Low-frequency dorsal root stimulation is effective for various pain etiologies and pain locations.

BACKGROUND: Dorsal root ganglion stimulation (DRG-S) has emerged as a novel therapeutic approach for managing chronic neuropathic pain. AIMS: This study aims to compare the effectiveness of 4-20 Hz DRG-S through a retrospective analysis of a cohort of 28 patients with various neuropathic pain etiologies and pain locations. MATERIALS AND METHODS: Patient responses to both stimulation frequencies were examined using the Numeric Rating Scale (NRS) and Patient Global Impression of Change (PGIC) assessments. Factors such as patient preference and satisfaction were also evaluated. RESULTS: The results indicate that 4 Hz DRG-S is not only as effective as 20 Hz stimulation but may also surpass it. Among the 28 patients, 26 assessed 4 Hz stimulation to be at least as effective as 20 Hz, with the majority (22 out of 26) considering 4 Hz stimulation superior. After trying 4 Hz stimulation, 24 out of 28 patients chose it over 20 Hz, while two patients opted for a combination of both settings. Only two patients reverted to their original 20 Hz stimulation program. A statistically significant pain reduction of 24% was observed when comparing the effects of 4 Hz versus 20 Hz. DISCUSSION: The study highlights the broader applicability of low-frequency DRG-S, extending its benefits beyond the realm of low back pain. Patients with diverse pain etiologies and locations experienced comparable positive outcomes, suggesting that the advantages of low-frequency stimulation are not confined to specific pain types or locations. CONCLUSION: This study emphasizes the potential of 4 Hz DRG-S as a valuable alternative to the standard 20 Hz stimulation. Although the exact mechanisms require further investigation, the observed clinical benefits and patient preferences for low-frequency stimulation suggest its viability across diverse pain indications and locations. Additional research is necessary to substantiate these findings and assess the durability and economic implications of low-frequency DRG-S.

Sacral neuromodulation therapy for urinary and defecatory disorders: experience in a Latin American public hospital.

Objective: To show the experience of a Latin American public hospital, with SNM in the management of either OAB, NOUR or FI, reporting feasibility, short to medium-term success rates, and complications. Methods: A retrospective cohort was conducted using data collected prospectively from patients with urogynecological conditions and referred from colorectal surgery and urology services between 2015 and 2022. Results: Advanced or basic trial phases were performed on 35 patients, 33 (94%) of which were successful and opted to move on Implantable Pulse Generator (GG) implantation. The average follow-up time after definitive implantation was 82 months (SD 59). Of the 33 patients undergoing, 27 (81%)reported an improvement of 50% or more in their symptoms at last follow-up. Moreover, 30 patients (90%) with a definitive implant reported subjective improvement, with an average PGI-I "much better" and 9 of them reporting to be "excellent" on PGI-I. Conclusion: SNM is a feasible and effective treatment for pelvic floor dysfunction. Its implementation requires highly trained groups and innovative leadership. At a nation-wide level, greater diffusion of this therapy among professionals is needed to achieve timely referral of patients who require it.

The Impact of Baseline Pain Intensity on the Effectiveness of Whole-Body Electromyostimulation (WB-EMS) for Nonspecific Chronic Back Pain.

INTRODUCTION: Recent clinical studies confirmed that whole-body electromyostimulation (WB-EMS) training is a safe and time-efficient therapeutic method for patients with nonspecific chronic back pain (NSCBP). However, significant variations in initial pain intensity among subjects in these studies have been observed. This study aims to determine if patients with differing initial pain intensities experience varying degrees of benefit from WB-EMS and to assess the overall correlation between initial pain levels and pain reduction. METHODS: Pain intensity datasets from two studies were combined. The pooled data included 121 NSCBP patients (38 males and 83 females) with an average age of 55.1 years (±11.8 years). Data was categorized by baseline pain intensity on the numeric rating scale (NRS) into seven groups: 0 to 2, >2 to 3, >3 to 4, >4 to 5, >5 to 6, >6 to 7, and >7. Both absolute and relative changes were analyzed. Additionally, a Spearman rho correlation test was performed on the entire dataset to evaluate the relationship between initial pain level and pain reduction. RESULTS: Significant improvements were noted across all NRS11 categories, with strong effect sizes (p) in all classes above 2, ranging from 0.56 to 0.90. The >7 category exhibited the highest rate of clinically significant changes (80%) and an average improvement of 3.72 points. The overall group from >1 to 10 showed an average improvement of 1.33 points, with 37% of the participants experiencing clinically significant improvements. The Spearman rho correlation test revealed a moderate positive relationship between initial pain level and pain reduction (r_s = 0.531, p < 0.001), indicating that, generally, higher initial pain levels are associated with greater pain reduction. CONCLUSION: The findings support the hypothesis that NSCBP patients with higher baseline NRS values benefit more substantially from WB-EMS. Those with NRS values above 7 show the greatest improvement and highest rate of clinical significance. The overall positive correlation between initial pain intensity and pain reduction further underscores the efficacy of WB-EMS in managing NSCBP across different pain intensities.

