The neurobiology of major depressive disorder (MDD) remains incompletely understood, and many individuals fail to respond to standard treatments. Repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex (DLPFC) has emerged as a promising antidepressant therapy. However, the heterogeneity of response underscores a pressing need for biomarkers of treatment outcome. We acquired resting state functional magnetic resonance imaging (rsfMRI) data in 47 MDD individuals prior to 5-8 weeks of rTMS treatment targeted using the F3 beam approach and in 29 healthy comparison subjects. The caudate, prefrontal cortex, and thalamus showed significantly lower blood oxygenation level-dependent (BOLD) signal power in MDD individuals at baseline. Critically, individuals who responded best to treatment were associated with lower pre-treatment BOLD power in these regions. Additionally, functional connectivity (FC) in the default mode and affective networks was associated with treatment response. We leveraged these findings to train support vector machines (SVMs) to predict individual treatment responses, based on learned patterns of baseline FC, BOLD signal power and clinical features. Treatment response (responder vs. nonresponder) was predicted with 85-95% accuracy. Reduction in symptoms was predicted to within a mean error of +/- 16% (r = .68, p < .001). These preliminary findings suggest that therapeutic outcome to DLPFC-rTMS could be predicted at a clinically meaningful level using only a small number of core neurobiological features of MDD, warranting prospective testing to ascertain generalizability. This provides a novel, transparent and physiologically plausible multivariate approach for classification of individual response to what has become the most commonly employed rTMS treatment worldwide. This study utilizes data from a larger clinical study (Australian New Zealand Clinical Trials Registry: Investigating Predictors of Response to Transcranial Magnetic Stimulation for the Treatment of Depression; ACTRN12610001071011; ).

OBJECTIVE To evaluate effectiveness of physical therapy, biofeedback, and/or cognitive behavioral therapy for chronic prostatitis/chronic pelvic pain syndrome (CP and/or CPPS). This symptom complex has resisted resolution from conventional urologic treatment of the prostate, which includes antibiotics, alpha-blockers, and analgesics. Beginning in 1995, a new paradigm was introduced viewing CP and/or CPPS as a psychoneuromuscular disorder driven by protective pelvic floor guarding and psychosocial stress. METHODS A literature search (PubMed, Google Scholar, and the Cochran Library) was conducted from inception through December 2017 using key words related to CP and/or CPPS (eg, prostatitis and pelvic pain) with physical therapy (eg, myofascial trigger point release) and/or biofeedback or cognitive behavioral treatment. Studies were required to include pre- and post-treatment with the National Institutes of Health Chronic Prostatitis Symptom Index (CPSI) scores. RESULTS Eight studies inclusive of 280 patients met primary inclusion criteria. Study sample sizes ranged from 8 to 116 men (mean = 35); treatment duration ranged from 8 to 26 weeks (mean = 14). Pre-treatment mean CPSI scores ranged from 21.7 to 33.5. The nonstandardized weighted mean reduction of CPSI score from baseline was 8.8 points; 95% confidence interval (7.5, 11.1); P <.001. The I-2 statistic = 18.5% indicating little heterogeneity between studies. A sensitivity analysis including an additional multimodal intervention study of with 100 patients produced similar findings. CONCLUSION Conventional medical treatment often fails to resolve CP and/or CPPS. A 6-point reduction in CPSI score is considered a clinically meaningful improvement of symptoms. This meta-analysis shows that treating CP and/or CPPS as a psychoneuromuscular disorder can significantly exceed this clinical threshold. (C) 2018 Elsevier Inc.

