1. Sign our petition calling on Cochrane to withdraw their review of Exercise Therapy for CFS here.
    Dismiss Notice
  2. Guest, the 'News in Brief' for the week beginning 18th March 2024 is here.
    Dismiss Notice
  3. Welcome! To read the Core Purpose and Values of our forum, click here.
    Dismiss Notice

Stellate Ganglion Block treatment

Discussion in 'Other treatments' started by Hutan, Mar 2, 2022.

  1. Hutan

    Hutan Moderator Staff Member

    Messages:
    26,547
    Location:
    Aotearoa New Zealand
    It seems like, another season, and another hyped ME/CFS/Long Covid treatment appears. The first day of Autumn in Australia and I've become aware of Stellate Ganglion Block Treatment.

    Bye-Bye Fight or Flight? Hello Better Blood Flows? Stellate Ganglion Blocks, Long COVID, and ME/CFS/FM/POTS
    Cort Johnson wrote an article about it in late December 2021.
    That article suggests that the fight or flight response is on high alert in ME/CFS, FM and POTS.

    The evidence for the technique in ME/CFS/Long Covid appears to be a single paper written by the owner of a company, Neuroversion, that offers the treatment. It consists of case studies, reporting reduced levels of symptoms following treatment in two women with Long Covid who underwent the procedure.

    That paper is discussed on the forum here:
    Stellate ganglion block reduces symptoms of Long COVID: A case series (2021) Liu et al
    It has the usual problems of case studies, notably open label treatment with a very small and selected sample (in this case, 2 people), compounded by the conflict of interest created by the author's ownership of a company selling the treatment.
     
    Last edited: Mar 2, 2022
  2. Wonko

    Wonko Senior Member (Voting Rights)

    Messages:
    6,674
    Location:
    UK
    I find the hypothesis confusing.

    Where, in the body below the 7th spinal vertebra, do they think the fight or flight 'reflex' comes from?

    Coz they must think it's somewhere other than the brain, or blocking its path to the brain would be pointless.
     
  3. shak8

    shak8 Senior Member (Voting Rights)

    Messages:
    2,205
    Location:
    California
    https://paincenterhouston.com/stellate-ganglion-blockade/

    Edit to add: quote from above link:

    "What does the procedure do?
    When you block the stellate ganglion, you are blocking the sympathetic nervous system, thus providing relief in neuropathic pain. In a sense, SGB “reboots” the sympathetic nervous system to its pre-trauma state, similar to a computer reboot.
    It is useful to:
    • Diagnose the cause of pain in the face and head, arms and chest
    • Manage pain in the head, neck, chest or arm caused by nerve injuries.
    • Reduce sweating in the face, head, arms and hands
    • Treat reflex sympathetic dystrophy, sympathetic maintained pain or complex regional pain syndrome, including phantom limb pain
    • Relieve symptoms of PTSD."
    bolding mine.
     
    Last edited: Mar 2, 2022
  4. Hutan

    Hutan Moderator Staff Member

    Messages:
    26,547
    Location:
    Aotearoa New Zealand
    Not only that @Wonko, but briefly blocking the flight or flight reflex's path to the brain just a couple of times seemed to do the trick for the two women in the case study.

    I'm presuming the anaesthetic lasts roughly as long as a dental anaesthetic. So, stopping the 'fight or flight reflex' getting to the brain for the half hour or whatever seems to have this miraculous permanent effect in a way that relaxing in a nice warm bath with a box of chocolates to hand does not.

    It is possible the hand-wavy fight or flight explanation could be wrong but the treatment actually does work in some other way. Cort provides this diagram ( :)) with the suggestion that blood flow to the upper body is increased - although again, if it does occur, it is presumably just a temporary effect.

    Screen Shot 2022-03-02 at 2.34.10 pm.png
     
    Last edited: Mar 2, 2022
    alktipping, Andy and Peter Trewhitt like this.
  5. Wonko

    Wonko Senior Member (Voting Rights)

    Messages:
    6,674
    Location:
    UK
    Even assuming that the brain plays absolutely no part in initiating the fight or flight 'reflex' then surely this 'reflex' isn't entirely composed/contained in the nervous system but also has other components, like hormones.

    I think that the hypothesis and it's proposed mechanism is 'unlikely'.
     
  6. Hutan

    Hutan Moderator Staff Member

    Messages:
    26,547
    Location:
    Aotearoa New Zealand

    That review is
    Effectiveness, Safety, and Predictive Potential in Ultrasound-Guided Stellate Ganglion Blockades for the Treatment of Sympathetically Maintained Pain
    Aleanakian et al 2020


    This was not actually a 'review of studies'. They retrospectively analysed the clinical records of 105 patients who, between them had 809 ultrasound guided SGBs at the authors' institution. The patients had 'complex regional pain syndrome (CRPS) and neuropathic pain syndromes (all potentially including sympathetically maintained pain)'.


    The paper notes that the evidence base for the treatment has been regarded as unsatisfactory:

    The paper's approach to deciding if the treatment is successful is if pain reduction is reported: (umm, controls, blinding, placebo effect, natural healing over time...)
    So, there's the potential for not just the passage of time to impact on the pain the patients report. For goodness sake, they were giving some of the patients opioids and gabapentin, as well as this treatment. That surely is a fatal flaw.


    And so they took the estimate of pain change from the baseline until the pain level reported stopped reducing. So, if the pain was 9 out of 10 to start with, and the pain reduced down to 8 out of 10 and then 7 out of 10 and then went back up to 9 out of 10, they would assume the level of pain had reduced from 9 to 7.

    This is a really rubbish study - there is no point in looking at the results. It certainly does not present evidence that the procedure is useful in treating neuropathic pain.

