Verghese, Susan T; Hannallah, Raafat S
The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain is constantly being refined; with newer drugs being used alone or in combination with other drugs continues to be explored. Several advances in developmental neurobiology and pharmacology, knowledge of new analgesics and newer applications of old analgesics in the last two decades have helped the pediatric anesthesiologist in managing pain in children more efficiently. The latter include administering opioids via the skin and nasal mucosa and their addition into the neuraxial local anesthetics. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The development of receptor specific drugs that can produce pain relief without the untoward side effects of respiratory depression will hasten the recovery and discharge of children after surgery. This review focuses on the overview of acute pain management in children, with an emphasis on pharmacological and regional anesthesia in achieving this goal. PMID:21197314
Verghese, Susan T; Hannallah, Raafat S
The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain is constantly being refined; with newer drugs being used alone or in combination with other drugs continues to be explored. Several advances in developmental neurobiology and pharmacology, knowledge of new analgesics and newer applications of old analgesics in the last two decades have helped the pediatric anesthesiologist in managing pain in children more efficiently. The latter include administering opioids via the skin and nasal mucosa and their addition into the neuraxial local anesthetics. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The development of receptor specific drugs that can produce pain relief without the untoward side effects of respiratory depression will hasten the recovery and discharge of children after surgery. This review focuses on the overview of acute pain management in children, with an emphasis on pharmacological and regional anesthesia in achieving this goal.
Becker, Daniel E.
Abstract Safe and effective management of acute dental pain can be accomplished with nonopioid and opioid analgesics. To formulate regimens properly, it is essential to appreciate basic pharmacological principles and appropriate dosage strategies for each of the available analgesic classes. This article will review the basic pharmacology of analgesic drug classes, including their relative efficacy for dental pain, and will suggest appropriate regimens based on pain intensity. Management of chronic pain will be addressed in the second part of this series. PMID:20553137
Schwenk, Eric S; Baratta, Jaime L; Gandhi, Kishor; Viscusi, Eugene R
Successful implementation of an acute pain management service involves a team approach in which team members have clearly defined roles. Clinical protocols are designed to help address common problems and prevent errors. As the complexity of surgery and patients' diseases continues to increase, current knowledge of new analgesic medications, acute pain literature, and skills in regional anesthesia techniques is imperative. Emphasizing a multimodal approach can improve analgesia and decrease opioid-related side effects.
Jungquist, Carla R; Vallerand, April Hazard; Sicoutris, Corinna; Kwon, Kyung N; Polomano, Rosemary C
: Acute pain, which is usually sudden in onset and time limited, serves a biological protective function, warning the body of impending danger. However, while acute pain often resolves over time with normal healing, unrelieved acute pain can disrupt activities of daily living and transition to chronic pain. This article describes the effects of unrelieved acute pain on patients and clinical outcomes. The authors call on nurses to assess and manage acute pain in accordance with evidence-based guidelines, expert consensus reports, and position statements from professional nursing organizations in order to minimize the likelihood of its becoming chronic.
Huynh, Mai-Phuong; Yagiela, John A
Analgesics most commonly prescribed in dentistry for acute pain relief include the nonsteroidal anti-inflammatory drug, acetaminophen, and various opioid-containing analgesic combinations. The NSAIDs and presumably acetaminophen act by inhibiting cyclooxgenase enzymes responsible for the formation of prostaglandins that promote pain and inflammation. Opioids such as codeine, hydrocodone, and oxycodone stimulate endogenous opioid receptors to bring about analgesic and other effects. Numerous clinical studies have confirmed that moderate to severe pain of dental origin is best managed through the use of ibuprofen or another NSAID whose maximum analgesic effect is at least equal to that of standard doses of acetaminophen-opioid combinations. If an NSAID cannot be prescribed because of patient intolerance, analgesic preparations that combine effective doses of an orally active opioid with 600 to 1,000 mg of acetaminophen are preferred in the healthy adult. On occasion, prescribing both an NSAID and an acetaminophen-opioid combination may be helpful in patients not responding to a single product. In all cases, however, the primary analgesic should be taken on a fixed schedule, not on a "prn" (or as needed) basis, which only guarantees the patient will experience pain.
Walker, David M. C.
Since cardiovascular and pulmonary disorders have significant morbidity and mortality, triage of patients who complain of chest pain is paramount. The less sophisticated the triage system, the more important the protocol should be to have these patients evaluated immediately. History and physical are still the most important diagnostic tools; information should be gathered from all available sources. Advanced cardiac life support training is most useful. Eight diagnostic classifications are described, together with the distinctions of onset, duration, location, radiation, precipitating and relieving factors, character and associated symptoms. The protocol for initial management is outlined, emphasizing coincident management wherever possible. Imagesp2005-a PMID:21286539
Hsu, Eric S
Fibromyalgia (FM) is a mysterious pain syndrome with progressive and widespread pain, explicit areas of tender points, stiffness, sleep disturbance, fatigue, and psychological distress without any obvious disease. FM is commonly perceived as a condition of central pain and sensory augmentation. There are documented functional abnormalities in pain and sensory processing in FM. Central sensitization and lack of descending analgesic activity are the 2 leading mechanisms that have been demonstrated by advance in both basic and clinical research. The pathogenesis of FM may also be attributed to the genetic polymorphisms involving serotoninergic, dopaminergic, and catecholaminergic systems. Any psychiatric disorders and psychosocial influences in FM may also affect the severity of pain. The various external stimuli or trigger such as infection, trauma, and stress may all contribute to proceed to presentation of FM. The recent launches of 3 US Food and Drug Administration-approved pharmacotherapy for FM namely pregabalin, duloxetine, and milnacipran have certainly raised the profile of optimal chronic pain management. However, appropriate evaluation and efficacious management of acute pain has not been as well publicized as chronic pain in FM. Acute pain or flare up caused by any trauma or surgery certainly may present a real challenge for patients with FM and their health care providers. Pre-emptive analgesia and pro-active treatment may offer the momentum for acute pain control based on model of central sensitization and pain in FM. This review article on FM appraises the modern practice of multimodal therapy focus on both acute and chronic pain management. Meanwhile, the evolving nonpharmacological approach is summarized and stressed as an essential component of integrated care in FM.
Masudi, Tahir; Capitelli-McMahon, Helen; Anwar, Suhail
AIM To review the evidence for the use of different non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of biliary colic. METHODS The strategies employed included an extensive literature review for articles and studies related to biliary colic from electronic databases including PubMed, Science Direct, Wiley Inter Science, Medline and Cochrane from last 15 years. Keywords: “Biliary colic”, “management of biliary colic”, “non-steroidal anti-inflammatory drugs”, “cholelithiasis” and “biliary colic management”. Six randomized control trials, 1 non-randomized trial and 1 meta-analysis were included in this review. The outcomes of these studies and their significance have been reviewed in this paper. RESULTS Current evidence suggests there are no set protocols for biliary colic pain management. NSAIDs are potent in the management of biliary colic, not only in terms of symptom control but in disease progression as well. Apart from the studies on diclofenac and ketorolac, there are studies which have shown that intravenous tenoxicam and injectable flurbiprofen are equally effective in managing biliary colic. The efficacy of NSAIDs is superior in terms of lower number of doses and longer duration of action in comparison to other analgesic agents. CONCLUSION This literature review has found that NSAIDs are safe and effective for pain control in biliary colic, and reduce the likelihood of further complications. PMID:27830044
Argoff, Charles E
Oral analgesics are commonly prescribed for the treatment of acute and chronic pain, but these agents often produce adverse systemic effects, which sometimes are severe. Topical analgesics offer the potential to provide the same analgesic relief provided by oral analgesics but with minimal adverse systemic effects. This article describes the results of a systematic review of the efficacy of topical analgesics in the management of acute and chronic pain conditions. A literature search of MEDLINE/PubMed was conducted using the keywords topical analgesic AND chronic pain OR acute pain OR neuropathic pain and focused only on individual clinical trials published in English-language journals. The search identified 92 articles, of which 65 were eligible for inclusion in the review. The most commonly studied topical analgesics were nonsteroidal anti-inflammatory drugs (n=27), followed by lidocaine (n=9), capsaicin (n=6), amitriptyline (n=5), glyceryl trinitrate (n=3), opioids (n=2), menthol (n=2), pimecrolimus (n=2), and phenytoin (n=2). The most common indications were acute soft tissue injuries (n=18), followed by neuropathic pain (n=17), experimental pain (n=6), osteoarthritis and other chronic joint-related conditions (n=5), skin or leg ulcers (n=5), and chronic knee pain (n=2). Strong evidence was identified for the use of topical diclofenac and topical ibuprofen in the treatment of acute soft tissue injuries or chronic joint-related conditions, such as osteoarthritis. Evidence also supports the use of topical lidocaine in the treatment of postherpetic neuralgia and diabetic neuropathy. Currently, limited evidence is available to support the use of other topical analgesics in acute and chronic pain.
Grillo, Cássia Maria; Wada, Ronaldo Seichi; da Luz Rosário de Sousa, Maria
Acute dental pain is the main reason for seeking dental services to provide urgent dental care; there is consensus about the use of alternative therapies, such as acupuncture, to control dental pain in pre-dental care. This study aimed to evaluate the use of acupuncture in reducing the intensity of acute dental pain in pre-dental care in patients waiting for emergency dental care, and was conducted at the After-Hours Emergency Dental Clinic of Piracicaba Dental School, and at the Emergency Center Dental Specialties I in Piracicaba, São Paulo, Brazil. The sample consisted of 120 patients. The Visual Analog Scale (VAS) was used to measure pain intensity. All patients underwent one session of acupuncture; the points LI4, ST44 and CV23 were selected and were used alone or in combinations. Reduction in pain was observed in 120 patients (mean initial VAS=6.558±1.886, p<0; mean final VAS=0.962±2.163, p<0.00001). The results of this study indicate that acupuncture analgesia could be a technical adjunct to pain control in patients with acute dental pain, contributing to the restoration of health with social benefit.
Unrelieved pain due to this nociception , after surgery or trauma is often unhealthy, but it is preventable or controllable in a majority of cases...DC 20503. 1. AGENCY USE ONLY (Leaveblank) 2. REPORT DATE 26-Sep-97 3. REPORT TYPE AND DATES COVERED 4. TITLE AND SUBTITLE ACUTE PAIN MANAGEMENT...Prescribed by ANSI Std. 239.18 Designed using Perform Pro, WHS/DIOR. Oct 94 ACUTE PAIN MANAGEMENT SERVICES: WHAT DOES THE AIR FORCE HAVE TO OFFER
Nolli, M; Nicosia, F
The Health Services, not only the Italian one, is under pressure because of request for improving treatment quality and the financial need for reorganization and cost-saving. It's required a rationalization of intervention, together with a careful choice of the best and cheapest techniques and the demonstration of their efficacy. The anaesthesia service activity, in a period of cost rationalization and funds restriction should be aimed to appropriate outcome measures corrected by both patient's risk factors and surgical-anaesthesiological case-mix. The development of a complete strategy for surgical pain management might run into two phases. The first phase, internal and mono-specialistic, should develop like the creation of an Acute Pain Team. The main processes are: focusing the problem (charge of the care), training, information, teaching methodology (timing, methods, drugs, techniques, etc.) and the audit (before and after changes). The main aims are the evaluation of the level of analgesia and pain relief or patient's satisfaction which are partial endpoints useful to demonstrate the improvement and the efficacy of the new pain management strategies. The second phase, multidisciplinary, is directed toward the creation of a Postoperative Evaluation Team. The main objective is to set up a collaborative clinical group able to identify the criteria for quality, efficacy and safety. The major purpose is the evaluation of major outcome measures: surgical outcome, morbidity, mortality and length of hospitalization. The improvement in the quality of postoperative pain treatment goes through a better organization and a progressive increase of the already available therapy. The achievement of the result and the quality projects depend on the interaction among staff members with different behaviours and settings. Internal teaching and training, continuous education for doctors and nurses, and external information, marketing and improvement of attractive capability of
Solhi, Hassan; Sanaei-Zadeh, Hossein; Solhi, Sadra; Azizi Nadian, Mohammad Ali; Gharibi, Morteza; Sadeghi Sedeh, Bahman
The present study aimed to evaluate the effectiveness of morphine and meperidine (pethidine) as pain relief in opioid-dependent patients with acute pain. A total of 122 opioid-dependent patients with acute pain were included in the study. Their pain severity was assessed, using visual analog scale (VAS) scores ranging from 0 to 10. The patients randomly received intravenous morphine (up to 0.15 mg/kg) or meperidine (up to 1.5 mg/kg) for pain control by patient control analgesia (PCA) pump. The clinical opioid withdrawal scale (COWS) was employed for the assessment of withdrawal symptoms. The pain relief and the emergence of withdrawal symptoms were measured at 15, 30, and 60 minutes after drug administration. The patients who received morphine reported a better pain control compared to those who received meperidine (mean ± standard deviation [SD] VAS scores 4.11±1.90 vs 5.85±2.08 at the end of the study; P<0.001). On the other hand, the patients who received meperidine indicated prominent withdrawal symptoms (mean ± SD COWS scores 4.80±2.18 vs. 1.98±0.82 at the end of the study; P<0.001). Our findings revealed that morphine can be recommended in acute pain management of opioid-dependent patients. In addition, emergency physicians should ask their patients about any drug dependence before selecting the appropriate drug for their acute pain management. PMID:27621675
Budiansky, Adele Sandra; Margarson, Michael P; Eipe, Naveen
Increasing numbers of patients with morbid obesity are presenting for surgery and their acute pain management requires an evidence-based clinical update. The objective of this study was to complete a literature review for acute pain management in morbid obesity and provide an evidence-based clinical update with recommendations. Using standardized search terms, in March 2015, we completed a literature search to determine evidence for different acute pain pharmacological modalities in morbid obesity. For each modality the highest level of evidence was ascertained and recommendations for each pharmacological modality are presented. Though overall evidence is limited to few well conducted clinical trials, mostly related to weight loss surgery, multimodal analgesia with step-wise, severity-based, opioid-sparing approach appears to improve acute pain management in morbid obesity. The perioperative use of non-opioid adjuvants appears to offer further improvements in patient safety and outcomes. Further research into standardization of pain assessments and implementation of acute pain management protocols is required.
Montgomery, Kayla; Hall, A Brad; Keriazes, Georgia
The timely administration of analgesics is crucial to the comprehensive management of trauma patients. When an emergency department (ED) pharmacist participates in trauma resuscitation, the pharmacist acts as a medication resource for trauma team members and facilitates the timely administration of analgesics. This study measured the impact of a pharmacist on time to first analgesic dose administered during trauma resuscitation. All adult (>18 years) patients who presented to this level II trauma center via activation of the trauma response system between January 1, 2009, and May 31, 2013, were screened for eligibility. For inclusion, patients must have received intravenous fentanyl, morphine, or hydromorphone in the trauma bay. The time to medication administration was defined as the elapsed time from ED arrival to administration of first analgesic. There were 1328 trauma response system activations during the study period; of which 340 patients were included. The most common analgesic administered was fentanyl (62% in both groups). When a pharmacist was participating, the mean time to first analgesic administered was decreased (17 vs 21 minutes; P = .03). Among the 78% of patients with documented pain scores, the overall mean reduction in pain scores from ED arrival to ED discharge was similar between the 2 groups. There was a 2.4 point reduction with a pharmacist versus 2.7 without a pharmacist, using a 0 to 10 numeric pain rating scale. The participation of a clinical pharmacist during trauma resuscitation significantly decreased the time to first analgesic administration in trauma patients. The results of this study supplement the literature supporting the integration of clinical ED pharmacists on trauma teams.
Backache; Low back pain; Lumbar pain; Pain - back; Acute back pain; Back pain - new; Back pain - short-term; Back strain - new ... lower back supports most of your body's weight. Low back pain is the number two reason that Americans see ...
Rayos, C L; McDonough, J P
The purpose of this descriptive study was to assess the prevalence of acute pain management services (APMS) in Air Force medical facilities. There are no published reports on the current status of Air Force pain programs. This study used a telephone survey to all facilities worldwide that house an anesthesia department. Anesthesia providers in charge of pain services or department chiefs were interviewed from December 1996 to May 1997. Respondents were asked questions related to the initiation of a formal APMS, components, and familiarity with the Agency for Health Care Policy and Research guidelines on pain management. Data analysis described current practices and used chi 2 analysis to compare results with a national study of U.S. hospitals. Air Force anesthesia departments (45%) had established as many acute pain services as U.S. hospitals (42%). Formal pain programs are becoming more prevalent in Air Force hospitals. These findings suggest an increased awareness of the need for pain management and future establishment of pain programs.
Adams, Rose; White, Barb; Beckett, Cynthia
Background Pain management remains a critical issue for hospitals and is receiving the attention of hospital accreditation organizations. The acute care setting of the hospital provides an excellent opportunity for the integration of massage therapy for pain management into the team-centered approach of patient care. Purpose and Setting This preliminary study evaluated the effect of the use of massage therapy on inpatient pain levels in the acute care setting. The study was conducted at Flagstaff Medical Center in Flagstaff, Arizona—a nonprofit community hospital serving a large rural area of northern Arizona. Method A convenience sample was used to identify research participants. Pain levels before and after massage therapy were recorded using a 0 – 10 visual analog scale. Quantitative and qualitative methods were used for analysis of this descriptive study. Participants Hospital inpatients (n = 53) from medical, surgical, and obstetrics units participated in the current research by each receiving one or more massage therapy sessions averaging 30 minutes each. The number of sessions received depended on the length of the hospital stay. Result Before massage, the mean pain level recorded by the patients was 5.18 [standard deviation (SD): 2.01]. After massage, the mean pain level was 2.33 (SD: 2.10). The observed reduction in pain was statistically significant: paired samples t52 = 12.43, r = .67, d = 1.38, p < .001. Qualitative data illustrated improvement in all areas, with the most significant areas of impact reported being overall pain level, emotional well-being, relaxation, and ability to sleep. Conclusions This study shows that integration of massage therapy into the acute care setting creates overall positive results in the patient’s ability to deal with the challenging physical and psychological aspects of their health condition. The study demonstrated not only significant reduction in pain levels, but also the interrelatedness of pain, relaxation
Murphy, Adrian; McCoy, Siobhan; O'Reilly, Kay; Fogarty, Eoin; Dietz, Jason; Crispino, Gloria; Wakai, Abel; O'Sullivan, Ronan
Pain is the most common symptom in the emergency setting and remains one of the most challenging problems for emergency care providers, particularly in the pediatric population. The primary objective of this study was to determine the prevalence of acute pain in children attending emergency departments (EDs) in Ireland by ambulance. In addition, this study sought to describe the prehospital and initial ED management of pain in this population, with specific reference to etiology of pain, frequency of pain assessment, pain severity, and pharmacological analgesic interventions. A prospective cross-sectional study was undertaken over a 12-month period of all pediatric patients transported by emergency ambulance to four tertiary referral hospitals in Ireland. All children (<16 years) who had pain as a symptom (regardless of cause) at any stage during the prehospital phase of care were included in this study. Over the study period, 6,371 children attended the four EDs by emergency ambulance, of which 2,635 (41.4%, 95% confidence interval 40.2-42.3%) had pain as a documented symptom on the ambulance patient care report (PCR) form. Overall 32% (n = 856) of children who complained of pain were subject to a formal pain assessment during the prehospital phase of care. Younger age, short transfer time to the ED, and emergency calls between midnight and 6 am were independently associated with decreased likelihood of having a documented assessment of pain intensity during the prehospital phase of care. Of the 2,635 children who had documented pain on the ambulance PCR, 26% (n = 689) received some form of analgesic agent prior to ED arrival. Upon ED arrival 54% (n = 1,422) of children had a documented pain assessment and some form of analgesic agent was administered to 50% (n = 1,324). Approximately 41% of children who attend EDs in Ireland by ambulance have pain documented as their primary symptom. This study suggests that the management of acute pain in children transferred by
Atlas, Steven J; Deyo, Richard A
Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations. PMID:11251764
Abdominal pain is among the most frequent ailments reported in the office setting and can account for up to 40% of ailments in the ambulatory practice. Also, it is in the top three symptoms of patients presenting to emergency departments (ED) and accounts for 5-10% of all ED primary presenting ailments. There are several common sources for acute abdominal pain and many for subacute and chronic abdominal pain. This article explores the history-taking, initial evaluation, and examination of the patient presenting with acute abdominal pain. The goal of this article is to help differentiate one source of pain from another. Discussion of acute cholecystitis, pancreatitis, appendicitis, ectopic pregnancy, diverticulitis, gastritis, and gastroenteritis are undertaken. Additionally, there is discussion of common laboratory studies, diagnostic studies, and treatment of the patient with the above entities.
Saroyan, John M; Schechter, William S; Tresgallo, Mary E; Sun, Lena; Naqvi, Zoon; Graham, Mark J
This pilot study was undertaken to evaluate the hypotheses that there are differences in pediatric pain management (PPM) knowledge across resident specialties, that questions in the form of multiple-choice items could detect such differences, and that resident knowledge of analgesic-related adverse drug events (ADEs) would be greater than knowledge of PPM. Questions were based on two general categories of knowledge within acute pain management in hospitalized children: pediatric pain assessment and treatment, and identification of analgesic-related ADEs. As part of the pilot nature of this study, a convenience sample of 60 residents completed a 10-item PPM knowledge assessment prior to a PPM lecture. Twenty-six were pediatric residents (43%), 19 were orthopedic residents (32%), and 15 were anesthesiology residents (25%). All items had content validity. When controlling for resident year, performance by resident specialty was significantly different between anesthesia and orthopedics (P=0.006) and between anesthesia and pediatrics (P<0.001). Resident knowledge of analgesic-related ADEs was not greater than knowledge of PPM. The most difficult topics were opioid equianalgesia, assessment of the cognitively impaired child, and maximal acetaminophen doses. Repeated administration of the PPM knowledge assessment at multiple institutions will allow further evaluation of our initial findings, and with directed educational interventions, provide opportunity for measurement of improvement.
Hall, Richard W.; Anand, Kanwaljeet J. S.
Effective pain management is a desirable standard of care for preterm and term newborns and may potentially improve their clinical and neurodevelopmental outcomes. Neonatal pain should be assessed routinely using context-specific, validated and objective pain methods, despite the limitations of currently available tools. Reducing invasive procedures, and using pharmacological, behavioral or environmental measures can be used to manage neonatal pain. Non-pharmacologic approaches include kangaroo care, facilitated tucking, non-nutritive sucking, sucrose and other sweeteners, massage and acupuncture therapy. They are used for procedures causing acute, transient, or mild pain, or as adjunctive therapy for moderate or severe pain. Local and topical anesthetics can reduce the acute pain caused by skin-breaking or mucosa-injuring procedures. Opioids form the mainstay for treatment of severe pain; morphine and fentanyl are the most commonly used drugs, although other opioids are also available. Non-opioid drugs include various sedatives and anesthetic agents, mostly used as adjunctive therapy in ventilated neonates. Acetaminophen, ibuprofen and other drugs are used for neonates, although their efficacy and safety remains unproven. Approaches for implementing an effective pain management program in the Neonatal ICU are summarized, together with practical protocols for procedural, postoperative, and mechanical ventilation-associated neonatal pain and stress. PMID:25459780
Khatib, Samina Khaliloddin; Razvi, Syed Shamim; Kulkarni, Sadhana Sudhir; Parab, Swapnil
Background and Aims: Undertreated pain can have negative consequences on patients' health as well as the health-care system. The present study was aimed at identifying the current trends in post-operative pain management and availability of acute pain services (APS). In addition, it is also an attempt to assess the availability of analgesia for non-surgical cases, and the attitudes, beliefs, and perceptions of clinicians regarding acute pain management in the tertiary hospitals in the state of Maharashtra (India). Methods: This was a cross-sectional, multicentre questionnaire survey involving the anaesthesiologists and surgeons. Percentages, median, interquartile ranges were calculated and compared by employing a Wilcoxon sign rank test. Results: Data from thirty centres revealed that the surgeons played a major role in treating pain, while most of the anaesthesiologists treated pain primarily in the operation theatre and recovery room. An APS was operational in seven hospitals. The most frequently employed techniques to achieve analgesia were the administration of non-steroidal anti-inflammatory drugs, opioids and epidural analgesia. The majority of the centres had no written protocol and dedicated staff for pain management, pain assessment was not adequately stressed, and only five out of the thirty centres included in the study provided ongoing pain education to health professionals even when the hospitals claimed to provide APS. The major hurdles in providing optimal analgesia and implementing APS were a lack of pain education, equipment and administrative problems. Conclusion: Thus, the tertiary centres in Maharashtra fall short of providing optimal acute post-operative pain management.
Introduction Low back pain affects about 70% of people in resource-rich countries at some point in their lives. Acute low back pain can be self-limiting; however, 1 year after an initial episode, as many as 33% of people still have moderate-intensity pain and 15% have severe pain. Acute low back pain has a high recurrence rate; 75% of those with a first episode have a recurrence. Although acute episodes may resolve completely, they may increase in severity and duration over time. Methods and outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments for acute low back pain? What are the effects of local injections for acute low back pain? What are the effects of non-drug treatments for acute low back pain? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). Results We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. Conclusions In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics (paracetamol, opioids), back exercises, back schools, bed rest, behavioural therapy, electromyographic biofeedback, epidural corticosteroid injections, lumbar supports, massage, multidisciplinary treatment programmes, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulation, temperature treatments (short-wave diathermy, ultrasound, ice, heat), traction, and transcutaneous electrical nerve stimulation
Twycross, Alison; Collis, Sue
This study set out to obtain a picture of pediatric pain management practices in one English hospital. Data were collected on two wards. Nonparticipant observation combined with a chart audit was used to collect data about actual practices. Questionnaires were used to collect information from parents and young people. Observational data showed that practices conformed to current guidelines in some but not all areas. When prescribed, the dosage of analgesic drugs complied with the hospital's guidelines, and drugs were usually administered as prescribed. There was some involvement of parents in decision making but this was usually initiated by them rather than the nurses. Pain assessment tools were not always used nor was a pain history routinely taken. Documentation about pain management was limited and there was little evidence of nonpharmacologic methods of pain relief being used. Parents and young people felt that their pain management was of an acceptable level or very good. This was despite the fact that 58% of children experienced severe pain and 24% moderate pain. The results provide a snapshot of pain management in one English hospital. As in other studies, pain management practices do not adhere to current guidelines in all areas, and children appear to be experiencing moderate to severe pain. Despite this, parents and children indicated that they were happy with the quality of pain management. There is a need to explore this further and to identify strategies that support the implementation of guidelines in practice.
Auerswald, Günter; Dolan, Gerry; Duffy, Anne; Hermans, Cedric; Jiménez-Yuste, Victor; Ljung, Rolf; Morfini, Massimo; Lambert, Thierry; Šalek, Silva Zupančić
Joint pain is common in haemophilia and may be acute or chronic. Effective pain management in haemophilia is essential to reduce the burden that pain imposes on patients. However, the choice of appropriate pain-relieving measures is challenging, as there is a complex interplay of factors affecting pain perception. This can manifest as differences in patients’ experiences and response to pain, which require an individualized approach to pain management. Prophylaxis with factor replacement reduces the likelihood of bleeds and bleed-related pain, whereas on-demand therapy ensures rapid bleed resolution and pain relief. Although use of replacement or bypassing therapy is often the first intervention for pain, additional pain relief strategies may be required. There is an array of analgesic options, but consideration should be paid to the adverse effects of each class. Nevertheless, a combination of medications that act at different points in the pain pathway may be beneficial. Nonpharmacological measures may also help patients and include active coping strategies; rest, ice, compression, and elevation; complementary therapies; and physiotherapy. Joint aspiration may also reduce acute joint pain, and joint steroid injections may alleviate chronic pain. In the longer term, increasing use of prophylaxis or performing surgery may be necessary to reduce the burden of pain caused by the degenerative effects of repeated bleeds. Whichever treatment option is chosen, it is important to monitor pain and adjust patient management accordingly. Beyond specific pain management approaches, ongoing collaboration between multidisciplinary teams, which should include physiotherapists and pain specialists, may improve outcomes for patients. PMID:27439216
van Oostrom, Hugo; Schoemaker, Nico J; Uilenreef, Joost J
The growing popularity of ferrets as pets has created the demand for advanced veterinary care for these patients. Pain is associated with a broad range of conditions, including acute or chronic inflammatory disease, neoplasia, and trauma, as well as iatrogenic causes, such as surgery and diagnostic procedures. Effective pain management requires knowledge and skills to assess pain, good understanding of the pathophysiology of pain, and general knowledge of pharmacologic and pharmacodynamic principles. Unfortunately, scientific studies on efficacy, pharmacokinetics, pharmacodynamics, and safety of analgesic drugs in the ferret are limited. However, basic rules on the treatment of pain and mechanisms of action, safety, and efficacy of analgesic drugs in other species can be adapted and applied to pain management in ferrets. This article aims to make an inventory of what is known on the recognition of pain in ferrets, what analgesic drugs are currently used in ferrets, and how they can be adopted in a patient-orientated pain management plan to provide effective pain relief while reducing and monitoring for unwanted side effects.