OBJECTIVES:Pelvic muscle tenderness occurs often in patients with urologic chronic pelvic pain syndrome; symptoms frequently can be reduced with pelvic myofascial physical therapy. This open-label pilot study evaluated the safety of a personal wand that enables patient's self-treatment of internal myofascial trigger points in the pelvic floor and its effect in reducing pelvic muscle tenderness.METHODS:A specially designed curved wand served as an extended finger to locate and release painful internal myofascial trigger points; an integrated algometer monitors and guides appropriate applied point pressure. Patients used the wand several times weekly after education and careful supervision. Evaluations for adverse events and assessments of pain sensitivity were conducted at 1 and 6 months after commencing use.RESULTS:One hundred and thirteen of the enrolled 157 patients completed 6 months of wand use-106 men and 7 women; 44 patients withdrew before study completion but none for adverse events. Median age was 41 years and 93% were male. Baseline median sensitivity visual analog scale score (1 to 10, 10=most sensitive) was 7.5 and decreased significantly at 6 months to 4 (P<0.001, Wilcoxon matched-pairs signed-rank test). Most patients (95.5%) reported the wand as either very or moderately effective in alleviating pain. No serious adverse events occurred.CONCLUSIONS:A multimodal protocol using an internal pelvic therapeutic wand seems to be a safe, viable treatment option in select refractory patients with pelvic pain.

•Depression is associated with significant abnormalities in functional and structural connectivity.•rTMS for treatment resistant depression modulates connectivity, normalising pre-treatment abnormalities.•Connectivity imaging can be used to optimise rTMS targeting, explore and predict treatment response.

Depression and AnxietyVolume 33, Issue 8 p. 677-683 Issue InformationFree Access Depression and Anxiety Issue Information First published: 26 July 2016 https://doi.org/10.1002/da.22415AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume33, Issue8FOCUS ON BIOLOGICAL TREATMENTS: KETAMINE AND BEYONDAugust 2016Pages 677-683 RelatedInformation

This study documents the voluntary reduction in medication use in patients with refractory chronic pelvic pain syndrome utilizing a protocol of pelvic floor myofascial trigger point release with an FDA approved internal trigger point wand and paradoxical relaxation therapy. Self-referred patients were enrolled in a 6-day training clinic from October, 2008 to May, 2011 and followed the protocol for 6 months. Medication usage and symptom scores on a 1-10 scale (10 = most severe) were collected at baseline, and 1 and 6 months. All changes in medication use were at the patient's discretion. Changes in medication use were assessed by McNemar's test in both complete case and modified intention to treat (mITT) analyses. 374 out of 396 patients met inclusion criteria; 79.7 % were male, median age of 43 years and median symptom duration of 5 years. In the complete case analysis, the percent of patients using medications at baseline was 63.6 %. After 6 months of treatment the percentage was 40.1 %, a 36.9 % reduction (p < 0.001). In the mITT analysis, there was a 22.7 % overall reduction from baseline (p < 0.001). Medication cessation at 6 months was significantly associated with a reduction in total symptoms (p = 0.03).

Differing levels of occipital lobe asymmetry and enlarged lateral ventricles have been reported within patients with bipolar disorder (BD) compared with healthy controls, suggesting different rates of occipital bending (OB). This may exert pressure on subcortical structures, such as the hippocampus, reduced among psychiatric patients. We investigated OB prevalence in 35 patients with BD and 36 healthy controls, and ventricular and occipital volumes. Prevalence was four times higher among BD patients (12/35 [34.3%]) than in control subjects (3/36 [8.3%]), as well as larger lateral ventricular volumes (LVVs). Furthermore, we found OB to relate to left-to-right ventricular and occipital lobe volume (OLV) ratios. Those with OB also had reduced left-to-right hippocampal volume ratios. The results suggest that OB is more common among BD patients than healthy subjects, and prevalent in both BD Type I and Type II patients. We posit that anomalies in neural pruning or ventricular enlargement may precipitate OB, consequently resulting in one occipital lobe twisting around the other. Although the clinical implications of these results are unclear, the study suggests that asymmetrical ventricular volume matched with a pattern of oppositely asymmetrical occipital volume is related to OB and may be a marker of psychiatric illness.

