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Erythropoietin (EPO) is an exciting neurotherapeutic option. Despite its potential, concerns exist regarding the potential for thrombosis and adverse events with EPO administration in normonemic adults. Systematic review of literature using PRISMA guidelines to examine the application and risks of EPO as a treatment option for neuroprotection in normonemic adults. Independent, systematic searches were performed in July 2019. PubMed (1960–2019) and the Cochrane Controlled Trials Register (1960–2019) were screened. Search terms included erythropoietin, neuroprotection, and humans. The PubMed search resulted in the following search strategy: (“erythropoietin” [MeSH Terms] OR “erythropoietin” [All Fields] OR “epoetin alfa” [MeSH Terms] OR (“epoetin” [All Fields] AND “alfa” [All Fields]) OR “epoetin alfa” [All Fields]) AND (“neuroprotection” [MeSH Terms] OR “neuroprotection” [All Fields]) AND “humans” [MeSH Terms]. PubMed, Cochrane Controlled Trials Register, and articles based on prior searches yielded 388 citations. 50 studies were included, comprising of 4351 patients. There were 13 studies that noted adverse effects from EPO. Three attributed serious adverse effects to EPO and complications were statistically significant. Two of these studies related the adverse events to the co-administration of EPO with tPA. Minor adverse effects associated with the EPO group included nausea, pyrexia, headache, generalized weakness and superficial phlebitis. Most published studies focus on spinal cord injury, peri-surgical outcomes and central effects of EPO. We found no studies to date evaluating the role of EPO in post-operative pain. Future trials could evaluate this application in persistent post-surgical pain and in the peri-operative period.

Stellate ganglion block (SGB) is believed to modify the pathologic sympathetic pain response and has been commonly used to treat complex regional pain syndrome. We report successful treatment of cancer-related facial pain with SGB in three patients, suggesting a possible sympathetic pain-related mechanism. All patients exhibited clinically significant improvement of pain 12 weeks following the procedure. SGB should be considered a palliative pain treatment option in cancer-related facial pain.

Integrative medicine is an approach to medical care that embraces all effective therapies including complementary treatments such as acupuncture and hypnosis. There is growing use of complementary therapies in the cancer patient population, making it important that health care providers be aware of both the risks and benefits of treatments that lie outside of the traditional allopathic medicine paradigm. This chapter will explore some of the most common and well-investigated complementary therapies for the treatment and prevention of cancer-related pain. This will include discussions of: acupuncture, dietary supplements, massage, guided imagery and cryotherapy among others. The goal of this is to provide a framework for discussions between medical providers and their patients to ensure safety, discussion of all available treatments, and to facilitate open lines of communication.

Background: Posttraumatic stress disorder (PTSD) is a highly disabling condition associated with alterations in multiple neurobiological systems, including increases in inflammatory and sympathetic function, responsible for maintenance of symptoms. Treatment options including medications and psychotherapies have limitations. We previously showed that transcutaneous Vagus Nerve Stimulation (tcVNS) blocks inflammatory (interleukin (IL)-6) responses to stress in PTSD. The purpose of this study was to assess the effects of tcVNS on PTSD symptoms and inflammatory responses to stress. Methods: Twenty patients with PTSD were randomized to double blind active tcVNS (N=9) or sham (N=11) stimulation in conjunction with exposure to personalized traumatic scripts immediately followed by active or sham tcVNS and measurement of IL-6 and other biomarkers of inflammation. Patients then self administered active or sham tcVNS twice daily for three months. PTSD symptoms were measured with the PTSD Checklist (PCL) and the Clinician Administered PTSD Scale (CAPS), clinical improvement with the Clinical Global Index (CGI) and anxiety with the Hamilton Anxiety Scale (Ham-A) at baseline and one-month intervals followed by a repeat of measurement of biomarkers with traumatic scripts. After three months patients self treated with twice daily open label active tcVNS for another three months followed by assessment with the CGI. Results: Traumatic scripts increased IL-6 in PTSD patients, an effect that was blocked by tcVNS (p

Conventional treatment of complex regional pain syndrome (CRPS) involves a pharmacologic regimen that supplements intensive physical and cognitive-behavioral therapy. Pharmacotherapies available for CRPS are at times insufficient for pain control or carry with them intolerable side effects. Frequently, patients and practitioners then turn to adjuvant therapies to facilitate treatment and symptom relief and reduce prescription pain medication use. This chapter offers an overview of adjuvant treatments, their proposed mechanisms of action, and a review of existing literature. Overall, there was a paucity of literature investigating the use of nonconventional therapies for CRPS, suggesting the need for further evidence-based research in this area.

