Contents part 1: Introduction


Insufficient evidence exists to determine Dynatron STS’ effectiveness in the treatment of chronic pain



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Insufficient evidence exists to determine Dynatron STS’ effectiveness in the treatment of chronic pain.

Rating: 7b


Washington State Department of Labor and Industries. Guidelines for outpatient prescription of oral opioids for injured workers with chronic, noncancer pain. Olympia (WA): Washington State Department of Labor and Industries; 2002 Aug.
Rating: 7a

Washington State Department of Labor and Industries. Antiepileptic drugs guideline for chronic pain. Provider Bull 2005 Aug;(PB 05-10):1-3.


Currently, there is lack of evidence to demonstrate that antiepileptic drugs (AEDs) significantly reduce the level of acute pain, myofascial pain, low back pain, or other sources of somatic pain. Gabapentin, along with older antiepileptic drugs, may be used as a first line therapy in the treatment of chronic neuropathic pain. There is no scientific evidence that antiepileptic drugs are effective in treating acute pain, somatic pain from strains or sprains, or myofascial pain.
Rating: 7a

Washington State Department of Labor and Industries. Complex regional pain syndrome (CRPS). Olympia (WA): Washington State Department of Labor and Industries; 2002 Aug.




  1. The term "complex regional pain syndrome" was introduced to replace the term "reflex sympathetic dystrophy." CRPS Type I used to be called reflex sympathetic dystrophy. CRPS Type II used to be called causalgia. The central difference between Type I and Type II is that, by definition, Type II occurs following a known peripheral nerve injury, whereas Type I occurs in the absence of any known nerve injury.


Table 1. Labor and Industries Criteria Number 13. Chronic Regional Pain Syndrome (CRPS) Conservative Treatment Guideline

Examination Findings And Diagnostic Test Results

Conservative Care

At least four of the following must be present in order for a diagnosis of CRPS to be made.

Examination Findings

  1. Temperature/color change

  2. Edema

  3. Trophic skin, hair, nail growth abnormalities

  4. Impaired motor function

  5. Hyperpathia/allodynia

  6. Sudomotor changes

Diagnostic Test Results

  1. Three phase bone scan that is abnormal in pattern characteristics for CRPS. This test is not needed if 4 or more of the above examination findings are present.

Early aggressive care is encouraged. Emphasis should be on improved functioning of the symptomatic limb.

First Six Weeks Of Care:

  • Sympathetic blocks, maximum of five. Each block should be followed immediately by physical/occupational therapy.

  • Physical/occupational therapy should be focused on increasing functional level (see Table 2).

  • Other treatment (e.g., medication at MD's discretion) as long as it promotes improved function.

After The 1st Six Weeks Of Care:

  • Strongly consider psychiatric or psychological consultation if disability has extended beyond 3 months

  • Continued physical/occupational therapy based on documented progress towards goals established during first 6 weeks (referenced above).

  • Sympathetic blocks only if response to previous blocks has been positive, maximum of 3** every six weeks for a maximum of 12 weeks.

Surgical Interventions (Sympathetectomy) For Treatment Of This Condition Is Not Covered

**A maximum of 11 blocks can be delivered over the total 18 week period

Rating: 7a


Washington State Health Care Authority. Health Technology Clinical Committee Findings and Coverage Decision, Implantable Drug Delivery System. Number and Coverage Topic 20080815A, Approved By Health Technology Clinical Committee 11/14/2008.
Rating: 7a

Wasner G, Schattschneider J, Baron R. Skin temperature side differences--a diagnostic tool for CRPS? Pain. 2002 Jul;98(1-2):19-26.
Skin temperature differences in the distal limbs are capable of reliably distinguishing CRPS I from other extremity pain syndromes with high sensitivity and specificity.
PMID: 12098613

Wasner G. Vasomotor disturbances in complex regional pain syndrome--a review. Pain Med. 2010;11:1267-73.


PMID: 20704675
Rating: 5c

Wasner G, Schattschneider J, Heckmann K, Maier C, Baron R. Vascular abnormalities in reflex sympathetic dystrophy (CRPS I): mechanisms and diagnostic value. Brain. 2001;124:587-99.