Drake, Gareth; de C Williams, Amanda C
The objective of this review was to examine the effects of nursing education interventions on clinical outcomes for acute pain management in hospital settings, relating interventions to health care behavior change theory. Three databases were searched for nursing education interventions from 2002 to 2015 in acute hospital settings with clinical outcomes reported. Methodological quality was rated as strong, moderate, or weak using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies. The 12 eligible studies used varied didactic and interactive teaching methods. Several studies had weaknesses attributable to selection biases, uncontrolled confounders, and lack of blinding of outcome assessors. No studies made reference to behavior change theory in their design. Eight of the 12 studies investigated nursing documentation of pain assessment as the main outcome, with the majority reporting positive effects of education interventions on nursing pain assessment. Of the remaining studies, two reported mixed findings on patient self-report of pain scores as the key measure, one reported improvements in patient satisfaction with pain management after a nursing intervention, and one study found an increase in nurses' delivery of a relaxation treatment following an intervention. Improvements in design and evaluation of nursing education interventions are suggested, drawing on behavior change theory and emphasizing the relational, contextual, and emotionally demanding nature of nursing pain management in hospital settings.
Dumas, Linda G; Ramadurai, Murali
This article is about pain management and some of the best practices to address the problem of pain in nursing home patients who have a serious illness and multiple comorbid conditions. Management of the emotional distress that accompanies chronic or acute pain is of foremost concern. In this article, the topics discussed include general pain management in a nursing home for a long-term care resident who has chronic pain, the relief of symptoms and suffering in a patient who is on palliative care and hospice, and the pain management of a postoperative patient with acute pain for a short transitional period (post-acute illness or surgery).
Pittet, O; Demartines, N; Hahnloser, D
Anal pain is a common reason for consultation, whose etiology is varied and should not be limited to the hemorrhoidal disease. The purpose of this article is to conduct a review of the literature on anorectal pathologies most frequently encountered and make recommendations regarding their management.
... analgesia, identify new targets for analgesic drugs, and test the efficacy and adverse reactions of newly developed or currently used drugs to treat pain. Researchers are currently using these technologies to discover the mechanisms by which drugs such ...
Cassin, M; Badano, L P; Solinas, L; Macor, F; Burelli, C; Antonini-Canterin, F; Cappelletti, P; Rubin, D; Tropeano, P; Deganuto, L; Nicolosi, G L
sensitive but not specific marker for cardiac damage, increases earlier than CK-MB and cardiac troponins. It should be used early after symptom onset and in conjunction with a more specific marker of myocardial damage. Cardiac troponins T and I are highly specific markers for cardiac damage, rise parallel to CK-MB and remain elevated longer, up to 5 to 9 days. They are useful for detection of less severe degrees of myocardial injury, which may occur in several patients with unstable angina who are at higher risk of cardiac events. Recent studies suggest that cardiac troponins have good diagnostic performance and prognostic value in the heterogeneous population of patients seen in the Emergency Department with acute chest pain. Despite these promising data, several analytical and interpretative problems in the routine use of cardiac troponins must be solved. Incremental value of echocardiography in acute chest pain patients is still uncertain. Echocardiography can be recommended as an adjunctive test if readily available during acute chest pain or prolonged pain, especially in patients without previous myocardial infarction. Rest myocardial radionuclide imaging has been studied in the emergency department setting and although the overall diagnostic performance and prognostic value of sestamibi has been found to be promising, it is not suitable, in our country, for extensive clinical use. ECG exercise stress test in the emergency department population has been shown to be safe and it has a good negative predictive value for cardiac events. It should be recommended that any institution identify specific and shared protocol and strategies for management of patients with chest pain. These should include basal clinical evaluation, serial ECG and the use of specific and sensitive myocardial markers. Adjunctive tests, such as echocardiography, nuclear studies and stress tests should be employed when indicated taking into account local facilities.
Vadivelu, Nalini; Singh-Gill, Harman; Kodumudi, Gopal; Kaye, Aaron Joshua; Urman, Richard D.; Kaye, Alan David
Background Drug tolerance has been on the rise in recent years worldwide, and consequently, pain management in our population has become challenging. Methods Discussed in this review are commonly abused drugs and considerations for treating acute and chronic pain states in patients with substance disorders. Results After marijuana, alcohol, and tobacco, the most widely abused substances are oxycodone (Oxycontin), diazepam (Valium), and methylphenidate (Ritalin). Urine testing can detect metabolites of drugs used by patients and is useful for assessing drug abuse, medication diversion, and drug interactions. The comprehensive treatment of pain in a patient with addictive disorder or tolerance must address 3 issues: the patient's addiction, any associated psychiatric conditions, and the patient's pain. Eliciting a detailed history of drug abuse—illicit drugs as well as prescription drugs—and ascertaining if the patient is currently enrolled in a methadone maintenance program for the treatment of drug addiction is vital. Conclusion Medical observation, supportive care, multidisciplinary pain management, and timely interventions as necessary are the keys to safe outcomes in these patients. PMID:25249810
conditions [e.g., peripheral neuropathies , lower extremity arthritis, non-specific LBP], cancer-related pain, post-surgical pain, and other acute pain...Integrative Pain Treatment Medicine .......................................................... 42 4.2.2 Osteopathic Manipulation...VHA and civilian hospitals. Visits outside of Army Medical Treatment Facilities (MTFs) were scheduled based on recommendations from Service
Parmar, Malvinder S
Chronic kidney disease is common and patients with many co-morbid conditions frequently have to undergo surgical procedures and, therefore, require effective pain management. The pharmacokinetics of various analgesic agents are not well studied in patients with chronic kidney disease and the risk of accumulation of the main drug or their metabolites, resulting in serious adverse events, is a common scenario on medical and surgical wards. It is common for these patients to be cared for by 'non-nephrologists' who often prescribe the standard dose of the commonly used analgesics, without taking into consideration the patient's kidney function. It is important to recognize the problems and complications associated with the use of standard doses of analgesics, and highlight the importance of adjusting analgesic dosage based on kidney function to avoid complications while still providing adequate pain relief. PMID:24358847
Fisher, Robert B; Johnson, Quinn L; Reeves-Viets, Joseph L
In the U.S., there is a growing percentage of chronic pain patients requiring surgery. Chronic pain patients require careful evaluation and planning to achieve appropriate acute pain management. Peri-surgical pain management often requires continuation of previously prescribed chronic pain modalities and careful selection of multimodal acute pain interventions. This article will provide a broad overview of chronic pain, definitions, and current recommendations for the treatment of perioperative pain in patients maintained on opioid therapy.
Carbajal, Ricardo; Gall, Olivier; Annequin, Daniel
Multiple lines of evidence suggest an increased sensitivity to pain in neonates. Repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior. Despite impressive gains in the knowledge of neonatal pain mechanisms and strategies to treat neonatal pain acquired during the last 15 years, a large gap still exists between routine clinical practice and research results. Accurate assessment of pain is crucial for effective pain management in neonates. Neonatal pain management should rely on current scientific evidence more than the attitudes and beliefs of care-givers. Parents should be informed of pain relief strategies and their participation in the health care plan to alleviate pain should be encouraged. The need for systemic analgesia for both moderate and severe pain, in conjunction with behavioral/environmental approaches to pain management, is emphasized. A main sources of pain in the neonate is procedural pain which should always be prevented and treated. Nonpharmacological approaches constitute important treatment options for managing procedural pain. Nonpharmacological interventions (environmental and preventive measures, non-nutritive sucking, sweet solutions, skin-skin contact, and breastfeeding analgesia) can reduce neonatal pain indirectly by reducing the total amount of noxious stimuli to which infants are exposed, and directly, by blocking nociceptive transduction or transmission or by activation of descending inhibitory pathways or by activating attention and arousal systems that modulate pain. Opioids are the mainstay of pharmacological pain treatment but there are other useful medications and techniques that may be used for pain relief. National guidelines are necessary to improve neonatal pain management at the institutional level, individual neonatal intensive care units need to develop specific practice guidelines regarding pain
musculoskeletal chest pain; b) pleurisy ; c) pulmonary erbolus; d) mediastinal emphysema a) Musculoskeletal chest pain and the pain of costochondritis denote muscle...includes mild A-22 analgesics/anti-inflammatory drugs, heat therapy, and rest. b) Pleurisy denotes inflammation of the pleura. It may be seen in the...setting of bronchitis or pneumonia. The symptoms of both assist in differentiating pleurisy fru pneumothorax. In the absence of signs of pneumonia or
It is now recognized that from the newborn period onwards, children are capable of experiencing pain. This includes the premature infant. The challenge for healthcare providers is to incorporate methods of pain assessment and treatment into their daily practices. The child's understanding of pain closely follows the cognitive and behavioral model developed by Jean Piaget. Based on these developmental stages, pain assessment measures have been developed. Pharmacologic advances have accompanied this improved understanding of infant, child, and adolescent psychology. While acute pain accounts for the majority of children's experiences, recurrent/chronic pain states do occur (e.g. sickle cell related and neuropathic) and can be effectively treated.
... ational C ancer I nstitute Managing Chemotherapy Side Effects Pain It’s important to treat pain. If you ... to pay for pain medicine. Managing Chemotherapy Side Effects: Pain Keep track of the pain. Each day, ...
chest pain and/or dyspnea are present. a. Musculoskeletal pain b. Pleurisy c. Pulmonary embolus d. Spontaneous mediastinal emphysema a...Treatment includes mild analgesics, heat therapy, and, perhaps, rest. b) Pleurisy denotes inflammation of the pleura. It is seen in the setting of...bronchitis or pneumonia; the symptoms of both assist in differentiating pleurisy from pneumothorax. Chest discomfort is pleuristic. Unless there are
Prevalence of acute post-operative pain in patients in adult age-group undergoing inpatient abdominal surgery and correlation of intensity of pain and satisfaction with analgesic management: A cross-sectional single institute-based study
Singh, Prashant Kumar; Saikia, Priyam; Lahakar, Mangala
Background and Aims: Considering the paucity of regional data, this study was designed to investigate the prevalence of post-operative pain and determine if there exists any correlation between the intensity of post-operative pain and patient's level of satisfaction with their pain management after inpatient abdominal surgery at an academic tertiary care government centre. Methods: Pain intensity was measured in 120 patients with numeric rating scale at the fifth post-operative hour, second and third post-operative day. A questionnaire was used to measure the level of satisfaction with nurse's and doctor's response to their pain and overall pain management. Results: The prevalence of post-operative pain was 84.17%, 92.5% and 96.66% at the fifth post-operative hour, second and third post-operative day, respectively. Less number of patients experienced severe intensity pain on the third post-operative day (P = 0.00046), whereas the number of patients experiencing mild pain increased (P < 0.000) compared to the fifth post-operative hour. The number of patients with complete analgesia decreased on the third post-operative day (P = 0.001 compared to fifth post-operative day). The Spearman correlation coefficient between pain score on the third post-operative day and level of satisfaction with nurse's response, doctor's response to pain and the overall pain management was − 0.0218 (P = 0.8107), 0.1307 (P = 0.1553) and 0.0743 (P = 0.4195), respectively. Conclusion: There is a high prevalence of acute post-operative pain in patients undergoing inpatient abdominal surgery at our institute. There is a weak correlation between the intensity of pain and level of satisfaction with pain management. PMID:27761037
There has been great progress in the understanding of basic neurobiologic mechanisms of pain, but this body of knowledge has not yet translated into new and improved analgesics. Progress has been made regarding pain assessment in horses, but more work is needed until sensitive and accurate pain assessment tools are available for use in clinical practice. This review summarizes and updates the knowledge concerning the cornerstones of pain medicine (understand, assess, prevent, and treat). It highlights the importance of understanding pain mechanisms and expressions to enable a rational approach to pain assessment, prevention, and management in the equine patient.
Samuels-Kalow, M.; Mollen, C.
Diagnosis and treatment of acute pelvic pain in the adolescent female requires differentiating among a broad differential diagnosis that includes potentially serious illness across several organ systems. The case presented provides an illustration of the assessment and management of acute pelvic pain, and key teaching points about important potential causes. PMID:26273230
Radvansky, Brian M.; Shah, Khushbu; Parikh, Anant; Sifonios, Anthony N.; Le, Vanny; Eloy, Jean D.
Objectives. The objective of this narrative review was to examine the usage of ketamine as a postoperative analgesic agent across a wide variety of surgeries. Design. A literature search was performed using the phrases “ketamine” and “postoperative pain.” The authors analyzed the studies that involved testing ketamine's effectiveness at controlling postoperative pain. Effectiveness was assessed through various outcomes such as the amount of opiate consumption, visual analog scale (VAS) pain scores, and persistent postoperative pain at long-term follow-up. Results. While many different administration protocols were evaluated, delivering ketamine both as a pre- or perioperative bolus and postoperative infusion for up to 48 hours appeared to be the most effective. These effects are dose-dependent. However, a number of studies analyzed showed no benefit in using ketamine versus placebo for controlling postoperative pain. While ketamine is a safe and well-tolerated drug, it does have adverse effects, and there are concerns for possible neurotoxicity and effects on memory. Conclusions. In a number of limited situations, ketamine has shown some efficacy in controlling postoperative pain and decreasing opioid consumption. More randomized controlled trials are necessary to determine the surgical procedures and administrations (i.e., intravenous, epidural) that ketamine is best suited for. PMID:26495312
Wu, Wei-Ting; Huang, Yu-Hui; Chen, Der-Cherng; Huang, Yu-Hsuan; Chou, Li-Wei
Transverse myelitis is a rare inflammatory myelopathy characterized by loss of motor and sensory function below the affected level of the spinal cord, and causes neurogenic bowel and bladder. Occasionally, it also causes neuropathic pain with spasticity. Traditional therapies for neuropathic pain are multiple, including multimodal analgesic regimens, antiepileptic or antidepressant medications, opioids, sympathetic blocks, and spinal cord stimulation. Persistent neuropathic pain can cause emotional distress by affecting sleep, work, recreation, and emotional well-being. Here we report the case of a patient suffering from intractable neuropathic pain following acute transverse myelitis that was not relieved by combinations of nonsteroidal anti-inflammatory, anti-epileptic, antidepressant, and opioid medications, or by acupuncture. Implantation of an intrathecal morphine pump controlled the pain successfully without side effects, and enabled the patient to embark on intensive rehabilitation. The patient's muscle strength has improved significantly and the patient may soon be able to use a walker with minimal assistance.
Wu, Wei-Ting; Huang, Yu-Hui; Chen, Der-Cherng; Huang, Yu-Hsuan; Chou, Li-Wei
Transverse myelitis is a rare inflammatory myelopathy characterized by loss of motor and sensory function below the affected level of the spinal cord, and causes neurogenic bowel and bladder. Occasionally, it also causes neuropathic pain with spasticity. Traditional therapies for neuropathic pain are multiple, including multimodal analgesic regimens, antiepileptic or antidepressant medications, opioids, sympathetic blocks, and spinal cord stimulation. Persistent neuropathic pain can cause emotional distress by affecting sleep, work, recreation, and emotional well-being. Here we report the case of a patient suffering from intractable neuropathic pain following acute transverse myelitis that was not relieved by combinations of nonsteroidal anti-inflammatory, anti-epileptic, antidepressant, and opioid medications, or by acupuncture. Implantation of an intrathecal morphine pump controlled the pain successfully without side effects, and enabled the patient to embark on intensive rehabilitation. The patient’s muscle strength has improved significantly and the patient may soon be able to use a walker with minimal assistance. PMID:23935366
Pain Management Post-Amputation Pain Volume 8 · Issue 2 · March/April 1998 Text size Larger text Smaller text Java Required Print page Save and share ... by G. Edward Jeffries, MD, FACS Post-Amputation Pain Post-amputation pain is one of the most ...
Stinley, Nora E.; Norris, Deborah O.; Hinds, Pamela S.
This randomized controlled clinical trial explored the feasibility of implementing a fast-acting mandala intervention to reduce physical pain and psychological anxiety experienced during needle sticks. Forty pediatric patients participated in this two-group study: 20 participants created a mandala on an iPad (Treatment Group) and 20 participants…
diagnosis, treatment plan with specific drug regimens as indicated, probable course with treatment, and possible complications and their management. Type "N...stress, cigarette smoking, alcohol abuse, and many drugs have been cited as risk factors for PRiD. Some drugs may alter the stoach’s protective lining...accouplished with a regimen of antacids and a relatively new class of drugs , the H-2 blockers, that inhibit acid production. Food adequately buffers
Brennan, Frank; Carr, Daniel B; Cousins, Michael
This article surveys worldwide medical, ethical, and legal trends and initiatives related to the concept of pain management as a human right. This concept recently gained momentum with the 2004 European Federation of International Association for the Study of Pain (IASP) Chapters-, International Association for the Study of Pain- and World Health Organization-sponsored "Global Day Against Pain," where it was adopted as a central theme. We survey the scope of the problem of unrelieved pain in three areas, acute pain, chronic noncancer pain, and cancer pain, and outline the adverse physical and psychological effects and social and economic costs of untreated pain. Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. The biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Strategies currently applied for improvement include framing pain management as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies. The role of the World Health Organization is discussed, particularly with respect to opioid availability for pain management. We conclude that, because pain management is the subject of many initiatives within the disciplines of medicine, ethics and law, we are at an "inflection point" in which unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.
Miller, D B
Chronic Pain extracts a "penalty" on society now estimated to be well in excess of $100 million per year. The "penalty" that Chronic Pain extracts from its victims is incalculable. Chronic Pain is a major component of Temporomandibular Disorders. The current neurological theory of the mechanism of chronic TMD pain is explored along with the current modes of treatment. Pharmacological management of Chronic Pain in a clinical setting is outlined. Dentists are involved in pain management on a daily basis. Dentists treat pain both prophylacticly and in response to specific patient symptoms. Most dental treatment involves some type of pain management. We, dentists, have become very adept at managing acute pain. We have much greater difficulty managing chronic pain. The word "pain" derives from the Greek word for penalty, and appeared to them to be a "penalty" inflicted by the gods. In 1984, Bonica estimated that one-third of all Americans suffered from some kind of chronic pain at a "penalty" to society of $65 Billion annually in medical expenses and lost wages and productivity. This figure is certainly much greater now. Chronic pain can be a very complex problem that can require a multidisciplinary approach to treatment. Chronic pain in the dental setting is most frequetly caused by prolonged Temporomandibular Disorders.
Poplawski, Steven; Johnson, Matthew; Philips, Philip; Eberhart, Leopold H J; Koch, Tilo; Itri, Loretta M
Fentanyl iontophoretic transdermal system (ITS) [IONSYS(®), The Medicines Company, Parsippany, NJ, USA] is a needle-free, patient-controlled, postoperative opioid pain management treatment. It is indicated for the short-term management of acute postoperative pain in adults requiring opioid analgesia in the hospital. The safety and effectiveness of fentanyl ITS for acute postoperative pain management has been demonstrated in a range of surgery and patient types studied in seven phase 3 trials (three placebo-controlled trials and four active-comparator trials). The majority of the patients in the phase 3 trials had undergone either abdominal/pelvic, orthopedic, or thoracic surgery. Consistent with the prescribing information, physicians in clinical practice may treat patients with this system following any type of surgery including those that may not have been included in the phase 3 trials. The purpose of this case series is to illustrate how fentanyl ITS is being utilized for postoperative pain management in real-world clinical practice following a variety of surgeries and in current pain management protocols that may have evolved since the completion of the phase 3 program. There are seven cases from three clinical centers described within this case series, each using fentanyl ITS according to the prescribing information. The surgery types included are bariatric (N = 3), prostate (N = 2), colorectal (N = 1), and perirectal abscess drainage (N = 1). A systematic review of each patient chart was conducted via a standardized retrospective assessment by the clinicians who managed each patient. Additionally, each healthcare professional was interviewed regarding their overall experience and key learnings using fentanyl ITS. Overall, fentanyl ITS was effective and well tolerated in these case reports in current-day clinical practice settings. These case studies are informative about fentanyl ITS use shortly after product approval and set the stage for
Bajwa, Z H; Gupta, S; Warfield, C A; Steinman, T I
Pain is a common complaint in patients with autosomal-dominant polycystic kidney disease, and a systematic approach is needed to differentiate the etiology of the pain and define an approach to management. A thorough history is the best clue to the multifactorial causes of the pain, superimposed upon an understanding of the complex innervation network that supplies the kidneys. The appropriate use of diagnostic radiology (especially MRI) will assist in differentiating the mechanical low back pain caused by cyst enlargement, cyst rupture and cyst infection. Also, the increased incidence of uric acid nephrolithiasis as a factor in producing renal colic must be considered when evaluating acute pain in the population at risk. MRI is not a good technique to detect renal calculi, a frequent cause of pain in polycystic kidney disease. If stone disease is a possibility, then abdominal CT scan and/or ultrasound should be the method of radiologic investigation. Pain management is generally not approached in a systematic way in clinical practice because most physicians lack training in the principles of pain management. The first impulse to give narcotics for pain relief must be avoided. Since chronic pain cannot be "cured," an approach must include techniques that allow the patient to adapt to chronic pain so as to limit interference with their life style. A detailed stepwise approach for acute and chronic pain strategies for the patient with autosomal dominant polycystic kidney disease is outlined.
Van de Velde, Marc; Jani, Jacques; De Buck, Frederik; Deprest, J
This paper gives an overview of current science related to the concept of fetal pain. We have answered three important questions: (1) does fetal pain exist? (2) does management of fetal pain benefit the unborn child? and (3) which techniques are available to provide good fetal analgesia?
Wilson, Bridget H; Nelson, Jessica
Sickle cell disease (SCD) pain continues to emerge in adolescents. More than 98,000 individuals are believed to have SCD in the United States. In fact, 1 in 500 Black infants will be affected by SCD. Identifying standards of care for this unique population can improve pain management and treatment. A significant effect of vaso-occlusive crisis is a decrease in the quality of life in children. Therefore, pain management is multidimensional and includes pharmacologic, physical, and psychological strategies. A review of the literature was conducted to identify best practices regarding pain management in adolescents with sickle cell anemia. Key words such as pain, pain management, adolescent sickle cell anemia, and acute sickle cell pain were entered into databases to reveal qualitative and quantitative studies from 2009 to the present. Many of the research articles identified poor SCD pain management. Studies showed that acute SCD pain management is essential and should be evaluated and robustly managed to achieve optimum pain relief for patients. Acute SCD pain usually occurs as a result of vaso-occlusive crisis. Untreated acute SCD pain can result in morbidity and mortality in adolescents. Nursing knowledge is critical to reducing the stigma and improving management of SCD pain. Nurses play a vital role in the introduction of evidence-based practice within the clinical setting. In an effort to educate nurses and other health care professionals about SCD, this article is a literature review of studies concerning SCD and pain management in emergency rooms.
Wu, Peter I-Kung; Meleger, Alec; Witkower, Alan; Mondale, Timothy; Borg-Stein, Joanne
This article provides a broad overview of the clinical nonpharmacologic treatment options for managing acute and chronic pain. Physical therapy and modalities, interventional techniques, emerging regenerative medicine, and cognitive behavioral paradigms of treatment are presented. Recommendations are evidence-based and are a practical resource for the musculoskeletal pain and sports medicine practitioner.
Kandreli, M G; Vadachkoriia, N R; Gumberidze, N Sh; Mandzhavidze, N A
The aim of the study was to determine the most effective dose of Ibuprofen - one of the non-steroidal anti-inflammatory drugs frequently used in dental practice for pain management. According to our observations, Ibuprofen markedly softens and quickly reduces procedural pain in 55 (91.67%) patients and post-procedural pain in 44 (73.33%) patients, reduces the post-procedural need for or the amount of the drug, removes the fear of anesthesia and endodontic treatment; with irreversible pulpits significantly increases the efficiency of the inferior alveolar nerve block by local anesthetics. Our clinical observation of taking ibuprofen pre-procedurally demonstrates its effectiveness not only as a means for the relief of pain episodes, but also as an excellent anti-inflammatory treatment for chronic toothache Based on our research, the appointment of non-steroidal anti-inflammatory drugs before dental interventions, in this case - Ibuprofen turned out to be the key to the success of effective pain management. We suggest that administration of analgesics in order to relieve and effectively pre-empt pain before, during or after treatment should start before surgery and furthermore, this treatment should be extended into the postoperative period. Premedication with ibuprofen significantly increased the success rates of inferior alveolar nerve block anesthesia in teeth with irreversible pulpitis.
Ahmadi, Alireza; Bazargan-Hejazi, Shahrzad; Heidari Zadie, Zahra; Euasobhon, Pramote; Ketumarn, Penkae; Karbasfrushan, Ali; Amini-Saman, Javad; Mohammadi, Reza
Abstract: Background: Pain in trauma has a role similar to the double-edged sword. On the one hand, pain is a good indicator to determine the severity and type of injury. On the other hand, pain can induce sever complications and it may lead to further deterioration of the patient. Therefore, knowing how to manage pain in trauma patients is an important part of systemic approach in trauma. The aim of this manuscript is to provide information about pain management in trauma in the Emergency Room settings. Methods: In this review we searched among electronic and manual documents covering a 15-yr period between 2000 and 2016. Our electronic search included Pub Med, Google scholar, Web of Science, and Cochrane databases. We looked for articles in English and in peer-reviewed journals using the following keywords: acute pain management, trauma, emergency room and injury. Results: More than 3200 documents were identified. After screening based on the study inclusion criteria, 560 studies that had direct linkage to the study aim were considered for evaluation based World Health Organization (WHO) pain ladder chart. Conclusions: To provide adequate pain management in trauma patients require: adequate assessment of age-specific pharmacologic pain management; identification of adequate analgesic to relieve moderate to severe pain; cognizance of serious adverse effects of pain medications and weighting medications against their benefits, and regularly reassessing patients and reevaluating their pain management regimen. Patient-centered trauma care will also require having knowledge of barriers to pain management and discussing them with the patient and his/her family to identify solutions. PMID:27414816
Breakthrough cancer pain has been defined as a transitory increase in pain intensity that occurs despite relatively stable and adequately controlled background pain. More than half of cancer patients with chronic pain suffer by some form of breakthrough cancer pain. The management of breakthrough cancer pain is comprehensive and includes pharmacological and nonpharmacological approaches. The principal treatment strategies are optimization of regular analgesic medication combined with effective rescues medication. The new transmucosal forms of fentanyl represent an important improvement in our treatment options.
Thompson, Lindsay A; Meinert, Elizabeth; Baker, Kimberly; Knapp, Caprice
Pain is common as a presenting complaint to outpatient and emergency departments for children, yet pain management represents one of the children's largest unmet needs. A child may present with acute pain for an intermittent issue or may have acute or chronic pain in the setting of chronic illness. The mainstay of treatment for pain uses a stepwise approach for pain management, such as set up by the World Health Organization. For children with life-limiting illnesses, the Institute of Medicine guidelines recommends referral upon diagnosis for palliative care, meaning that the child receives comprehensive services that include pain control in coordination with curative therapies; yet barriers remain. From the provider perspective, pain can be better addressed through a careful assessment of one's own knowledge, skills, and attitudes. The key components of pain management in children are multimodal, regardless of the cause of the pain.
