients that achieved a ≥50% reduction in mean daily visual analog scale scores) in each group at 12 weeks. Results: There was not a significant difference in the percentage of responders in the Active compared with the Control group (95% lower confidence bound (LCB) of −0.06; p = 0.55). However, there was a significant difference in the percentage of patients that achieved a 30% reduction (p = 0.01). Importantly, compared with sham-treated patients, there were also significant differences in reduction of number of headache days (Active Group = 6.1, baseline = 22.4; Control Group = 3.0, baseline = 20.1; p = 0.008), migraine-related disability (p = 0.001) and direct reports of pain relief (p = 0.001). The most common adverse event was persistent implant site pain. Conclusion: Although this study failed to meet its primary endpoint, this is the first large-scale study of PNS of the occipital nerves in CM patients that showed significant reductions in pain, headache days, and migraine-related disability. Additional controlled studies using endpoints that have recently been identified and accepted as clinically meaningful are warranted in this highly disabled patient population with a large unmet medical need. Trial registration: Clinical trials.gov (NCT00615342). [ABSTRACT FROM AUTHOR]