PMID: 11222458
Rating: 4b

Watkins PB, Kaplowitz N, Slattery JT, Colonese CR, Colucci SV, Stewart PW, Harris SC. Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial. JAMA. 2006 Jul 5;296(1):87-93.


Should add caution about daily dose of acetaminophen and liver disease if > 4 g/day or in combination with other NSAID.
PMID: 16820551
Rating: 2b

Weiss RD, Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, Gardin J, Griffin ML, Gourevitch MN, Haller DL, Hasson AL, Huang Z, Jacobs P, Kosinski AS, Lindblad R, McCance-Katz EF, Provost SE, Selzer J, Somoza EC, Sonne SC, Ling W. Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial. Arch Gen Psychiatry. 2011 Nov 7. [Epub ahead of print]


Prescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment.
PMID: 22065255
Rating: 2a

Wenham CY, Conaghan PG. Optimising pain control in osteoarthritis. Practitioner. 2010;254:23-6, 2-3.


Paracetamol and topical NSAIDs should be tried before oral NSAIDs. Topical NSAIDs are effective in the short-term and are not associated with systemic toxicity. Oral NSAIDs should be used at the lowest effective dose for the shortest possible time.
PMID: 21306035
Rating: 5a

Wermeling DP. Ziconotide, an intrathecally administered N-type calcium channel antagonist for the treatment of chronic pain. Pharmacotherapy. 2005 Aug;25(8):1084-94.


Therefore, patients with psychiatric symptoms are not candidates for this drug.
PMID: 16207099
Rating: 5a

Weschules DJ, Bain KT, Richeimer S. Actual and potential drug interactions associated with methadone. Pain Med. 2008;9:315-44.


Genetic variability may play a role in the pharmacokinetics and pharmacodynamics of many medications, including methadone.
PMID: 18386306
Rating: 1a

White JA, Tao X, Artuso RD, Bilinski C, Rademacher J, Bernacki EJ. Effect of physician-dispensed medication on workers' compensation claim outcomes in the state of Illinois. J Occup Environ Med. 2014 May;56(5):459-64. doi: 10.1097/JOM.0000000000000145.


OBJECTIVE: To evaluate differences between physician-dispensed and non-physician-dispensed medication with regard to lost time, prescription volume, and pharmaceutical, medical, indemnity costs in the Illinois workers' compensation system.
METHODS: They studied a sample of 6824 workers' compensation indemnity claims that were opened and closed between January 1, 2007, and December 31, 2012, by Accident Fund Holdings in the State of Illinois.
RESULTS: The number of prescriptions per claim and pharmaceutical, medical, and indemnity costs, as well as time out from work, were significantly higher in claims where a pharmaceutical was dispensed by the physician within 90 days of injury than in claims where physician dispensing did not occur. These differences persisted controlling for age, sex, attorney involvement, and injury complexity.
CONCLUSION: Physician dispensing is associated with higher costs and more lost time than pharmacy-dispensed medications in workers' compensation claims.

PMID: 24806556


Rating: 4a

Wiffen P, Collins S, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001133.


Although anticonvulsants are used widely in chronic pain surprisingly few trials show analgesic effectiveness. Only one study considered cancer pain. There is no evidence that anticonvulsants are effective for acute pain. In chronic pain syndromes other than trigeminal neuralgia, anticonvulsants should be withheld until other interventions have been tried. While gabapentin is increasingly being used for neuropathic pain the evidence would suggest that it is not superior to carbamazepine.
PMID: 16034857
Rating: 1a
Conclusion: Currently, there is lack of evidence to demonstrate that AEDs significantly reduce the level of acute pain, myofascial pain, low back pain, or other sources of somatic pain.(2)

(2) Cochrane Review. Anticonvulsant drugs for acute and chronic pain. The Cochrane Database of Systematic Reviews, 2005; 1.

Wiffen PJ, McQuay HJ, Edwards JE, Moore RA. Gabapentin for acute and chronic pain. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005452.
There is evidence to show that gabapentin is effective in neuropathic pain. There is limited evidence to show that gabapentin is ineffective in acute pain.
PMID: 16034978
Rating: 1a

Wiffen PJ, Rees J. Lamotrigine for acute and chronic pain. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD006044.