Integrative medicine is an approach to medical care that embraces all effective therapies including complementary treatments such as acupuncture and hypnosis. There is growing use of complementary therapies in the cancer patient population, making it important that health care providers be aware of both the risks and benefits of treatments that lie outside of the traditional allopathic medicine paradigm. This chapter will explore some of the most common and well-investigated complementary therapies for the treatment and prevention of cancer-related pain. This will include discussions of: acupuncture, dietary supplements, massage, guided imagery and cryotherapy among others. The goal of this is to provide a framework for discussions between medical providers and their patients to ensure safety, discussion of all available treatments, and to facilitate open lines of communication.

Objective To evaluate the feasibility of recruitment, preliminary efficacy, and acceptability of auricular percutaneous electrical nerve field stimulation (PENFS) for the treatment of fibromyalgia in veterans, using neuroimaging as an outcome measure and a biomarker of treatment response. Design Randomized, controlled, single-blind. Setting Government hospital. Subjects Twenty-one veterans with fibromyalgia were randomized to standard therapy (ST) control or ST with auricular PENFS treatment. Methods Participants received weekly visits with a pain practitioner over 4 weeks. The PENFS group received reapplication of PENFS at each weekly visit. Resting-state functional connectivity magnetic resonance imaging (rs-fcMRI) data were collected within 2 weeks prior to initiating treatment and 2 weeks following the final treatment. Analysis of rs-fcMRI used a right posterior insula seed. Pain and function were assessed at baseline and at 2, 6, and 12 weeks post-treatment. Results At 12 weeks post-treatment, there was a nonsignificant trend toward improved pain scores and significant improvements in pain interference with sleep among the PENFS treatment group as compared with the ST controls. Neuroimaging data displayed increased connectivity to areas of the cerebellum and executive control networks in the PENFS group as compared with the ST control group following treatment. Conclusions There was a trend toward improved pain and function among veterans with fibromyalgia in the ST + PENFS group as compared with the ST control group. Pain and functional outcomes correlated with altered rs-fcMRI network connectivity. Neuroimaging results differed between groups, suggesting an alternative underlying mechanism for PENFS analgesia.

Erythropoietin (EPO) is an exciting neurotherapeutic option. Despite its potential, concerns exist regarding the potential for thrombosis and adverse events with EPO administration in normonemic adults. Systematic review of literature using PRISMA guidelines to examine the application and risks of EPO as a treatment option for neuroprotection in normonemic adults. Independent, systematic searches were performed in July 2019. PubMed (1960-2019) and the Cochrane Controlled Trials Register (1960-2019) were screened. Search terms included erythropoietin, neuroprotection, and humans. The PubMed search resulted in the following search strategy: ("erythropoietin" [MeSH Terms] OR "erythropoietin" [All Fields] OR "epoetin alfa" [MeSH Terms] OR ("epoetin" [All Fields] AND "alfa" [All Fields]) OR "epoetin alfa" [All Fields]) AND ("neuroprotection" [MeSH Terms] OR "neuroprotection" [All Fields]) AND "humans" [MeSH Terms]. PubMed, Cochrane Controlled Trials Register, and articles based on prior searches yielded 388 citations. 50 studies were included, comprising of 4351 patients. There were 13 studies that noted adverse effects from EPO. Three attributed serious adverse effects to EPO and complications were statistically significant. Two of these studies related the adverse events to the co-administration of EPO with tPA. Minor adverse effects associated with the EPO group included nausea, pyrexia, headache, generalized weakness and superficial phlebitis. Most published studies focus on spinal cord injury, peri-surgical outcomes and central effects of EPO. We found no studies to date evaluating the role of EPO in post-operative pain. Future trials could evaluate this application in persistent post-surgical pain and in the peri-operative period.