Brooks, Peter; Kubler, Paul
Nonsteroidal antiinflammatory drugs (NSAIDs), including selective cyclooxygenase (COX)-2 inhibitors, have come to play an important role in the pharmacologic management of arthritis and pain. Clinical trials have established the efficacy of etoricoxib in osteoarthritis, rheumatoid arthritis, acute gouty arthritis, ankylosing spondylitis, low back pain, acute postoperative pain, and primary dysmenorrhea. Comparative studies indicate at least similar efficacy with etoricoxib versus traditional NSAIDs. Etoricoxib was generally well tolerated in these studies with no new safety findings during long-term administration. The gastrointestinal, renovascular, and cardiovascular tolerability profiles of etoricoxib have been evaluated in large patient datasets, and further insight into the cardiovascular tolerability of etoricoxib and diclofenac will be gained from a large ongoing cardiovascular outcomes program (MEDAL). The available data suggest that etoricoxib is an efficacious alternative in the management of arthritis and pain, with the potential advantages of convenient once-daily administration and superior gastrointestinal tolerability compared with traditional NSAIDs. PMID:18360581
Guo, Yifei; Wang, Yuzheng; Sun, Yabin; Wang, Jin-Yan
The transition from acute pain to chronic pain entails considerable changes of patients at multiple levels of the nervous system and in psychological states. An accurate differentiation between acute and chronic pain is essential in pain management as it may help optimize analgesic treatments according to the pain state of patients. Given that acute and chronic pain could modulate brain states in different ways and that brain states could greatly shape the neural processing of external inputs, we hypothesized that acute and chronic pain would show differential effects on cortical responses to non-nociceptive sensory information. Here by analyzing auditory-evoked potentials (AEPs) to pure tones in rats with acute or chronic pain, we found opposite influences of acute and chronic pain on cortical responses to auditory inputs. In particular, compared to no-pain controls, the N100 wave of rat AEPs was significantly enhanced in rats with acute pain but significantly reduced in rats with chronic pain, indicating that acute pain facilitated cortical processing of auditory information while chronic pain exerted an inhibitory effect. These findings could be justified by the fact that individuals suffering from acute or chronic pain would have different vigilance states, i.e., the vigilance level to external sensory stimuli would be increased with acute pain, but decreased with chronic pain. Therefore, this auditory response holds promise of being a brain signature to differentiate acute and chronic pain. Instead of investigating the pain system per se, the study of pain-induced influences on cortical processing of non-nocicpetive sensory information might represent a potential strategy to monitor the progress of pain chronification in clinical applications. PMID:27199727
Chronic pain is a major personal, family, and community disaster. The sufferer usually has difficulties in every aspect of life. The key to successful treatment lies in a comprehensive and accurate assessment that must include family, marital, legal, behavioural, mental, and organic considerations. With comprehensive assessment, a logical plan of treatment can be constructed. Non-compliance, substance abuse, doctor shopping and secondary gain, as well as complex psychodynamics, make management of such pain difficult and frustrating. The patients are frequently playing “games” in which they control the rules, and which the physician can never win. Success rates are poor even in specialized centres, and many patients are ultimately injured by inappropriate investigation or treatment. Physicians who have become over-involved with such patients may also be injured by the process, to the detriment of their general care of other patients and themselves. PMID:21248889
Pain is the body's way of telling us something is wrong, and has a sensory and emotional component. This three-part series focuses on acute pain, describing the physiology of a normal and well-behaved pain pathway and how this relates to commonly used pain management strategies. The first article introduced the pain system and how the body detects a threatening (noxious) stimulus. This article describes how that "pain message" is transmitted to the spinal cord and the brain and how the brain responds to the stimulus, while identifying pain relief strategies linked to the physiological process. Part 3, to be published next week, discusses pain assessment.
Patrick, Nathan; Emanski, Eric; Knaub, Mark A
Low back pain is an extremely common presenting complaint that occurs in upward of 80% of persons. Treatment of an acute episode of back pain includes relative rest, activity modification, nonsteroidal anti-inflammatories, and physical therapy. Patient education is also imperative, as these patients are at risk for further future episodes of back pain. Chronic back pain (>6 months' duration) develops in a small percentage of patients. Clinicians' ability to diagnose the exact pathologic source of these symptoms is severely limited, making a cure unlikely. Treatment of these patients should be supportive, the goal being to improve pain and function.
Patrick, Nathan; Emanski, Eric; Knaub, Mark A
Low back pain is an extremely common presenting complaint that occurs in upward of 80% of persons. Treatment of an acute episode of back pain includes relative rest, activity modification, nonsteroidal anti-inflammatories, and physical therapy. Patient education is also imperative, as these patients are at risk for further future episodes of back pain. Chronic back pain (>6 months' duration) develops in a small percentage of patients. Clinicians' ability to diagnose the exact pathologic source of these symptoms is severely limited, making a cure unlikely. Treatment of these patients should be supportive, the goal being to improve pain and function.
Hsieh, Ming-Ju; Wang, Kuo-Cheng; Liu, Hung-Pin; Gonzalez-Rivas, Diego; Wu, Ching-Yang; Liu, Yun-Hen; Wu, Yi-Cheng; Chao, Yin-Kai
Background Effective postoperative pain control for thoracic surgery is very important, not only because it reduces pulmonary complications but also because it accelerates the pace of recovery. Moreover, it increases patients’ satisfaction with the surgery. In this study, we present a simple approach involving the safe placement of intercostal catheter (ICC) after single port video-assisted thoracoscopic surgery (VATS) anatomic resection and we evaluate postoperative analgesic function with and without it. Methods We identified patients who underwent single port anatomic resection with ICC placed intraoperatively as a route for continuous postoperative levobupivacaine (0.5%) administration and retrospectively compared them with a group of single port anatomic resection patients without ICC. The operation time, postoperative day 0, 1, 2, 3 and discharge day pain score, triflow numbers, narcotic requirements, drainage duration and post-operative hospital stay were compared. Results In total, 78 patients were enrolled in the final analysis (39 patients with ICC and 39 without). We found patients with ICC had less pain sensation numerical rating scale (NRS) on postoperative day 0, 1 (P=0.023, <0.001) and better triflow performance on postoperative day 1 and 2 (P=0.015, 0.032). In addition, lower IV form morphine usage frequency and dosage (P=0.009, 0.017), shorter chest tube drainage duration (P=0.001) and postoperative stay (P=0.005) were observed in the ICC group. Conclusions Continuous intercostal nerve blockade by placing an ICC intraoperatively provides effective analgesia for patients undergoing single port VATS anatomic resection. This may be considered a viable alternative for postoperative pain management. PMID:28149550
Downie, Aron S; Hancock, Mark J; Rzewuska, Magdalena; Williams, Christopher M; Lin, Chung-Wei Christine; Maher, Christopher G
Characterising the clinical course of back pain by mean pain scores over time may not adequately reflect the complexity of the clinical course of acute low back pain. We analysed pain scores over 12 weeks for 1585 patients with acute low back pain presenting to primary care to identify distinct pain trajectory groups and baseline patient characteristics associated with membership of each cluster. This was a secondary analysis of the PACE trial that evaluated paracetamol for acute low back pain. Latent class growth analysis determined a 5 cluster model, which comprised 567 (35.8%) patients who recovered by week 2 (cluster 1, rapid pain recovery); 543 (34.3%) patients who recovered by week 12 (cluster 2, pain recovery by week 12); 222 (14.0%) patients whose pain reduced but did not recover (cluster 3, incomplete pain recovery); 167 (10.5%) patients whose pain initially decreased but then increased by week 12 (cluster 4, fluctuating pain); and 86 (5.4%) patients who experienced high-level pain for the whole 12 weeks (cluster 5, persistent high pain). Patients with longer pain duration were more likely to experience delayed recovery or nonrecovery. Belief in greater risk of persistence was associated with nonrecovery, but not delayed recovery. Higher pain intensity, longer duration, and workers' compensation were associated with persistent high pain, whereas older age and increased number of episodes were associated with fluctuating pain. Identification of discrete pain trajectory groups offers the potential to better manage acute low back pain.
Liljekvist, Mads Svane; Pommergaard, Hans-Christian; Burcharth, Jakob; Rosenberg, Jacob
Acute abdominal pain is a common clinical condition. Clinical signs and symptoms can be difficult to interpret, and diagnostic imaging may help to identify intra-abdominal disease. Conventional X-ray, ultrasound (US) and computed tomography (CT) of the abdomen vary in usability between common surgical causes of acute abdominal pain. Overall, conventional X-ray cannot confidently diagnose or rule out disease. US and CT are equally trustworthy for most diseases. US with subsequent CT may enhance diagnostic precision. Magnetic resonance seems promising for future use in acute abdominal imaging.
Manias, Elizabeth; Bucknall, Tracey; Botti, Mari
Acute pain is a significant problem in the postoperative setting. Patients report a lack of information about pain-control measures and ineffective pain control. Nurses continue to rely on pharmacologic measures and tend to under-administer analgesics. The purpose of this study was to determine the strategies nurses used to manage patients' pain in the postoperative setting. It also sought to examine the effect of context, including organization of care, nurses' prioritization of work activities, and pressures during a working shift, on their pain-management strategies. An observational design was used in two surgical units of a metropolitan teaching hospital in Melbourne, Australia. Six fixed observation times were identified as key periods for pain activities, each comprising a 2-hour duration. An observation period was examined at least 12 times, resulting in the completion of 74 observations and the identification of 316 pain cases. Fifty-two nurses were observed during their normal day's work with postoperative patients. Six themes were identified: managing pain effectively; prioritizing pain experiences for pain management; missing pain cues for pain management; regulators and enforcers of pain management; preventing pain; and reactive management of pain. The findings highlighted the critical nature of communication between clinicians and patients and among clinicians. It also demonstrated the influence of time on management strategies and the relative importance that nurses place on nonpharmacologic measures in actual practice. This research, which portrays what happens in actual clinical practice, has facilitated the identification of new data that were not evident from other research studies.
Evans, Subhadra; Tsao, Jennie C I; Zeltzer, Lonnie K
Children undergo acute painful procedures and many also experience chronic pain.Due to their developing systems, infants and children may be at greater risk than adults for protracted pain sensitivity.There is a need to manage acute and chronic paediatric pain to reduce children's suffering and to prevent future pain problems.Consistent with a biopsychosocial perspective, complementary and alternative medicine (CAM) should be considered in management of acute and chronic paediatric pain.Although research is limited for paediatric pain, CAM interventions receiving the most empirical attention include hypnotherapy, acupuncture and music therapy. Evidence also exists for the therapeutic benefits of yoga, massage, humor therapy and the use of certain biological based therapies.
Johnson, J A; Repp, E C
This article has presented the critical elements of arthritic pain, the role of nonpharmacologic pain management, and a selection of techniques for therapeutic pain management. The author believes that these techniques are particularly suited to nursing intervention. Nursing is concerned with the total person and nonpharmacological techniques involve the total person in developing self-help coping strategies. The nurse interested in pursuing nonpharmacologic pain management techniques will find the outline, with explanation of "Skill Training: Summary of Training for Role Playing" to be particularly helpful. Further reading will enable the nurse to become familiar with and to pursue interventions of particular interest.
Ballas, Samir K
Pain is the insignia of sickle cell disease and the acute painful crisis is the number-one cause of hospital admissions. Tissue damage due to vaso-occlusion releases numerous inflammatory mediators that initiate the transmission of painful stimuli and the perception of pain. The acute sickle cell painful crisis evolves along four distinct phases coupled with changes in certain markers of the disease. Hospital readmission within 1 week occurs in about 16% of discharged patients. Failure to treat acute pain aggressively may lead to chronic pain syndrome. Management of sickle pain is primarily pharmacologic in nature, and opioids are the analgesics used most often. Cellular and molecular mechanisms of opioids explain individual differences among patients and justify the use of individualized treatment plans.
Ojeda, Antonio; Moreno, Luis A
Pain management in patients with liver cirrhosis is a real challenge and is often inadequate due to a lack of therapeutic efficacy or the high incidence of adverse effects. The focus of treatment differs depending on whether the pain is acute or chronic and involves understanding the causative pathophysiological mechanism. Analgesics should be started with the minimum effective dose and should be titrated slowly with avoidance of polypharmacy. Adverse effects must be monitored, especially sedation and constipation, which predispose the patient to the development of hepatic encephalopathy. The first-line drug is paracetamol, which is safe at doses of 2-3g/day. Non-steroidal anti-inflammatory agents are contraindicated because they can cause acute renal failure and/or gastrointestinal bleeding. Tramadol is a safe option for moderate-severe pain. The opioids with the best safety profile are fentanyl and hydromorphone, with methadone as an alternative. Topical treatment can reduce oral drug consumption. In neuropathic pain the first-line therapeutic option is gabapentin. The use of antidepressants such as amitriptyline can be considered in some patients. Interventional techniques are a valuable tool in moderate to severe pain, since they allow a reduction in drug therapy and consequently its adverse effects. Psychological treatment, physical therapy and rehabilitation should be considered as part of multimodality therapy in the management of chronic pain.
Traditional pain management strategies have relied on the use of opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen, as well as other adjuvant analgesics. However, the limited activity of these drugs and the substantial adverse effects associated with their use has left many patients without dependable options for effective treatment. Recent advances in the understanding of pain and its pathophysiologic mechanisms have led to the development of novel therapeutic options. Cyclooxygenase (COX)-2-specific inhibitors (coxibs) have an established efficacy in the treatment of chronic arthritic pain comparable to that of traditional NSAIDs, without the degree of gastrointestinal (GI) complications commonly attributed to NSAID use. Recent trials also have shown the effectiveness of 1 of the coxibs for relief of chronic lower back pain. Numerous studies have shown that coxibs are efficacious for the management of acute pain in various clinical settings, including orthopedic surgery, dental surgery, and dysmenorrhea. The superior safety profile of coxibs in conjunction with a comparable efficacy to nonselective NSAIDs supports the use of coxibs in balanced analgesic regimens. Decreased GI and antiplatelet effects of coxibs compared to traditional NSAIDs provide the potential to incorporate coxibs into the pain management algorithm used to treat cancer pain.
Rapkin, A J; Kames, L D
Chronic pelvic pain remains a difficult management problem that is often refractory to traditional medical or surgical therapy. The pain management center approach used successfully for the treatment of cancer pain and headache can be adapted to the treatment of chronic pelvic pain. The results of this pilot study suggest that the multidisciplinary techniques of pain management promise to be an effective modality for the treatment of chronic pelvic pain.
TU, Frank F.; HELLMAN, Kevin; BACKONJA, Miroslav
Obstetrician/gynecologists often are the initial management clinicians for pelvic neuropathic pain. While treatment may require comprehensive team management and consultation with other specialists, there a few critical and basic steps that can be performed on an office visit that offer the opportunity to significantly improve quality of life in this patient population. A key first step is a thorough clinical examination to physically map the pain site and identify potentially involved nerves. Only limited evidence exists on how best to manage neuropathic pain, but generally a combination of surgical, manipulative or pharmacological methods should be considered. Experimental methods for more precisely characterizing the nature of the nerve dysfunction exist to diagnose and treat neuropathic pain, but additional scientific evidence is needed to unanimously recommend these options. In the meantime, an approach adopted from guidelines of the International Association for Study of Pain tailored for gynecological pain is suggested. PMID:21777899
Slipp, Marlene; Burnham, Robert
Background: The prevalence of chronic pain is high and increasing. Medication management is an important component of chronic pain management. There is a shortage of physicians who are available and comfortable providing this service. In Alberta, pharmacists have been granted an advanced scope of practice. Given this empowerment, their availability, training and skill set, pharmacists are well positioned to play an expanded role in the medication management of chronic pain sufferers. Objective: To compare the effectiveness and cost of a physician-only vs a pharmacist-physician team model of medication management for chronic nonmalignant pain sufferers. Method: Data was analyzed for 89 patients who had received exclusively medication management at a rural Alberta multidisciplinary clinic. 56 were managed by a sole physician. 33 were managed by a team (pharmacist + physician). In the team model, the physician did the medical assessment, diagnosis, and established a treatment plan in consultation with the patient and pharmacist. The pharmacist then provided the ongoing follow-up including education, dose titration and side effect management and consulted with the physician as needed. Change in pain (Numerical Rating Scale) and disability (Pain Interference Questionnaire) over the course of treatment were recorded. The treatment duration and number of visits were used to calculate cost of care. Results: Both models of medication management resulted in significant and comparable improvements in pain, disability and patient perception of medication effectiveness. Patients in the physician-only group were seen more frequently and at a greater cost. The pharmacist-physician team approach was markedly more cost-effective, and patients expressed a high level of satisfaction with their medication management. Conclusions: The pharmacist-physician team model of medication management results in significant reductions of pain and disability for chronic nonmalignant pain sufferers
Olesen, Anne E; Farmer, Adam D; Olesen, Søren S; Aziz, Qasim; Drewes, Asbjørn M
Despite marked differences in underlying pathophysiology, the current management of visceral pain largely follows the guidelines derived from the somatic pain literature. The effective management of patients with chronic visceral pain should be multifaceted, including both pharmacological and psychological interventions, thereby providing a mechanism-orientated approach to treatment. Patients can frequently become disenfranchised, and subsequently disengaged, with healthcare providers leading to repeated consultations. Thus, a key aspect of management is to break this cycle by validating patients' symptoms, adopting an empathic approach and taking time to educate patients. To optimize treatment and outcomes in chronic visceral pain we need to move away from approaches exclusively based on dealing with peripheral nociceptive input toward more holistic strategies, taking into account alterations in central pain processing.
Brix Finnerup, Nanna; Hein Sindrup, Søren; Staehelin Jensen, Troels
Neuropathic pain is the most common type of pain in neuropathy. In painful polyneuropathies the pain usually has a "glove and stocking" distribution. The pain may be predominantly spontaneous, e.g., with a burning, pricking, or shooting character or characterized by evoked pain such as mechanical or cold allodynia. In the clinical setting, the prevention of painful neuropathies and treatment of underlying neuropathy remains inadequate and thus symptomatic treatment of the pain and related disability needs to be offered. Most randomized, double-blind, placebo-controlled trials (RCTs) published in painful neuropathy have been conducted in patients with diabetes and to what extent a treatment which is found effective in painful diabetic polyneuropathy can be expected to relieve other conditions like chemotherapy- or HIV-induced neuropathy is unknown. Tricyclic antidepressants (TCAs), gabapentin, pregabalin, and serotonin noradrenaline reuptake inhibitors (SNRIs) are first drug choices. In patients with localized neuropathic pain, a topical lidocaine patch may also be considered. Second-line treatments are tramadol and other opioids. New types of treatment include botulinum toxin type A (BTX-A), high-dose capsaicin patches, and cannabinoids. Other types of anticonvulsant drugs such as lamotrigine, oxcarbazepine, and lacosamide have a more questionable efficacy in painful polyneuropathy but may have an effect in a subgroup of patients. Combination therapy may be considered in patients with insufficient effect from one drug. Treatment is usually a trial-and-error process and has to be individualized to the single patient, taking into account all comorbidities such as possible concomitant depression, anxiety, diseases, and drug interactions. Side-effects to antidepressants include dry mouth, nausea, constipation, orthostatic hypotension, and sedation. ECG should always be obtained prior to treatment with TCAs, which also should not be used in patients with cardiac
Chapman, C Richard; Vierck, Charles J
The nature of the transition from acute to chronic pain still eludes explanation, but chronic pain resulting from surgery provides a natural experiment that invites clinical epidemiological investigation and basic scientific inquiry into the mechanisms of this transition. The primary purpose of this article is to review current knowledge and hypotheses on the transition from acute to persistent postsurgical pain, summarizing literature on clinical epidemiological studies of persistent postsurgical pain development, as well as basic neurophysiological studies targeting mechanisms in the periphery, spinal cord, and brain. The second purpose of this article is to integrate theory, information, and causal reasoning in these areas. Conceptual mapping reveals 5 classes of hypotheses pertaining to pain. These propose that chronic pain results from: 1) persistent noxious signaling in the periphery; 2) enduring maladaptive neuroplastic changes at the spinal dorsal horn and/or higher central nervous system structures reflecting a multiplicity of factors, including peripherally released neurotrophic factors and interactions between neurons and microglia; 3) compromised inhibitory modulation of noxious signaling in medullary-spinal pathways; 4) descending facilitatory modulation; and 5) maladaptive brain remodeling in function, structure, and connectivity. The third purpose of this article is to identify barriers to progress and review opportunities for advancing the field. This review reveals a need for a concerted, strategic effort toward integrating clinical epidemiology, basic science research, and current theory about pain mechanisms to hasten progress toward understanding, managing, and preventing persistent postsurgical pain.
Trescot, Andrea M
Cryoneuroablation, also known as cryoanalgesia or cryoneurolysis, is a specialized technique for providing long-term pain relief in interventional pain management settings. Modern cryoanalgesia traces its roots to Cooper et al who developed in 1961, a device that used liquid nitrogen in a hollow tube that was insulated at the tip and achieved a temperature of - 190 degrees C. Lloyd et al proposed that cryoanalgesia was superior to other methods of peripheral nerve destruction, including alcohol neurolysis, phenol neurolysis, or surgical lesions. The application of cold to tissues creates a conduction block, similar to the effect of local anesthetics. Long-term pain relief from nerve freezing occurs because ice crystals create vascular damage to the vasonervorum, which produces severe endoneural edema. Cryoanalgesia disrupts the nerve structure and creates wallerian degeneration, but leaves the myelin sheath and endoneurium intact. Clinical applications of cryoanalgesia extend from its use in craniofacial pain secondary to trigeminal neuralgia, posterior auricular neuralgia, and glossopharyngeal neuralgia; chest wall pain with multiple conditions including post-thoracotomy neuromas, persistent pain after rib fractures, and post herpetic neuralgia in thoracic distribution; abdominal and pelvic pain secondary to ilioinguinal, iliohypogastric, genitofemoral, subgastric neuralgia; pudendal neuralgia; low back pain and lower extremity pain secondary to lumbar facet joint pathology, pseudosciatica, pain involving intraspinous ligament or supragluteal nerve, sacroiliac joint pain, cluneal neuralgia, obturator neuritis, and various types of peripheral neuropathy; and upper extremity pain secondary to suprascapular neuritis and other conditions of peripheral neuritis. This review describes historical concepts, physics and equipment, various clinical aspects, along with technical features, indications and contraindications, with clinical description of multiple conditions
Nurwidya, Fariz; Syahruddin, Elisna; Yunus, Faisal
Lung cancer is the leading cause of cancer-related mortality worldwide. Not only burdened by the limited overall survival, lung cancer patient also suffer from various symptoms, such as pain, that implicated in the quality of life. Cancer pain is a complicated and transiently dynamic symptom that results from multiple mechanisms. This review will describe the pathophysiology of cancer pain and general approach in managing a patient with lung cancer pain. The use of opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and adjuvant analgesia, as part of the pharmacology therapy along with interventional strategy, will also be discussed.
Pain Management and the Amputee Translated into plain language by Helen Osborne, 2006 Health Literacy Consulting, www.healthliteracy.com ... The Amputee Coalition is a national, nonprofit amputee consumer educational organization representing people who have experienced amputation ...
Egan, M; Seeger, D; Schöps, P
Patients attend physiotherapy and physical therapy (PT) due to pain problems and/or functional impairments. Although the main focus for therapists has traditionally been physical examination and treatment of tissue structures and biomechanics, over the last few decades a growing body of research has highlighted the importance of central nervous system processing and psychosocial contributors to pain perception. Treatment with PT aims to reduce disability and suffering by reducing pain and increasing tolerance to movement. In Germany, pain management conducted by physiotherapists is currently undergoing major changes. Firstly, PT education is transitioning from a vocational to a degree level and additionally new concepts for improved multidisciplinary treatment approaches are being developed. However, there still remain substantial differences between therapists working in multidisciplinary pain clinics and those following medical referral in private practices. This article provides information on how national and international impulses have contributed to the development of different concepts of passive therapies and active/functional pain rehabilitation in Germany. In the future PT will need to provide more evidence about efficiency and modes of actions for different treatment options to selectively reason the application to patients with acute, subacute and chronic pain.
Dedeli, Ozden; Kaptan, Gulten
Pain relief is a management problem for many patients, their families, and the medical professionals caring for them. Although everyone experiences pain to some degree, responses to it vary from one person to another. Recognizing and specifying someone else’s pain is clinically a well know challenge. Research on the biology and neurobiology of pain has given us a relationship between spirituality and pain. There is growing recognition that persistent pain is a complex and multidimensional experience stemming from the interrelations among biological, psychological, social, and spiritual factors. Patients with pain use a number of cognitive and behavioral strategies to cope with their pain, including religious/spiritual factors, such as prayers, and seeking spiritual support to manage their pain. This article provides an overview of the complex phenomenon of pain, with a focus on spiritual and religious issues in pain management. PMID:26973914
Personal stories of illness give depth to otherwise clinical descriptions of diagnoses. This article offers an autobiographical narrative of complications after total knee replacement surgery. Diagnosis and nursing management of acute compartment syndrome, nociceptive and neuropathic origins of pain, pharmacologic and nursing interventions for pain, the use of prayer in illness, and compassionate caring from a Christian perspective are discussed.
Dahl, June L; Gordon, Deb; Ward, Sandra; Skemp, Marty; Wochos, Sarah; Schurr, Michael
Clinical practice and quality improvement (QI) guidelines for acute postoperative pain management have been developed to address the well-documented problem of undertreatment of postoperative pain. The Post-Operative Pain Management Quality Improvement Project (the POP Project) was initiated to determine whether an intervention designed to support hospitals in the development of QI efforts would lead to improvements in structures, processes, and outcomes consistent with recommended guidelines. A nationwide sample of 233 hospitals joined the project. The intervention consisted of written resource materials accompanied by support services that included an e-mail list server, a resource Web page, and assistance from POP Project staff via telephone. Data regarding critical structures, processes (practice patterns), and patient outcomes were collected at baseline before the intervention began and at follow-up 12 to 18 months later. Results showed a statistically significant increase from baseline (45%) to follow-up (72%) in the presence of structural elements that are critical to improving pain management. There were statistically significant improvements in practices including documented use of pain rating scales, decreased use of intramuscular opioids, and increased use of nonpharmacologic strategies. Patient survey data showed no change in pain outcomes. Evaluation data showed that 70% of hospitals were very or extremely satisfied with their participation in the POP Project and 90% of them planned to continue efforts to improve pain management after the POP Project ended. Further research is needed to determine how to translate the excellent results obtained for structure and process into meaningful outcomes for patients.
Quigley, Columba; Wiffen, Phil
While morphine is historically the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable side effects from this drug. For these patients, alternatives such as hydromorphone are recommended. This review explores the evidence for the efficacy of hydromorphone in the management of pain. A systematic search, from 1966 to 2000, of published and unpublished randomized trials that involved the administration of hydromorphone for both acute and chronic pain conditions in adults and children, was conducted. Forty-three studies were included in the review; 11 involved chronic cancer pain and 32 acute pain. Approximately half the studies received a low quality score. In addition, the heterogeneity of the studies precluded combination of data and results. Overall, hydromorphone appears to be a potent analgesic. The limited number of studies available suggests that there is little difference between hydromorphone and other opioids in terms of analgesic efficacy, adverse effect profile and patient preference. However, most studies involved small numbers of patients and wide ranges in equianalgesic dose ratios, making it difficult to determine real differences between interventions.
the past such as high blood 2ipressure, angina, pericarditis , pneumonia, pneumothorax, pulmonary 2,embolism, and asthma. 3,PREVIOUS MAJOR SURGERY...other sections of these protocols. a) pulmonary embolus b) pericarditis c) aortic dissection d) acute pancreatitis e) spontaneous mediastinal...anticoagulation. Since anticoagulation camat be accanplished safely aboard ship MECCVAC should be arranged. b) Pericarditis is characterized by mild to
Upp, Justin; Kent, Michael; Tighe, Patrick J.
Background In recent years the field of acute pain medicine has witnessed a surge in its development, and pain has begun to be recognized not merely as a symptom, but as an actual disease process. This development warrants increased education of residents, both in the performance of regional anesthesia, as well as in the disease course of acute pain and the biopsychosocial mechanisms that define inter-individual variability. Review Summary We reviewed the organization and function of the modern acute pain medicine program. Following a discussion of the nomenclature of acute pain related practices, we discuss the historical evolution and modern role of acute pain medicine teams, including the use of traditional, as well as complementary and alternative, therapies for treating acute pain. Staffing and equipment requirements are also evaluated, in addition to the training requirements for achieving expertise in acute pain medicine. Lastly, we briefly explore future considerations related to the essential role and development of acute pain medicine. Conclusion The scope and practice of acute pain medicine must be expanded to include pre-pain/pre-intervention risk stratification and extended through the phase of subacute pain. PMID:23241132
Madhusudhan, Santhosh Kumar
Background Acute low back pain is one the leading cause of doctor's visit in our country with innumerable medication for treatment. Finding an ideal analgesic medication with better efficacy and least adverse effects is always a challenging task to the treating doctor. Methods In this study we compared the efficacy and safety profile of a fixed dose combination of novel analgesic tramadol 37.5 mg/paracetamol 325 mg/caffeine 30 mg/taurine 250 mg with commonly used tramadol 37.5 mg/paracetamol 325 mg tablet in the treatment of moderate to moderately severe acute low back pain. Patients attending 50 clinics throughout India were enrolled in either of the above group and were asked to take one tablet every 6th hour for five consecutive days. The pain evaluation in both groups was done with verbal pain relief scale and pain intensity scale at end of treatment. Results Proportion of patients in novel combination group compared to tramadol/paracetamol only group responding to treatment based on treatment satisfaction (good and excellent) and mean pain intensity (no pain or mild pain), were 81% Vs 45%, (p < 0.001) and 83% Vs 66% (p < 0.001) respectively. Common expected adverse drug reaction like nausea, vomiting and dizziness occurred with far less frequency in patients under novel combination group. Conclusion We conclude that significantly more patients in novel combination drug group compared to tramadol/paracetamol only group had a superior analgesic effect with lesser adverse reactions. PMID:24396231
Scarpato, Salvatore; Atzeni, Fabiola; Sarzi-Puttini, Piercarlo; Brucato, Antonio; Quartuccio, Luca; Pietrogrande, Maurizio; Monti, Giuseppe; Galli, Massimo
Cryoglobulinaemic syndrome (CS) includes clinical signs and symptoms that range from the classic triad of Meltzer and Franklin (purpura, weakness and arthralgias) to multiple organ involvement, and it may be characterised by nociceptive or neuropathic pain. Both types of pain use the same pathways and neurotransmitters, but nociceptive pain has an adaptive system and biological function whereas neuropathic pain does not. Managing CS means dealing with often very different clinical patterns, activity and severity with the aim of preventing irreversible organ damage, reducing pain, improving the patients' quality of life and reducing social costs. However, treatment is still largely empirical, and it is often delayed. The Italian Group for the Study of Cryoglobulinaemia (GISC) strongly recommended a low-antigen-content diet and colchicine for all symptomatic CS patients. Patients with mild-moderate symptoms (such as purpura, weakness, arthralgia and initial neuropathy) have been treated with low or medium doses of steroids, and, in the presence of chronic hepatitis C virus (HCV)-related hepatitis, an attempt has been made to eradicate HCV with pegylated interferon plus ribavirin. In the case of severe or rapidly progressive disease (glomerulonephritis, neuropathy, leg ulcers, widespread vasculitis or hyperviscosity syndrome), more aggressive treatment should be used (e.g., high doses of corticosteroids, plasma exchange plus cyclophosphamide or rituximab). Pain management in CS therefore depends on the type of pain (nociceptive, neuropathic or mixed), the characteristics of the patients and their co-morbidities. Drug therapy should be carefully monitored in order to obtain prompt and beneficial results.