Given the availability of more effective treatments including anticonvulsants and antidepressant medicines, lamotrigine does not have a significant place in therapy at present. The limited evidence currently available suggests that lamotrigine is unlikely to be of benefit for the treatment of neuropathic pain.
PMID: 17443611
Rating: 1b
Wiffen PJ, Derry S, Moore RA, Aldington D, Cole P, Rice ASC, Lunn MPT, Hamunen K, Haanpaa M, Kalso EA. Antiepileptic drugs for neuropathic pain and fibromyalgia – an overview of Cochrane reviews (Review). Cochrane Database Syst Rev. 2013 Nov 11;(11):CD010567.

PMID: 24217986


Rating: 1a

Wild JE, Grond S, Kuperwasser B, Gilbert J, McCann B, Lange B, Steup A, Häufel T, Etropolski MS, Rauschkolb C, Lange R. Long-term Safety and Tolerability of Tapentadol Extended Release for the Management of Chronic Low Back Pain or Osteoarthritis Pain. Pain Pract. 2010 Jun 29. [Epub ahead of print]


Results: A total of 1,117 patients received at least 1 dose of study drug. Gastrointestinal treatment-emergent adverse events led to discontinuation in 8.6% versus 21.5% of patients.
PMID: 20602712
Rating: 2b
Note: Tapentadol ER is not yet approved by the FDA.

Wilhelmsen M, Amirian I, Reiter RJ, Rosenberg J, Gögenur I. Analgesic effects of melatonin: a review of current evidence from experimental and clinical studies. J Pineal Res. 2011 Oct;51(3):270-7. doi: 10.1111/j.1600-079X.2011.00895.x.


In clinical studies, melatonin has been shown to have analgesic benefits in patients with chronic pain.
PMID: 21615490
Rating: 5b

Wilsey B, Marcotte T, Tsodikov A, Millman J, Bentley H, Gouaux B, Fishman S. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. J Pain. 2008 Jun;9(6):506-21. Epub 2008 Apr 10.


This study adds to a growing body of evidence that cannabis may be effective at ameliorating neuropathic pain, and may be an alternative for patients who do not respond to, or cannot tolerate, other drugs. However, the use of marijuana as medicine may be limited by its method of administration (smoking) and modest acute cognitive effects, particularly at higher doses.
PMID: 18403272
Rating: 2c

Winkelmuller M, Winkelmuller W. Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology. J Neurosurg. 1996 Sep;85(3):458-67.


Ninety-two percent of the patients were satisfied with the therapy and 81% reported an improvement in their quality of life.
PMID: 8751633
Rating: 3b
Witt CM, Schützler L, Lüdtke R, Wegscheider K, Willich SN. Patient Characteristics and Variation in Treatment Outcomes: Which Patients Benefit Most From Acupuncture for Chronic Pain? Clin J Pain. 2011 Feb 11. [Epub ahead of print]
Patients' characteristics that enlarged the acupuncture effect were being female, living in a multi-person household, failure of other therapies before the study, and former positive acupuncture experience.
PMID: 21317771
Rating: 1b

Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990;33:160---72.


American College of Rheumatology, 1990 criteria for the classification of Fibromyalgia

1. History of widespread pain.

2. Pain in 11 of 18 tender point sites on digital palpation.

Digital palpation should be performed with an approximate force of 4 kg.

For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender is not to be considered "painful."

* For classification purposes, patients will be said to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present for at least 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia.


Rating: 6b

Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May;62(5):600-10.


RESULTS: The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, unrefreshed sleep, fatigue, and number of somatic symptoms.
PMID: 20461783
Rating: 4b

Wolfe GI, Trivedi JR. Painful peripheral neuropathy and its nonsurgical treatment. Muscle Nerve. 2004;30:3-19.


Antidepressants and anticonvulsants are the two pharmacological classes most widely studied and represent first-line agents in the management of neuropathic pain.
PMID: 15221874
Rating: 5b

Wong MC, Chung JW, Wong TK. Effects of treatments for symptoms of painful diabetic neuropathy: systematic review. BMJ. 2007;335:87. Epub 2007 Jun 11.