Background: Although radiofrequency (RF) has been used to treat several types of chronic osteoarthritic pain, the role of percutaneous thermal RF ablation and pulsed RF in treating nonmalignant hip pain has not been well established. Objective: To estimate the effectiveness of thermal and pulsed RF therapy in treating nonmalignant hip pain and encourage further research. Study Design: A systematic review of English and non-English articles was performed on 1/20/2017 using the following databases: PubMed (1960-2017), Cochrane Controlled Trials Register (1960-2017), and EMBASE (1966-2017). Studies for which complete articles were not accessible were excluded if primary authors could not be successfully contacted after attempts via at least 2 different mediums. Search terms included RF, hip, and human (“radiofrequency”[All Fields] AND (“hip”[MeSH Terms] AND “humans”[MeSH Terms]). Results: Two clinical trials for hip RF (n = 32) and a collection of 7 case series or studies (n = 25) met our inclusion criteria. Both trials used percutaneous RF of the periarticular sensory branches of the obturator and femoral nerves near the hip joint. Ten studies were found to be eligible after screening title, abstract, and full text for inclusion and exclusion criteria. Both clinical trials saw improved post procedure pain scores when compared with standard conservative treatment for inoperable chronic hip pain. The overall complication rate of pooled cohort of all cases reviewed was 9.5% (6/57), but did not result in any self-reported injury. Conclusions: There is low quality evidence to suggest that thermal or pulsed RF therapy is a suitable option for chronic inoperable hip pain. Higher quality trials are needed for stronger recommendations. Key words: Radiofrequency, ablation, hip, pain, coxalgia, review, chronic, inoperable, nonsurgical, femoral, obturator

Introduction Anaphylaxis to protamine is a rare and potentially fatal complication. Risk factors for protamine reaction may include history of prior cardiac surgery (with intraoperative protamine exposure), true fish allergy (as protamine is commonly derived from salmon sperm), history of vasectomy (due to formation of anti-sperm antibodies), insulin-dependent diabetes (due to exposure to neutral protamine Hagedorn (NPH) and other protamine containing forms of insulin), as well as excessively rapid administration of protamine. Aim To report a case of anaphylaxis to protamine, increase awareness of protamine anaphylaxis and its treatments. Case study Our patient had several risk factors not identified preoperatively and experienced a type 1 allergic reaction with anaphylaxis upon protamine administration. The patient was appropriately treated and made a full recovery from this potentially catastrophic event. Results and discussion We present this case of a known drug reaction to remind our colleagues of the importance of screening for risk factors for protamine reaction, which include: shellfish allergy, insulin-dependent diabetes, prior protamine exposure, and vasectomy. The patient presented in this case had risk factors for allergic reaction to protamine including prior protamine exposure and vasectomy. The risks and benefits of protamine administration in a patient with multiple risk factors for protamine reaction are discussed, as is the controversy surrounding the clinical utility (or lack thereof) for protamine administration in elective peripheral vascular procedures. Conclusions Identification of patient risk factors prior to protamine administration could result in (1) avoidance of protamine administration or (2) improved preparation for potential anaphylaxis.

A patient underwent C2-T2 decompression and fusion with excessive intraoperative bleeding and no clear source. The patient denied the use of blood-thinning medications, but had consumed the equivalent of 12 g garlic daily in the days leading up to the surgery. He was treated with desmopressin acetate (DDAVP) and cryoprecipitate with adequate control of bleeding. Garlic is known to have an antiplatelet effect, although the dose range necessary to create a bleeding abnormality has not yet been well described nor has the effect of taking garlic with sertraline or other agents with an established or potential effect on coagulation.