We examined the functional, psychological, and pain-related outcomes among children with chronic pain completing an intensive interdisciplinary pediatric pain rehabilitation program. We hypothesized that baseline psychological measures would predict a longer treatment course while baseline pain severity would not correlate with program duration. This outpatient program provides 5-6 hours of daily intensive physical therapy and occupational therapy in addition to yoga, self-regulation training, individual and group behavioral health intervention, group-based music and art therapy, and parent group intervention. All pain medications are discontinued, and no invasive therapeutic procedures are utilized. 22 patients (18 female) aged 11-18 with chronic musculoskeletal pain completed Functional Disability Inventory, 100mm Visual Analog Scale, PROMIS Anxiety, Depression, Pain Interference, and Mobility, PRCQ-catastrophizing, and the Pain Acceptance Questionnaire for Adolescents at baseline, the end of each week, and 19 have completed a one-month follow-up. The mean program duration was 3.6 (± 0.9) weeks, determined by achievement of functional goals. Using paired samples t-tests, current pain (VAS 0-100) significantly decreased from 61.7 to 31.0 (P=0.001) at post-treatment followup. FDI improved from 27.6 to 13.9 between baseline and program end (P<.0001), and continues to improve following treatment (P=0.002). Patient reported anxiety and depression decline significantly (P=0.004 and P=0.001, respectively), while pain acceptance increases significantly during treatment (P<.001). Patients report less catastrophizing following treatment (P=.001). Treatment program duration correlated with baseline pain interference (r=.470; P=.027), functional disability (FDI r=.664; P=.001), and presence of conversion symptoms (r=.548; P=.008). Patients with greater mobility (PROMIS; r =-.671; P =.001) and pain acceptance (CPAQ-A; r = -.537; P=.018) at baseline required shorter treatment intervention. Children with chronic musculoskeletal pain successfully restore function and improve pain without pharmacotherapy. Baseline functional disability and psychological factors correlate with treatment program duration. Prospective studies are warranted to determine long-term efficacy and effectiveness of this interdisciplinary program.

Parental responses to their child's pain, particularly protective responses, are associated with the young person's pain-related impairment, pain complaints, mood, and engagement in social activities. Research suggests these responses may be affected by the parent's feelings of distress and helplessness, parent catastrophizing, and parent attributions about the cause of symptoms. However, few studies have investigated the effect of pediatric pain rehabilitation on parental responses or directly targeted these potential contributors to parent responses. While their adolescent children (ages 11-18) participated in a 3-6 week intensive interdisciplinary pediatric pain rehabilitation program, all 22 parents (primarily mothers) consistently attended two 60-90 minute parent groups per week led by a psychologist or social worker. Groups maintained a supportive and educational format, and parents were encouraged to share challenges of parenting a teen with pain, while also being prompted to interact with a specific topic each session (e.g. coping with own emotions, responding to teen pain, promoting appropriate teen independence, behavior management, and education about chronic pain). One parent from each family completed measures at baseline, the end of each week of treatment, and one-month follow-up, including the Adult Responses to Children's Symptoms (ARCS) and the parent Functional Disability Inventory (FDI-parent). Teens reported their pain on a 100mm visual analog scale. Results indicate, on average, both parent protective and monitoring responses declined throughout the program (t=5.37; p<.001; t=6.18; p<.001, respectively) and these effects were maintained at follow-up. FDI-parent was somewhat associated with protective and monitoring parent responses at baseline (p's<.05), but only with protective responses at program end (p<.05). Child pain was not associated with parent responses. In conclusion, parent groups during intensive interdisciplinary pediatric pain rehabilitation may be an effective format to target parent responses to their child's pain, and these effects are not solely explained by improvements in child disability or pain. Parental responses to their child's pain, particularly protective responses, are associated with the young person's pain-related impairment, pain complaints, mood, and engagement in social activities. Research suggests these responses may be affected by the parent's feelings of distress and helplessness, parent catastrophizing, and parent attributions about the cause of symptoms. However, few studies have investigated the effect of pediatric pain rehabilitation on parental responses or directly targeted these potential contributors to parent responses. While their adolescent children (ages 11-18) participated in a 3-6 week intensive interdisciplinary pediatric pain rehabilitation program, all 22 parents (primarily mothers) consistently attended two 60-90 minute parent groups per week led by a psychologist or social worker. Groups maintained a supportive and educational format, and parents were encouraged to share challenges of parenting a teen with pain, while also being prompted to interact with a specific topic each session (e.g. coping with own emotions, responding to teen pain, promoting appropriate teen independence, behavior management, and education about chronic pain). One parent from each family completed measures at baseline, the end of each week of treatment, and one-month follow-up, including the Adult Responses to Children's Symptoms (ARCS) and the parent Functional Disability Inventory (FDI-parent). Teens reported their pain on a 100mm visual analog scale. Results indicate, on average, both parent protective and monitoring responses declined throughout the program (t=5.37; p<.001; t=6.18; p<.001, respectively) and these effects were maintained at follow-up. FDI-parent was somewhat associated with protective and monitoring parent responses at baseline (p's<.05), but only with protective responses at program end (p<.05). Child pain was not associated with parent responses. In conclusion, parent groups during intensive interdisciplinary pediatric pain rehabilitation may be an effective format to target parent responses to their child's pain, and these effects are not solely explained by improvements in child disability or pain.