Oral tricyclic antidepressants and traditional anticonvulsants are better for short-term pain relief than newer generation anticonvulsants. Evidence of the long-term effects of oral antidepressants and anticonvulsants is still lacking.
PMID: 17562735
Rating: 1b

Wright TM, Cluver JS, Myrick H. Management of intoxication and withdrawal: General principles. In Reis RK, Fiellin DA, Miller SC, Saitz R. eds. Principles of Addiction Medicine, 4th edition. Lippincott Williams & Wilkins, 2009.


An overview of the natural history and variations found with withdrawal from substances known for abuse. It is noted that all therapies should be tailored to the patient’s needs and adjusted to response to treatment.
Rating: 9a

Wüppenhorst N, Maier C, Frettlöh J, Pennekamp W, Nicolas V. Sensitivity and specificity of 3-phase bone scintigraphy in the diagnosis of complex regional pain syndrome of the upper extremity. Clin J Pain. 2010;26:182-9.


PMID: 20173431
Rating: 4b

Wynn BO. Use of Compound Drugs, Medical Foods, and Co-Packs in California’s Workers’ Compensation Program, An Overview of the Issues. WR-828-CHSWC. RAND Institute for Civil Justice. Prepared for the Commission on Health, Safety and Workers’ Compensation. January 2011.


The purpose of this paper is to explore the issues surrounding the use of compound drugs, co-packs and medical foods under the California workers’ compensation (WC) program and to assess whether policy changes are needed to promote medically appropriate and efficient use of these products.
Rating: 5a

Yentur EA, Okcu G, Yegul I. The role of trigger point therapy in knee osteoarthritis. Pain Clinic 2003;15:385-90.


Physical activity results improved significantly for the combined group vs. the group with the intra-articular injection (improvement in squatting and walking only).
Rating: 2c

Yokoyama M, Sun X, Oku S, Taga N, Sato K, Mizobuchi S, Takahashi T, Morita K. Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain. Anesth Analg. 2004 Jun;98(6):1552-6, table of contents.


Results indicate that although PENS is effective for chronic LBP, treatments need to be continued to sustain analgesia.
PMID: 15155304
Rating: 2b
Note: Not a “curative” treatment.

Yoshida GM, Nelson RW, Capen DA, Nagelberg S, Thomas JC, Rimoldi RL, Haye W. Evaluation of continuous intraspinal narcotic analgesia for chronic pain from benign causes. Am J Orthop. 1996 Oct;25(10):693-4.


Overall, only 4 patients had objective evidence of benefit from INA, for a success rate of 25%. Results of this review suggest INA should not be used for the long-term management of chronic pain from nonmalignant causes.
PMID: 8922167
Rating: 4b

Yousefi-Nooraie R, Schonstein E, Heidari K, Rashidian A, Akbari-Kamrani M, Irani S, Shakiba B, Mortaz Hejri S, Mortaz Hejri S, Jonaidi A. Low level laser therapy for nonspecific low-back pain. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005107.


There is a need for further methodologically rigorous RCTs to evaluate the effects of LLLT compared to other treatments, different lengths of treatment, different wavelengths and different dosages.
PMID: 17443572
Rating: 1b
Yung Chung O, Bruehl SP. Complex Regional Pain Syndrome. Curr Treat Options Neurol. 2003 Nov;5(6):499-511.
Sympathetic nerve blocks should be performed at least once to assess if sympathetically maintained pain is present. Pain relief, however it is achieved and however temporary it is, is intended to facilitate participation in functional therapies to normalize use and to improve motion, strength, and dexterity.
PMID: 14516527
Rating: 5a

Zambito A, Bianchini D, Gatti D, Viapiana O, Rossini M, Adami S. Interferential and horizontal therapies in chronic low back pain: a randomized, double blind, clinical study. Clin Exp Rheumatol. 2006 Sep-Oct;24(5):534-9.


This randomized double-blind controlled study provides the first evidence that IFT and HT therapy are significantly effective in alleviating both pain and disability in patients with CLBP. The placebo effect is remarkable at the beginning of the treatment but it tends to vanish within a couple of weeks.
PMID: 17181922
Rating: 2b

Zambito A, Bianchini D, Gatti D, Rossini M, Adami S, Viapiana O. Interferential and horizontal therapies in chronic low back pain due to multiple vertebral fractures: a randomized, double blind, clinical study. Osteoporos Int. 2007 Nov;18(11):1541-5. Epub 2007 Jul 4.