Pressure injury treatment by intermittent electrical stimulation (PROTECT-2): protocol for a multicenter randomized clinical trial.

BACKGROUND: Pressure ulcers account for a substantial fraction of hospital-acquired pathology, with consequent morbidity and economic cost. Treatments are largely focused on preventing further injury, whereas interventions that facilitate healing remain limited. Intermittent electrical stimulation (IES) increases local blood flow and redistributes pressure from muscle-bone interfaces, thus potentially reducing ulcer progression and facilitating healing. METHODS: The Pressure Injury Treatment by Intermittent Electrical Stimulation (PROTECT-2) trial will be a parallel-arm multicenter randomized trial to test the hypothesis that IES combined with routine care reduces sacral and ischial pressure injury over time compared to routine care alone. We plan to enroll 548 patients across various centers. Hospitalized patients with stage 1 or stage 2 sacral or ischial pressure injuries will be randomized to IES and routine care or routine care alone. Wound stage will be followed until death, discharge, or the development of an exclusion criteria for up to 3 months. The primary endpoint will be pressure injury score measured over time. DISCUSSION: Sacral and ischial pressure injuries present a burden to hospitalized patients with both clinical and economic consequences. The PROTECT-2 trial will evaluate whether IES is an effective intervention and thus reduces progression of stage 1 and stage 2 sacral and ischial pressure injuries. TRIAL REGISTRATION: ClinicalTrials.gov NCT05085288 Registered October 20, 2021.

Acute Autonomic Nervous System Response to Direct Sacral Nerve Root Stimulation in Lower Urinary Tract Dysfunction: A New Approach to Understand the Mechanism of Action of Sacral Nerve Modulation.

PURPOSE: Our goal was to assess acute autonomic nervous system (ANS) response to direct sacral nerve root (SNR) stimulation in the context of lower urinary tract dysfunction. MATERIALS AND METHODS: In this retrospective monocentric study, patients undergoing 2-stage sacral nerve modulation for overactive bladder, nonobstructive urinary retention, or chronic bladder pain syndrome between March 2022 and June 2023 were analyzed. A standardized stimulation protocol was applied during the lead implantation, each of the 4 contact points being sequentially stimulated at the amplitude required to elicit anal motor response. Stimulations were labeled as StimA, StimB, StimC, and StimD, ordered by ascending order of minimum amplitude required for anal motor response. Heart rate variability parameters were collected using PhysioDoloris Monitor, and computed through the time-domain (standard deviation of normal-to-normal intervals [SDNN], root mean square of successive differences), the frequency-domain (low frequency, high frequency) and the graphical (Analgesia Nociception Index [ANI]) methods. RESULTS: Fifty patients were analyzed, including 35 females. Twelve patients had an underlying neurological disease. Efficacy was deemed achieved in 54% of patients. SDNN variability significantly increased during StimA to StimC, while maximum SDNN significantly increased only during StimA. ANI variability significantly increased during all 4 stimulations, while maximum ANI significantly increased only during StimA. CONCLUSIONS: Direct stimulation of SNR is responsible for a significant increase in ANS and relative parasympathetic nervous system activity, with a greater effect observed when the stimulation was delivered closer to the SNR. These results shed light on potential mechanisms underlying sacral nerve modulation, particularly regarding the treatment of ANS dysregulation in lower urinary tract dysfunction.

Effectiveness of Rehabilitation for Osteoarthritis of the Knee: A Scoping Review of Network Meta-Analyses.

