The Korean Pain Intervention Society (KORSIS) strives to advance research and education rin pain intervention procedures in spinal, neural, and joint pain and promote imaging-guided pain interventions [1]. The KORSIS holds biannual symposiums. In 2023, the seond symposium was held on October 29 at Lavender Hal, Samjung Hotel, Seoul. This paper summarizes the symposium highlights.

The symposium broadly addressed the following sessions. 1) Functional medicine applicable to the pain clinic. 2) Available procedures when the epidural steroid injection is ineffective. 3) The evidence for using ESWT in regeneration in the pain clinic and the prescription.

A functional medicine approach may benefit patients who attend the pain clinic with unmanageable pain that fails to respond to drugs or interventions.

1. Patients with chronic fatigue syndrome

Chronic fatigue syndrome is extreme exhaustion and fatigue that lasts for six months or longer. Chronic fatigue syndrome is associated with autoimmunity and increased inflammation. Autoimmune activities may increase due to lipopolysaccharide toxins generated by the gut microbiota. These toxins are absorbed into the bloodstream and promote inflammation by adhering to nociceptor sensory neurons. This, in turn, causes abnormal immunomodulatory effector functions by increasing calcitonin gene-related peptide, substance P, somatostatin, and galanin. To test the gut microbiome, the fecal calprotectin test, hydrogen breath test, and urine organic acid analysis may be utilized. Moreover, leaky gut syndrome is a proposed gastrointestinal disorder that affects the intestinal lining. An unhealthy gut lining may allow undigested foods or toxins to penetrate the underlying tissues with greater ease, thereby activating various cytokines and causing chronic fatigue in the human body. A food IgG test may also be relevant, especially for patients with food digestion insufficiency. By measuring gut IgG advised to abstain from foods that have tested positive for approximately three months.

2. Patients with rheumatism or autoimmune disease

Rheumatism and autoimmune disease may result from exposure to heavy metals or endocrine-disruptors. Hence, it is recommended that tests to identify heavy metals and endocrine disruptors be performed on patients with these suspected conditions. Based on the test results, chelation therapy may be performed as necessary. As nutrients and ions may be released from the body during chelation therapy, supplemental nutrients and ions may be required during the therapy.

3. Heavy metal and mineral chelation in the pain clinic

Testing for heavy metals should be performed when a patient presents with unresolved nonspecific symptom and the cause is unknown but may be inflammation, skin disease, respiratory disease, and neurological disorder. Heavy metal exposure, except in the case of large-scale occupational exposure, generally do not present with specific symptoms. As a result, the condition often progresses to a chronic state. Heavy metal exposure can cause diabetes, hypertension, cardiovascular disease, and various cancers, so early detection is crucial. The main sources and toxic symptoms of exposure to As, Pb, Hg, Cd, Al, Cr, Co, and Ni should be examined.

For lower back pain and lumbosacral radicular pain, the epidural steroid injection is most commonly used in pain clinics. In many cases, the therapeutic effects of epidural steroid injection are inadequate, while valid effects tend to be short-term. When epidural steroid injection is ineffective, radiofrequency (RF), neuroplasty using Racz and Navi catheters, or discoplasty may be used.

1. Radiofrequency

Radiofrequency can be categorized into continuous radiofrequency (CRF) and pulsed radiofrequency (RPF). CRF exposes the target nerves or tissues to high temperatures (70-90°C) via continuous electrical stimulations. Nerves or tissues treated with CRF are ablated. The ablation of targeted nociceptive nerve fibers is the key mechanism by which CRF works. In contrast, PRF does not produce sufficient heat to cause structural damage. The pain control mechanism in PRF involves modulating pain signals of the nociceptive nerves. The detailed mechanism of PRF for pain control were presented in a review article by Park et al. (Table 1) [2]. When pain reduction through transforaminal epidural injection (TFESI) is inadequate for spinal radicular pain, PRF of the nerve root may prove effective. TFESI may also be replaced by PRF when frequent steroid use becomes burdensome. Furhermore, PRF may be used to manage failed back surgery syndrome.