    And, not a risk-free procedure.
    This is the report on side effects relating to the 809 procedures. Note that 3 were categorised as potentially life-threatening. 'Aspiration of blood' probably wasn't a fun time either.

    Screen Shot 2022-03-02 at 3.20.04 pm.png
     
    Last edited: Mar 2, 2022
    alktipping, Michelle, Lilas and 4 others like this.
  7. Hutan

    Hutan Moderator Staff Member

    Messages:
    26,547
    Location:
    Aotearoa New Zealand
    Sorry to hammer home the point. Cort's reporting on that Aleanakian study was inaccurate in terms of it being evidence of efficacy, as was the impression he gives of the safety profile of the treatment. Cort should have done better when it came to reporting on SGB treatment.
     
    alktipping, Michelle, shak8 and 4 others like this.
  8. Milo

    Milo Senior Member (Voting Rights)

    Messages:
    2,107
    Very honestly, nothing is gained by reading his interpretations of “science”.
     
    Last edited: Mar 2, 2022
  9. Hutan

    Hutan Moderator Staff Member

    Messages:
    26,547
    Location:
    Aotearoa New Zealand
    There seems to be an industry built around providing SGB treatment to people with PTSD. See for example the Stella network of clinics in Australia. It seems that these treatments are covered by private health insurers.

    So, what's the evidence of SGB for PTSD? It's actually pretty minimal, and unconvincing.


    Stellate Ganglion Block for the Treatment of Posttraumatic Stress Disorder: A Randomized, Double-Blind, Controlled Trial
    Hanling et al, 2016
    I can't see the whole study and the abstract does not report sample size or quantify outcomes. It's a military study. It concludes

    Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder SymptomsA Randomized Clinical Trial
    Olmsted et al, 2019
    The study (also a military one) aimed to be blinded, with the SGB treatment and a sham treatment, and it does sound as though they went to quite a bit of effort to ensure the blinding was effective. Even so, I think, and the researchers acknowledge, that some of the participants could probably tell if they actually received the nerve blocker - there are tell-tale symptoms. The sham injection was not in the same place as the real injection.

    The clinicians who did the procedure could not be blinded. Probably they had expertise in the procedure, so perhaps they stood to gain prestige if the procedure was found to be useful. So, it's possible that the clinicians did give some hint of whether the person was receiving the real or sham treatments.

    The primary outcome was PTSD symptoms measured at baseline and at 8 weeks (CAPS-5 scale). Two SGBs (or shams) were administered. 74 people were allocated to the SGB treatment and 39 were allocated to the sham treatment.

    The people receiving the real treatment did show better improvement than the people receiving the sham treatment. There were a few different approaches to analysis (intention to treat, some exclusions), but most of them resulted in the people with the real treatment getting a mean reduction in the PTSD score of around 12 ( on a scale from 0 to 80), whereas the people with the sham treatment had a mean reduction in the PTSD score of around 6. Some of the people knew the intervening physician or received a non-centrally randomised intervention. There were some dropouts (only 31 out of the 39 sham treatment participants were counted).

    I don't find the outcome of the trial convincing as there was quite a bit of overlap in results, the numbers of people in the sham treatment was a bit low and the percentage of sham dropouts was high, the previous RCT was negative, the US defence forces seem to offering the treatment to personnel with PTSD so there are people in the system who want the treatment to be found useful, and the common signs of the nerve block mean that complete blinding was impossible. Also, we still don't have any sensible mechanism to explain why this would work, other than as a high quality placebo. Nevertheless, it was a decent trial and it found some benefit.

    I think it's reasonable for proponents of the treatment for PTSD to conclude that further trials making an even greater effort to manage the blinding and involve researchers with equipoise could be justified. I don't think it's reasonable for this treatment, which is not risk-free, to be offered to people outside of good trials. Particularly, I don't think private companies should be allowed to suggest the treatment is proven useful. Companies like the Stella Group should absolutely not be allowed to say, as they do on their website:
     
    Last edited: Mar 2, 2022
    alktipping, Michelle, Lilas and 5 others like this.
  10. Mij

    Mij Senior Member (Voting Rights)

    Messages:
    8,215
    They have an ongoing clinical study for post-menopausal women.

    Exclusion Criteria:

    conditions that preclude SGB or sham intervention (e.g., anatomic abnormalities of the anterior neck or cervical spine ; goiter, cardiac/pulmonary compromise; contralateral (left-sided) phrenic nerve paralysis or diaphragmatic paresis; history of seizure, coma, or stroke; history of neurologic deficit to the brachial plexus or an abnormal brachial plexus neurologic exam; history of Zenker's diverticulum; acute illness/infection; coagulopathy or bleeding abnormalities; INR >1.3; hemoglobin<9.0, platelets <100,000, BUN ≥ 30mg/dl; creatinine ≥ 2 mg/ml; ALT (SGPT), AST (SGOT), Alk Phos ≥ three times the upper limit of normal; serum potassium (K+) ≤ 3.5 or ≥ 5.0 mEq/L allergic reactions or contraindications to a local anesthetic or contrast dye, systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg, pregnancy.

    https://clinicaltrials.gov/ct2/show/NCT02907983

    The exclusion criteria includes acute illness/infection; coagulopathy or bleeding abnormalities. Wouldn't that be an exclusion criteria for LC?
     
  11. Hutan

    Hutan Moderator Staff Member

    Messages:
    26,547
    Location:
    Aotearoa New Zealand
    Thanks Mij, it does feel as though this is a treatment in search of a disease.
     
    Wonko, boolybooly, Milo and 5 others like this.

Share This Page