Grosse, A; Grosse, C
The objective of this article is the description of imaging techniques for the evaluation of patients with acute flank pain and suspicion of urolithiasis and the impact of these techniques in the therapy management of patients with calculi.
Raffa, Robert B; Clark-Vetri, Rachel; Tallarida, Ronald J; Wertheimer, Albert I
At least two factors relating to pain management using oral analgesics suggest that combination strategies merit consideration: many pains arise from more than one physiological cause and current analgesics have adverse effect profiles that might be reduced by combination with another agent in smaller doses or with less frequent dosing. In addition to increased convenience, combinations sometimes also result in the unexpected benefit of synergy. But not all pains, clinical settings or combinations merit the extra expense or other potential negative features of fixed-ratio products. This review examines the multiple basic science, clinical and pharmacoeconomic issues relating to analgesic combinations and the methodologies available for assessing these issues.
Romero-Reyes, Marcela; Uyanik, James M
Some of the most prevalent and debilitating pain conditions arise from the structures innervated by the trigeminal system (head, face, masticatory musculature, temporomandibular joint and associated structures). Orofacial pain (OFP) can arise from different regions and etiologies. Temporomandibular disorders (TMD) are the most prevalent orofacial pain conditions for which patients seek treatment. Temporomandibular disorders include a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ) or both. Trigeminal neuropathic pain conditions can arise from injury secondary to dental procedures, infection, neoplasias, or disease or dysfunction of the peripheral and/or central nervous system. Neurovascular disorders, such as primary headaches, can present as chronic orofacial pain, such as in the case of facial migraine, where the pain is localized in the second and third division of the trigeminal nerve. Together, these disorders of the trigeminal system impact the quality of life of the sufferer dramatically. A multidisciplinary pain management approach should be considered for the optimal treatment of orofacial pain disorders including both non-pharmacological and pharmacological modalities. PMID:24591846
Romero-Reyes, Marcela; Uyanik, James M
Some of the most prevalent and debilitating pain conditions arise from the structures innervated by the trigeminal system (head, face, masticatory musculature, temporomandibular joint and associated structures). Orofacial pain (OFP) can arise from different regions and etiologies. Temporomandibular disorders (TMD) are the most prevalent orofacial pain conditions for which patients seek treatment. Temporomandibular disorders include a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ) or both. Trigeminal neuropathic pain conditions can arise from injury secondary to dental procedures, infection, neoplasias, or disease or dysfunction of the peripheral and/or central nervous system. Neurovascular disorders, such as primary headaches, can present as chronic orofacial pain, such as in the case of facial migraine, where the pain is localized in the second and third division of the trigeminal nerve. Together, these disorders of the trigeminal system impact the quality of life of the sufferer dramatically. A multidisciplinary pain management approach should be considered for the optimal treatment of orofacial pain disorders including both non-pharmacological and pharmacological modalities.
Idvall, Ewa; Bergqvist, Anna; Silverhjelm, Jenny; Unosson, Mitra
This study aimed to describe the perspectives of surgical patients towards postoperative pain management during their hospital stay. Thirty strategically chosen postoperative inpatients from different surgical wards in a university hospital in Sweden participated. A qualitative, descriptive approach using individual interviews was chosen. These were tape-recorded, transcribed verbatim, and analyzed according to a qualitative content analysis. The patients' descriptions of postoperative pain management indicated that pain was a symptom that was always in focus, either because it was constantly present or because pain could appear abruptly during different activities and movements. Although the focus was on pain and an awareness that it should be relieved or avoided, the solutions were often routine, short-term, and involved the regular intake of drugs, plus additional medication if needed for an acute pain episode. From the patients' descriptions of their experience with postoperative pain management, we distinguished three categories: "patients' pain knowledge", "patients' pain management approaches", and "patients' views of health-care professionals". The findings from this study highlight important aspects of nursing care that should receive greater attention in postoperative pain management. The patients' narratives could be a valuable asset in the quality improvement of postoperative pain management as these narratives highlight episodes difficult to elicit in other ways.
Derry, Sheena; Faura, Clara; Edwards, Jayne; McQuay, Henry J; Moore, R Andrew
Background Dipyrone (metamizole) is a non-steroidal anti-inflammatory drug used in some countries to treat pain (postoperative, colic, cancer, and migraine); it is banned in others because of an association with life-threatening blood agranulocytosis. This review updates a 2001 Cochrane review, and no relevant new studies were identified, but additional outcomes were sought. Objectives To assess the efficacy and adverse events of single dose dipyrone in acute postoperative pain. Search methods The earlier review searched CENTRAL, MEDLINE, EMBASE, LILACS and the Oxford Pain Relief Database to December 1999. For the update we searched CENTRAL, MEDLINE,EMBASE and LILACS to February 2010. Selection criteria Single dose, randomised, double-blind, placebo or active controlled trials of dipyrone for relief of established moderate to severe postoperative pain in adults. We included oral, rectal, intramuscular or intravenous administration of study drugs. Data collection and analysis Studies were assessed for methodological quality and data extracted by two review authors independently. Summed total pain relief over six hours (TOTPAR) was used to calculate the number of participants achieving at least 50% pain relief. Derived results were used to calculate, with 95% confidence intervals, relative benefit compared to placebo, and the number needed to treat (NNT) for one participant to experience at least 50% pain relief over six hours. Use and time to use of rescue medication were additional measures of efficacy. Information on adverse events and withdrawals was collected. Main results Fifteen studies tested mainly 500 mg oral dipyrone (173 participants), 2.5 g intravenous dipyrone (101), 2.5 g intramuscular dipyrone (99); fewer than 60 participants received any other dose. All studies used active controls (ibuprofen, paracetamol, aspirin, flurbiprofen, ketoprofen, dexketoprofen, ketorolac, pethidine, tramadol, suprofen); eight used placebo controls. Over 70% of participants
Rana, SPS; Gupta, Rahul; Chaudhary, Prakash; Khurana, Deepa; Mishra, Seema; Bhatnagar, Sushma
Cancer pain is multifactorial and complex. The impact of cancer pain is devastating, with increased morbidity and poor quality of life, if not treated adequately. Cancer pain management is a challenging task both due to disease process as well as a consequence of treatment-related side-effects. Optimization of analgesia with oral opioids, adjuvant analgesics, and advanced pain management techniques is the key to success for cancer pain. Early access of oral opioid and interventional pain management techniques can overcome the barriers of cancer pain, with improved quality of life. With timely and proper anticancer therapy, opioids, nerve blocks, and other non-invasive techniques like psychosocial care, satisfactory pain relief can be achieved in most of the patients. Although the WHO Analgesic Ladder is effective for more than 80% cancer pain, addition of appropriate adjuvant drugs along with early intervention is needed for improved Quality of Life. Effective cancer pain treatment requires a holistic approach with timely assessment, measurement of pain, pathophysiology involved in causing particular type of pain, and understanding of drugs to relieve pain with timely inclusion of intervention. Careful evaluation of psychosocial and mental components with good communication is necessary. Barriers to cancer pain management should be overcome with an interdisciplinary approach aiming to provide adequate analgesia with minimal side-effects. Management of cancer pain should comprise not only a physical component but also psychosocial and mental components and social need of the patient. With risk–benefit analysis, interventional techniques should be included in an early stage of pain treatment. This article summarizes the need for early and effective pain management strategies, awareness regarding pain control, and barriers of cancer pain. PMID:21976852
Blacker, Kara J.; Herbert, James D.; Forman, Evan M.; Kounios, John
This study compared two theoretically opposed strategies for acute pain management: an acceptance-based and a change-based approach. These two strategies were compared in a within-subjects design using the cold pressor test as an acute pain induction method. Participants completed a baseline pain tolerance assessment followed by one of the two…
Zakrzewska, J M
The diagnosis and management of facial pain below the eye can be very different dependant on whether the patient visits a dentist or medical practitioner. A structure for accurate diagnosis is proposed beginning with a very careful history. The commonest acute causes of pain are dental and these are well managed by dentists. Chronic facial pain can be unilateral or bilateral and continuous or episodic. The commonest non-dental pains are temporomandibular disorders (TMDs), especially musculoskeletal involving the muscles of mastication either unilaterally or bilaterally; they may be associated with other chronic pains. A very wide range of treatments are used but early diagnosis, reassurance and some simple physiotherapy is often effective in those with good coping strategies. Dentists will often make splints to wear at night. Neuropathic pain is usually unilateral and of the episodic type; the most easily recognized is trigeminal neuralgia. This severe electric shock like pain, provoked by light touch, responds best to carbamazepine, and neurosurgery in poorly controlled patients. Trauma, either major or because of dental procedures, results in neuropathic pain and these are then managed as for any other neuropathic pain. Red flags include giant cell arteritis which much be distinguished from temporomandibular disorders (TMD), especially in >50 yr olds, and cancer which can present as a progressive neuropathic pain. Burning mouth syndrome is rarely recognized as a neuropathic pain as it occurs principally in peri-menopausal women and is thought to be psychological. Chronic facial pain patients are best managed by a multidisciplinary team.
González-Iglesias, Javier; Fernández-de-las-Peñas, Cesar; Cleland, Joshua A; Alburquerque-Sendín, Francisco; Palomeque-del-Cerro, Luis; Méndez-Sánchez, Roberto
Our aim was to examine the effects of a seated thoracic spine distraction thrust manipulation included in an electrotherapy/thermal program on pain, disability, and cervical range of motion in patients with acute neck pain. This randomized controlled trial included 45 patients (20 males, 25 females) between 23 and 44 years of age presenting with acute neck pain. Patients were randomly divided into 2 groups: an experimental group which received a thoracic manipulation, and a control group which did not receive the manipulative procedure. Both groups received an electrotherapy program consisting of 6 sessions of TENS (frequency 100Hz; 20min), superficial thermo-therapy (15min) and soft tissue massage. The experimental group also received a thoracic manipulation once a week for 3 consecutive weeks. Outcome measures included neck pain (numerical pain rate scale; NPRS), level of disability (Northwick Park Neck Pain Questionnaire; NPQ) and neck mobility. These outcomes were assessed at baseline and 1 week after discharge. A 2-way repeated-measures ANOVA with group as between-subject variable and time as within-subject variable was used. Patients receiving thoracic manipulation experienced greater reductions in both neck pain, with between-group difference of 2.3 (95% CI 2-2.7) points on a 11-NPRS, and perceived disability with between-group differences 8.5 (95% CI 7.2-9.8) points. Further, patients receiving thoracic manipulation experienced greater increases in all cervical motions with between-group differences of 10.6 degrees (95% CI 8.8-12.5 degrees) for flexion; 9.9 degrees (95% CI 8.1-11.7 degrees) for extension; 9.5 degrees (95% CI 7.6-11.4 degrees) for right lateral-flexion; 8 degrees (95% CI 6.2-9.8 degrees) for left lateral-flexion; 9.6 degrees (95% CI 7.7-11.6 degrees) for right rotation; and 8.4 degrees (95% CI 6.5-10.3 degrees) for left rotation. We found that the inclusion of a thoracic manipulation into an electrotherapy/thermal program was effective in
Geva, Nirit; Pruessner, Jens; Defrin, Ruth
Anecdotes on the ability of individuals to continue to function under stressful conditions despite injuries causing excruciating pain suggest that acute stress may induce analgesia. However, studies exploring the effect of acute experimental stress on pain perception show inconsistent results, possibly due to methodological differences. Our aim was to systematically study the effect of acute stress on pain perception using static and dynamic, state-of-the-art pain measurements. Participants were 29 healthy men who underwent the measurement of heat-pain threshold, heat-pain intolerance, temporal summation of pain, and conditioned pain modulation (CPM). Testing was conducted before and during exposure to the Montreal Imaging Stress Task (MIST), inducing acute psychosocial stress. Stress levels were evaluated using perceived ratings of stress and anxiety, autonomic variables, and salivary cortisol. The MIST induced a significant stress reaction. Although pain threshold and pain intolerance were unaffected by stress, an increase in temporal summation of pain and a decrease in CPM were observed. These changes were significantly more robust among individuals with stronger reaction to stress ("high responders"), with a significant correlation between the perception of stress and the performance in the pain measurements. We conclude that acute psychosocial stress seems not to affect the sensitivity to pain, however, it significantly reduces the ability to modulate pain in a dose-response manner. Considering the diverse effects of stress in this and other studies, it appears that the type of stress and the magnitude of its appraisal determine its interactions with the pain system.
Massey, Thomas; Derry, Sheena; Moore, R Andrew; McQuay, Henry J
Background Use of topical NSAIDs to treat acute musculoskeletal conditions is widely accepted in some parts of the world, but not in others. Their main attraction is their potential to provide pain relief without associated systemic adverse events. Objectives To review the evidence from randomised, double-blind, controlled trials on the efficacy and safety of topically applied NSAIDs in acute pain. Search methods We searched MEDLINE, EMBASE, The Cochrane Library, and our own in-house database to December 2009. We sought unpublished studies by asking personal contacts and searching on-line clinical trial registers and manufacturers web sites. Selection criteria We included randomised, double-blind, active or placebo (inert carrier)-controlled trials in which treatments were administered to adult patients with acute pain resulting from strains, sprains or sports or overuse-type injuries (twisted ankle, for instance). There had to be at least 10 participants in each treatment arm, with application of treatment at least once daily. Data collection and analysis Two review authors independently assessed trial quality and validity, and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment. Main results Forty-seven studies were included; most compared topical NSAIDs in the form of a gel, spray, or cream with a similar placebo, with 3455 participants in the overall analysis of efficacy. For all topical NSAIDs combined, compared with placebo, the number needed to treat to benefit (NNT) for clinical success, equivalent to 50% pain relief, was 4.5 (3.9 to 5.3) for treatment periods of 6 to 14 days. Topical diclofenac, ibuprofen, ketoprofen, and piroxicam were of similar efficacy, but indomethacin and benzydamine were not significantly better than placebo. Local skin reactions were generally mild and transient, and did not differ from
Baratta, Jaime L; Gandhi, Kishor; Viscusi, Eugene R
Pain management following total knee arthroplasty (TKA) can be challenging. Inadequate pain management following TKA may inhibit rehabilitation, increase morbidity and mortality, decrease patient satisfaction, and lead to chronic persistent postsurgical pain. Traditionally the mainstay of postoperative pain management was opioids; however, the current recommendations to pain management emphasize a multimodal approach and minimizing opioids whenever possible. With careful planning and a multimodal analgesic approach instituted perioperatively, appropriate pain management following TKA can be achieved. Utilizing an extensive review of the literature, this article discusses the analgesic techniques available for the perioperative management of TKA.
Feldman, Kira; Berall, Anna; Karuza, Jurgis; Senderovich, Helen; Perri, Giulia-Anna; Grossman, Daphna
Management of pain in the frail elderly presents many challenges in both assessment and treatment, due to the presence of multiple co-morbidities, polypharmacy, and cognitive impairment. At Baycrest Health Sciences, a geriatric care centre, pain in its acute care unit had been managed through consultations with the pain team on a case-by-case basis. In an intervention informed by knowledge translation (KT), the pain specialists integrated within the social network of the acute care team for 6 months to disseminate their expertise. A survey was administered to staff on the unit before and after the intervention of the pain team to understand staff perceptions of pain management. Pre- and post-comparisons of the survey responses were analysed by using t-tests. This study provided some evidence for the success of this interprofessional education initiative through changes in staff confidence with respect to pain management. It also showed that embedding the pain team into the acute care team supported the KT process as an effective method of interprofessional team building. Incorporating the pain team into the acute care unit to provide training and ongoing decision support was a feasible strategy for KT and could be replicated in other clinical settings.
Warner, Nafisseh S; Warner, Matthew A; Moeschler, Susan M; Hoelzer, Bryan C
Acute pain following amputation can be challenging to treat due to multiple underlying mechanisms and variable clinical responses to treatment. Furthermore, poorly controlled preoperative pain is a risk factor for developing chronic pain. Evidence suggests that epidural analgesia and peripheral nerve blockade may decrease the severity of residual limb pain and the prevalence of phantom pain after lower extremity amputation. We present the perioperative analgesic management of a patient with gangrene of the bilateral upper and lower extremities as a result of septic shock and prolonged vasopressor administration who underwent four-limb amputation in a single procedure. A multimodal analgesic regimen was utilized, including titration of preoperative opioid and neuropathic pain agents, perioperative intravenous, epidural and peripheral nerve catheter infusions, and postoperative oral medication titration. More than 8 months postoperatively, the patient has satisfactory pain control with no evidence for phantom limb pain. To our knowledge, there have been no publications to date concerning analgesic regimens in four-limb amputation.
Mizel, Dennis H
A case of chronic neck and low back pain, resistant to standard chiropractic management of manipulation/adjustment and verbal exercise instruction is presented. Identification of psychosocial factors and deconditioning, with a subsequent three month program of in-office rehabilitation including supervised progressive/resistance exercises and behavioural therapy was administered in conjunction with spinal manipulation/adjustment and passive modalities. The program proved effective in reducing the patient’s neck and low back pain. The beneficial effect of supervised exercises and behavioural therapy in patient management is illustrated.
Dzakovic, Alexander; Superina, Riccardo
Pancreatitis is becoming increasingly prevalent in children, posing new challenges to pediatric health care providers. Although some general adult treatment paradigms are applicable in the pediatric population, diagnostic workup and surgical management of acute and chronic pancreatitis have to be tailored to anatomic and pathophysiological entities peculiar to children. Nonbiliary causes of acute pancreatitis in children are generally managed nonoperatively with hydration, close biochemical and clinical observation, and early initiation of enteral feeds. Surgical intervention including cholecystectomy or endoscopic retrograde cholangiopancreatography is often required in acute biliary pancreatitis, whereas infected pancreatic necrosis remains a rare absolute indication for pancreatic debridement and drainage via open, laparoscopic, or interventional radiologic procedure. Chronic pancreatitis is characterized by painful irreversible changes of the parenchyma and ducts, which may result in or be caused by inadequate ductal drainage. A variety of surgical procedures providing drainage, denervation, resection, or a combination thereof are well established to relieve pain and preserve pancreatic function.
Rosser, Benjamin A; Eccleston, Christopher
Smartphone applications (or apps) are becoming increasingly popular. The lack of regulation or guidance for health-related apps means that the validity and reliability of their content is unknown. We have conducted a review of available apps relating to the generic condition of pain. The official application stores for five major smartphone platforms were searched: iPhone, Android, Blackberry, Nokia/Symbian and Windows Mobile. Apps were included if they reported a focus on pain education, management or relief, and were not solely aimed at health-care professionals (HCPs). A total of 111 apps met the inclusion criteria. The majority of apps reviewed claimed some information provision or electronic manual component. Diary tracking of pain variables was also a common feature. There was a low level of stated HCP involvement in app development and content. Despite an increasing number of apps being released, the frequency of HCP involvement is not increasing. Pain apps appear to be able to promise pain relief without any concern for the effectiveness of the product, or for possible adverse effects of product use. In a population often desperate for a solution to distressing and debilitating pain conditions, there is considerable risk of individuals being misled.
Reported Knowledge and Management of Acute Low Back Pain by United States Army Nurse Practitioners as Compared to Clinical Practice Guidelines Published by the Agency for Health Care Policy and Research
39 Table 7 Patient education identified as appropriate to provide to patient with initial acute low back pain...implications of Guidelines for Acute Low Back Problems 19 acute low back pain and patient education are also examined and presented for consideration by...selection of examinations routinely performed, awareness of danger signs and symptoms warranting urgent referral, patient education , and satisfaction with
... Therapy Pain Management Recommendations References April 15, 2017 Definitions and Types of Pain Defining Pain Pain is ... there are many mechanisms involved in nociception. More definitions ... Classifying Pain Pain can be "acute" or "chronic." ...
Wiffen, Philip J; Derry, Sheena; Moore, R Andrew; McQuay, Henry J
Background Carbamazepine is used to treat chronic neuropathic pain. Objectives Evaluation of analgesic efficacy and adverse effects of carbamazepine for acute and chronic pain management (except headaches). Search methods Randomised controlled trials (RCTs) of carbamazepine in acute, chronic or cancer pain were identified, searching MEDLINE, EMBASE, SIGLE and Cochrane CENTRAL to June 2010, reference lists of retrieved papers, and reviews. Selection criteria RCTs reporting the analgesic effects of carbamazepine. Data collection and analysis Two authors independently extracted results and scored for quality. Numbers needed to treat to benefit (NNT) or harm (NNH) with 95% confidence intervals (CI) were calculated from dichotomous data for effectiveness, adverse effects and adverse event withdrawal. Issues of study quality, size, duration, and outcomes were examined. Main results Fifteen included studies (12 cross-over design; three parallel-group) with 629 participants. Carbamazepine was less effective than prednisolone in preventing postherpetic neuralgia following acute herpes zoster (1 study, 40 participants). No studies examined acute postoperative pain. Fourteen studies investigated chronic neuropathic pain: two lasted eight weeks, others were four weeks or less (mean 3 weeks, median 2 weeks). Five had low reporting quality. Ten involved fewer than 50 participants; mean and median maximum treatment group sizes were 34 and 29. Outcome reporting was inconsistent. Most placebo controlled studies indicated that carbamazepine was better than placebo. Five studies with 298 participants provided dichotomous results; 70% improved with carbamazepine and 12% with placebo. Carbamazepine at any dose, using any definition of improvement was significantly better than placebo (70% versus 12% improved; 5 studies, 298 participants); relative benefit 6.1 (3.9 to 9.7), NNT 1.7 (1.5 to 2.0). Four studies (188 participants) reporting outcomes equivalent to 50% pain reduction or more
Jindal, Gaurav; Ramchandani, Parvati
This article discusses the radiologic management of the patient who has acute flank pain. It describes the evolution of radiologic imaging in patients who present with acute symptoms caused by suspected urolithiasis, the advantages of unenhanced helical CT and the limitations of abdominal radiography, intravenous urography, and ultrasonography in this setting, and the alternative diagnoses encountered within the urinary tract, abdomen, and pelvis.
This article details a self-hypnosis technique designed to teach patients how to manage acute or chronic pain through directed focus. The focused suggestion with somatic anchoring technique has been used with various types of pain, including somatic pain (arthritis, post-injury pain from bone breaks, or muscle tears), visceral pain (related to irritable bowel disease), and neuropathic pain (related to multiple sclerosis). This technique combines cognitive restructuring and mindfulness meditation with indirect and direct suggestions during hypnosis. The case examples demonstrate how the focused suggestion with somatic anchoring technique is used with both acute and chronic pain conditions when use of long-term medication has been relatively ineffective.
Srouji, Rasha; Ratnapalan, Savithiri; Schneeweiss, Suzan
Pain perception in children is complex, and is often difficult to assess. In addition, pain management in children is not always optimized in various healthcare settings, including emergency departments. A review of pain assessment scales that can be used in children across all ages, and a discussion of the importance of pain in control and distraction techniques during painful procedures are presented. Age specific nonpharmacological interventions used to manage pain in children are most effective when adapted to the developmental level of the child. Distraction techniques are often provided by nurses, parents or child life specialists and help in pain alleviation during procedures. PMID:20706640
Balch, Robert J; Trescot, Andrea
Morphine is the archetypal opioid analgesic. Because it is a short-acting opioid, its use has been limited to the management of acute pain. The development of extended-release formulations have resulted in the increased utilization of morphine in chronic pain conditions. This review documents the history of morphine use in pain treatment, and describes the metabolism, pharmacodynamics, formulations, and efficacy of the currently available extended-release morphine medications. PMID:21197323
Vallerand, April Hazard; Cosler, Patricia; Henningfield, Jack E; Galassini, Pam
BACKGROUND: Wounded soldiers often experience substantial pain, which must be addressed before returning to active duty or civilian life. The United States (US) military has instituted several guidelines and initiatives aimed at improving pain management by providing rapid access to medical care, and developing interdisciplinary multimodal pain management strategies based on outcomes observed both in combat and hospital settings. OBJECTIVE: To provide a narrative review regarding US military pain management guidelines and initiatives, which may guide improvements in pain management, particularly chronic pain management and prevention, for the general population. METHODS: A literature review of US military pain management guidelines and initiatives was conducted, with a particular focus on the potential of these guidelines to address shortcomings in chronic pain management in the general population. DISCUSSION: The application of US military pain management guidelines has been shown to improve pain monitoring, education and relief. In addition, the US military has instituted the development of programs and guidelines to ensure proper use and discourage aberrant behaviours with regard to opioid use, because opioids are regarded as a critical part of acute and chronic pain management schemes. Inadequate pain management, particularly inadequate chronic pain management, remains a major problem for the general population in the US. Application of military strategies for pain management to the general US population may lead to more effective pain management and improved long-term patient outcomes. PMID:26448972
Linhares, M.B.M.; Doca, F.N.P.; Martinez, F.E.; Carlotti, A.P.P.; Cassiano, R.G.M.; Pfeifer, L.I.; Funayama, C.A.; Rossi, L.R.G.; Finley, G.A.
The goal of this study was to examine the prevalence, assessment and management of pediatric pain in a public teaching hospital. The study sample consisted of 121 inpatients (70 infants, 36 children, and 15 adolescents), their families, 40 physicians, and 43 nurses. All participants were interviewed except infants and children who could not communicate due to their clinical status. The interview included open-ended questions concerning the inpatients' pain symptoms during the 24 h preceding data collection, as well as pain assessment and pharmacological/non-pharmacological management of pain. The data were obtained from 100% of the eligible inpatients. Thirty-four children/adolescents (28%) answered the questionnaire and for the other 72% (unable to communicate), the family/health professional caregivers reported pain. Among these 34 persons, 20 children/adolescents reported pain, 68% of whom reported that they received pharmacological intervention for pain relief. Eighty-two family caregivers were available on the day of data collection. Of these, 40 family caregivers (49%) had observed their child's pain response. In addition, 74% reported that the inpatients received pharmacological management. Physicians reported that only 38% of the inpatients exhibited pain signs, which were predominantly acute pain detected during clinical procedures. They reported that 66% of patients received pharmacological intervention. The nurses reported pain signs in 50% of the inpatients, which were detected during clinical procedures. The nurses reported that pain was managed in 78% of inpatients by using pharmacological and/or non-pharmacological interventions. The findings provide evidence of the high prevalence of pain in pediatric inpatients and the under-recognition of pain by health professionals. PMID:22983181
Cavalieri, Thomas A
The elderly are often untreated or undertreated for pain. Barriers to effective management include challenges to proper assessment of pain; underreporting on the part of patients; atypical manifestations of pain in the elderly; a need for increased appreciation of the pharmacokinetic and pharmacodynamic changes of aging; and misconceptions about tolerance and addiction to opioids. Physicians can effectively manage pain in the elderly by understanding different types of pain (nociceptive and neuropathic), and appropriate use of nonopioid, opioid, and adjuvant medications. Opioids have become more widely accepted for treating older adults who have persistent pain, but their use requires physicians have an understanding of prevention and management of side effects, opioid titration and withdrawal, and careful monitoring. Placebo use is unwarranted and unethical. Nonpharmacologic approaches to pain management are essential and include osteopathic manipulative treatment, cognitive behavioral therapy, exercise, and spiritual interventions. The holistic and interdisciplinary approach of osteopathic medicine offers an approach that can optimize effective pain management in older adults.