BACKGROUND:  Although an increasing number of network meta-analyses have been conducted on the effectiveness of conservative therapy for knee osteoarthritis, these may have been poorly planned and executed.We aimed to review the qualities of a comprehensive set of network meta-analyses on rehabilitation therapies for knee osteoarthritis and provide an overview of the effectiveness of each therapy. METHODS: The eligibility criteria were as follows: (i) conservative rehabilitation was the primary treatment in the intervention group, (ii) included patients were diagnosed with knee osteoarthritis, and (iii) patient groups were aged ≤75 years, and rehabilitation interventions comprised exercise, orthotic, or physical therapies or patient education. Two independent reviewers screened the titles and abstracts of the identified records and selected the eligible reviews; their full texts were further assessed for eligibility. Then, a checklist derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement for the reporting of systematic reviews incorporating network meta-analyses of healthcare Interventions was used to validate the completeness of the reporting of each network meta-analysis. Furthermore, the statistical and outcome data regarding the quality of life, knee joint function and pain, adverse events, and physical functions were extracted using a customized spreadsheet. RESULTS: Overall, 2701 titles and abstracts were screened, and eight network meta-analyses were ultimately selected. Nearly all reviews adequately addressed the PRISMA extension checklist, and the completeness of reporting was adequate; therefore, all expected information could be extracted. However, the methodology used to confirm the transitivity assumption was insufficient in many reviews. The following interventions were effective in reducing pain and improving physical function: (i) strengthening, flexibility, aerobic, and mind-body exercises, (ii) pulsed ultrasound, (iii) focused and radial extracorporeal shockwave therapy, and (iv) continuous ultrasound. The following interventions were effective in improving the quality of life: (i) strengthening, (ii) mixed, and (iii) mind-body exercises. CONCLUSIONS: Our results suggested that exercise therapies, including muscle-strengthening, aerobic, flexibility, and mind-body exercises, are likely to be effective for pain relief and functional improvement in knee osteoarthritis. This may be the first review to provide a comprehensive perspective for considering priorities for future rehabilitation interventions for knee osteoarthritis.

Right-sided vagus nerve stimulation for drug-resistant epilepsy: A systematic review of the literature and perspectives.

BACKGROUND: Right-sided vagus nerve stimulation (RS-VNS) is indicated when the procedure was deemed not technically feasible or too risky on the indicated left side. OBJECTIVE: The present study aims to systematically review the literature on RS-VNS, assessing its effectiveness and safety. METHODS: A systematic review following PRISMA guidelines was conducted: Pubmed/MEDLINE, The Cochrane Library, Scopus, Embase and Web of science databases were searched from inception to August 13th,2023. Gray literature was searched in two libraries. Eligible studies included all studies reporting, at least, one single case of RS-VNS in patients for the treatment of drug-resistant epilepsy. RESULTS: Out of 2333 initial results, 415 studies were screened by abstract. Only four were included in the final analysis comprising seven patients with RS-VNS for a drug-resistant epilepsy. One patient experienced nocturnal asymptomatic bradycardia whereas the other six patients did not display any cardiac symptom. RS-VNS was discontinued in one case due to exercise-induced airway disease exacerbation. Decrease of epileptic seizure frequency after RS-VNS ranged from 25 % to 100 % in six cases. In the remaining case, VNS effectiveness was unclear. In one case, RS-VNS was more efficient than left-sided VNS (69 % vs 50 %, respectively) whereas in another case, RS-VNS was less efficient (50 % vs 95 %, respectively). CONCLUSION: Literature on the present topic is limited. In six out of seven patients, RS-VNS for drug-resistant epilepsy displayed reasonable effectiveness with a low complication rate. Further research, including prospective studies, is necessary to assess safety and effectiveness of RS-VNS for drug-resistant epilepsy patients.

Repetitive peripheral sensory stimulation for motor recovery after stroke: a scoping review.