s The Journal of Pain S113 (548) Trajectories of child pain and function in intensive interdisciplinary pediatric pain rehabilitation C Hoffart, R Anderson, D Feltrop, M Wilson, B Dorton, A Chapman, and D Wallace; Children’s Mercy Hospital, Kansas City, MO Given the prevalence of pediatric chronic pain, degree of disability, and compromise in quality of life, there is a critical need to identify the natural history of pain anddisability. Few studies investigate the effect of interdisciplinary treatment on pain and functional trajectories in children with chronic musculoskeletal pain. We hypothesized function would improve prior to decrease in pain. 22 patients (18 female) aged 11-18 with chronic musculoskeletal pain completed the modified Bruce Treadmill Test, Functional Disability Inventory (FDI-patient), and reported pain using a 100mm Visual Analog Scale (VAS 0-100) at program start, the end of each week, and 19 completed one-month follow-up. One parent from each family completed FDI-parent, a measure of parent perception of pain-related functional limitations. Mean treatment program duration was 3.64 weeks (6 0.9). Patients’ pain worsens before it improves approximately halfway through the program. Pain increased from 61.7 at baseline to 72.1 and 67.5 at the end of weeks 1 (P=0.03) and 2 (P=0.22), respectively, with subsequent significant decrease in pain to 31.9 through post-treatment follow-up (P=0.001). Baseline patient and parent FDI scores correlated (27.6 and 25.5, respectively, r=.861; P< .0001) and demonstrated steady declines at week one and throughout treatment, indicating improved function prior to pain decrease. Patient FDI improved to 13.9 by program end (P<.0001) and continues to improve following treatment to 7.6 (P=.002). Bruce treadmill endurance increased steadily from baseline of 7.11 minutes with continued improvement through program end to 10.4 minutes (P<.0001). Concurrent trajectories of patient outcomes suggest that function improves before pain. Whereas pain gets worse during the first weeks of treatment, patient function increases within the first week. These trajectories may aid in determining the projected course for patients requiring intensive interdisciplinary pain rehabilitation. (549) Relationships among fear of pain and movement, strength test performance, and indicators of hypothalamic pituitary adrenal axis (HPA axis) activity E Dannecker and P Hinton; University of Missouri, Columbia, MO Two studies were located that tested associations between fear of pain and movement and performance during strength testing. They reported mixed results. In this study, we advance the literature by incorporating measures of Hypothalamic Pituitary Adrenal (HPA) axis activity – cortisol and blood pressure, whichwe collected directly before upper extremity strength tests. During a single session, healthy, upper-body untrained participants (N = 32, 46.9%women, 78% Caucasian, 24 yrs old (SD = 5.18)) completed measures of fear of pain and movement and pain catastrophizing before two consecutive strength tests using the non-dominant elbow flexors. Immediately before the strength tests, we collected blood pressure readings and saliva via an oral swab for cortisol. We also recorded perceived exertion, pain intensity, pain unpleasantness, and force output during the strength tests. Contrary to our hypotheses, we detected no significant associations among fear of pain and movement and cortisol, blood pressure, perceived effort, pain, or force output. However, systolic and diastolic blood pressure and perceived effort positively correlated with force output (r’s = .49 .61, p < .01; r’s = .57 .60, p < .01; r’s = .35 .42, p < .05). In addition, the total score of the Pain Catastrophizing Scale (PCS) and rumination subscale of the PCS inversely correlated with force output (r’s = -.37 -.40, p < .04; r’s = -.42 .46, p < .02). These results support that pain catastrophizing is more strongly related to force output than fear of pain and movement, but none of the psychological constructs were significantly associated with indicators of HPA axis activity. Future studies should test relationships among these variables in samples with clinical pain, conduct alternative types of strength and function tests, and administer otherHPAmeasures such as the corticotropin-releasing hormone challenge test. (550) Functional disability through initial and follow-up evaluations in a multidisciplinary pediatric headache clinic A Caruso, E Mahoney, L Lazdowsky, and A LeBel; Boston Children’s Hospital,