Harrison, Denise; Yamada, Janet; Stevens, Bonnie
Health care professionals caring for neonates (birth to 28 days of life) and infants up to 1 year of age have a professional and ethical responsibility to provide safe and effective pain management during painful procedures. Despite 14 years of research reports highlighting that sick infants are exposed to large numbers of painful procedures with minimal or no provision of pain management strategies, and generation of abundant evidence to support effectiveness of pain reduction strategies, insufficient practice changes have been made. As untreated pain in infancy has both immediate and longer-term negative consequences, such as increased sensitivity and responses to subsequent pain, it is imperative that widespread sustained practice changes are made to reduce the burden of pain. This review highlights recent advances within the past 2 to 3 years in pain management of acute procedural pain for neonates and infants, proposes recommendations for future research, and addresses practical implications and challenges for implementing best pain management practices.
Roth, Maya L; Tripp, Dean A; Harrison, Mark H; Sullivan, Michael; Carson, Patricia
BACKGROUND: As the North American population ages, the prevalence of knee osteoarthritis and the surgical interventions (ie, total knee arthroplasty [TKA]) aimed at correcting pain and disability will also rise proportionally. Therefore, efforts to better understand the factors associated with surgical outcomes are warranted. To date, no studies have examined the impact of psychosocial factors on acute postoperative TKA pain. OBJECTIVES: The primary objective was to examine the associations among catastrophizing, negative mood, demographics and acute postoperative pain following TKA. Ancillary analyses examined the association of preoperative psychological variables with postoperative pain. METHODS: Patients completed questionnaire packages 2 h before their surgery and on three consecutive postoperative days while in the hospital. The questionnaire packages included the Short Form –McGill Pain Questionnaire, the Pain Catastrophizing Scale and the Shortened Version of Profile of Mood States. The Mini-Mental State Examination was also administered. Demographic data were extracted from patients’ medical charts. RESULTS: Associations among catastrophizing, negative mood and pain were established. Regressions showed that younger age predicted greater preoperative and postoperative day 1 pain; catastrophizing predicted preoperative and postoperative day 2 pain; and negative mood predicted postoperative day 3 pain. Catastrophizing and negative mood were highly correlated at several assessment points. Preoperative variables did not predict postoperative pain. CONCLUSION: These results have postoperative pain management implications. Heightened attention to psychosocial variables, such as postoperative catastrophizing and negative mood, may be useful in identifying patients at risk for greater postoperative pain. PMID:17717610
Gupte, Chinmay; St Mart, Jean-Pierre
The acutely swollen knee is a common presentation of knee pathology in both primary care and the emergency department. The key to diagnosis and management is a thorough history and examination to determine the primary pathology, which includes inflammation, infection or a structural abnormality in the knee. The location of pain and tenderness can aid to localization of structural pathology even before radiological tests are requested, and indeed inform the investigations that should be carried out. Aspiration of an acutely swollen knee can aid diagnosis and help relieve pain. The management of the swollen knee depends on underlying pathology and can range from anti-inflammatory medication for inflammation to operative intervention for a structural abnormality.
Gupte, Chinmay; St Mart, Jean-Pierre
The acutely swollen knee is a common presentation of knee pathology in both primary care and the emergency department. The key to diagnosis and management is a thorough history and examination to determine the primary pathology, which includes inflammation, infection or a structural abnormality in the knee. The location of pain and tenderness can aid to localization of structural pathology even before radiological tests are requested, and indeed inform the investigations that should be carried out. Aspiration of an acutely swollen knee can aid diagnosis and help relieve pain. The management of the swollen knee depends on underlying pathology and can range from anti-inflammatory medication for inflammation to operative intervention for a structural abnormality. PMID:23821708
Thapa, Deepak; Rastogi, V; Ahuja, Vanita
Cancer pain is still one of the most feared entities in cancer and about 75% of these patients require treatment with opioids for severe pain.The cancer pain relief is difficult to manage in patients with episodic or incidental pain, neuropathic pain, substance abuse and with impaired cognitive or communication skills. This non-systematic review article aims to discuss reasons for under treatment, tools of pain assessment, cancer pain and anxiety and possibly carve new approaches for cancer pain management in future. The current status of World Health Organization analgesic ladder has also been reviewed. A thorough literature search was carried out from 1998 to 2010 for current status in cancer pain management in MEDLINE, WHO guidelines and published literature and relevant articles have been included. PMID:21772673
Joshi, Gunjan S; Fomin, Daren A; Joshi, Gargi S; Serano, Richard D
Acute calcific longus colli tendinitis (ACLCT), a very rare cause of severe neck pain, dysphagia and odynophagia, is often mistaken for other common causes of neck pain. However, prompt recognition of this uncommon presentation is important to prevent unnecessary medical and surgical intervention. A 46-year-old Caucasian man presented with a 1-day history of severe neck pain, headache and odynophagia. The patient was afebrile with stable vital signs, however, the laboratory data showed mildly elevated C reactive protein and erythrocyte sedimentation rate. The physical examination was remarkable for markedly reduced cervical range of motion. MRI revealed the pathognomonic findings of paravertebral oedema and calcification. The definitive diagnosis of ACLCT was made and the patient was successfully managed with a short course of oral steroid, benzodiazepine and aural acupuncture, with complete resolution of the condition within a week.
Hariharan, Mahesh; Balasubramaniam, Rajan; Shetty, Sharath Kumar; Yadavalli, Shanthala; Ahetasham, Mohammed; Devarapalli, Sravya
Acute abdomen is one of the most common clinical conditions requiring a radiological investigation. Ultrasound is the primary modality of choice which can diagnose some of the common causes of acute abdomen. However, sometimes the underlying cause for the pain is far more complicated than expected mandating a high degree of suspicion to suggest further investigation with contrast enhanced computed tomography or magnetic resonance imaging. Here, we have compiled a comprehensive series of selected cases to highlight the conditions which can be easily overlooked unless carefully sought for. This article also emphasizes the importance of multimodality approach to arrive at the final diagnosis with an increased overall diagnostic accuracy which in turn improves patient management and prognosis. PMID:27014500
Wang, Ning; Wang, Jin-Yan; Luo, Fei
It has been widely accepted that the primary somatosensory cortex (SI) plays an essential role in the sensory-discriminative aspect of pain perception. However, it remains unclear whether the SI has a role in the descending modulation of pain. Although there are abundant fibers projecting back from sensory cortex to thalamic nuclei, and the influence of cortical modulation from SI on the thalamic nociceptive relay neurons has been addressed, little is known about how the cortical outputs modulate the nociceptive behaviors resulting from tissue injury or evoked by painful stimulation. The present study was designed to test whether the cortical outputs influenced the nociceptive behaviors using rat models of noxious thermal-induced acute pain, formalin-induced acute and CFA-evoked chronic inflammatory pain. The results showed that intracortical microinjection of GABAA agonist muscimol significantly reduced the first and second phase behaviors in formalin tests and elevated the nociceptive thresholds in the thermal stimulus-elicited acute pain, suggesting a facilitatory influence of SI on the acute pain sensation. By contrast, microinjection of GABAA antagonist bicuculline remarkably reduced the thermal hyperalgesia of the CFA-inflamed hindpaws, indicating an inhibitory effect of SI output in the chronic pain state. The opposite modulatory effects in acute and chronic pain states suggest that there exists a functional switch for the SI cortex at different stages of pain disease, which is of great significance for the biological adaptation.
Kubik, Alicja; Biedroń, Agnieszka
Pain management is based mainly on pharmacotherapy which has many limitations. Non-pharmacological techniques, like neurofeedback (EEG-biofeedback) are alternative methods of pain treatment. Data from literature confirm high efficacy of neurofeedback in pain syndromes treatment, chronic and acute as well. Neurofeedback plays an important role in management of post stroke, post traumatic headaches and in primary headaches like tension type headaches or migraine. Literature review and own experience indicate importance of number and frequency of performed neurofeedback trainings on treatment effectiveness. Satisfactory results have already been observed after 30 trainings however usually 40-60 training have to be performed. Effectiveness of such therapy in pain syndromes is usually good or less often acceptable (50% reduction of headaches). Children with tension type headaches (differently than adults) need reminder therapy every 6-12 months, otherwise recurrence of headaches is observed. Based on our own experience neurofeedback therapy seems to play role in neuropathic pain and cancer pain management.
Low, Sheng Jia; Wong, Stanley Sau Ching; Qiu, Qiu; Lee, Yvonne; Chan, Timmy Chi Wing; Irwin, Michael G.; Cheung, Chi Wai
Abstract Acute pain services (APS) have evolved over time. Strategies nowadays emphasize multimodal analgesic regimes using a combination of nonopioid adjuvant analgesic drugs, peripheral nerve blocks, and local anaesthetic wound infiltration where appropriate. APS should be assessed over time to evaluate changes in outcomes which form the basis for future development. In this audit, data of patients under APS care in Queen Mary hospital, Hong Kong, between 2009 and 2012 were analyzed and compared with data from a previous audit between 1992 and 1995. The use of patient-controlled analgesia (PCA) was increased (from 69.3% to 86.5%, P < 0.001), while the use of epidural analgesia reduced (from 25.3% to 8.3%, P < 0.001) significantly. Although postoperative pain scores did not improve, PCA opioid consumption and the incidence of analgesia-related side effects were significantly less (all P < 0.001). More patients graded their postoperative analgesic techniques used as good when the results from these 2 audit periods were compared (P < 0.001 and P = 0.001 for PCA and epidural analgesia, respectively). In conclusion, there has been a change in analgesic management techniques, but there has been no improvement in overall pain relief. While changes over time have led to improvement in important parameters such as the incidence of side effects and patient satisfaction, further and continuous efforts and improvements are warrant to reduce acute pain relief and suffering of the patients after the surgery. PMID:26448012
Cole, Elaine; Lynch, Antonia; Cugnoni, Helen
Abdominal pain has many causes, from simple to complex presentations. Patients with abdominal pain may have a number of physiological and psychological needs. Nurses have a key role to play in patient assessment, history talking and management.
Darawad, Muhammad W; Al-Hussami, Mahmoud; Saleh, Ali M; Al-Sutari, Manal
Pain is still undertreated among hospitalized patients. Recently, patient satisfaction with pain management has received significant attention. This field has not yet been explored among Jordanian patients. The purpose of this study was to determine the knowledge regarding pain characteristics, beliefs, and satisfaction that can be included in planning pain management strategies and protocols within Jordanian hospitals. Using descriptive cross-sectional methodology, the American Pain Society Patient Outcome Questionnaire (APS-POQ) was used to survey 375 inpatients from Jordanian hospitals. Participants reported relatively severe pain and pain interferences while being hospitalized and seemed to be well informed regarding pain and pain management. Participants reported high levels of pain management satisfaction. Also, the Arabic version of the APS-POQ was found to be reliable among the Jordanian population. Findings of this study are similar to those reported by earlier studies in other countries and support the need for applying the caring attitude in managing patients' reports of having pain. This study is the first in Jordan, opening the door for future studies to be conducted in this important field.
Heiskanen, Tarja; Hamunen, Katri; Hirvonen, Outi
Palliative pain management is usually successful, if the medication is strengthened in a stepwise manner in accordance with pain intensity, and initiation of a strong opioid is not delayed. Finding of a sufficiently effective dose of the opioid drug with simultaneous management of adverse effects requires continuous pain assessment and patient monitoring. In many cases it is possible to enhance analgesia by supplementing the medication with an antidepressant or an antiepileptic along with the opioid and paracetamol or the analgesic. Palliative radiotherapy will relieve tissue injury pain caused by bone metastases and soft tissue tumors as well as pain due to the possible nerve entrapments caused by them.
Englbrecht, J S; Pogatzki-Zahn, E M
Abdominal and thoracic surgical procedures can result in significant acute postoperative pain. Present evidence shows that postoperative pain management remains inadequate especially after "minor" surgical procedures. Various therapeutic options including regional anesthesia techniques and systemic pharmacotherapy are available for effective treatment of postoperative pain. This work summarizes the pathophysiological background of postoperative pain after abdominal and thoracic surgery and discusses the indication, effectiveness, risks, and benefits of the different therapeutic options. Special focus is given to the controversial debate about the indication for epidural analgesia, as well as various alternative therapeutic options, including transversus abdominis plane (TAP) block, paravertebral block (PVB), wound infiltration with local anesthetics, and intravenous lidocaine. In additional, indications and contraindications of nonopioid analgesics after abdominal and thoracic surgery are discussed and recommendations based on scientific evidence and individual risk and benefit analysis are made. All therapeutic options discussed are eligible for clinical use and may contribute to improve postoperative pain outcome after abdominal and thoracic surgical procedures.
DiLorenzo, Miranda; Pillai Riddell, Rebecca; Holsti, Liisa
This topical review presents the current challenges in defining chronic pain in infants, summarizes evidence from animal and human infant studies regarding the biological processes necessary for chronic pain signaling, and presents observational/experiential evidence from clinical experts. A literature search of four databases (CINAHL, EMBASE, PsycINFO, and MEDLINE) was conducted, along with hand searches of reference lists. Evidence from animal studies suggest that important neurophysiological mechanisms, such as the availability of key neurotransmitters needed for maintenance of chronic pain, may be immature or absent in the developing neonate. In some cases, human infants may be significantly less likely to develop chronic pain. However, evidence also points to altered pain perception, such as allodynia and hyperalgesia, with significant injury. Moreover, clinicians and parents in pediatric intensive care settings describe groups of infants with altered behavioral responses to repeated or prolonged painful stimuli, yet agreement on a working definition of chronic pain in infancy remains elusive. While our understanding of infant chronic pain is still in the rudimentary stages, a promising avenue for the future assessment of chronic pain in infancy would be to develop a clinical tool that uses both neurophysiological approaches and clinical perceptions already presented in the literature. PMID:27834860
Bastian, Brock; Jetten, Jolanda; Hornsey, Matthew J
The idea that pain may serve to produce pleasurable states has been noted by theorists and, more recently, substantiated by empirical findings. We explored the possibility that, beyond producing positive hedonic states, the offset of pain may serve to enhance the capacity for gustatory pleasure. Across three studies we examined whether pain offset may enhance responsiveness to taste. In Study 1 participants enjoyed chocolate more after the experience of pain compared to completing a similar but non-painful task. In Study 2, pain offset increased the perceived intensity of a range of tastes, both pleasant and unpleasant, indicating that the effects of pain offset are not limited to the processing of positive hedonic stimuli. In Study 3, pain offset increased sensitivity to different flavors. The findings suggest that the offset of acute pain increases awareness of, and therefore sensitivity to, gustatory input, thereby enhancing the capacity for gustatory pleasure.
Bastian, Brock; Jetten, Jolanda; Hornsey, Matthew J
The idea that pain may serve to produce pleasurable states has been noted by theorists and, more recently, substantiated by empirical findings. We explored the possibility that, beyond producing positive hedonic states, the offset of pain may serve to enhance the capacity for gustatory pleasure. Across three studies we examined whether pain offset may enhance responsiveness to taste. In Study 1 participants enjoyed chocolate more after the experience of pain compared to completing a similar but non-painful task. In Study 2, pain offset increased the perceived intensity of a range of tastes, both pleasant and unpleasant, indicating that the effects of pain offset are not limited to the processing of positive hedonic stimuli. In Study 3, pain offset increased sensitivity to different flavors. The findings suggest that the offset of acute pain increases awareness of, and therefore sensitivity to, gustatory input, thereby enhancing the capacity for gustatory pleasure.
Tighe, Patrick; Buckenmaier, Chester C.; Boezaart, Andre P.; Carr, Daniel B.; Clark, Laura L.; Herring, Andrew A.; Kent, Michael; Mackey, Sean; Mariano, Edward R.; Polomano, Rosemary C.; Reisfield, Gary M.
Background Consensus indicates that a comprehensive, multimodal, holistic approach is foundational to the practice of acute pain medicine (APM), but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service, which is often unavailable or inconsistently applied. This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. Methods A multidisciplinary panel was nominated through the Acute Pain Medicine Shared Interest Group (APMSIG) of the American Academy of Pain Medicine (AAPM). The panel met in Chicago, Illinois, in July 2014, to identify gaps and set priorities in APM research and education. Results The panel identified 3 areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers, hospital administrators, and other key stakeholders to convey the importance of APM. Conclusion This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain. PMID:26535424
Jamison, Robert N.; Edwards, Robert R.
There is much evidence to suggest that psychological and social issues are predictive of pain severity, emotional distress, work disability, and response to medical treatments among persons with chronic pain. Psychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management, leading to a greater likelihood of treatment success. The assessment of different domains using semi-structured clinical interviews and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral and social issues in order to facilitate treatment planning. We briefly describe measures to assess constructs related to pain and intervention strategies for the behavioral treatment of chronic pain and discuss related psychiatric and substance abuse issues. Finally, we offer a future look at the role of integrating pain management in clinical practice in the psychological assessment and treatment for persons with chronic pain. PMID:22383018
Kuusniemi, Kristiina; Pöyhiä, Reino
This paper is a summary of presentations on postoperative pain control by the authors at the 2014 PainForum meeting in People’s Republic of China. Postoperative pain is often untreated or undertreated and may lead to subsequent chronic pain syndromes. As more procedures migrate to the outpatient setting, postoperative pain control will become increasingly more challenging. Evidence-based guidelines for postoperative pain control recommend pain assessment using validated tools on a consistent basis. In this regard, consistency may be more important than the specific tool selected. Many hospitals have introduced a multidisciplinary acute pain service (APS), which has been associated with improved patient satisfaction and fewer adverse events. Patient education is an important component of postoperative pain control, which may be most effective when clinicians chose a multimodal approach, such as paracetamol (acetaminophen) and opioids. Opioids are a mainstay of postoperative pain control but require careful monitoring and management of side effects, such as nausea, vomiting, dizziness, and somnolence. Opioids may be administered using patient-controlled analgesia systems. Protocols for postoperative pain control can be very helpful to establish benchmarks for pain management and assure that clinicians adhere to evidence-based standards. The future of postoperative pain control around the world will likely involve more and better established APSs and greater communication between patients and clinicians about postoperative pain. The changes necessary to implement and move forward with APSs is not a single step but rather one of continuous improvement and ongoing change. PMID:26893579
Linkewich, Barbara; Sevean, Patricia; Habjan, Sonja; Poling, Margaret; Bailey, Susan; Kortes-Miller, Kathy
The Centre for Education and Research on Aging and Health at Lakehead University, Thunder Bay, Ontario, was the lead agency in developing a pain management continuing education program for front-line nurses in a variety of settings in northwestern Ontario. A committee of experts from the centre as well as from the Thunder Bay Regional Health Sciences Centre; Regional Cancer Care; the Pain and Symptom Management Team, North West Community Care Access Centre; the Victorian Order of Nurses and Lakehead University school of nursing developed the program. The program included a pre-test of knowledge and attitudes; four two-hour educational sessions focusing on total pain, acute pain, chronic pain and cancer pain; and a post self-test at the end of each session. The educational sessions were evaluated through a survey to participants. Overall, the nurses expressed high satisfaction with the workshops, and the post self-tests indicated a better understanding of patients' pain management experiences. As a result of the evaluation, the education planning committee refined the program, which is currently being delivered to nurses in rural and remote communities via telehealth.
Szumita, Richard P; Szumita, Paul M; Just, Nancy
The specialty of oral and maxillofacial surgery has had at its core the foundations of anesthesia and pain and anxiety control. This article attempts to refamiliarize the reader with clinical pearls helpful in the management of patients with chronic pain conditions. The authors also hope to highlight the interplay of chronic pain and psychology as it relates to the oral and maxillofacial surgery patient. To that end, the article outlines and reviews the neurophysiology of pain, the definitions of pain, conditions encountered by the oral and maxillofacial surgeon that produce chronic pain, the psychological impact and comorbidities associated with patients experiencing chronic pain conditions, and concepts of multimodal treatment for patients experiencing chronic pain conditions.
Laing, F C; Federle, M P; Jeffrey, R B; Brown, T W
To define the role of ultrasound in evaluating acute right upper quadrant pain, a prospective study was performed on 52 patients having clinically suspected acute cholecystitis. Ultrasonographic determination of acute or chronic cholecystitis, or diagnosis of a normal gallbladder, was based on analysis of location of tenderness, calculi, sludge, and wall thickness. The diagnosis of acute cholecystitis (34.6% of patients) was based on the highly significant observations of focal gallbladder tenderness and calculi. Sludge and wall thickening were also statistically significant, but to a lesser degree. Cholelithiasis allowed differentiation of patients with chronic cholecystitis (32.7%) from patients with normal gallbladders (32.7%). Neither of these two groups had significant focal gallbladder tenderness, sludge, or thickened walls. Because acute cholecystitis is found in the minority of patients with acute right upper quadrant pain, and because ultrasound is rapid, accurate, and noninvasive, it should be the initial modality used to evaluate these patients.
Soulen, Michael C.
This case presented challenging diagnostic and management issues in a young healthy man who presented with abdominal pain and new-onset hypertension. The differential diagnosis evolved over the course of the clinical presentation. The patient had severe vascular involvement of his renal and basal cerebral arteries that initially was assumed to be due to a vasculitic process or hypercoagulable state. Finally it became apparent that the patient did not have a systemic illness but rather a localized vascular disease most likely due to segmental arterial mediolysis, a rare, under-recognized condition that can potentially be fatal. This condition is often difficult to distinguish from fibromuscular dysplasia. It is important to recognize and correctly diagnose the condition, particularly in the acute phase of the disease, because delay in diagnosis can contribute to morbidity and mortality. PMID:25583291
Cohen, Debbie L; Soulen, Michael C
This case presented challenging diagnostic and management issues in a young healthy man who presented with abdominal pain and new-onset hypertension. The differential diagnosis evolved over the course of the clinical presentation. The patient had severe vascular involvement of his renal and basal cerebral arteries that initially was assumed to be due to a vasculitic process or hypercoagulable state. Finally it became apparent that the patient did not have a systemic illness but rather a localized vascular disease most likely due to segmental arterial mediolysis, a rare, under-recognized condition that can potentially be fatal. This condition is often difficult to distinguish from fibromuscular dysplasia. It is important to recognize and correctly diagnose the condition, particularly in the acute phase of the disease, because delay in diagnosis can contribute to morbidity and mortality.
Driessen, Bernd; Bauquier, Sébastien H; Zarucco, Laura
Managing pain in horses afflicted by chronic laminitis is one of the greatest challenges in equine clinical practice because it is the dreadful suffering of the animals that most often forces the veterinarian to end the battle with this disease. The purpose of this review is to summarize our current understanding of the complex mechanisms involved in generating and amplifying pain in animals with laminitis and, based on this information, to propose a modified approach to pain therapy. Furthermore, a recently developed pain scoring technique is presented that may help better quantify pain and the monitoring of responses to analgesic treatment in horses with laminitis.
Amorin-Woods, Lyndon G.; Beck, Randy W.; Parkin-Smith, Gregory F.; Lougheed, James; Bremner, Alexandra P.
Aim: To determine adherence to clinical practice guidelines in the medical, physiotherapy and chiropractic professions for acute and subacute mechanical low back pain through best-evidence synthesis of the healthcare literature. Methods: A structured best-evidence synthesis of the relevant literature through a literature search of relevant databases for peer-reviewed papers on adherence to clinical practice guidelines from 1995 to 2013. Inclusion of papers was based on selection criteria and appraisal by two reviewers who independently applied a modified Downs & Black appraisal tool. The appraised papers were summarized in tabular form and analysed by the authors. Results: The literature search retrieved 23 potentially relevant papers that were evaluated for methodological quality, of which 11 studies met the inclusion criteria. The main finding was that no profession in the study consistently attained an overall high concordance rating. Of the three professions examined, 73% of chiropractors adhered to current clinical practice guidelines, followed by physiotherapists (62%) and then medical practitioners (52%). Conclusions: This review showed that quality papers in this area of research are very limited. Notwithstanding, chiropractors appear to adhere to clinical practice guidelines more so than physiotherapists and medical practitioners, although there is scope for improvement across all three professions. PMID:25202150
Jones, R. Carter W.; Wallace, Mark S.
Pain is a common complaint in inflammatory bowel disease, and it has significant consequences for patients' quality of life. A thorough evaluation to determine the source of patients' pain should include clinical, laboratory, radiologic, and endoscopic assessments as indicated. Differentiating among active inflammation, secondary complications, and functional pain can be complicated. Even when all active disease is adequately treated, clinicians are often left with the difficulty of managing chronic pain. This paper will review the benefits and limitations of several commonly used treatments and promising future therapies. A suggested treatment algorithm will provide some guidance in this challenging area of inflammatory bowel disease management. PMID:22298998
McGreevy, Kai; Bottros, Michael M.; Raja, Srinivasa N.
Chronic pain is the leading cause of disability in the United States. The transition from acute to persistent pain is thought to arise from maladaptive neuroplastic mechanisms involving three intertwined processes, peripheral sensitization, central sensitization, and descending modulation. Strategies aimed at preventing persistent pain may target such processes. Models for studying preventive strategies include persistent post-surgical pain (PPP), persistent post-trauma pain (PTP) and post-herpetic neuralgia (PHN). Such entities allow a more defined acute onset of tissue injury after which study of the long-term effects is more easily examined. In this review, we examine the pathophysiology, epidemiology, risk factors, and treatment strategies for the prevention of chronic pain using these models. Both pharmacological and interventional approaches are described, as well as a discussion of preventive strategies on the horizon. PMID:22102847
Cofano, Gregory P.; Anderson, Benjamin C.; Stumpff, Eric R.
Objective The purpose of this case report is to describe chiropractic care of an adolescent with acute low back pain and incidental finding of spina bifida occulta managed with high-velocity low-amplitude manipulation. Clinical Features A 10-year-old boy was referred for chiropractic care by his pediatrician for the management of low back pain after a fall 3 days prior. Examination and medical records revealed the patient also had spina bifida occulta at the level of L5. Intervention and Outcome High-velocity low-amplitude treatment for lower back pain showed resolution of patient's pain after 6 visits. No adverse effects were reported. Conclusion An adolescent patient with lower back pain and incidental finding of spina bifida occulta improved with a course of care that included with high-velocity low-amplitude manipulation therapy. PMID:25435841
Leite, Adriana Moraes; Castral, Thaila Correa; Scochi, Carmen Gracinda Silvan
This review study aimed to identify the efficacy of breastfeeding and its component aspects (contact, sucking, odor and milk) as nonpharmacological measures for pain relief in newborns. 14 articles from Medline/PubMed were analyzed. We observed methodological differences related to sampling, painful procedures, periods, treatment administration and variables measured. Breastfeeding and its component aspects were perceived as efficient to relieve acute pain. We observed the need for studies to evaluate the analgesic effect of breastfeeding before the painful procedure until recovery. This period is sufficient to achieve the analgesic effect after milk absorption. The interaction between all breastfeeding components must be considered.
Llorens Marina, Carlos I; Cedeño, Alex; Lugo-Vicente, Humberto; Chapel, Cristel; Rivera, Glorimar; Diaz, Antonio
Wandering spleen is a rare occurrence where the spleen normal fixation to the abdominal wall is lost and thus allowed to change in position. We report a case of a child who presented with acute abdominal pain secondary to a wandering spleen complicated by torsion of its vascular pedicle. The diagnosis was promptly made using computed tomography and managed with splenectomy.
Likar, R; Jaksch, W; Aigmüller, T; Brunner, M; Cohnert, T; Dieber, J; Eisner, W; Geyrhofer, S; Grögl, G; Herbst, F; Hetterle, R; Javorsky, F; Kress, H G; Kwasny, O; Madersbacher, S; Mächler, H; Mittermair, R; Osterbrink, J; Stöckl, B; Sulzbacher, M; Taxer, B; Todoroff, B; Tuchmann, A; Wicker, A; Sandner-Kiesling, A
Despite many positive developments, postoperative pain and its treatment is still not always given the necessary attention. Severe pain after surgical procedures affects a significant proportion of patients. This very fact is not only detrimental to the immediate recovery process, but can also form the basis for the development of chronic pain conditions.An adequate and effective management of perioperative pain requires appropriate organizational structures. This multidisciplinary paper which was initiated by the Austrian Society for Anaesthesiology and Intensive Care and the Austrian Pain Society and developed together with numerous specialist and professional societies dealing with the subject aims at supporting the organization of perioperative pain management structures and to make best use of proven concepts. Additional recommendations describe specific interventions for selected types of intervention.