BACKGROUND AND PURPOSE: Enhancing afferent information from the paretic limb can improve post-stroke motor recovery. However, uncertainties exist regarding varied sensory peripheral neuromodulation protocols and their specific impacts. This study outlines the use of repetitive peripheral sensory stimulation (RPSS) and repetitive magnetic stimulation (rPMS) in individuals with stroke. METHODS: This scoping review was conducted according to the JBI Evidence Synthesis guidelines. We searched studies published until June 2023 on several databases using a three-step analysis and categorization of the studies: pre-analysis, exploration of the material, and data processing. RESULTS: We identified 916 studies, 52 of which were included (N = 1,125 participants). Approximately 53.84% of the participants were in the chronic phase, displaying moderate-to-severe functional impairment. Thirty-two studies used RPSS often combining it with task-oriented training, while 20 used rPMS as a standalone intervention. The RPSS primarily targeted the median and ulnar nerves, stimulating for an average of 92.78 min at an intensity that induced paresthesia. RPMS targeted the upper and lower limb paretic muscles, employing a 20 Hz frequency in most studies. The mean stimulation time was 12.74 min, with an intensity of 70% of the maximal stimulator output. Among the 114 variables analyzed in the 52 studies, 88 (77.20%) were in the "s,b" domain, with 26 (22.8%) falling under the "d" domain of the ICF. DISCUSSION AND CONCLUSION: Sensory peripheral neuromodulation protocols hold the potential for enhancing post-stroke motor recovery, yet optimal outcomes were obtained when integrated with intensive or task-oriented motor training.

Efficacy of diadynamic currents as an adjunct to exercise to manage symptoms of knee osteoarthritis in adults: A randomized controlled clinical trial.

OBJECTIVE: To investigate the effect of diadynamic currents administered prior to exercises on pain and disability in patients with osteoarthritis of the knee. DESIGN: A randomized-controlled trial. SETTING: Special Rehabilitation Services in Taboão da Serra. PARTICIPANTS: Patients with bilateral knee osteoarthritis. INTERVENTION: Participants were randomly allocated to Group I (diadynamic currents and exercises; n = 30, 60 knees) or Group II (exercises alone; n = 30, 60 knees) and were treated three times a week for 8 weeks. MAIN OUTCOME MEASURES: The primary outcome measures were change in knee pain evaluated by visual analog scale and disability Index Score (Lequesne). Secondary outcomes included change in mobility (Timed Up and Go test), range of motion (goniometer), muscle strength (dynamometer), a composite score for pain and disability (Western Ontario and McMaster Universities Osteoarthritis questionnaire), and a drug diary to measure consumption of rescue pain medication (paracetamol). All measurements were collected at baseline, 8 weeks, and 6 months from baseline (follow-up). RESULTS: There were 60 participants with a mean (SD) age of 63.40 (8.20) years. Between-group differences in the follow-up (8 weeks and 6 months) were observed for pain at rest, pain during activities of daily living and disability. There was improvement in Group I that was maintained for the three variables 6 months after treatment. Mean difference for pain at rest was -3.08 points (95% confidence interval -4.13; -2.02), p < 0.01 with an effect size of 1.4; mean difference for pain during activities of daily living was -2.40 points (95% confidence interval -3.34; -1.45), p < 0.01 with an effect size of 1.24; and mean difference for disability was -4.08 points (95% confidence interval -5.89; -2.26), p < 0.01 with an effect size of 1.04. CONCLUSION: Patients with symptomatic knee osteoarthritis receiving 8 weeks of treatment with diadynamic currents as an adjunct to a program of exercises had significantly greater improvements in pain and disability than those receiving exercises alone. Beneficial effects were sustained for 6 months.

Effectiveness and Safety of Non-Invasive Neuromodulation for Vision Restoration: A Systematic Review and Meta-Analysis.

We carried out a systematic review and meta-analysis to determine the effectiveness and safety of non-invasive electrical stimulation (NES) for vision restoration. We systematically searched for randomised controlled trials (RCTs) comparing NES with sham stimulation, for vision restoration between 2000 and 2022 in CENTRAL, MEDLINE, EMBASE, and LILACS. The main outcomes were as follows: visual acuity (VA); detection accuracy; foveal threshold; mean sensitivity as the parameter for the visual field; reading performance; contrast sensitivity (CS); electroencephalogram; quality of life (QoL), and safety. Two reviewers independently selected studies, extracted data, and evaluated the risk of bias using the Cochrane risk of bias 2.0 tool. The certainty in the evidence was determined using the GRADE framework. Protocol registration: CRD42022329342. Thirteen RCTs involving 441 patients with vision impairment indicate that NES may improve VA in the immediate post-intervention period (mean difference [MD] = -0.02 logMAR, 95% confidence intervals [CI] -0.08 to 0.04; low certainty), and probably increases QoL and detection accuracy (MD = 0.08, 95% CI -0.25 to 0.42 and standardised MD [SMD] = 0.09, 95% CI -0.58 to 0.77, respectively; both moderate certainty). NES likely results in little or no difference in mean sensitivity (SMD = -0.03, 95% CI -0.53 to 0.48). Compared with sham stimulation, NES increases the risk of minor adverse effects (risk ratio = 1.24, 95% CI 0.99 to 1.54; moderate certainty). The effect of NES on CS, reading performance, and electroencephalogram was uncertain. Our study suggests that although NES may slightly improve VA, detection accuracy, and QoL, the clinical relevance of these findings remains uncertain. Future research should focus on improving the available evidence's precision and consistency.