There are reports of differences in occipital lobe asymmetry within psychiatric populations when compared with healthy control subjects. Anecdotal evidence and enlarged lateral ventricles suggests that there may also be a different pattern of curvature whereby one occipital lobe wraps around the other, termed 'occipital bending'. We investigated the prevalence of occipital bending in 51 patients with major depressive disorder (males mean age = 41.96 ± 14.00 years, females mean age = 40.71 ± 12.41 years) and 48 age- and sex-matched healthy control subjects (males mean age = 40.29 ± 10.23 years, females mean age = 42.47 ± 14.25 years) and found the prevalence to be three times higher among patients with major depressive disorder (18/51, 35.3%) when compared with control subjects (6/48, 12.5%). The results suggest that occipital bending is more common among patients with major depressive disorder than healthy subjects, and that occipital asymmetry and occipital bending are separate phenomena. Incomplete neural pruning may lead to the cranial space available for brain growth being restricted, or ventricular enlargement may exacerbate the natural occipital curvature patterns, subsequently causing the brain to become squashed and forced to 'wrap' around the other occipital lobe. Although the clinical implications of these results are unclear, they provide an impetus for further research into the relevance of occipital bending in major depression disorder.

Sir, We thank Professor Siebert for this comment and interest in our recent article regarding occipital bending in depression. The focus of our article was to investigate the prevalence of occipital bending in this patient group relative to control subjects, and our findings suggest that this is separate to previous findings of asymmetry or cortical thinning in the occipital lobe (Peterson …

Intensive interdisciplinary pediatric pain rehabilitation programs seek to return children and adolescents who are disabled by pain to normal physical, social, and academic functioning. Psychological outcomes represent an important domain of functioning for these teens as they tend to show high levels of catastrophizing, have increased depressive symptoms, and tend to make avoidance of pain a priority over the pursuit of other goals and values. However, no study has specifically investigated the longitudinal pattern of change in these variables over the course of intensive treatment. Adolescents in our interdisciplinary pediatric pain rehabilitation program engage in physical therapy and occupational therapy, and each week also participate in 4.5 hours of yoga, 1 hour of self-regulation training, 2-3 hours of individual and 2-3 hours of group behavioral health intervention, and one hour each of group-based music and art therapy. Parents also attend 2-3 hours per week of group behavioral health intervention and occasional individual family sessions. For this investigation of initial outcomes, 22 participants completed measures (PROMIS anxiety and depression, PRCQ-catastrophizing, Pain Acceptance Questionnaire for Adolescents, and VAS pain ratings) at program baseline, the end of each week, and 19 completed one-month follow-up. Statistically-significant improvements in depression, anxiety, catastrophizing, and pain acceptance (all p's<.01), but not pain, were observed during the program. Self-reported pain improved significantly between the end of the program and follow-up (t=3.14, p<.01), and pain acceptance showed further improvement between program-end and follow-up (t=3.17, p=.001). Heirarchical linear modeling analysis supports consistent improvement in psychological variables across the program and follow-up (all p's<.001). Data also suggest that psychological variables change prior to changes in pain. These results suggest that interdisciplinary pediatric pain rehabilitation leads to steady improvements in psychological factors relevant to adolescents' return to normal activities, and that changes in psychological functioning precede changes in self-reported pain. Intensive interdisciplinary pediatric pain rehabilitation programs seek to return children and adolescents who are disabled by pain to normal physical, social, and academic functioning. Psychological outcomes represent an important domain of functioning for these teens as they tend to show high levels of catastrophizing, have increased depressive symptoms, and tend to make avoidance of pain a priority over the pursuit of other goals and values. However, no study has specifically investigated the longitudinal pattern of change in these variables over the course of intensive treatment. Adolescents in our interdisciplinary pediatric pain rehabilitation program engage in physical therapy and occupational therapy, and each week also participate in 4.5 hours of yoga, 1 hour of self-regulation training, 2-3 hours of individual and 2-3 hours of group behavioral health intervention, and one hour each of group-based music and art therapy. Parents also attend 2-3 hours per week of group behavioral health intervention and occasional individual family sessions. For this investigation of initial outcomes, 22 participants completed measures (PROMIS anxiety and depression, PRCQ-catastrophizing, Pain Acceptance Questionnaire for Adolescents, and VAS pain ratings) at program baseline, the end of each week, and 19 completed one-month follow-up. Statistically-significant improvements in depression, anxiety, catastrophizing, and pain acceptance (all p's<.01), but not pain, were observed during the program. Self-reported pain improved significantly between the end of the program and follow-up (t=3.14, p<.01), and pain acceptance showed further improvement between program-end and follow-up (t=3.17, p=.001). Heirarchical linear modeling analysis supports consistent improvement in psychological variables across the program and follow-up (all p's<.001). Data also suggest that psychological variables change prior to changes in pain. These results suggest that interdisciplinary pediatric pain rehabilitation leads to steady improvements in psychological factors relevant to adolescents' return to normal activities, and that changes in psychological functioning precede changes in self-reported pain.