Administering pain medication to terminal patients can cause legal problems when it has a life-shortening effect, because according to some authors it equates with manslaughter. The legal basis of the acceptance of pain alleviation with life-shortening effect can be found on the grounds of necessity. In different countries physicians have been prosecuted because of their pain management, which to the public prosecutor was in fact a sort of euthanasia. On the other hand, it is not unknown that physicians administer opioids to mask euthanasia. Pain management needs some rules, which can reassure the physician who alleviates pain. The physician who alleviates pain with life-shortening effect will have to act with due care to avoid a liability risk. This implies at least an informed consent, to observe the proportionality rule, and to keep a medical record.
Mekaroonkamol, Parit; Willingham, Field F; Chawla, Saurabh
Pancreatic cancer is the fourth leading cause of cancer-related death in the United States and one of the leading causes of cancer mortality in the United States. Due to its aggressive behavior and lack of effective therapies, palliation plays a critical role in the management of the disease. Most patients with pancreatic cancer suffer from severe pain, which adversely predicts prognosis and significantly impacts the quality of life. Therefore pain management plays a central role in palliation. Non-steroidal anti-inflammatory drugs and opioid agents are often first line medications in pain management, but they do not target the underlying pathophysiology of pain and their use is limited by adverse effects and dependence. The proposed mechanisms of pain development in pancreatic cancer include neurogenic inflammation and ductal hypertension which may be targeted by endoscopic therapies. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) and pancreatic duct stent placement are the two primary endoscopic modalities for palliative management in pancreatic cancer patients with refractory pain. Other endoscopic treatments such as biliary stent placement and enteral stent placement for biliary and duodenal obstruction may also help palliate pain in addition to their role in decompression. This article reviews the existing evidence for these endoscopic interventions for pain management in pancreatic cancer.
Moore, Sarah A.
Disorders of the somatosensory system such as neuropathic pain are common in people with chronic neurologic and musculoskeletal diseases, yet these conditions remain an underappreciated morbidity in veterinary patients. This is likely because assessment of neuropathic pain in people relies heavily on self-reporting, something our veterinary patients are not able to do. The development of neuropathic pain is a complex phenomenon, and concepts related to it are frequently not addressed in the standard veterinary medical curriculum such that veterinarians may not recognize this as a potential problem in patients. The goals of this review are to discuss basic concepts in the pathophysiology of neuropathic pain, provide definitions for common clinical terms used in association with the condition, and discuss pharmacological treatment options for dogs with neuropathic pain. The development of neuropathic pain involves key mechanisms such as ectopic afferent nerve activity, peripheral sensitization, central sensitization, impaired inhibitory modulation, and pathologic activation of microglia. Treatments aimed at reducing neuropathic pain are targeted at one or more of these mechanisms. Several drugs are commonly used in the veterinary clinical setting to treat neuropathic pain. These include gabapentin, pregabalin, amantadine, and amitriptyline. Proposed mechanisms of action for each drug, and known pharmacokinetic profiles in dogs are discussed. Strong evidence exists in the human literature for the utility of most of these treatments, but clinical veterinary-specific literature is currently limited. Future studies should focus on objective methods to document neuropathic pain and monitor response to therapy in veterinary patients. PMID:26942185
Liu, Donghua; Ma, Jianzhong; Zhang, Zongwang; Yu, Ailan; Chen, Xueli; Feng, Cuicui; Lei, Weifu
Abstract The aim of the study was to investigate current situation of postoperative pain management in medical institutions in Shandong Province.A questionnaire was developed on the basis of guidelines of acute pain and pain quality assessment scale. The questionnaire was used to obtain information regarding the nature and scale of the medical institution, structure of pain management organization, implementation of pain assessment, and analgesic techniques and processes used in clinical practice. A multistage stratified and cluster sampling method was employed to investigate the current situation of postoperative pain management in 168 medical institutions in Shandong Province. For acute pain service (APS), 32% of the hospitals established postoperative pain management organizations similar to APS. For pain evaluation, 57.1% of the hospitals evaluated pain as the fifth vital sign, and 47.0% of the hospitals evaluated pain at rest and during activity. Furthermore, 43.0% of the surveyed hospitals employed patient-controlled analgesia mode, of which hospitals employing brachial plexus block, lumbar plexus block, and femoral nerve block analgesia accounted for 5.0%, 1.0%, and 4.0%, respectively. The survey revealed that 51.0% of the hospitals educated patients about pain and pain management, of which patients were postoperatively educated by ward nurses in 5.0% and patients were educated by APS during ward rounds in 2.0%. There is a lack of standardized postoperative pain management, the involvement of nurses in pain management is scarce, and the pain assessment and education and application of advanced analgesic management techniques were found to be inadequate in medical institutions in Shandong Province. PMID:26871800
Chauhan, Aman; Weiss, Jared; Warrier, Raj
In the last several decades, there have been major advances in the treatment of pediatric cancers. 5 year survival of children with acute lymphoblastic leukemia has increased from 25% to 80%. Early stages of non -Hodgkin's, Hodgkin's and Wilms tumors all have more than 90% long term survival. In addition to improving survival, the comprehensive care of children with cancer must offer total care including special emphasis on pain management and psychosocial support by a multidisciplinary team. Pain considerations in children are unique and differ from those in adults. For example, bone pain is often one of the presenting symptoms of leukemia in children, but can be mistaken for growing pain or labeled psychological. Bone pain is also a prominent symptom in late stage neuroblastoma, and of course in bone tumors. The American Medical Association and National Cancer Institute promote the absence of pain as a patient right and a marker of good clinical care and a quality of care issue. Pain due to disease burden responds dramatically to chemotherapy and the uninitiated are often surprised by the sudden increase in activity and playfulness of children undergoing induction chemotherapy. History and physical data, with special assessment of pain should be part of the medical record of all children.
Wiederhold, Brenda K; Gao, Kenneth; Kong, Lingjun; Wiederhold, Mark D
Approximately 108 million people in North America and Europe suffer from chronic pain. Virtual reality (VR) is a promising method for pain management in a clinical setting due to the distracting properties of an immersive virtual environment. In this study, we demonstrated the potential use of mobile phones as a means of delivering an easily accessible, immersive experience. Thirty-one patients tested VR pain distraction. Objective measurements of heart rate correlated to decreased anxiety, while, subjectively, patients also reported reduced levels of discomfort. The positive results of this study indicate that mobile phones can provide an immersive experience sufficient to deliver pain management distraction. Because mobile devices are widely available, the potential for developing pain management programs that are accessible has become a realistic possibility.
Pain is a symptom associated with prolonged recovery from illness and procedures, decreased quality of life, and increased health-care costs. While there have been advances in the management of cancer pain, there is a need for therapeutic strategies that complement pharmaceutical management without significantly contributing to the side-effect profile of these agents. Hypnosis provides a safe and efficacious supplement to pharmaceutical management of cancer pain. One barrier to the regular use of hypnosis is health-care providers’ lack of current knowledge of the efficacy and safety of hypnosis. Advanced practitioners who are well-informed about hypnosis have an opportunity to increase the treatment options for patients who are suffering with cancer pain by suggesting to the health-care team that hypnosis be incorporated into the plan of care. Integration of hypnosis into the standard of care will benefit patients, caregivers, and survivors by reducing pain and the suffering associated with it. PMID:25031986
Miaskowski, Christine; Rustøen, Tone; Rosseland, Leiv Arne; Paul, Steven M.; Cooper, Bruce A.; Lerdal, Anners
Objective. Total knee arthroplasty is a painful procedure. No studies have evaluated modifiable predictors of acute postoperative pain trajectories during hospitalization. Methods. Consecutive patients (N = 188) were enrolled in a longitudinal cohort study and completed a demographic questionnaire, as well as the Brief Pain Inventory, Hospital Depression and Anxiety Scale, Lee Fatigue Scale, Fatigue Severity Scale, and Brief Illness Perception Questionnaire on the day before surgery. Clinical data were extracted from medical records. Setting and Patients. Each patient completed a pain diary that assessed pain at rest and with activity, and hours per day in pain every evening from day of surgery until postoperative day 3. Using hierarchical linear modeling, we investigated which demographic, clinical, symptom, and psychological characteristics predicted initial levels as well as the trajectories of acute pain at rest and with activity, and hours per day in pain. Results. Higher levels of all three acute pain characteristics on the day of surgery resulted in worse trajectories. Higher pain scores with rest and with activity on the day of surgery were associated with more days with femoral block, higher average dose of opioids, and higher emotional response to osteoarthritis. Higher number of comorbidities, higher average dose of opioids, and lower perceived control predicted more hours per day in pain on the day of surgery. Conclusions. This study identified several potentially modifiable predictors of worsening pain trajectories following total knee arthroplasty. Optimal pain management warrants identification of these high-risk patients and treatment of modifiable risk factors. PMID:27165969
Lumbar intervertebral disk protrusion can cause excruciating pain in severe cases, which can be exacerbated by activity such as sitting down and straining at stool. Acute sciatica due to disk rupture will improve within 1 to 3 months. The efficacy of drugs used for the management of sciatica in primary care is unclear. Severe cases can require opioid analgesia, however people taking opioids for pain relief frequently present with opioid-induced bowel dysfunction. The use of transforaminal steroid injections is a controversial issue and repeat steroid injections should be considered in light of the risk-benefit profile of the individual patient.
Waseem, Tariq; Latif, Hina; Shabbir, Bilquis
Dengue fever is an acute febrile viral disease caused by the bite of Aedes aegypti mosquito. It is a major health problem especially in tropical and subtropical areas including South East Asia and Pakistan. In the past few years, dengue fever has been endemic in Northern Punjab. Physicians managing dengue fever come across varied and uncommon complications of dengue fever. We report a case of dengue fever that developed severe right upper quadrant abdominal pain and induration after extreme retching and vomiting for 2 days. A rectus sheath hematoma was confirmed on noncontrast computed tomography (CT). Rectus sheath hematoma as a complication of dengue fever has rarely been reported before and never from this part of the world. Rectus sheath hematoma is an uncommon and often clinically misdiagnosed cause of abdominal pain. It is the result of bleeding into the rectus sheath from damage to the superior or inferior epigastric artery or their branches or from a direct tear of the rectus muscle. It can mimic almost any abdominal condition (See Fig.) (See Table).
Love, Brandy L; Jensen, Louise A; Schopflocher, Donald; Tsui, Ban CH
BACKGROUND: Quality assurance is increasingly important in the current health care climate. An electronic database can be used for tracking patient information and as a research tool to provide quality assurance for patient care. OBJECTIVE: An electronic database was developed for the Acute Pain Service, University of Alberta Hospital (Edmonton, Alberta) to record patient characteristics, identify at-risk populations, compare treatment efficacies and guide practice decisions. METHOD: Steps in the database development involved identifying the goals for use, relevant variables to include, and a plan for data collection, entry and analysis. Protocols were also created for data cleaning quality control. The database was evaluated with a pilot test using existing data to assess data collection burden, accuracy and functionality of the database. RESULTS: A literature review resulted in an evidence-based list of demographic, clinical and pain management outcome variables to include. Time to assess patients and collect the data was 20 min to 30 min per patient. Limitations were primarily software related, although initial data collection completion was only 65% and accuracy of data entry was 96%. CONCLUSIONS: The electronic database was found to be relevant and functional for the identified goals of data storage and research. PMID:22518364
Waddell, G; Feder, G; Lewis, M
BACKGROUND: In the United Kingdom (UK), 9% of adults consult their doctor annually with back pain. The treatment recommendations are based on orthopaedic teaching, but the current management is causing increasing dissatisfaction. Many general practitioners (GPs) are confused about what constitutes effective advice. AIM: To review all randomized controlled trials of bed rest and of medical advice to stay active for acute back pain. METHOD: A systematic review based on a search of MEDLINE and EMBASE from 1966 to April 1996 with complete citation tracking for randomized controlled trials of bed rest or medical advice to stay active and continue ordinary daily activities. The inclusion criteria were: primary care setting, patients with low back pain of up to 3 months duration, and patient-centred outcomes (rate of recovery from the acute attack, relief of pain, restoration of function, satisfaction with treatment, days off work and return to work, development of chronic pain and disability, recurrent attacks, and further health care use). RESULTS: Ten trials of bed rest and eight trials of advice to stay active were identified. Consistent findings showed that bed rest is not an effective treatment for acute low back pain but may delay recovery. Advice to stay active and to continue ordinary activities results in a faster return to work, less chronic disability, and fewer recurrent problems. CONCLUSION: A simple but fundamental change from the traditional prescription of bed rest to positive advice about staying active could improve clinical outcomes and reduce the personal and social impact of back pain. PMID:9474831
Pace, Jonathan; Jaeger, Melanie; Nickel, J. Curtis; Siemens, D. Robert
Introduction: We explore the attitudes and experience of urology residents toward acute and chronic pain management during their training. Method: A convenience sample of Canadian Urology chief residents were invited to complete an anonymous questionnaire involving both open and closed-ended questions using a 5-point Likert scale. Descriptive and quantitative statistics were used to analyze the attitudes toward pain management, including their experience and training issues. Results: The response rate was 97%. Most residents agreed or strongly agreed that more formal training in acute pain (77% agreement, mean 4.03 ± 0.98 SD) and chronic pain (68%, 3.97 ± 0.95) management would be valuable in urology residency with only 1 respondent disagreeing that training should be mandatory. There was a significant difference of training experience in chronic versus acute pain management, with only 13% agreement (2.99 ± 0.67) that their training in chronic pain was adequate. Most residents agreed (74%, 3.84 ± 1.00) that most of their training in pain management came from their senior residents or fellows. Many of the residents (65%, 3.61 ± 0.84) felt that they could manage their patients’ acute pain issues independently, even in the absence of an acute pain service, although apparent knowledge of opioids was poor. Conclusions: The results of this survey suggest that urology residents attain their knowledge of pain management experientially with what may be insufficient formal training, particularly in chronic pain. These observations are limited by the relatively small number of respondents and by the nature of a cross-sectional, self-reported survey; however, they would appear to underscore a need to redouble efforts in residency education. PMID:24381670
... Data Fentanyl Encounters Data CDC Guideline for Prescribing Opioids for Chronic Pain For Patients For Providers Guideline Resources Clinical Tools ... used carefully. The new CDC Guideline for Prescribing Opioids for Chronic Pain helps inform providersâ€™ ability to offer safer, more ...
Hochberg, Uri; Elgueta, Maria Francisca; Perez, Jordi
Lung cancer is one of the four most prevalent cancers worldwide. Comprehensive patient care includes not only adherence to clinical guidelines to control and when possible cure the disease but also appropriate symptom control. Pain is one of the most prevalent symptoms in patients diagnosed with lung cancer; it can arise from local invasion of chest structures or metastatic disease invading bones, nerves, or other anatomical structures potentially painful. Pain can also be a consequence of therapeutic approaches like surgery, chemotherapy, or radiotherapy. Conventional medical management of cancer pain includes prescription of opioids and coadjuvants at doses sufficient to control the symptoms without causing severe drug effects. When an adequate pharmacological medical management fails to provide satisfactory analgesia or when it causes limiting side effects, interventional cancer pain techniques may be considered. Interventional pain management is devoted to the use of invasive techniques such as joint injections, nerve blocks and/or neurolysis, neuromodulation, and cement augmentation techniques to provide diagnosis and treatment of pain syndromes resistant to conventional medical management. Advantages of interventional approaches include better analgesic outcomes without experiencing drug-related side effects and potential for opioid reduction thus avoiding central side effects. This review will describe various pain syndromes frequently described in lung cancer patients and those interventional techniques potentially indicated for those cases. PMID:28261561
Induru, Raghava R; Lagman, Ruth L
For a variety of reasons, cancer pain is often undertreated, adversely affecting the quality of life for patients and caregivers. To manage cancer pain effectively, physicians need to understand its pathogenesis, how to assess it, how to treat it, and, in particular, how to optimize opioid treatment. We discuss common questions faced by physicians in everyday practice.
Hargreaves, K; Abbott, P V
Pain is one of the most common reasons patients seek dental treatment. It may be due to many different diseases/conditions or it may occur after treatment. Dentists must be able to diagnose the source of pain and have strategies for its management. The '3-D's' principle--diagnosis, dental treatment and drugs--should be used to manage pain. The first, and most important, step is to diagnose the condition causing the pain and identify what caused that condition. Appropriate dental treatment should then be undertaken to remove the cause of the condition as this usually provides rapid resolution of the symptoms. Drugs should only be used as an adjunct to the dental treatment. Most painful problems that require analgesics will be due to inflammation. Pain management drugs include non-narcotic analgesics (e.g., non-steroidal anti-inflammatory drugs, paracetamol, etc) or opioids (i.e., narcotics). Non-steroidal anti-inflammatory drugs (NSAIDs) provide excellent pain relief due to their anti-inflammatory and analgesic action. The most common NSAIDs are aspirin and ibuprofen. Paracetamol gives very effective analgesia but has little anti-inflammatory action. The opioids are powerful analgesics but have significant side effects and therefore they should be reserved for severe pain only. The most commonly-used opioid is codeine, usually in combination with paracetamol. Corticosteroids can also be used for managing inflammation but their use in dentistry is limited to a few very specific situations.
Williams, Christopher G.; Dellon, A. Lee; Rosson, Gedge D.
Pain persisting for at least 6 months is defined as chronic. Chronic facial pain conditions often take on lives of their own deleteriously changing the lives of the sufferer. Although much is known about facial pain, it is clear that those physicians who treat these conditions should continue elucidating the mechanisms and defining successful treatment strategies for these life-changing conditions. This article will review many of the classic causes of chronic facial pain due to the trigeminal nerve and its branches that are amenable to surgical therapies. Testing of facial sensibility is described and its utility introduced. We will also introduce some of the current hypotheses of atypical facial pain and headaches secondary to chronic nerve compressions and will suggest possible treatment strategies. PMID:22110799
Haussler, Kevin K
Manual therapy includes a diverse array of techniques, such as touch therapies, massage, physical therapy, osteopathy, and chiropractic, that were originally developed for use in humans and have been gradually applied to horses. All forms of manual therapy have variable reported levels of effectiveness for treating musculoskeletal issues in humans, but mostly only anecdotal evidence exists in horses. This article explores the scientific literature for evidence of efficacy, safety, and common mechanisms of action of the different forms of manual therapies for potential use in managing acute or chronic pain syndromes in horses. Currently, there is limited evidence supporting the effectiveness of spinal mobilization and manipulation in reducing pain and muscle hypertonicity. Further research is needed to assess the efficacy of specific manual therapy techniques and their contribution to multimodal protocols for managing specific somatic pain conditions in horses.
Wheeler, A H
Acute low back pain with associated sciatica is usually a benign, self-limited disorder. Appropriate medical treatment may include passive forms of physical therapy, including McKenzie exercises, manipulation, medication and therapeutic injections. After pain is controlled, the patient should be taught self-management techniques, including exercises and ergonomic protection of the spine. Evidence is increasing that exercise programs are effective, although the optimal regimen has yet to be defined and may vary from patient to patient. Chronic low back pain is a complex disorder that must be managed aggressively with a multidisciplinary approach that addresses physical, psychologic and socioeconomic aspects of the illness. Self-administered traction, corsets, medications and other treatment methods may prove to be useful adjuncts to an active program of exercise and education that promotes functional restoration.
Tighe, Patrick J.; Bzdega, Matthew; Fillingim, Roger B.; Rashidi, Parisa; Aytug, Haldun
Prior investigations on acute postoperative pain dynamicity have focused on daily pain assessments, and so were unable to examine intra-day variations in acute pain intensity. We analyzed 476,108 postoperative acute pain intensity ratings clinically documented on postoperative days 1 to 7 from 8,346 surgical patients using Markov Chain modeling to describe how patients are likely to transition from one pain state to another in a probabilistic fashion. The Markov Chain was found to be irreducible and positive recurrent, with no absorbing states. Transition probabilities ranged from 0.0031 for the transition from state 10 to state 1, to 0.69 for the transition from state zero to state zero. The greatest density of transitions was noted in the diagonal region of the transition matrix, suggesting that patients were generally most likely to transition to the same pain state as their current state. There were also slightly increased probability densities in transitioning to a state of asleep or zero from the current state. Examination of the number of steps required to traverse from a particular first pain score to a target state suggested that overall, fewer steps were required to reach a state of zero (range 6.1–8.8 steps) or asleep (range 9.1–11) than were required to reach a mild pain intensity state. Our results suggest that Markov Chains are a feasible method for describing probabilistic postoperative pain trajectories, pointing toward the possibility of using Markov decision processes to model sequential interactions between pain intensity ratings and postoperative analgesic interventions. PMID:26588689
Tse, Mimi Mun Yee; Ho, Suki S K
The aim of the study was to examine the effectiveness of a pain management program (PMP) in enhancing the knowledge and attitudes of health care workers in pain management. Many nursing home residents suffer from pain, and treatment of pain is often inadequate. Failure of health care workers to assess pain and their insufficient knowledge of pain management are barriers to adequate treatment. It was a quasiexperimental pretest and posttest study. Four nursing homes were approached, and 88 staff joined the 8-week PMP. Demographics and the knowledge and attitudes regarding pain were collected with the use of the Nurse's Knowledge and Attitudes Survey Regarding Pain-Chinese version (NKASRP-C) before and after the PMP. A deficit in knowledge and attitudes related to pain management was prominent before the PMP, and there was a significant increase in pain knowledge and attitudes from 7.9 ± SD 3.52 to 19.2 ± SD4.4 (p < .05) after the 8-week PMP. A PMP can improve the knowledge and attitudes of nursing staff and enable them to provide adequate and appropriate care to older persons in pain. PMPs for nurses and all health care professionals are important in enhancing care for older adults and to inform policy on the provision of pain management.
Dionne, Raymond A; Gordon, Sharon M; Moore, Paul A
As the nation comes to terms with a prescription opioid epidemic, dentistry is beginning to understand its own unintentional contribution and seek ways to address it. The article urges dental providers to reexamine entrenched prescribing habits and thought patterns regarding treatment of acute dental pain. It points to evidence suggesting that nonsteroidal anti-inflammatory drugs are nonaddictive and usually more effective for managing many cases of acute dental pain. The authors provide therapeutic recommendations to help dental providers change prescribing patterns.
Kosharskyy, Boleslav; Almonte, Wilson; Shaparin, Naum; Pappagallo, Marco; Smith, Howard
In the United States, millions of Americans are affected by chronic pain, which adds heavily to national rates of morbidity, mortality, and disability, with an ever-increasing prevalence. According to a 2011 report titled Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research by the Institute of Medicine of the National Academies, pain not only exacts its toll on people's lives but also on the economy with an estimated annual economic cost of at least $560 - 635 billion in health care costs and the cost of lost productivity attributed to chronic pain. Intravenous infusions of certain pharmacologic agents have been known to provide substantial pain relief in patients with various chronic painful conditions. Some of these infusions are better, and although not necessarily the first therapeutic choice, have been widely used and extensively studied. The others show promise, however are in need of further investigations. This article will focus on non-opiate intravenous infusions that have been utilized for chronic painful disorders such as fibromyalgia, neuropathic pain, phantom limb pain, post-herpetic neuralgia, complex regional pain syndromes (CRPS), diabetic neuropathy, and central pain related to stroke or spinal cord injuries. The management of patients with chronic pain conditions is challenging and continues to evolve as new treatment modalities are explored and tested. The following intravenous infusions used to treat the aforementioned chronic pain conditions will be reviewed: lidocaine, ketamine, phentolamine, dexmedetomidine, and bisphosphonates. This overview is intended to familiarize the practitioner with the variety of infusions for patients with chronic pain. It will not, however, be able to provide guidelines for their use due to the lack of sufficient evidence.
Idvall, Ewa; Ehrenberg, Anna
Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware.
Vadivelu, Nalini; Kai, Alice M; Tran, Daniel; Kodumudi, Gopal; Legler, Aron; Ayrian, Eugenia
Moderate-to-severe pain following neurosurgery is common but often does not get attention and is therefore underdiagnosed and undertreated. Compounding this problem is the traditional belief that neurosurgical pain is inconsequential and even dangerous to treat. Concerns about problematic effects associated with opioid analgesics such as nausea, vomiting, oversedation, and increased intracranial pressure secondary to elevated carbon dioxide tension from respiratory depression have often led to suboptimal postoperative analgesic strategies in caring for neurosurgical patients. Neurosurgical patients may have difficulty or be incapable of communicating their need for analgesics due to neurologic deficits, which poses an additional challenge. Postoperative pain control should be a priority, because pain adversely affects recovery and patient outcomes. Inconsistent practices and the quality of current analgesic strategies for neurosurgical patients still leave room for improvement. Given the complexity of postoperative pain management for these patients, multimodal strategies are often required to optimize pain control and at the same time limit undesired side effects. PMID:26929661
Davis, Mellar P; Walsh, Declan; Lagman, Ruth; LeGrand, Susan B
Since the establishment of the WHO three-step ladder for management of cancer pain, several controversies have arisen, which are partly due to new drug development, reformulations of older analgesics, and technological advancements. As a result, clinicians need clarification of several questions. Is morphine the opioid of choice for moderate to severe pain in cancer? Should combinations of opioids be used? When should spinal opioids be used to treat pain in cancer? What are the appropriate opioid doses for breakthrough pain? Should selective cyclo-oxygenase (COX) 2 inhibitors be used? What is the best tactic to treat neuropathic pain, and what first-line adjuvant analgesic should be used? And do bisphosphonates relieve bone pain in cancers other than breast cancer and myeloma? This review addresses these questions.
Morrow, L J; Smith, S
Lower back pain (LBP) is one of the most common musculoskeletal conditions, with an estimated 60-70% of the adult population experiencing a back problem at some point in their lives. It can have a significant social and occupational impact on a patient, and therefore is a major concern to both civilian and military populations. The impact of low back pain in the military setting, regardless of chronicity, can result in considerable restrictions on a patient's ability to perform his or her job. This may have important ramifications for deployability, medical category and, potentially, a patient's future career. This article will consider the diagnosis and classification of lower back pain (LBP) in the pre-shore, pre-hospital and hospital settings. It will detail management options including investigations, pain management and referral options; furthermore, the potential occupational implications of lower back pain will be detailed.
Mehling, Wolf E.; Ebell, Mark H.; Avins, Andrew L.; Hecht, Frederick M.
Background Context Primary care clinicians need to identify candidates for early interventions to prevent patients with acute pain from developing chronic pain. Purpose We conducted a 2-year prospective cohort study of risk factors for the progression to chronic pain and developed and internally validated a clinical decision rule (CDR) that stratifies patients into low, medium and high-risk groups for chronic pain. Study Design/Setting Prospective cohort study in primary care. Patient Sample Patients with acute low back pain (LBP; ≤30 days duration) Outcome measures Self-reported perceived non-recovery and chronic pain. Methods Patients were surveyed at baseline, 6 months and 2 years. We conducted bivariate and multivariate regression analyses of demographic, clinical and psychosocial variables for chronic pain outcomes, developed a CDR and assessed its performance by calculating the bootstrapped areas under the receiver operating characteristic curve (AUC) and likelihood ratios. This study was supported by NIH/NCCAM grants K23 AT002298, R21 AT004467, NIH/NCCAM K24 AT007827, the Research Evaluation and Allocation Committee (REAC) of the University of California San Francisco, and the Mount Zion Health Fund, San Francisco. The funding agencies played no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The authors report no conflict of interests. Results 605 patients enrolled. 13% had chronic pain at 6 months, 19% at 2 years. An eight-item CDR was most parsimonious for classifying patients into three risk levels. Bootstrapped AUC was 0.76 (0.70–0.82) for the 6-month CDR. Each 10-point score increase (60-point range) was associated with an odds ratio of 11.1 (10.8–11.4) for developing chronic pain. Using a <5% probability of chronic pain as the cutoff for low risk and a >40% probability for high risk, likelihood ratios were 0.26 (0.14–0.48) and 4
Epstein, Lawrence J; Palmieri, Marco
Since its introduction as a procedure of last resort in a terminally ill patient with intractable cancer-related pain, spinal cord stimulation has been used to effectively treat chronic pain of varied origins. Spinal cord stimulation is commonly used for control of pain secondary to failed back surgery syndrome and complex regional pain syndrome, as well as pain from angina pectoris, peripheral vascular disease, and other causes. By stimulating one or more electrodes implanted in the posterior epidural space, the patient feels paresthesias in their areas of pain, which reduces the level of pain. Pain is reduced without the side effects associated with analgesic medications. Patients have improved quality of life and improved function, with many returning to work. Spinal cord stimulation has been shown to be cost effective as compared with conservative management alone. There is strong evidence for efficacy and cost effectiveness of spinal cord stimulation in the treatment of pain associated with intractable angina, failed back surgery syndrome, and complex regional pain syndrome. In this article, we review the history and pathophysiology of spinal cord stimulation, and the evidence (or lack thereof) for efficacy in common clinical practice.