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study.

OBJECTIVES: Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose. METHODS: Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0. RESULTS: A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05). CONCLUSIONS: There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

Treatment of Women With Primary Dysmenorrhea With Manual Therapy and Electrotherapy Techniques: A Systematic Review and Meta-Analysis.

OBJECTIVE: The objective of this study was to evaluate the efficacy of electrotherapy and manual therapy for the treatment of women with primary dysmenorrhea. METHODS: Systematic searches were conducted in Scopus, Web of Science, PubMed, CINAHL, and MEDLINE. The articles must have been published in the last 10 years, had a sample exclusively of women with primary dysmenorrhea, had a randomized controlled trial design, and used interventions that included some form of manual therapy and/or electrotherapy techniques. Two reviewers independently screened articles for eligibility and extracted data. Difference in mean differences and their 95% CIs were calculated as the between-group difference in means divided by the pooled standard deviation. The I2 statistic was used to determine the degree of heterogeneity. RESULTS: Twelve selected studies evaluated interventions, with 5 evaluating electrotherapy techniques and 7 evaluating manual therapy techniques. All studies analyzed identified improvements in pain intensity and meta-analysis confirmed their strong effect. CONCLUSIONS: Manual therapy and electrotherapy are effective for the treatment of women with primary dysmenorrhea. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage stands out for its effects on the intensity and duration of pain with the application of a few sessions and their long-term effects. IMPACT: Manual therapy techniques and electrotherapy methods reduce the pain intensity of women with primary dysmenorrhea. Quality of life and degree of anxiety improved significantly with manual therapy interventions. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage are the interventions with which positive effects were achieved with fewer sessions.

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis.

Background: Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear. Objective: To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented. Methods: Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains. Results: Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps. Scoping review: 651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations. Effectiveness systematic reviews: studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators. Conclusions: Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children. Study registration: This study is registered as PROSPERO CRD42019159008. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

Between 5% and 30% of children experience constipation at some stage. In one-third of these children, this progresses to chronic functional constipation. Chronic functional constipation affects more children with additional needs. We aimed to find and bring together published information about treatments for chronic functional constipation, to help establish best treatments and treatment combinations. We did not cover assessment or diagnosis of chronic functional constipation. This project was guided by a 'stakeholder group', including parents of children with constipation, people who experienced constipation as children, and healthcare professionals/continence experts. We carried out a 'scoping review' and a series of 'systematic reviews'. Our 'scoping review' provides an overall picture of research about treatments, with 651 studies describing 48 treatments. This helps identify important evidence gaps. 'Systematic reviews' are robust methods of bringing together and interpreting research evidence. Our stakeholder group decided to structure our systematic reviews to reflect who delivered the interventions. We brought together evidence about how well treatments worked when delivered by families/carers (32 studies), the wider children's workforce (e.g. general practitioner, health visitor) (21 studies), continence teams (31 studies) or specialist consultant-led teams (42 studies). We also considered complementary therapies (15 studies) and behavioural strategies (4 studies). Care is affected by what is done and how it is done. We brought together evidence about different models of delivering care (15 studies), barriers and facilitators to implementation of treatments (106 studies) and costs (31 studies). Quality of evidence was mainly low to very low. Despite numerous studies, there was often insufficient information to support generalisable conclusions. Our findings generally agreed with current clinical guidelines. Management of childhood chronic functional constipation should be child-centred, multifaceted and adapted according to the individual child, their needs, the situation in which they live and the health-care setting in which they are looked after. Research is needed to address our identified evidence gaps.

Effectiveness, safety and cost-effectiveness of sacral neuromodulation for idiopathic slow-transit constipation: a systematic review.