OBJECTIVE:To evaluate safety and effectiveness of low-dose (100 U) onabotulinumtoxinA (onabotA) bladder injections as an office procedure with topical anesthesia only for patients with Parkinson's disease (PD) and incontinence. METHODS:Qualified patients who failed oral antimuscarinic agents participated in an open-label study. They discontinued antimuscarinics, provided a King's Health Questionnaire (KHQ), voiding symptom score, and 3-day voiding diary. Free uroflowmetry with post-void ultrasounds and cystometrogram pressure/flow studies were performed. Patients underwent flexible cystoscopy and injections of onabotA 100 U (10 U/mL) dispersed into 10-20 submucosal/detrusor sites of the bladder, including the trigone. Voiding diaries, questionnaires, and free uroflowmetry with post-void ultrasound residual urine measurements were repeated after 1, 3, and 6 months. RESULTS:Twelve men and 8 women were treated: mean age, 70.4 years; duration of disease, 10.6 years; median bladder contraction volume, 115 mL; maximum bladder pressure, 62 cm; and post-void volume, 9 mL. Moderate to marked symptom relief at 3 months and a 50% incontinence decrease over 6 months relative to pretreatment was reported in 59% patients (P ≤.02); 5 patients failed to complete the 6-month endpoint. No urinary retention required catheterization. CONCLUSION:Office cystoscopy with low-dose onabotA injection treatment is a potential long-term management strategy for patients with PD and urinary incontinence who fail oral antimuscarinic agents. The treatment seems to be safely utilized for older men with BPH as well as women with potential hypoactive detrusor function.

recent network meta-analysis of α-blockers, antibiotics and other drug therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) found that they provided modest-to-no benefit for this condition, confirming previous findings. However, a casual reading of the article may give a false impression of the efficacy and appropriateness of these drugs.