Previous studies have demonstrated that fibromyalgia results in gray matter alterations as well as changes in GABA concentrations in various cortical regions when compared to healthy controls [1,2,3]. In veterans with fibromyalgia, we investigate the effect of PENFS on gray matter alterations and GABA concentrations and correlate them with clinical outcomes such as pain scores and function. PENFS applied to the ear stimulates auricular branches of cranial nerves including the vagus. Subjects: 21 veterans aged 20-60 years old with fibromyalgia were randomized to standard therapy control (ST) or standard therapy with auricular PENFS (ST+PENFS). (ST+PENFS: n = 12; ST: n = 9) Total n = 21. Intervention: ST involved standard therapy. ST+PENFS group included ST+PENFS weekly (5 days on) for 4 weeks. Imaging: Neuroimaging data was collected within 2 weeks of initiating treatment and 2 weeks following the final treatment. Self-reported pain and function were assessed and correlated to MRI timepoints. Analysis was performed of GABA concentrations using a right posterior insula voxel placement. Volumetric assessments were performed of the structural MRI data. Clinical assessments were also conducted. Findings: auricular PENFS results in novel changes observed as neural plasticity on fMRI. This study provides valuable insight on the role of potential biomarkers such as GABA and further investigates cortical gray matter alterations and its association with pain. This research was supported in part by Career Development Awards 1IK1RX002113-01A2, 1IK2RX003227-01 (Anna Woodbury), and 1IK2RX002934 (Venkatagiri Krishnamurthy); by Senior Research Career Scientist Award Grant B6364L (Bruce Crosson) and Center Grant 5I50RX002358 from the US Department of Veterans Affairs Rehabilitation Research and Development Service; and by the National Institute of Mental Health of the National Institutes of Health under Award No. R01MH105561 and R01MH118771 (Ying Guo).

Coccygodynia, or coccygeal pain, is also known as coccydynia, coccalgia, or coccygalgia. It is a painful syndrome affecting the coccyx (tailbone). It is relatively uncommon, and may have a variety of causes. Pain is typically aggravated by sitting, particularly on hard areas, and can severely affect quality of life. Imaging should be correlated with a detailed medical history, including any therapies previously tried, and a thorough physical exam. Treatment options must be tailored to individual patient needs. Conservative treatments include massage, physical therapy, and medications. Interventional procedures, including ganglion impar blocks, caudal injections, and radiofrequency ablation, have all been used in management of this painful condition. For coccygeal pain that does not respond to conservative therapy, surgical treatment involving coccygectomy is available.

This chapter explores therapeutic targets and the anti-inflammatory nature of some naturally- occurring compounds and the current or potential use of these compounds in the treatment of chronic inflammatory pain states. We will review the mechanisms of chronic inflammatory pain, the molecular targets of selected natural compounds in inhibiting inflammatory pain, and the traditional and current approaches to treating pain using these compounds. Previous research on experimental as well as clinical pain will be summarized from in vitro to animal and human models. Potential areas for further research will also be discussed.

Background: Fibromyalgia and complex regional pain syndrome (CRPS) are both chronic pain syndromes with pathophysiologic mechanisms related to autonomic nervous system dysregulation and central sensitization. Both syndromes are considered difficult to treat with conventional pain therapies. Case presentations: Here we describe a female veteran with fibromyalgia and a male veteran with CRPS, both of whom failed multiple pharmacologic, physical and psychological therapies for pain, but responded to percutaneous electrical neural field stimulation (PENFS) targeted at the auricular branches of the cranial nerves. Discussion: While PENFS applied to the body has been previously described for treatment of localized pain, PENFS effects on cranial nerve branches of the ear is not well-known, particularly when used for regional and full-body pain syndromes such as those described here. PENFS of the ear is a minimally-invasive, non-pharmacologic therapy that could lead to improved quality of life and decreased reliance on medication. However, further research is needed to guide clinical application, particularly in complex pain patients.