Jacob, Eufemia; Miaskowski, Christine; Savedra, Marilyn; Beyer, Judith E; Treadwell, Marsha; Styles, Lori
As part of a larger study that examined pain experience, pain management, and pain outcomes among children with sickle cell disease, functional status (sleep, food intake, and activity levels) was examined during hospitalization for acute painful episodes. Children were asked to rate the amount of pain they experienced as well as the amount of time they slept, the amount of food they ate, and the amount of activity they had everyday. Children reported high levels of pain, which showed only a small decrease throughout hospitalization, and had disrupted sleep and wake patterns, decreased food intake, and decreased activity levels. Nurses need to routinely monitor functional status during acute painful episodes so that strategies to promote adequate sleep, food intake, and activity may be incorporated to minimize long-term negative outcomes in children with sickle cell disease.
This article deals with the classification, assessment, and management of painful nerves of the distal upper limb. The author's preferred surgical and rehabilitation techniques in managing these conditions are discussed in detail and include (1) relocation of end-neuromas to specific sites, (2) division and relocation of painful nerves in continuity (neuromas-in-continuity and scar-tethered nerves) involving small nerves to the same sites, and (3) fascial wrapping of painful nerves in continuity involving larger nerves such as the median and ulnar nerves. The results of these treatments are presented as justification for current use of these techniques.
Aim This study explores the effects of improvised somatic dance (ISD) on children and young people experiencing acute pain following orthopaedic or cardiac surgery, or post-acquired brain injury. Methods The study involved 25 children and young people and adopted a mixed methods approach. This included a descriptive qualitative approach to help the participants and witnesses verbalise their experience of ISD, and pain scores were assessed before and after ISD using validated pain assessment tools. Data were analysed using descriptive statistical analysis. Findings A total of 92% of participants experienced a reduction in pain, with 80% experiencing a >50% reduction. There was an improved sense of well-being for all. Conclusion Although not a replacement for pharmacological treatments, a multidimensional, child-centred and inclusive approach with ISD can be a useful complementary, non-pharmacological method of pain management in children and young people.
McDonald, Deborah Dillon; Barri, Caroline
Pain management trajectory data that includes previous pain treatments, timing, changes, and outcomes provide crucial data for patients with chronic pain and their practitioners to use when discussing ways to optimize pain management regimens. The aim of this study was to test the use of the life history calendar method to identify pain treatments, treatment regimens, timing, and outcomes of the pain management trajectory of individuals with chronic pain, and to examine feasibility. A pilot, descriptive, methodological design was used. Settings included community-based sites such as congregate housing. Nineteen community-dwelling older adults with osteoarthritis (OA) pain of at least 1 year's duration participated. Participants were interviewed and asked to chronicle from the beginning of the OA pain to the present all of their pain treatments and treatment effects (pain outcomes and adverse events). Raters independently content analyzed the transcribed interviews to identify pain treatments, treatment groupings (regimens), and treatment effects on pain. Feasibility of patients reporting their pain management trajectories was content analyzed by identifying participant difficulty identifying pain treatments, treatment effects, treatment sequence; and difficulty discriminating between treatments, and between OA pain and other pain sources. Individual pain management trajectories were constructed that depicted chronological order of pain treatment regimens and treatment effects. Participants identified pain treatments, discriminate between treatments and between OA and other conditions, and identified treatment effects. Treatment sequence was identified, but more precise timing was generally not reported. Pain management trajectories could provide a helpful way for practitioners to discuss safe, efficacious pain management options with patients.
Tang, V; Baker, A; Blades, R
A significant proportion of emergency urological admissions are comprised of ureteric colic presenting as loin pain. A variety of alternative pathologies present in this manner and should be considered during systematic assessment. We report the case of a patient admitted with severe unilateral back and flank pain after strenuous deadlift exercise. Clinical examination and subsequent investigation following a significant delay demonstrated acute paraspinal compartment syndrome (PCS) after an initial misdiagnosis of ureteric colic. The patient was managed conservatively. We review the current literature surrounding the rare diagnosis of PCS and discuss the management options. PMID:25723672
Twycross, Alison; Parker, Roslyn; Williams, Anna; Gibson, Faith
Advances in treatment mean children are increasingly cared for by their parents at home, leading to a shift in responsibility from health care professionals to parents. Little is known about parents' pain management experiences and the etiology of pain experienced by children with cancer especially when at home. A rapid review of the literature was undertaken investigating children's cancer-related pain, with emphasis on the management of pain outside the health care setting. Electronic databases were searched and a quality assessment was conducted. Forty-two articles were included. Despite advances in pain management techniques, children with cancer regularly cite pain as the most prevalent symptom throughout the cancer trajectory. The source of pain is usually treatment side effects or painful procedures. Parents find dealing with their child's pain distressing and demanding and may hold misconceptions about pain management. Findings indicate a need for more robust research into parental pain management leading to the development of effective pain management resources for parents.
Skipworth, James R A; Shankar, Arjun; Pereira, Stephen P
Pancreatitis may be acute or chronic. Although both can be caused by similar aetiologies, they tend to follow distinct natural histories. Around 80% of acute pancreatitis (AP) diagnoses occur secondary to gallstone disease and alcohol misuse. AP is commonly associated with sudden onset of upper abdominal pain radiating to the back that is usually severe enough to warrant the patient seeking urgent medical attention. Onset of pain may be related to a recent alcohol binge or rich, fatty meal. The patient may appear unwell, be tachycardic and have exquisite tenderness in the upper abdomen. Overall, 10-25% of AP episodes are classified as severe, leading to an associated mortality rate of 7.5%. Disease severity is best predicted from a number of clinical scoring systems which can be applied at diagnosis in association with repeated clinical assessment, measurement of acute inflammatory markers, and CT. All patients with suspected AP should be referred urgently. Chronic pancreatitis (CP) follows continued, repetitive or sustained injury to the pancreas and 70% of diagnoses occur secondary to alcohol abuse. The characteristic presenting feature of CP is insidious progression of chronic, severe, upper abdominal pain, radiating to the back, caused by a combination of progressive pancreatic destruction, inflammation and duct obstruction. Signs and symptoms include weight loss and steatorrhoea and later on diabetes. CP patients may also present with recurrent episodes mimicking AP, both symptomatically and metabolically. Diagnosis of CP should be based on symptom profile, imaging and assessment of exocrine and endocrine pancreatic function. CT should be the first-line imaging investigation.
Moore, Owen A; McIntyre, Mairead; Moore, R Andrew; Derry, Sheena; McQuay, Henry J
Background Tenoxicam is a non-steroidal anti-inflammatory drug (NSAID) licensed for use in rheumatic disease and other musculoskeletal disorders in the UK, and is widely available in other countries worldwide. This review sought to evaluate the efficacy and safety of oral tenoxicam in acute postoperative pain, using clinical studies of patients with established pain, and with outcomes measured primarily over 6 hours using standard methods. This type of study has been used for many decades to establish that drugs have analgesic properties. Objectives To assess the efficacy of single dose oral tenoxicam in acute postoperative pain, and any associated adverse events. Search methods We searched The Cochrane Library (Issue 1, 2009), MEDLINE (March 2009); EMBASE via Ovid (March 2009); the Oxford Pain Relief Database. Selection criteria Randomised, double-blind, placebo-controlled clinical trials of oral tenoxicam for relief of acute postoperative pain in adults. Data collection and analysis Two review authors independently assessed trial quality and extracted data. The area under the “pain relief versus time” curve was used to derive the proportion of participants with tenoxicam experiencing least 50% pain relief over 4 to 6 hours, using validated equations. The number needed to treat to benefit (NNT) was calculated using 95% confidence intervals (CI). The proportion of participants using rescue analgesia over a specified time period, and time to use of rescue analgesia, were sought as additional measures of efficacy. Information on adverse events and withdrawals was also collected. Main results Not one of sixteen studies identified by the searches and examined in detail studied oral tenoxicam in patients with established postoperative pain and therefore no results are available. Authors’ conclusions In the absence of evidence of efficacy for oral tenoxicam in acute postoperative pain, its use in this indication is not justified at present. Because trials clearly
Jiang, Hai-liang; Huang, Shuang; Song, Jiang; Wang, Xiang; Cao, Zhong-shu
Abstract Background: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of pregabalin for pain management following spine surgery. Methods: In September 2016, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, and Cochrane Database of Systematic Reviews. RCTs of patients prepared for spine surgery that compared pregabalin with placebo were retrieved. The primary endpoint was the VAS score with rest or mobilization at 12 hours, 24 hours, and 48 hours and cumulative morphine consumption at 24 hours and 48 hours. The secondary outcomes were complications of nausea, sedation, dizziness, headache, and visual disturbances. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary. Results: Ten clinical studies with 535 patients (pregabalin group = 294, control group = 241) were included in the meta-analysis. Pregabalin was associated with reduced pain scores at 12 hours, 24 hours, and 48 hours, corresponding to a reduction of 1.91 points (95% CI, –4.07 to 0.24 point) at 12 hours, 2.66 points (95% CI, –4.51 to –0.81 point) at 24 hours, and 4.33 points (95% confidence interval, –6.38 to –2.99 point) at 48 hours on a 100-point numeric rating scale. There was no significant difference between VAS scores with mobilization at 12 hours, 24 hours, or 48 hours. Similarly, pregabalin was associated with a reduction in cumulative morphine consumption at 24 hours (–7.07, 95% CI –9.84, –4.30) and 48 hours (–6.52, 95% CI –7.78, –5.25, P = 0.000). Furthermore, pregabalin can reduce the occurrence of nausea (RR 0.57, 95% CI 0.41, 0.79, P = 0.001, number needed to treat = 8.4). There were no significant differences in the occurrence of sedation, dizziness, headache, or visual disturbances. Conclusions: Preoperative use of pregabalin was
Bravo Acosta, Tania; Martín Cordero, Jorge E.; Hernández Tápanes, Solangel; Pedroso Morales, Isis; Fernández Cuesta, José Ignacio; Leyva Serrano, Maritza
Objective. To evaluate the usefulness of the pain tracking technique in acute mechanical low back pain. Method. We performed an experimental prospective (longitudinal) explanatory study between January 2011 and September 2012. The sample was randomly divided into two groups. Patients were assessed at the start and end of the treatment using the visual analogue scale and the Waddell test. Treatment consisted in applying the pain tracking technique to the study group and interferential current therapy to the control group. At the end of treatment, cryotherapy was applied for 10 minutes. The Wilcoxon signed-rank test and the Mann Whitney test were used. They were performed with a predetermined significance level of p ≤ 0.05. Results. Pain was triggered by prolonged static posture and intense physical labor and intensified through trunk movements and when sitting and standing. The greatest relief was reported in lateral decubitus position and in William's position. The majority of the patients had contracture. Pain and disability were modified with the rehabilitation treatment in both groups. Conclusions. Both the pain tracking and interferential current techniques combined with cryotherapy are useful treatments for acute mechanical low back pain. The onset of analgesia is faster when using the pain tracking technique. PMID:26240758
The vast majority of those with back pain respond extremely well to chiropractic spinal manipulation. There are several hundred procedures available to a well trained chiropractor, including high velocity manipulation, mobilisation, soft tissue techniques and pressure point therapy, which may be used to eliminate the need for manipulation under anaesthesia or surgery.
Osteoarthritis (OA) is a painful, progressive joint disorder. This article discusses pharmacological management of OA, such as non-steroidal anti-inflammatory drugs and opioids, and non-pharmacological management, including weight reduction, acupuncture and joint replacement surgery. The third part, to be published online, will cover the physical, psychological and social impact of OA.
Govindarajah, Narendranath; Hameed, Waseem; Middleton, Simon; Booth, Michael
This is a case of a 75-year-old man being admitted to the on-call surgical department with acute abdominal pain. On arrival he was clinically dehydrated and shocked with localised pain over McBurney's point and examination findings were suggestive of appendiceal or other colonic pathology. Full blood testing revealed a white cell count of 38×109/L and a C reactive protein (CRP) of 278 mg/L. A CT scan revealed a gallbladder empyema that extended into the right iliac fossa. This case highlights the potential for a hyperdistended gallbladder empyema to present as acute right iliac fossa pain with blood tests suggestive of complicated disease. Further analysis confirmed Actinomyces infection as the underlying aetiology prior to a laparoscopic subtotal cholecystectomy. This case serves to remind clinicians of this as a rare potential cause of atypical gallbladder pathology. PMID:24872493
Mongolu, S; Sharp, P
Although uncommon, lead poisoning should be considered as a differential diagnosis in cases of unexplained acute abdominal pain in both adults and children. We present the case of a 35-year-old Asian male who presented with abdominal pain and constipation secondary to lead poisoning. Initially, the source of lead exposure was not apparent; this was later found to be due to ingestion of an Ayurvedic herbal medicine for the treatment of infertility. Lead poisoning due to the ingestion of Ayurvedic remedies is well described. We discuss the diagnosis, pathophysiology and treatment of lead poisoning. This case illustrates one of the rarer medical causes of acute abdominal pain and emphasizes the need to take a thorough history (including specific questioning regarding the use of over-the-counter and traditional/ herbal remedies) in cases of suspected poisoning or drug toxicity.
Pages-Bouic, E; Millet, I; Curros-Doyon, F; Faget, C; Fontaine, M; Taourel, P
Acute pelvic pain in women is a common reason for emergency department admission. There is a broad range of possible aetiological diagnoses, with gynaecological and gastrointestinal causes being the most frequently encountered. Gynaecological causes include upper genital tract infection and three types of surgical emergency, namely ectopic pregnancy, adnexal torsion, and haemorrhagic ovarian cyst rupture. The main gastrointestinal cause is acute appendicitis, which is the primary differential diagnosis for acute pelvic pain of gynaecological origin. The process of diagnosis will be guided by the clinical examination, laboratory study results, and ultrasonography findings, with suprapubic transvaginal pelvic ultrasonography as the first-line examination in this young population, and potentially cross-sectional imaging findings (computed tomography and MR imaging) if diagnosis remains uncertain.
Slonimski, Marc; Abram, Stephen E; Zuniga, Robert E
Baclofen is a GABA(B) agonist that is administered spinally via an implanted drug delivery device to treat spasticity. It has been shown to have powerful antinociceptive effects in experimental animal models at doses that produce little or no motor-blocking effects but has rarely been used as a spinal analgesic agent in patients without spasticity. Several studies have indicated that intrathecal baclofen provides relief of central pain in patients with spasticity. To date, only 3 studies have shown it to be effective in patients with peripheral nociceptive or neuropathic pain mechanisms. Combinations of baclofen and morphine or clonidine are more effective than each drug alone in clinical as well as animal studies.
Nijs, Jo; Van Houdenhove, Boudewijn
During the past decade, scientific research has provided new insight into the development from an acute, localised musculoskeletal disorder towards chronic widespread pain/fibromyalgia (FM). Chronic widespread pain/FM is characterised by sensitisation of central pain pathways. An in-depth review of basic and clinical research was performed to design a theoretical framework for manual therapy in these patients. It is explained that manual therapy might be able to influence the process of chronicity in three different ways. (I) In order to prevent chronicity in (sub)acute musculoskeletal disorders, it seems crucial to limit the time course of afferent stimulation of peripheral nociceptors. (II) In the case of chronic widespread pain and established sensitisation of central pain pathways, relatively minor injuries/trauma at any locations are likely to sustain the process of central sensitisation and should be treated appropriately with manual therapy accounting for the decreased sensory threshold. Inappropriate pain beliefs should be addressed and exercise interventions should account for the process of central sensitisation. (III) However, manual therapists ignoring the processes involved in the development and maintenance of chronic widespread pain/FM may cause more harm then benefit to the patient by triggering or sustaining central sensitisation.
Derry, Christopher J; Derry, Sheena; Moore, R Andrew; McQuay, Henry J
Background This review updates a 1999 Cochrane review showing that ibuprofen at various doses was effective in postoperative pain in single dose studies designed to demonstrate analgesic efficacy. New studies have since been published. Ibuprofen is one of the most widely used non-steroidal anti-inflammatory (NSAID) analgesics both by prescription and as an over-the-counter medicine. Ibuprofen is used for acute and chronic painful conditions. Objectives To assess analgesic efficacy of ibuprofen in single oral doses for moderate and severe postoperative pain in adults. Search methods We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to May 2009. Selection criteria Randomised, double blind, placebo-controlled trials of single dose orally administered ibuprofen (any formulation) in adults with moderate to severe acute postoperative pain. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Pain relief or pain intensity data were extracted and converted into the dichotomous outcome of number of participants with at least 50% pain relief over 4 to 6 hours, from which relative risk and number-needed-to-treat-to-benefit (NNT) were calculated. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals were collected. Main results Seventy-two studies compared ibuprofen and placebo (9186 participants). Studies were predominantly of high reporting quality, and the bulk of the information concerned ibuprofen 200 mg and 400 mg. For at least 50% pain relief compared with placebo the NNT for ibuprofen 200 mg (2690 participants) was 2.7 (2.5 to 3.0) and for ibuprofen 400 mg (6475 participants) it was 2.5 (2.4 to 2.6). The proportion with at least 50% pain relief was 46% with 200 mg and 54% with 400 mg. Remedication within 6 hours was less
Cartwright, Sarah L; Knudson, Mark P
Acute abdominal pain is a common presentation in the outpatient setting and can represent conditions ranging from benign to life-threatening. If the patient history, physical examination, and laboratory testing do not identify an underlying cause of pain and if serious pathology remains a clinical concern, diagnostic imaging is indicated. The American College of Radiology has developed clinical guidelines, the Appropriateness Criteria, based on the location of abdominal pain to help physicians choose the most appropriate imaging study. Ultrasonography is the initial imaging test of choice for patients presenting with right upper quadrant pain. Computed tomography (CT) is recommended for evaluating right or left lower quadrant pain. Conventional radiography has limited diagnostic value in the assessment of most patients with abdominal pain. The widespread use of CT raises concerns about patient exposure to ionizing radiation. Strategies to reduce exposure are currently being studied, such as using ultrasonography as an initial study for suspected appendicitis before obtaining CT and using low-dose CT rather than standard-dose CT. Magnetic resonance imaging is another emerging technique for the evaluation of abdominal pain that avoids ionizing radiation.
Brito, Carlos Alexandre Antunes de; Sohsten, Ana Karla Arraes von; Leitão, Clezio Cordeiro de Sá; Brito, Rita de Cássia Coelho Moraes de; Valadares, Lilian David De Azevedo; Fonte, Caroline Araújo Magnata da; Mesquita, Zelina Barbosa de; Cunha, Rivaldo Venâncio; Luz, Kleber; Leão, Helena Maria Carneiro; Brito, Cecília Moraes de; Frutuoso, Lívia Carla Vinhal
From the arrival of Chikungunya virus in the Americas in 2013 until March 2016, approximately two million cases of the disease have been reported. In Brazil, the virus was identified in 2014 and thousands of people have been affected. The disease has high attack rates, infecting 50% of a population within a few months. Approximately 50% of infected people develop chronic symptoms lasting for months or years. Joint involvement is the main clinical manifestation of Chikungunya. It is characterized by swelling and intense pain that is poorly responsive to analgesics, both in the acute and chronic phase of the disease. This significantly compromises quality of life and may have immeasurable psychosocial and economic repercussions, constituting therefore, a serious public health problem requiring a targeted approach. Physicians are often not familiar with how to approach the management of pain, frequently prescribing limited analgesics, such as dipyrone, in sub-therapeutic doses. In addition, there are few published studies or guidelines on the approach to the treatment of pain in patients with Chikungunya. Some groups of specialists from different fields have thus developed a protocol for the pharmacologic treatment of Chikungunya-associated acute and chronic joint pain; this will be presented in this review.
Tsze, Daniel S.; Hirschfeld, Gerrit; von Baeyer, Carl L.; Bulloch, Blake; Dayan, Peter S.
Objectives The objective was to determine the minimum and ideal clinically significant differences (MCSD, ICSD) of the Faces Pain Scale–Revised (FPS-R) and the Color Analog Scale (CAS) in children and to identify any differences in these estimates based on patient characteristics. Methods This was a prospective study of children aged 4 to 17 years with acute pain presenting to two urban pediatric emergency departments. Participants self-reported their pain severity using the FPS-R and CAS and qualitatively described their changes in pain. Changes in pain score reported using the FPS-R and CAS that were associated with “a little less” and “much less” pain (MCSD and ICSD, respectively) were identified using a receiver operating characteristic–based method and expressed as raw change score and percent reductions. Estimates of MCSD and ICSD were determined for each category of initial pain severity (mild, moderate, and severe) and patient characteristics (age, sex, and ethnicity). Post hoc exploratory analyses evaluated categories of race, primary language, and etiology of pain. Results A total of 314 children with acute pain were enrolled; mean (±SD) age was 9.8 (±3.8) years. The FPS-R raw change score and percent reduction MCSD estimates were 2/10 and 25%, with ICSD estimates of 3/10 and 60%. For the CAS, raw change score and percent reduction MCSD estimates were 1/10 and 15%, with ICSD estimates of 2.75/10 and 52%. For both scales, raw change score and percent reduction estimates of the MCSD remained unchanged in children with either moderate or severe pain. For both scales, estimates of ICSD were not stable across categories of initial pain severity. There was no difference in MCSD or ICSD based on age, sex, ethnicity, race, primary language, or etiology of pain. Conclusions The MCSD estimates can be expressed as raw change score and percent reductions for the FPS-R and CAS. These estimates appear stable for children with moderate to severe pain
Russell, J S
In the last few years, much medical-facility construction has been driven by what insurers want. Hospitals have built facilities for well-reimbursed procedures and closed money-losing ones. Health-maintenance organizations increasingly expect to hold down costs by making prepayment arrangements with doctors and their hospitals. President Clinton has pledged early action on health-care reform, which will likely change planners' priorities. Whether the nation goes to Clintonian "managed competition" or a Canadian-style nationwide single-payer system (the two most likely options), the projects on these pages reflect two large-scale trends that are likely to continue: the movement of more procedures from inpatient to outpatient facilities and the separation of treatment functions from ordinary office and administrative tasks so that the latter are not performed in the same high-cost buildings as technology-intensive procedures. Various schemes that make care more "patient-centered" have been tried and been shown to speed healing, even for outpatients, but such hard-to-quantify issues get short shrift in an era of knee-jerk cost containment. The challenge in tomorrow's healthcare universe--whatever it becomes--will be to keep these issues on the table.
Boyer, Stéphanie C; Goldfinger, Corrie; Thibault-Gagnon, Stéphanie; Pukall, Caroline F
Our understanding of the sexual pain disorders vaginismus and dyspareunia has been fundamentally altered over the past two decades due to increased attention and empirically sound research in this domain. This increased knowledge base has included a shift from a dualistic view of the etiology of painful and/or difficult vaginal penetration being due to either psychological or physiological causes, to a multifactorial perspective. The present chapter reviews current classification and prevalence rates, including ongoing definitional debates. Research regarding the etiology, assessment and management of sexual pain disorders is discussed from a biopsychosocial perspective. Cyclical theories of the development and maintenance of sexual pain disorders, which highlight the complex interplay among physiological, psychological and social factors, are described. Medical/surgical treatment options, pelvic floor rehabilitation and psychological approaches are reviewed, as well as future directions in treatment research.
At least 5 million patients with chronic and severely debilitating pain exist among the adult population in Germany, i.e. 8% of this population. Various biological and psychosocial risk factors contribute to the continuing chronicity of pain, resulting in enormous direct and indirect costs totalling an estimated 38 billion euro annually. The introduction of a medical specialty for pain treatment in 1998 has not appreciably affected the quality of outpatient pain management. In contrast, more recent approaches of multimodal treatment, including medical, psychological and behavioral components, have shown a significant and lasting effect in patients with a high incidence of workplace incapacitation and sick leave. In particular, the GRIP pilot project (Göttingen Intensive Back Project) has resulted in an increased rate (to 200%) of return to the workplace and in a decrease in health system expenses to 50% of the pretreatment level.
Smith, Matthew J
The health care landscape has changed with new legislation addressing the unsustainable rise in costs in the US system. Low-value service lines caring for expensive chronic conditions have been targeted for reform; for better or worse, the treatment of spine pain has been recognized as a representative example. Examining the Patient Protection and Affordable Care Act and existing pilot studies can offer a preview of how chronic care of spine pain will be sustained. Accountable care in an organization capable of collecting, analyzing, and reporting clinical data and operational compliance is forthcoming. Interdisciplinary spine pain centers integrating surgical and medical management, behavioral medicine, physical reconditioning, and societal reintegration represent the model of high-value care for patients with chronic spine pain.
Friedrichsdorf, Stefan J
Dr Stefan Friedrichsdorf speaks to Commissioning Editor Jade Parker: Stefan Friedrichsdorf, MD, is medical director of the Department of Pain Medicine, Palliative Care and Integrative Medicine at Children's Hospitals and Clinics of Minnesota in Minneapolis/St Paul, MN, USA, home to one of the largest and most comprehensive programs of its kind in the country. The pain and palliative care program is devoted to control acute, chronic/complex and procedural pain for inpatients and outpatients in close collaboration with all pediatric subspecialties at Children's Minnesota. The team also provides holistic, interdisciplinary care for children and teens with life limiting or terminal diseases and their families. Integrative medicine provides and teaches integrative, nonpharmacological therapies (such as massage, acupuncture/acupressure, biofeedback, aromatherapy and self-hypnosis) to provide care that promotes optimal health and supports the highest level of functioning in all individual children's activities. In this second part of the interview they discuss multimodal (opioid-sparing) analgesia for hospitalized children in pain and how analgesics and adjuvant medications, interventions, rehabilitation, psychological and integrative therapies act synergistically for more effective pediatric pain control with fewer side effects than a single analgesic or modality.
Nahin, Richard L; Boineau, Robin; Khalsa, Partap S; Stussman, Barbara J; Weber, Wendy J
Although most pain is acute and resolves within a few days or weeks, millions of Americans have persistent or recurring pain that may become chronic and debilitating. Medications may provide only partial relief from this chronic pain and can be associated with unwanted effects. As a result, many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches-acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga-as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.
Filos, K S; Lehmann, K A
Despite a growing trend in acute pain management, many deficiencies still account for the high incidence of moderate to severe postoperative pain to date. Patients nowadays continue to receive inadequate doses of analgesics, but additionally the identification and treatment of those patients with pain still remains a significant health care problem. Advanced techniques are available including epidural or intrathecal administration of local anaesthetics and opioids, various opioid administration techniques such as patient-controlled analgesia and infusions via sublingual, oral-transmucosal, nasal, intra-articular and rectal routes. Nonopioid analgesics such as nonsteroidal anti-inflammatory drugs and newer nonopioid drugs such as alpha2-adrenergic agonists, calcium channel antagonists and various combinations of the above are possible. However, the solution to the problem of inadequate pain relief lies not so much in the development of new drugs and new techniques, but in the effective strategy of delivering these to patients through the introduction of acute pain management services on surgical wards.
Moore, R Andrew; Derry, Sheena; Mason, Lorna; McQuay, Henry J; Edwards, Jayne
Background This is an updated version of the original Cochrane review published in Issue 4, 2004. Indometacin is a non-steroidal anti-inflammatory drug (NSAID) used most commonly for the treatment of inflammation and pain resulting from rheumatic disease (arthritis), and less commonly in postoperative pain management. When taken for chronic pain conditions, indometacin has been associated with a high incidence of adverse events. The benefits and harms of orally-administered indometacin for postoperative pain are not clear. Objectives To determine the efficacy of a single dose of oral indometacin compared with placebo in treating acute postoperative pain in adults, and to analyse information relating to adverse events. Search methods We searched the Cochrane CENTRAL Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE and the Oxford Pain Relief Database for relevant studies in January 2002 and for the updated search in December 2007. Additional studies were sought from the reference lists of retrieved studies. Selection criteria Studies were included in the review if they were randomised, double blind, placebo-controlled clinical trials using a single oral dose of indometacin in adults with acute postoperative pain. Data collection and analysis Studies were assessed independently by two review authors. Pain relief or pain intensity data were extracted and converted into dichotomous information to give the number of participants with at least 50% pain relief over four to six hours. The relative benefit for at least 50% pain relief was calculated. Main results In the original review one study of 59 women with post-episiotomy pain met the inclusion criteria. The dose of indometacin assessed against placebo was 50 mg, and the results concluded that indometacin was not significantly better than placebo for relieving postoperative pain at four to six hours. There was insufficient information to conduct further efficacy analyses or assess adverse events
Original Contribution Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial☆,☆☆ Joshua P. Miller, MD a,b,⁎, Steven G...numeric rating scale (NRS) pain scores, in patients receiving low-dose ketamine (LDK) or morphine (MOR) for acute pain in the emergency department...convenience sample of patients aged 18 to 59 years with acute abdominal, flank, low back, or extremity pain were enrolled. Subjects were consented and
Fischer, A A
This is a review of local anesthetic (LA) injections and infiltrations particularly combined with 'needling' for management of local musculoskeletal pain. New techniques are described including preinjection blocks (PIBs) which consist of blocking the sensory input from an area prior to giving an injection. PIBs prevent pain which would be caused by needle penetration of sensitive tissue. Needling and infiltration (N and I) with 1% lidocaine has been performed after PIB in 179 tender spots (TSs), trigger points (TrPs), and muscle spasms by the author, in 123 patients with the goal to relieve pain and promote healing. The immediate effect after the procedure as well as long-term results from 1 week to 7 months have been evaluated independently by a physiatrist experienced with injections (Dr. Tae Mo Chang). N and I extending over the entire taut band of abnormal muscle fibers, caused effective relief of pain and functional improvement in tender spots (TSs), trigger points (TrPs) and in muscle spasm caused by a variety of conditions including: acute and chronic sports and work injuries, motor vehicle accidents, muscle and ligament sprains (supraspinous, sacroiliac), overuse and repetitive stress syndromes, tennis elbow; local injuries or radicular irritation; and local inflammations such as bursitis, tendinitis, and osteoarthritis; and traumatic dystrophy, a type of reflex sympathetic dystrophy. Needling and infiltration of trigger areas and tender spots is effective treatment in several conditions. Pre-injection blocks allow the performance of the N and I of tender areas without pain.