Table 1 . The pain-reducing mechanisms of pulsed radiofrequency.

Long-term depression of pain signaling

Changes at the molecular level

Deactivation of microglia at the level of the spinal dorsal horn

Reduction of pro-inflammatory cytokines

Incremental increase in endogenous opioid precursor messenger ribonucleic acid

Changes in neuronal activity

Enhancement of the noradrenergic and serotonergic descending pain inhibitory pathways

Suppression of C-afferent fiber excitation

Microscopic damage of the nociceptive C- and A-delta fibers

2. Neuroplasty using Racz and Navi catheters

Racz and Navi catheters may be used to perform neuroplasty when the effects of epidural steroid injection are inadequate. The procedure was explained in detail. Tips for performing neuroplasty using Racz and Navi catheters were highlighted.

3. Discoplasty

Discoplasty is another general surgical procedure that can be considered in cases of uncontrolled discogenic pain. The methods of discoplasty were described, and previous reports on the treatment outcomes of discoplasty were reviewed.

Recently, ESWT has been widely prescribed in pain clinics. Notably, ESWT is indicated for tissue regeneration. In this session, the relevant evidence and the ways to increase treatment compliance among patients were explored.

1. ESWT for tendon and muscle regeneration

Animal studies have shown that damaged tissues can be regenerated, except for tendon or muscle ruptures. The mechanisms by which ESWT enhances tissue regeneration include enhanced neovascularity, accelerated growth factor release, selective neural inhibition, stem cell recruitment, and inhibition inflammatory mediators.

2. ESWT for cartilage regeneration in osteoarthritis

There is sufficient theoretical evidence from animal studies to support the effects of ESWT on cartilage and subchondral bone. Various human studies have also revealed that ESWT contributes significantly to pain reduction and functional improvement. Nevertheless, considering the quality of past studies, the evidence regarding ESWT for cartilage regeneration in osteoarthritis is currently insufficient.

3. Application of ESWT in the pain clinic and the management know-how

The National Electrical Contractors Association recommends the use of ESWT for the following musculoskeletal diseases: calcific tendinitis of the shoulder, nonunion and delayed union, plantar fasciitis, Achilles tendinopathy, knee tendinopathy, hip greater trochanteric bursitis, and myofascial pain syndrome. The therapeutic effects of ESWT for non-calcific tendinitis of the shoulder, lateral and medial epicondylitis, De Quervian’s tenosynovitis, Dupuytren’s contracture, trigger finger, osteoarthritis, stress fracture, avascular necrosis, osteo-chondritis dissecans, Osgood Schlatter disease, bone edema, muscle sprain, and medial tibial stress syndrome are controversial. Suggestions based on the presenter’s experience is that the simultaneous use of the focused radial ESWT types can led to better outcomes. The ESWT protocol for each specific condition was presented.

In this session, pain treatment was initiated for an indirect experience from pain treatment.

1. Management of venous pain in patients who frequent pain clinics

Chronic venous insufficiency is one of the main causes of lower extremity pain, which is often neglected by pain physicians in clinical practice. The symptoms of chronic venous insufficiency are leg or ankle swelling, a tight feeling, pain, or itching in the legs, pain when walking, and pain disappearing when resting, brown-colored skin often near the ankles, varicose veins, leg ulcers that are sometimes hard to treat, uncomfortable feelings in the legs and an urge to move legs (restless leg syndrome). Numerous cases of chronic venous insufficiency were presented. The audience was reminded that venous disease should be considered as a possible differential diagnosis when a patient remains unresponsive to treatment applied to the musculoskeletal system.

2. Botulinum toxin use in patients with uncontrolled chronic pain

The presented cases were 1) successful pain control in a patient with complex regional pain syndrome through subcutaneous botulinum toxin injection; 2) successful pain control in a patient with dystonia-induced neck pain through intramuscular injection of neck muscle; and 3) an attempt at control pain with botulinum toxin injection to the stump in a lower limb amputee although positive pain-reducing effects were not observed.

None.

No potential conflict of interest relevant to this article was reported.