Study Objective To evaluate whether proper implementation of safety measures was uniform at 5 hospitals, and to elucidate motivating factors that lead to nonadherence. Design Electronic anonymous survey instrument. Setting Academic medical center. Measurements Of the 319 surveys sent to anesthesia providers across 5 hospitals, 89 responses were obtained. Questions addressed compliance with Centers of Disease Control (CDC) safety standards and the rationale for anesthesia providers' decisions to comply or not comply with these standards. Main Results 59.6% of respondents reported that they had reused vials between cases, while 40.4% had never done so. Of the 89 respondents, 63 (44%) felt that cost was the primary factor that prevented them from using entirely new medications on each case. Thirty-two (23%) reported convenience/efficiency as the reason; 11 (8%) responded that time prevented them from using entirely new medications on each case; 14 (10%) reported that the environment was a driving factor; and 3 individuals (2%) responded apathy. Eighteen (13%) responded "other" and, when asked to amplify a response, most of these individuals reported that they do use entirely new medications on each case. Conclusions Safe anesthetic practices were not uniform among respondents, and one of the main reasons given for noncompliance with safe standards was cost.

Dear Editor: It is important for the pain physician to accurately diagnose spinal pathology that requires urgent surgical intervention. When signs of spinal cord compression occur, prompt diagnosis and surgical decompression are necessary ⇓. Thoracic disk herniations account for approximately 0.25–0.75% of all symptomatic disk herniations, with 70% showing signs of spinal cord compression by the time of diagnosis ⇓. Unfortunately, because thoracic spinal lesions are rare, they can often be misdiagnosed at first ⇓. Extradural spinal lesions such as calcified, herniated disks in the thoracic spine most commonly present as localized pain in the uper back or pain along a dermatomal distribution in the chest or abdominal area ⇓. They can also mimic lesions of the lumbar spine and initially mislead a physician who is attempting to manage the symptoms of lumbar radicular pain. We present a case of a patient who presented with severe low back and bilateral lower extremity radicular pain who was found to have an extradural thoracic spinal lesion causing critical spinal stenosis and was successfully diagnosed and managed. A 38-year-old-female presented to the Emergency Department for an acute exacerbation of her 2-year history of chronic bilateral back and lower extremity pain. In her right …

Background: Fibromyalgia is a chronic pain state that includes widespread musculoskeletal pain, fatigue, psychiatric symptoms, cognitive and sleep disturbances, and multiple somatic symptoms. Current therapies are often insufficient or come with significant risks, and while there is an increasing demand for non-pharmacologic and especially non-opioid pain management such as that offered through complementary and alternative medicine therapies, there is currently insufficient evidence to recommend these therapies. Percutaneous electrical neural stimulation (PENS) is an evidence-based treatment option for pain conditions that involves electrical current stimulation through needles inserted into the skin. Percutaneous electrical neural field stimulation (PENFS) of the auricle is similar to PENS, but instead of targeting a single neurovascular bundle, PENFS stimulates the entire ear, covering all auricular branches of the cranial nerves, including the vagus nerve. The neural mechanisms of PENFS for fibromyalgia symptom relief are unknown. Objective: We hypothesize that PENFS treatment will decrease functional brain connectivity between the default mode network (DMN) and right posterior insula in fibromyalgia patients. We expect that the decrease in functional connectivity between the DMN and insula will correlate with patient-reported analgesic improvements as indicated by the Defense and Veterans Pain Rating Scale (DVPRS) and will be anti-correlated with patient-reported analgesic medication consumption. Exploratory analyses will be performed for further hypothesis generation. Methods: A total of 20 adults from the Atlanta Veterans Affairs Medical Center diagnosed with fibromyalgia will be randomized into 2 groups: 10 subjects to a control (standard therapy) group and 10 subjects to a PENFS treatment group. The pragmatic, standard therapy group will include pharmacologic treatments such as anticonvulsants, non-steroidal anti-inflammatory drugs, topical agents and physical therapy individualized to patient comorbidities and preferences, prescribed by a pain management practitioner. The PENFS group will include the above therapies in addition to the PENFS treatments. The PENFS subject group will have the Neuro-Stim System placed on the ear for 5 days then removed and replaced once per week for 4 weeks. The primary outcome will be resting functional magnetic resonance imaging connectivity between DMN and insula, which will also be correlated with pain relief and functional improvements. This connectivity will be analyzed utilizing functional connectivity magnetic resonance imaging (fcMRI) and will be compared with patient-reported analgesic improvements as indicated by the DVPRS and patient-reported analgesic medication consumption. Pain and function will be further evaluated using Patient-Reported Outcomes Measurement Information System measures and measures describing a person’s functional status from Activity and Participation section of the International Classification of Functioning Disability and Health. Results: This trial has been funded by the Veterans Health Administration Program Office. This study attained approval by the Emory University/Veterans Affairs (VA) institutional review board and VA Research & Development committee. Institutional review board expedited approval was granted on 2/7/17 (IRB00092224). The study start date is 6/1/17 and estimated completion date is 5/31/20. The recruitment started in June 2017. Conclusions: This is a feasibility study that is meant to demonstrate the practicality of using fcMRI to study the neural correlates of PENFS outcomes and provide information regarding power calculations in order to design and execute a larger randomized controlled clinical trial to determine the efficacy of PENFS for improving pain and function. Trial Registration: ClinicalTrials.gov NCT03008837; https://clinicaltrials.gov/ct2/show/NCT03008837 (Archived by WebCite at http://www.webcitation.org/6wrY3NmaQ). [JMIR Res Protoc 2018;7(2):e39]