This randomized double-blind controlled study provides the first evidence that IFT and HT therapy are significantly effective in alleviating both pain and disability in patients with CBPMF.
PMID: 17609842
Rating: 2b

Zammit G, Erman M, Wang-Weigand S, Sainati S, Zhang J, Roth T. Evaluation of the efficacy and safety of ramelteon in subjects with chronic insomnia. J Clin Sleep Med. 2007;3:495-504.


Ramelteon reduced LPS over 5 weeks of treatment in subjects with chronic insomnia, with no clinically meaningful sleep architecture alterations, next-morning residual pharmacologic effects, and no evidence of rebound insomnia or withdrawal.
Rating: 2c

Zaremba PD, Białek M, Błaszczyk B, Cioczek P, Czuczwar SJ. Non-epilepsy uses of antiepilepsy drugs. Pharmacol Rep. 2006;58:1-12.


Both conventional and newer AEDs may be used in patients suffering from neuropathic pain, migraine, essential tremor, spasticity, restless legs syndrome and a number of psychiatric disorders (f.e. bipolar disease or schizophrenia).
PMID: 16531624
Review: 5b

Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-62.


PMID: 18279766
Rating: 6a

Zhang W, Doherty M, Leeb BF, Alekseeva L, Arden NK, Bijlsma JW, Dinçer F, Dziedzic K, Häuselmann HJ, Herrero-Beaumont G, Kaklamanis P, Lohmander S, Maheu E, Martín-Mola E, Pavelka K, Punzi L, Reiter S, Sautner J, Smolen J, Verbruggen G, Zimmermann-Górska I. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66:377-88.


CONCLUSION: Eleven key recommendations for treatment of hand OA were developed.
PMID: 17046965
Rating: 6a
The recommendation made was that local treatments were preferred over systemic treatments, especially for mild to moderate pain and when only a few joints were affected. Topical NSAIDs and capsaicin were considered effective and safe treatments for hand OA.

Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010;18:476-99.


Among pharmacological therapies, the cumulative evidence for the benefits and harms of oral and topical non-steroidal anti-inflammatory drugs, diacerhein and intra-articular (IA) corticosteroid was not greatly changed.
PMID: 20170770
Rating: 6a

Zhang CS, Yang AW, Zhang AL, May BH, Xue CC. Sham control methods used in ear-acupuncture/ear-acupressure randomized controlled trials: a systematic review. J Altern Complement Med. 2014 Mar;20(3):147-61. doi: 10.1089/acm.2013.0238.


PMID: 24138333
Rating: 1c

Zuniga JR, Noveck RJ, Schmidt WK, Boesing SE, Hersh EV. Onset of action of diclofenac potassium liquid-filled capsules in dental surgery patients. Curr Med Res Opin. 2011 Sep;27(9):1733-9.


These results indicate that DPSGC was efficacious in providing a rapid onset of confirmed perceptible pain relief within 30 minutes of administration in these single dose postoperative dental pain studies.
PMID: 21770716
Rating: 2b

Zwanzger P, Diemer J, Jabs B. Comparison of combined psycho- and pharmacotherapy with monotherapy in anxiety disorders: controversial viewpoints and clinical perspectives. J Neural Transm. 2008 Sep 23. [Epub ahead of print]


Anxiety disorders are among the most frequent psychiatric disorders. Experimental evidence supports both psychotherapy as well as pharmacotherapy as effective treatments. We present the results from two recent meta-analyses and discuss implications for clinical practice and further research. We suggest that a research strategy that strives to establish differential indications based on patient characteristics should be preferred over attempts to reach a global judgement of the question, which appears too simplistic given the complexity of the issue.
PMID: 18810307
Rating: 5a

Zyluk A, Puchalski P. Complex regional pain syndrome: observations on diagnosis, treatment and definition of a new subgroup. J Hand Surg Eur. Vol. 2013; 38:599-606.


PMID: 23221182
Rating: 5c


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