AIM: Sacral neuromodulation (SNM) is a minimally invasive treatment option for functional constipation. Evidence regarding its effectiveness is contradictory, driven by heterogeneous study populations and designs. The aim of this study was to assess the effectiveness, safety and cost-effectiveness of SNM in children and adults with refractory idiopathic slow-transit constipation (STC). METHOD: OVID Medline, OVID Embase, Cochrane Library, the KSR Evidence Database, the NHS Economic Evaluation Database and the International HTA Database were searched up to 25 May 2023. For effectiveness outcomes, randomized controlled trials (RCTs) were selected. For safety outcomes, all study designs were selected. For cost-effectiveness outcomes, trial- and model-based economic evaluations were selected for review. Study selection, risk of bias and quality assessment, and data extraction were independently performed by two reviewers. For the intervention 'sacral neuromodulation' effectiveness outcomes included defaecation frequency and constipation severity. Safety and cost-effectiveness outcomes were, respectively, adverse events and incremental cost-effectiveness ratios. RESULTS: Of 1390 records reviewed, 67 studies were selected for full-text screening. For effectiveness, one cross-over and one parallel-group RCT was included, showing contradictory results. Eleven studies on safety were included (four RCTs, three prospective cohort studies and four retrospective cohort studies). Overall infection rates varied between 0% and 22%, whereas reoperation rates varied between 0% and 29%. One trial-based economic evaluation was included, which concluded that SNM was not cost-effective compared with personalized conservative treatment at a time horizon of 6 months. The review findings are limited by the small number of available studies and the heterogeneity in terms of study populations, definitions of refractory idiopathic STC and study designs. CONCLUSION: Evidence for the (cost-)effectiveness of SNM in children and adults with refractory idiopathic STC is inconclusive. Reoperation rates of up to 29% were reported.

Effectiveness of neuromuscular electrical stimulation training combined with exercise on patient-reported outcomes measures in people with knee osteoarthritis: A systematic review and meta-analysis.

OBJECTIVE: This study examined the effectiveness of neuromuscular electrical stimulation (NMES) added to the exercise or superimposed on voluntary contractions on patient-reported outcomes measures (PROMs) in people with knee osteoarthritis (OA). METHODS: This systematic review was described according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) were obtained from a systematic literature search in five electronic databases (PubMed, PEDro, LILACS, EMBASE, and SPORTDiscus) in April 2022. We described the effects of intervention according to each PROMs (scores for Pain; Self-reported functional ability; Symptoms (hear clicking, swelling, catching, restricted range of motion, and stiffness); Daily living function; Sports function; and Quality of life) and used a random-effect model to examine the impact of NMES plus exercise on pain compared with exercise in people with knee OA. RESULTS: Six RCTs (n = 367) were included. In the qualitative synthesis, the systematic literature analysis showed improvement in pain after NMES plus exercise compared with exercise alone in three studies. The other three studies revealed no difference between groups in pain, although similar improvement after treatments. In the meta-analysis, NMES at a specific joint angle combined with exercise was not superior to exercise alone in pain management (standardized mean difference = -0.33, 95% CI = -1.05 to 0.39, p = 0.37). There was no additional effect of NMES on exercise on self-reported functional ability, stiffness, and physical function compared with exercise alone. In only one study, symptoms, activities of daily living, sports function, and quality of life improved after whole-body electrostimulation combined with exercise. CONCLUSION: This review found insufficient evidence for the effectiveness of NMES combined with exercise in treating knee OA considering PROMs. While pain relief was observed in some studies, more high-quality clinical trials are needed to support the use of NMES added to the exercise in clinical practice. Electrical stimulation in a whole-body configuration combined with exercise shows promise as an alternative treatment option.

Efficacy of cranial electrotherapy stimulation on mood and sense of well-being in people with subclinical insomnia.