A 49-year-old male became hypotensive, bradycardic, and suffered myocardial injury during induction of anesthesia with lidocaine, propofol, and rocuronium in the operating room. Coronary arteriography revealed coronary vasospasm in coronary arteries otherwise free of disease. In the ICU, the patient was again administered rocuronium for a procedure with subsequent hypotension, bradycardia, and ST elevation on telemetry that resolved with administration of diphenhydramine and hydrocortisone. An allergic reaction to rocuronium with coronary vasospasm is suspected, suggestive of the Type 1 variant of Kounis syndrome. This is the first report to describe a case of rocuronium-induced Type 1 Kounis syndrome.

This study examined the short- and long-term neuroprotective and analgesic activity of honokiol (a naturally occurring lignan isolated from Magnolia) on developing brains in neonates exposed to inflammatory pain, known to cause neuronal cell death. Postnatal day 4 (P4) neonatal rat pups were subjected to intraplantar formalin injection to four paws as a model of severe neonatal pain. Intraperitoneal honokiol (10 mg/kg) or corn oil vehicle control was administered 1 h prior to formalin insult, and animals were maintained on honokiol through postnatal day 21 (P21). Behavioral tests for stress and pain were performed after the painful insult, followed by morphological examinations of the brain sections at P7 and P21. Honokiol significantly attenuated acute pain responses 30 min following formalin insult and decreased chronic thermal hyperalgesia later in life. Honokiol-treated rats performed better on tests of exploratory behavior and performed significantly better in tests of memory. Honokiol treatment normalized hippocampal and thalamic c-Fos and hippocampal alveus substance P receptor expression relative to controls at P21. Together, these findings support that (1) neonatal pain experiences predispose rats to the development of chronic behavioral changes and (2) honokiol prevents and reduces both acute and chronic pathological pain-induced deteriorations in neonatal rats.

Even when addiction is not a concern, opioids are not a good choice of painkiller for patients with chronic neuropathic pain, who instead might be prescribed neuropathic pain medications, referred to a specialist, or offered spinal cord stimulation.

Thrombin's role in the nervous system is not well understood. Under conditions of blood-brain barrier compromise (e.g., neurosurgery or stroke), thrombin can result in neuroapoptosis and the formation of glial scars. Despite this, preconditioning with thrombin has been found to be neuroprotective in models of cerebral ischemia and intracerebral hemorrhage. We investigated the effects of physiologically relevant concentrations of thrombin on cortical neurons using two culture-based assays. We examined thrombin's effect on neurites by quantitative analysis of fluorescently labeled neurons. To characterize thrombin's effects on neuron survival, we spectrophotometrically measured changes in enzymatic activity. Using receptor agonists and thrombin inhibitors, we separately examined the role of thrombin and its receptor in neuroprotection. We found that low concentrations of thrombin (1 nM) enhances neurite growth and branching, neuron viability, and protects against excitotoxic damage. In contrast, higher concentrations of thrombin (100 nM) are potentially detrimental to neuronal health as evidenced by inhibition of neurite growth. Lower concentrations of thrombin resulted in equivalent neuroprotection as the antifibrinolytic, aprotinin, and the direct thrombin inhibitor, argatroban. Interestingly, exogenous application of the species-specific thrombin inhibitor, antithrombin III, was detrimental to neuronal health; suggesting that some endogenous thrombin is necessary for optimal neuron health in our culture system. Activation of the thrombin receptor, protease-activated receptor-1 (PAR-1), via micromolar concentrations of the thrombin receptor agonist peptide, TRAP, did not adversely affect neuronal viability. An optimal concentration of thrombin exists to enhance neuronal health. Neurotoxic effects of thrombin do not involve activation of PAR receptors and thus separate pharmacologic manipulation of thrombin's receptor in the setting of direct thrombin inhibitors could be a potential neuroprotective strategy.