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Prostate & Genitalia1 Apr 20111431 SAFETY AND EFFECTIVENESS OF AN INTERNAL PELVIC MYOFASCIALTRIGGER POINT WAND FOR UROLOGICAL CHRONIC PELVIC PAIN SYNDROMES Rodney Anderson, David Wise, Timothy Sawyer, and Brian Nathanson Rodney AndersonRodney Anderson Stanford, CA , David WiseDavid Wise Sebastopol, CA , Timothy SawyerTimothy Sawyer Sebastopol, CA , and Brian NathansonBrian Nathanson Longmeadow, MA View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1343AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urologic chronic pelvic pain syndromes challenge physicians seeking adequate treatment alternatives. Pelvic muscle tenderness phenotypes occur often in these patients and pelvic myofascial physical therapy is helpful. We evaluated safety and tolerability of an internal therapeutic trigger point wand to enable patient self-treatment and determined effectiveness in decreasing pelvic muscle tenderness. METHODS A curved wand served as an extended finger to locate and release painful myofascial trigger points; an integrated algometer sensor monitors point pressure to prevent excessive or dangerous force. Patients used the wand weekly after education and careful supervision by a physical therapist. Assessments of pain sensitivity were conducted at pretreatment, 1 and 6 months; adverse events were documented. There were 169 patients enrolled in the study from October 2008 through mid-December 2009 with intent to obtain a 6-month follow-up. 92% of patients were men and 8% women with a median age of 41 years (25th percentile, 75% percentile; 32.5, 52.5). RESULTS 113 of the enrolled 169 patients completed 6 months of wand use; 56 patients withdrew but none for adverse events. Pelvic muscle sensitivity scores relative to pretreatment were available for 109 patients at 6 months. The median (25thpercentile, 75th percentile) sensitivity before wand use was 7.5 (6, 8.5); it decreased significantly after one month of wand use to a median of 5 (4, 6.5), p<0.001 (paired Wilcoxon matched-pairs signed-ranks test). At 6 months the median sensitivity decreased further to 4 (2.5, 5.5); the median difference in sensitivity was 2.5 (1.5, 4) compared with pretreatment values (p<0.001). Eighty-seven percent (95/109) of patients reported some (>0) reduction in muscle sensitivity and 93% indicated they were very satisfied or moderately satisfied with use of the wand. There were no serious side effects and rare transient episodes of mucosal bleeding. CONCLUSIONS This pilot trial represents an attempt to relieve the painful symptoms of UCPPS in a select population who were seeking treatment beyond the unsuccessful traditional multi-modal therapies they had previously received. Patient self-treatment utilizing a therapeutic wand for myofascial TrP release appears to be a safe, viable and economical chronic pelvic pain management option. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185 Issue 4S April 2011 Page: e573 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.Metrics Author Information Rodney Anderson Stanford, CA More articles by this author David Wise Sebastopol, CA More articles by this author Timothy Sawyer Sebastopol, CA More articles by this author Brian Nathanson Longmeadow, MA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

This article represents a small, but compelling, feasibility trial of targeted therapy for psychosocial abnormalities occurring in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).1 All physicians are intimately familiar with the psychological manifestations, including depression and anxiety, suffered by individuals with this disorder as well as with any other chronic pain syndrome. This group of authors has established their expertise in identifying these risk factors and prevalence within the syndrome of CP/CPPS. Clearly, their observation that catastrophic thinking is a unique factor in chronic pain and that it has been found to be the strongest biopsychosocial predictor of CP/CPPS is important for treating physicians to understand.

PURPOSE:Sacral nerve modulation is a Food and Drug Administration approved treatment for refractory urgency, frequency, urge incontinence and nonobstructive urinary retention in adults. The sparse literature on sacral nerve modulation in children focuses on its initial efficacy in patients with neurogenic bladder and dysfunctional elimination. We describe our initial experience with sacral nerve modulation and the phenomenon of growth spurts associated with lead malfunction that necessitates revision.MATERIALS AND METHODS:After receiving institutional review board approval we retrospectively reviewed the charts of pediatric patients who underwent sacral nerve modulation surgery at our institution. Charts were examined for patient demographics, subjective success, the need for further surgery and success after revision.RESULTS:Four patients underwent sacral nerve modulation at an average age of 12.1 years. All patients reported initial success, defined as greater than 50% symptom improvement. Subsequently 3 patients required a total of 5 revisions due to lead malfunction with an average of 1.5 years between surgeries. In those requiring revision the average somatic growth between revisions was 8.1 cm. Return of efficacy was reported after each revision. All patients had functioning nerve stimulators in place and continued to have a positive subjective response.CONCLUSIONS:The sparse data on sacral nerve modulation in children shows efficacy and safety similar to those in adults. Somatic growth may be associated with lead malfunction and require surgical revision. We report a small series showing that revision can be done successfully and safely. Informed consent for sacral nerve modulation in pediatric patients should include a discussion of somatic growth as a possible cause of lead malfunction necessitating revision.