Cranial electrotherapy stimulation is a non-invasive brain stimulation method characterised by using a microcurrent. The objective of the study was to investigate whether a novel device with a stable supplement of electronic stimulation would improve sleep and the accompanying mood symptoms in people with subclinical insomnia. People who had insomnia symptoms without meeting the criteria for chronic insomnia disorder were recruited and randomly assigned to an active or a sham device group. They were required to use the provided device for 30 min each time, twice a day for 2 weeks. Outcome measures included questionnaires for sleep, depression, anxiety, and quality of life, 4 day actigraphy, and 64-channel electroencephalography. Fifty-nine participants (male 35.6%) with a mean age of 41.1 ± 12.0 years were randomised. Improvement of depression (p = 0.032) and physical well-being (p = 0.041) were significant in the active device group compared with the sham device group. Anxiety was also improved in the active device group, although the improvement was not statistically significant (p = 0.090). Regarding sleep, both groups showed a significant improvement in subjective rating, showing no significant group difference. The change in electroencephalography after the 2 week intervention was significantly different between the two groups, especially for occipital delta (p = 0.008) and beta power (p = 0.012), and temporo-parieto-occipital theta (p = 0.022). In conclusion, cranial electrotherapy stimulation can serve as an adjunctive therapy to ameliorate psychological symptoms and to alter brain activity. The effects of the device in a clinical population and an optimal set of parameters of stimulation should be further investigated.

Sacral neuromodulation therapy for urinary and defecatory disorders: experience in a Latin American public hospital

Abstract Objective: To show the experience of a Latin American public hospital, with SNM in the management of either OAB, NOUR or FI, reporting feasibility, short to medium-term success rates, and complications. Methods: A retrospective cohort was conducted using data collected prospectively from patients with urogynecological conditions and referred from colorectal surgery and urology services between 2015 and 2022. Results: Advanced or basic trial phases were performed on 35 patients, 33 (94%) of which were successful and opted to move on Implantable Pulse Generator (GG) implantation. The average follow-up time after definitive implantation was 82 months (SD 59). Of the 33 patients undergoing, 27 (81%)reported an improvement of 50% or more in their symptoms at last follow-up. Moreover, 30 patients (90%) with a definitive implant reported subjective improvement, with an average PGI-I "much better" and 9 of them reporting to be "excellent" on PGI-I. Conclusion: SNM is a feasible and effective treatment for pelvic floor dysfunction. Its implementation requires highly trained groups and innovative leadership. At a nation-wide level, greater diffusion of this therapy among professionals is needed to achieve timely referral of patients who require it.

The Influence of Active, Passive, and Manual Therapy Interventions for Low Back Pain on Opioid Prescription and Health Care Utilization.

OBJECTIVE: The aim of this study was to explore associations between the utilization of active, passive, and manual therapy interventions for low back pain (LBP) with 1-year escalation-of-care events, including opioid prescriptions, spinal injections, specialty care visits, and hospitalizations. METHODS: This was a retrospective cohort study of 4827 patients identified via the Military Health System Data Repository who received physical therapist care for LBP in 4 outpatient clinics between January 1, 2015 and January 1, 2018. One-year escalation-of-care events were evaluated based on type of physical therapist interventions (ie, active, passive, or manual therapy) received using adjusted odds ratios. RESULTS: Most patients (89.9%) received active interventions. Patients with 10% higher proportion of visits that included at least 1 passive intervention had a 3% to 6% higher likelihood of 1-year escalation-of-care events. Similarly, with 10% higher proportion of passive to active interventions used during the course of care, there was a 5% to 11% higher likelihood of 1-year escalation-of-care events. When compared to patients who received active interventions only, the likelihood of incurring 1-year escalation-of-care events was 50% to 220% higher for those who received mechanical traction and 2 or more different passive interventions, but lower by 50% for patients who received manual therapy. CONCLUSION: Greater use of passive interventions for LBP was associated with elevated odds of 1-year escalation-of-care events. In addition, the use of specific passive interventions such as mechanical traction in conjunction with active interventions resulted in suboptimal escalation-of-care events, while the use of manual therapy was associated with more favorable downstream health care outcomes. IMPACT: Physical therapists should be judicious in the use of passive interventions for the management of LBP as they are associated with greater likelihood of receiving opioid prescriptions, spinal injections, and specialty care visits.

Beyond Hypoglossal Hype: Social Media Perspectives on the Inspire Upper Airway Stimulation System.