This narrative review provides an overview of the complementary and alternative medicine (CAM) therapies that anesthesiologists and pain management practitioners commonly encounter along with recommendations for evaluation and implementation. A literature search of PubMed was performed using the comprehensive MeSH term, “Complementary Therapies OR Dietary Supplements”, and a search was conducted of the various licensing organizations and books published on the topics of CAM and integrative medicine. In North America, the most commonly encountered CAM therapies include 1) manipulation and procedural therapies; 2) herbs, nutritional supplements (nutraceuticals), and dietary therapies; and 3) mind-body and energy therapies. Controversy exists regarding many of these therapies, particularly those with a higher risk of harm, such as chiropractic manipulation, acupuncture, and nutraceutical use. Several well-conducted studies were analyzed to show how research in CAM can control for placebo responses. Practical considerations are provided for patients and practitioners interested in pursuing or already employing CAM in perioperative and chronic pain management settings. Complementary and alternative medicine therapies in general may provide a useful adjunct in the management of chronic pain. Nevertheless, many patients are not aware of the risks and benefits of individual therapies. In the perioperative setting, the most concerning CAM therapy is the use of herbs and other supplements that may produce physiologic and metabolic derangements and may interact with prescription medications. Resources exist to aid pain specialists, anesthesiologists, and patients in the evidence-based utilization of CAM therapies.

Current conventional pharmacologic options are occasionally insufficient to provide maximal medical benefit alone in the treatment of some fibromyalgia patients. Therefore, many seek complementary and alternative medical modalities to augment their therapies. Acupuncture, repetitive transcranial magnetic stimulation (rTMS), biofeedback, massage, balneotherapy (spa therapy), hypnotherapy, and alternative exercise modalities such as yoga and tai qi are among the therapies most commonly used and studied in fibromyalgia patients. Herbs and music therapy are undergoing investigation as well, but the level of evidence is still insufficient to make any recommendations regarding their use. This chapter provides an analysis of the most commonly encountered therapies in the treatment of fibromyalgia and suggests recommendations for their use.

Stroke remains a leading cause of human death and disability. There is a growing consensus that an effective stroke therapy needs to exert protective and/or regenerative actions on both gray and white matters. However, white matter injury after ischemic stroke has been less investigated and is inadequately understood. This review summarizes the current understanding of the pathophysiology and potential treatments for white matter injury, focusing on animal data and its potential application to human patients. It is expected that more investigations on white matter injury and more comprehensive therapeutic approaches will increase the chances of developing an effective clinical treatment for ischemic stroke.

Honokiol is a polyphenolic compound that exerts neuroprotective properties through a variety of mechanisms. It has therapeutic potential in anxiety, pain, cerebrovascular injury, epilepsy, and cognitive disorders including Alzheimer’s disease. It has been traditionally used in medical practices throughout much of Southeast Asia, but has now become more widely studied due to its pleiotropic effects. Most current research regarding this compound has focused on its chemotherapeutic properties. However, it has the potential to be an effective neuroprotective agent as well. This review summarizes what is currently known regarding the mechanisms involved in the neuroprotective and anesthetic effects of this compound and identifies potential areas for further research.

Moraxella lacunata is a rare, usually commensal gram-negative rod most commonly associated with eye infections. We report a unique case of noniatrogenic M . l acunata bacteremia and septic knee arthritis in a patient with class III-IV lupus nephritis and speculate on the association between invasive Moraxella infection and renal impairment.