In the landscape of sleep surgery, the Inspire® Upper Airway Stimulation (UAS) device has gained prominence as an increasingly popular treatment option for obstructive sleep apnea, prompting significant discourse across social media platforms. This study explores the social media narrative of the UAS device, particularly the nature of multimedia content, author demographics, and audience engagement on Instagram, Facebook, and TikTok. Our analysis encompassed 423 public posts, revealing images (67.4%) and videos (28.1%) as the dominant content types, with over a third of posts authored by physicians. A notable 40% of posts were advertisements, whereas patient experiences comprised 34.5%. TikTok, although presenting a smaller sample size, showed a substantially higher engagement rate, with posts averaging 152.9 likes, compared with Instagram and Facebook at 32.7 and 41.2 likes, respectively. The findings underscore the need for otolaryngologists and healthcare professionals to provide clear, evidence-based information on digital platforms. Given social media's expanding role in healthcare, medical professionals must foster digital literacy and safeguard the accuracy of health information online. In this study, we concluded that maintaining an evidence-based, transparent digital dialogue for medical innovations such as the UAS device necessitates collaborative efforts among physicians, health institutions, and technology companies.

Combined ultrasound and electric field stimulations improve pain and functional capacity in immediate cesarean delivery: a randomized clinical trial, double-blind, and placebo-controlled / Terapia combinada de estimulação elétrica por meio do ultrassom melhora a dor e a capacidade funcional no pós-parto imediato de cesariana: ensaio clínico randomizado, duplo-cego e placebo

ABSTRACT BACKGROUND AND OBJECTIVES: Wound complications and pharmacological pain relief methods used at the skin surgical site after cesarean delivery may result in women's physical and emotional burden. Thus, nonpharmacological treatments must be explored to avoid these complications and side effects on maternal health. The objective of this study was to investigate the effects of Combined Ultrasound and Electric Field Stimulation (CUSEFS) on cicatricial pain and functional capacity in immediate cesarean delivery. METHODS: This study has a randomized clinical trial, double-blind, and placebo-controlled design. Thirty women (25.7±5.0 years) in immediate postpartum were randomly assigned to three groups: Control (CG, n:9), CUSEFS (TG, n:11), and Placebo (PG, n:10). CUSEFS was performed once for 20 minutes. Cicatricial pain (McGill Pain Questionnaire) and functional capacity (Functional Capacity Check) was assessed at baseline, after the intervention, and after 30 minutes. Cohen's (d) and Mixed-design analysis of variance were used to compare groups. RESULTS: Immediately after the intervention, TG showed a decrease in cicatricial pain compared with CG in sensory (d:3.8 to 4.0), affective (d:4.0), and total categories (d:3.9). In functional capacity, TG had less difficulty than CG at walking (d:0.6) and lying down (d:1.1), and PG at rest (d: 0.9). CONCLUSION: CUSEFS might be a resource for managing cicatricial pain and functional capacity in immediate cesarean delivery. Further studies with longer duration and different CUSEFS doses/parameters are required.

RESUMO JUSTIFICATIVA E OBJETIVOS: As complicações na ferida e o uso de métodos farmacológicos de alívio da dor no local cirúrgico após a cesariana podem resultar em sobrecarga física e emocional para a mulher. Assim, tratamentos não farmacológicos devem ser explorados para evitar essas complicações e efeitos adversos à saúde materna. O objetivo deste estudo foi investigar os efeitos da terapia combinada de estimulação elétrica por meio do ultrassom (CUSEFS) na dor cicatricial e na capacidade funcional no pós-parto imediato de cesariana. MÉTODOS: Este estudo possui um desenho de ensaio clínico randomizado, duplo-cego e controlado por placebo. Trinta mulheres (25,7±5,0 anos) em pós-parto imediato de cesariana foram distribuídas aleatoriamente em três grupos: Controle (CG, n:9), CUSEFS (TG:11) e Placebo (PG, n:10). O CUSEFS foi realizado uma vez por 20 minutos. A dor cicatricial (Questionário de Dor McGill) e a capacidade funcional (Functional Capacity Check) foram avaliadas no início, após a intervenção e após 30 minutos. As análises de variância de design misto e Cohen (d) foram usadas para comparar os grupos. RESULTADOS: Imediatamente após a intervenção, o TG apresentou diminuição na dor cicatricial em relação ao CG nas categorias sensorial (d:3,8 a 4,0), afetiva (d:4,0) e total (d:3,9). Na capacidade funcional, o TG apresentou menor dificuldade que o CG na marcha (d:0,6) e deitado (d:1,1), e que o PG em repouso (d:0,9). CONCLUSÃO: O CUSEFS pode ser um recurso para o manejo da dor cicatricial e da capacidade funcional imediatamente após a cesariana. Além disso, são necessários mais estudos com maior duração e diferentes doses/parâmetros de CUSEFS.