Durham, Catherine O; Fowler, Terri; Donato, AnneMarie; Smith, Whitney; Jensen, Elizabeth
Rheumatoid arthritis (RA) is one of the most common inflammatory conditions in the United States affecting approximately 1 million adults. This article briefly reviews the evidence-based diagnosis of RA, mainstays of treatment to prevent joint destruction, and pain management.
Hylands-White, Nicholas; Duarte, Rui V; Raphael, Jon H
Pain which persists after healing is expected to have taken place, or which exists in the absence of tissue damage, is termed chronic pain. By definition chronic pain cannot be treated and cured in the conventional biomedical sense; rather, the patient who is suffering from the pain must be given the tools with which their long-term pain can be managed to an acceptable level. This article will provide an overview of treatment approaches available for the management of persistent non-malignant pain. As well as attempting to provide relief from the physical aspects of pain through the judicious use of analgesics, interventions, stimulations, and irritations, it is important to pay equal attention to the psychosocial complaints which almost always accompany long-term pain. The pain clinic offers a biopsychosocial approach to treatment with the multidisciplinary pain management programme; encouraging patients to take control of their pain problem and lead a fulfilling life in spite of the pain.
Joshi, Mandar; Chambers, William A
Pharmacological treatment forms the foundation of the management of pain in patients with advanced cancer. Although the majority of patients in the realm of palliative care can be provided with acceptable pain relief using the three-step WHO cancer pain guidelines, a significant minority still have pain that is not adequately controlled by conventional pharmacological management. Development of pain management strategies using a multidisciplinary input with appropriate and timely use of interventional pain management techniques can provide satisfactory pain relief for these patients, helping to reduce distress in the patient and their relatives during this difficult period. This clinical review aims to discuss the commonly used interventional techniques in pain management in palliative care. As patients with advanced cancer are the major recipients of palliative care services, the main focus of this article remains on pain management in advanced cancer. The use of central neuraxial blockade, autonomic blockade and peripheral nerve blocks are summarized.
Treatment of craniofacial pain disorders is often complicated by diverse factors such as acute or chronic trauma and persistent postural changes. In addition, emotional issues and life stress often cloud the recovery process. Physical therapists, with their diverse knowledge base and highly competent treatment skills, can be quite effective in assisting dentists and physicians with management of the many difficult upper quarter and craniofacial pain syndromes. This article reviews the role of myofascial and craniosacral dysfunction, as well as the function of posture, tension, and stress in the development of these syndromes. Additionally, it provides a comprehensive overview of the many evaluative techniques and treatment options that can be provided by today's physical therapists.
Avoiding pain, agitation and delirium as well as avoiding unnecessary deep sedation is a powerful yet challenging strategy in critical care medicine. A number of interactions between cerebral function and respiratory function should be regarded in patients with respiratory failure and mechanical ventilation. A cooperative sedation strategy (i.e. patient is awake and free of pain and delirium) is feasible in many patients requiring invasive mechanical ventilation. Especially patients with mild acute respiratory distress syndrome (ARDS) seem to benefit from preserved spontaneous breathing. While completely disabling spontaneous ventilation with or without neuromuscular blockade is not a standard strategy in ARDS, it might be temporarily required in patients with severe ARDS, who have substantial dyssynchrony or persistent hypoxaemia. Since pain, agitation and delirium compromise respiratory function they should also be regarded during noninvasive ventilation and during ventilator weaning. Pharmacological sedation can have favourable effects in these situations, but should not be given routinely or uncritically.
Li, Adrienne L K; Gomez, Manuel; Fish, Joel S
The purpose of this study was to evaluate the effectiveness of pain management after electrical injury. A retrospective hospital chart review was conducted among electrically injured patients discharged from the outpatient burn clinic of a rehabilitation hospital (July 1, 1999, to July 31, 2008). Demographic data, numeric pain ratings (NPRs) at initial assessment and discharge, medications, nonpharmacologic modalities, and their effects before admission and after rehabilitation were collected. Pain management effects were compared between high (> or =1000 v) and low (<1000 v) voltage, and between electrical contact and electrical flash patients, using Student's t-test and chi, with a P < .05 considered significant. Of 82 electrical patients discharged during the study period, 27 were excluded because of incomplete data, leaving 55 patients who had a mean age +/-SD of 40.7 +/- 11.3 years, TBSA of 19.2 +/- 22.7%, and treatment duration of 16.5 +/- 15.7 months. The majority were men (90.9%), most injuries occurred at work (98.2%), mainly caused by low voltage (n = 32, 58.2%), and the rest caused by high voltage (n = 18, 32.7%). Electrical contact was more common (54.5%) than electrical flash (45.5%). Pain was a chief complaint (92.7%), and hands were the most affected (61.8%), followed by head and neck (38.2%), shoulders (38.2%), and back torso (38.2%). Before rehabilitation, the most common medication were opioids (61.8%), relieving pain in 82.4%, followed by acetaminophen (47.3%) alleviating pain in 84.6%. Heat treatment was the most common nonpharmacologic modality (20.0%) relieving pain in 81.8%, followed by massage therapy (14.5%) alleviating pain in 75.0%. During the rehabilitation program, antidepressants were the most common medication (74.5%), relieving pain in 22.0%, followed by nonsteroidal antiinflammatory drugs (61.8%), alleviating pain in 70.6%. Massage therapy was the most common nonpharmacologic modality (60.0%), alleviating pain in 75.8%, and then
Spadini, Silvia; De Tommasi, Valentina; Benini, Franca
We report our clinical experience on the effect of Scrambler Therapy (ST) for a child with acute mixed pain refractory to pharmacological treatment. ST, recently proposed as an alternative treatment for chronic neuropathic pain in adults, is a noninvasive approach to relieve pain, by changing pain perception at brain level. It is safe and has no side effects. Further research is needed to assess its efficacy for acute pain and for paediatric population. PMID:26977329
Jamison, David; Cohen, Steven P.
As in the general population, chronic pain is a prevalent and burdensome affliction in active-duty military personnel. Painful conditions in military members can be categorized broadly in terms of whether they arise directly from combat injuries (gunshot, fragmentation wound, blast impact) or whether they result from non-combat injuries (sprains, herniated discs, motor vehicle accidents). Both combat-related and non-combat-related causes of pain can further be classified as either acute or chronic. Here we discuss the state of pain management as it relates to the military population in both deployed and non-deployed settings. The term non-battle injury (NBI) is commonly used to refer to those conditions not directly associated with the combat actions of war. In the history of warfare, NBI have far outstripped battle-related injuries in terms not only of morbidity, but also mortality. It was not until improvements in health care and field medicine were applied in World War I that battle-related deaths finally outnumbered those attributed to disease and pestilence. However, NBI have been the leading cause of morbidity and hospital admission in every major conflict since the Korean War. Pain remains a leading cause of presentation to military medical facilities, both in and out of theater. The absence of pain services is associated with a low return-to-duty rate among the deployed population. The most common pain complaints involve the low-back and neck, and studies have suggested that earlier treatment is associated with more significant improvement and a higher return to duty rate. It is recognized that military medicine is often at the forefront of medical innovation, and that many fields of medicine have reaped benefit from the conduct of war.
Ring, Johannes; Grosber, Martine; Möhrenschlager, Matthias; Brockow, Knut
Anaphylaxis is the maximal variant of an acute life-threatening immediate-type allergy. Due to its often dramatic onset and clinical course, practical knowledge in the management of these reactions is mandatory both for physicians and patients. It has to be distinguished between acute treatment modalities and general recommendations for management of patients who have suffered from an anaphylactic reaction. Acute treatment comprises general procedures like positioning, applying an intravenous catheter, call for help, comfort of the patient as well as the application of medication. The acute treatment modalities are selected depending upon the intensity of the clinical symptomatology as they are categorized in 'severity grades'. First of all it is important to diagnose anaphylaxis early and consider several differential diagnoses. This diagnosis is purely clinical and laboratory tests are of no help in the acute situation. Epinephrine is the essential antianaphylactic drug in the pharmacologic treatment. It should be first applied intramuscularly, only in very severe cases or under conditions of surgical interventions intravenous application can be tried. Furthermore, glucocorticosteroids are given in order to prevent protracted or biphasic courses of anaphylaxis; they are of little help in the acute treatment. Epinephrine autoinjectors can be used by the patient him/herself. Histamine H(1)-antagonists are valuable in mild anaphylactic reactions; they should be given intravenously if possible. The replacement of volume is crucial in antianaphylactic treatment. Crystalloids can be used in the beginning, in severe shock colloid volume substitutes have to be applied. Patients suffering from an anaphylactic episode should be observed over a period of 4-10 h according to the severity of the symptomatology. It is crucial to be aware or recognize risk patients as for example patients with severe uncontrolled asthma, or under beta-adrenergic blockade. When bronchial
Diaz, J A; Cuervo, C; Valderrama, A M; Kohles, J
We sought to determine whether valdecoxib is as effective as diclofenac in treating acute ankle sprain. Patients (n=202) with acute first- and second-degree ankle sprain were randomized to valdecoxib (40 mg twice daily on day 1 followed by 40 mg once daily on days 2-7) or diclofenac (75 mg twice daily). The primary efficacy end-point was the Patient's Assessment of Ankle Pain visual analogue scale (VAS, 0-100 mm) value on day 4. Valdecoxib was as efficacious as diclofenac in treating the signs and symptoms of acute ankle sprain. The mean VAS reduction in ankle pain on day 4 was not different between groups; the two-sided 95% confidence interval for the between-group difference was within the prespecified limit for non-inferiority (10 mm). There were no significant differences between groups for all secondary efficacy end-points. The two treatments were similarly effective and well tolerated for treatment of acute ankle sprain.
Pal, Uma Shanker; Kumar, Lakshya; Mehta, Gagan; Singh, Nimisha; Singh, Geeta; Singh, Mayank; Yadav, Hemant Kumar
We systematically reviewed the myofascial pain publications in the literature. The aim of this article is to review the methods of management and their outcome and factors associated with prognosis. The topics of interest in the diagnostic process are myofascial trigger points electromyography, jaw tracking, joint sound recorder, sonography, and vibratography, exclusion of other orofacial pain and temporomandibular disorders. Management modalities are occlusal therapy, physiotherapy, multidimensional rehabilitation antinociceptive therapy, anti-inflammatory and analgesics, muscle relaxants, stretch, and spray technique, transcutaneous electric nerve stimulation, and in severe cases botulinum toxin may be tried. The disease required interdisciplinary interaction in terms of occlusal therapy, antinociceptive therapy and physiotherapy because management of the disease may be influenced by the specialist primarily treating the patients. PMID:25937719
Pozek, John-Paul J; Beausang, David; Baratta, Jaime L; Viscusi, Eugene R
Chronic postsurgical pain (CPSP) is a distressing disease process that can lead to long-term disability, reduced quality of life, and increased health care spending. Although the exact mechanism of development of CPSP is unknown, nerve injury and inflammation may lead to peripheral and central sensitization. Given the complexity of the disease process, no novel treatment has been identified. The preoperative use of multimodal analgesia has been shown to decrease acute postoperative pain, but it has no proven efficacy in preventing development of CPSP.
Pischik, Elena; Kauppinen, Raili
Acute intermittent porphyria (AIP) is due to a deficiency of the third enzyme, the hydroxymethylbilane synthase, in heme biosynthesis. It manifests with occasional neuropsychiatric crises associated with overproduction of porphyrin precursors, aminolevulinic acid and porphobilinogen. The clinical criteria of an acute attack include the paroxysmal nature and various combinations of symptoms, such as abdominal pain, autonomic dysfunction, hyponatremia, muscle weakness, or mental symptoms, in the absence of other obvious causes. Intensive abdominal pain without peritoneal signs, acute peripheral neuropathy, and encephalopathy usually with seizures or psychosis are the key symptoms indicating possible acute porphyria. More than fivefold elevation of urinary porphobilinogen excretion together with typical symptoms of an acute attack is sufficient to start a treatment. Currently, the prognosis of the patients with AIP is good, but physicians should be aware of a potentially fatal outcome of the disease. Mutation screening and identification of type of acute porphyria can be done at the quiescent phase of the disease. The management of patients with AIP include following strategies: A, during an acute attack: 1) treatment with heme preparations, if an acute attack is severe or moderate; 2) symptomatic treatment of autonomic dysfunctions, polyneuropathy and encephalopathy; 3) exclusion of precipitating factors; and 4) adequate nutrition and fluid therapy. B, during remission: 1) exclusion of precipitating factors (education of patients and family doctors), 2) information about on-line drug lists, and 3) mutation screening for family members and education about precipitating factors in mutation-positive family members. C, management of patients with recurrent attacks: 1) evaluation of the lifestyle, 2) evaluation of hormonal therapy in women, 3) prophylactic heme therapy, and 4) liver transplantation in patients with severe recurrent attacks. D, follow-up of the AIP
Pischik, Elena; Kauppinen, Raili
Acute intermittent porphyria (AIP) is due to a deficiency of the third enzyme, the hydroxymethylbilane synthase, in heme biosynthesis. It manifests with occasional neuropsychiatric crises associated with overproduction of porphyrin precursors, aminolevulinic acid and porphobilinogen. The clinical criteria of an acute attack include the paroxysmal nature and various combinations of symptoms, such as abdominal pain, autonomic dysfunction, hyponatremia, muscle weakness, or mental symptoms, in the absence of other obvious causes. Intensive abdominal pain without peritoneal signs, acute peripheral neuropathy, and encephalopathy usually with seizures or psychosis are the key symptoms indicating possible acute porphyria. More than fivefold elevation of urinary porphobilinogen excretion together with typical symptoms of an acute attack is sufficient to start a treatment. Currently, the prognosis of the patients with AIP is good, but physicians should be aware of a potentially fatal outcome of the disease. Mutation screening and identification of type of acute porphyria can be done at the quiescent phase of the disease. The management of patients with AIP include following strategies: A, during an acute attack: 1) treatment with heme preparations, if an acute attack is severe or moderate; 2) symptomatic treatment of autonomic dysfunctions, polyneuropathy and encephalopathy; 3) exclusion of precipitating factors; and 4) adequate nutrition and fluid therapy. B, during remission: 1) exclusion of precipitating factors (education of patients and family doctors), 2) information about on-line drug lists, and 3) mutation screening for family members and education about precipitating factors in mutation-positive family members. C, management of patients with recurrent attacks: 1) evaluation of the lifestyle, 2) evaluation of hormonal therapy in women, 3) prophylactic heme therapy, and 4) liver transplantation in patients with severe recurrent attacks. D, follow-up of the AIP
Kim, Y-C.; Bok, D. H.; Chang, H-G.; Kim, S. W.; Park, M. S.; Oh, J. K.; Kim, J.
Objectives Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients. Patients and Methods Patients with single-level acute osteoporotic vertebral compression fracture at thoracolumbar junction (T10 to L2) were followed. If the patients were not satisfied with acute pain reduction after a three-week conservative treatment, vertebroplasty was recommended. Pain assessment was carried out at the time of diagnosis, as well as three, four, six, and 12 weeks after the diagnosis. The effect of vertebroplasty, compared with conservative treatment, on back pain (visual analogue score, VAS) was analysed with the use of analysis-of-covariance models that adjusted for pre-operative VAS scores. Results A total of 342 patients finished the 12-week follow-up, and 120 patients underwent vertebroplasty (35.1%). The effect of vertebroplasty over conservative treatment was significant regardless of age, body mass index, medical comorbidity, previous fracture, pain duration, bone mineral density, degree of vertebral body compression, and canal encroachment. However, the effect of vertebroplasty was not significant at all time points in patients with increased sagittal vertical axis. Conclusions For single-level acute osteoporotic vertebral compression fractures, the effect of vertebroplasty was less favourable in patients with increased sagittal vertical axis (> 5 cm) possible due to aggravation of kyphotic stress from walking imbalance. Cite this article: Y-C. Kim, D. H
Acute low back pain with or without sciatica usually is self-limited and has no serious underlying pathology. For most patients, reassurance, pain medications, and advice to stay active are sufficient. A more thorough evaluation is required in selected patients with "red flag" findings associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require closer follow-up and, in some cases, urgent referral to a surgeon. In patients with nonspecific mechanical low back pain, imaging can be delayed for at least four to six weeks, which usually allows the pain to improve. There is good evidence for the effectiveness of acetaminophen, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physical therapy, and advice to stay active. Spinal manipulative therapy may provide short-term benefits compared with sham therapy but not when compared with conventional treatments. Evidence for the benefit of acupuncture is conflicting, with higher-quality trials showing no benefit. Patient education should focus on the natural history of the back pain, its overall good prognosis, and recommendations for effective treatments.
Jensen, Mark P.; Patterson, David R.
The empirical support for hypnosis for chronic pain management has flourished over the past two decades. Clinical trials show that hypnosis is effective for reducing chronic pain, although outcomes vary between individuals. The findings from these clinical trials also show that hypnotic treatments have a number of positive effects beyond pain control. Neurophysiological studies reveal that hypnotic analgesia has clear effects on brain and spinal-cord functioning that differ as a function of the specific hypnotic suggestions made, providing further evidence for the specific effects of hypnosis. The research results have important implications for how clinicians can help their clients experience maximum benefits from hypnosis and treatments that include hypnotic components. PMID:24547802
Akerman, Nicholas; Dresner, Martin
There is a long history of attempts to alleviate the pain of childbirth, particularly in Asian and Middle Eastern civilisations. In the UK, it was the administration of chloroform to Queen Victoria by John Snow in 1853 that is widely credited with popularizing the idea that labour pain should and could be treated. Medical analgesia is now well established around the globe with a wealth of research evidence describing methods, efficacy and complications. In this article, we define 'primary breakthrough pain' as the moment when a woman first requests analgesia during labour. The management of this can include simple emotional support, inhaled analgesics, parenteral opioids and epidural analgesia. 'Secondary breakthrough pain' can be defined as the moment when previously used analgesia becomes ineffective. We concentrate our discussion of this phenomenon on the situation when epidural analgesia begins to fail. Only epidural analgesia offers the potential for complete analgesia, so when this effect is lost the recipient can experience significant distress and dissatisfaction. The best strategy to avert this problem is prevention by using the best techniques for epidural catheterisation and the most effective drug combinations. Even then, epidurals can lose their efficacy for a variety of reasons, and management is hampered by the fact that each rescue manoeuvre takes about 30 minutes to be effective. If the rescue protocol is too cautious, analgesia may not be successfully restored before delivery, leading to patient dissatisfaction. We therefore propose an aggressive response to epidural breakthrough pain using appropriate drug supplementation and, if necessary, the placement of a new epidural catheter. Combined spinal epidural techniques offer several advantages in this situation. The goal is to re-establish analgesia within 1 hour. The primary aim of pain management during labour and delivery is to provide the level of comfort determined as acceptable to each
Smereck, Janet A; Papafilippaki, Argyro; Sudarshan, Sawali
Bench press exercise, which involves repetitive lifting of weights to full arm extension while lying supine on a narrow bench, has been associated with complications ranging in acuity from simple pectoral muscle strain, to aortic and coronary artery dissection. A 39-year-old man, physically fit and previously asymptomatic, presented with acute chest pain following bench press exercise. Diagnostic evaluation led to the discovery of critical multivessel coronary occlusive disease, and subsequently, highly elevated levels of lipoprotein (a). Judicious use of ancillary testing may identify the presence of “high-risk” conditions in a seemingly “low-risk” patient. Emergency department evaluation of the young adult with acute chest pain must take into consideration an extended spectrum of potential etiologies, so as to best guide appropriate management. PMID:27703399
Niezgoda, Jeffrey A; Hardin, Scott T; Kubat, Nicole; Acompanado, Jocelyn
This case describes a 51-year-old woman who reported experiencing severe, constant pain, diffusely located in the region of her right mandible neck (primarily involving the mandible, lower right molars, the neck, the upper back, and the shoulder) during the course of several years. Surgical interventions (root canal, spinal fusion) were performed to address potential sources of pain. Despite these interventions, the patient reported severe pain after both surgeries, which persisted beyond the acute postoperative period. Additional pharmacological interventions and physical therapy were also attempted; nonetheless, the patient reported that pain remained severe and constant for approximately 2 years. On the basis of the patient's poor response to conventional treatments, a novel approach of botulinum toxin (BTX) injections was initiated. When pulsed electromagnetic field therapy was added, the need for BTX injections decreased, with the patient reporting a noticeable decrease in pain intensity and an improvement in quality of life measures. Currently, the patient continues to use pulsed electromagnetic field therapy regularly for pain management, which has allowed her to reduce the use of other interventions and avoid continued use of narcotic medications. Considering the need for multifaceted pain management approaches in the treatment of chronic pain, this case is relevant for wound care practitioners attending to patients with chronic postincisional wound pain because the outcome highlights the utility of a nonpharmacological, complementary pain management intervention for closed, yet persistently painful, postoperative wounds.
Solowiej, Kazia; Upton, Dominic
Wound pain can arise from the wound itself, continuing wound treatment and anticipatory pain, which occurs in some patients as a consequence of negative experiences of care. Specifically, pain caused by the removal and application of dressings has been identified as a major contributor to wound pain, from both patient and health professional perspectives. This article reviews literature on the impact of pain at dressing change, and provides practical suggestions for assessment and management of pain during wound care.
Takemura, Yoshinori; Furuta, Sadayoshi; Hirayama, Shigeto; Miyashita, Kazuhiko; Imai, Satoshi; Narita, Michiko; Kuzumaki, Naoko; Tsukiyama, Yoshi; Yamazaki, Mitsuaki; Suzuki, Tsutomu; Narita, Minoru
Although the way for pain management associated with acute pancreatitis has been searched for, there are not enough medications available for it. The aim of the present study was to investigate the role of bradykinin (BK) in pain related to acute pancreatitis. After repeated injections of caerulein (50 μg/kg and 6 times), mice showed edema in the pancreas, and blood concentrations of pancreatic enzymes (amylase and lipase) were clearly elevated. A histopathological study demonstrated that caerulein caused tissue damage characterized by edema, acinar cell necrosis, interstitial hemorrhage, and inflammatory cell infiltrates. Furthermore, the mRNA levels of interleukin-1β and monocyte chemotactic protein (MCP)-1 were significantly increased in the pancreas of caerulein-treated mice. The sensitivity of abdominal organs as measured by abdominal balloon distension was enhanced in caerulein-injected mice, suggesting that caerulein caused pancreatic hyperalgesia. Moreover, repeated treatment with caerulein resulted in cutaneous tactile allodynia of the upper abdominal region as demonstrated by the use of von Frey filaments, indicating that caerulein-treated mice exhibited referred pain. Under this condition, the mRNA levels of bradykinin B1 receptor (BKB1R) and bradykinin B2 receptor (BKB2R) were significantly increased in the dorsal root ganglion (DRG). Finally, we found that des-Arg⁹-(Leu⁸)-bradykinin (BKB1R antagonist) and HOE-140 (BKB2R antagonist) attenuated the acute pancreatitis pain-like state in caerulein-treated mice. These findings suggest that the upregulation of BK receptors in the DRG may, at least in part, contribute to the development of the acute pancreatitis pain-like state in mice.
Huang, David; Wun, Edmund; Stern, Avichai
In light of preoperative and postoperative mortality and morbidity, continued advancement in pain and anxiety management would benefit millions. Although significant strides have been made in the past few decades, it is imperative that research and development continue. This article discusses types of pain and anxiety, the relationship between pain and anxiety, the physiology of pain and anxiety, and current trends in pain and anxiety management.
Psychological distress increases with the intensity of cancer pain. Cancer pain is often under-reported and under-treated for a variety of complex reasons, including a number of beliefs held by patients, families and healthcare professionals. There is evidence that cognitive behavioural techniques that address catastrophising and promote self-efficacy lead to improved pain management. Group format pain management programmes could contribute to the care of cancer survivors with persistent pain. PMID:26526551
Hayes, Kim; Gordon, Debra B
The delivery of high-quality pain management in the perioperative environment can be challenging and difficult to quantify. Commonly used tools in delivering care, such as pain intensity ratings, individual pain experience reporting, assessments of individual patients' expectations, and patient satisfaction scores, have limitations and are not always useful when addressing quality improvement measures. Despite clinical advances in pain management, patients continue to experience inadequate pain control and inconsistent pain management practices. In this article, we discuss the challenges in providing consistent quality pain management, the need for a coordinated plan of care with a goal of meeting desired pain outcomes, and the essential role that perianesthesia and perioperative nurses play throughout the transitions in perioperative care to promote optimal pain management interventions based on the patient's individual needs.
Rantala, Maija; Kankkunen, Päivi; Kvist, Tarja; Hartikainen, Sirpa
The aim of this study is to describe current post-operative pain management practices for patients with dementia and hip fracture in Finland. Older adults with hip fracture are at high risk of under treatment for pain, especially if they also have a cognitive disorder at the stage of dementia. Previous studies have provided limited information about the quality of acute pain treatment for persons with dementia. In this study data concerning current pain management practices was collected by questionnaire from 333 nursing staff. They worked in surgical wards of seven universities and ten city-centre hospitals. The response rate to the questionnaire was 53%. The data was analysed using factor analysis and parametric methods. Half the respondents (53%) considered that post-operative pain management was sufficient for patients with dementia. Less than one third of respondent nurses reported that pain scales were in use on their unit: the most commonly used scale was VAS. The use of pain scales was significantly related to the respondents’ opinion of the sufficiency of post-operative pain management in this patient group (p<0.001). The findings can be utilised in nursing practice and research when planning suitable complementary educational interventions for nursing staff of surgical wards. Further research is needed to explain the current situation of pain management practices from the viewpoint of patients with dementia. PMID:22723810
Rantala, Maija; Kankkunen, Päivi; Kvist, Tarja; Hartikainen, Sirpa
The aim of this study is to describe current post-operative pain management practices for patients with dementia and hip fracture in Finland. Older adults with hip fracture are at high risk of under treatment for pain, especially if they also have a cognitive disorder at the stage of dementia. Previous studies have provided limited information about the quality of acute pain treatment for persons with dementia. In this study data concerning current pain management practices was collected by questionnaire from 333 nursing staff. They worked in surgical wards of seven universities and ten city-centre hospitals. The response rate to the questionnaire was 53%. The data was analysed using factor analysis and parametric methods. Half the respondents (53%) considered that post-operative pain management was sufficient for patients with dementia. Less than one third of respondent nurses reported that pain scales were in use on their unit: the most commonly used scale was VAS. The use of pain scales was significantly related to the respondents' opinion of the sufficiency of post-operative pain management in this patient group (p<0.001). The findings can be utilised in nursing practice and research when planning suitable complementary educational interventions for nursing staff of surgical wards. Further research is needed to explain the current situation of pain management practices from the viewpoint of patients with dementia.
Lee, Regent; Lomas, Oliver; Handa, Ashok
Raynaud's phenomenon is an exaggerated vasospastic response to cold or emotional stress which not only may cause the patient severe pain but also critical ischaemia and necrosis of the digits. We report the case of a 69-year-old woman who presented with rest pain, impending ulceration and necrosis of finger tips due to an episode of left-sided Raynaud's phenomenon. Intravenous prostacyclin was administered successfully as a bridge to endoscopic thoracic sympathectomy. Vascular surgery units are ideally positioned for the acute management of severe Raynaud's phenomenon to provide continuity of care to patients with profound digital ischaemia and impending tissue loss.
O'Neill, Søren; Graven-Nielsen, Thomas; Manniche, Claus; Arendt-Nielsen, Lars
Quantitative sensory testing has indicated generalized muscle hyperalgesia in patients with chronic low back pain. The temporal development of such hyperalgesia is not well understood. The aim of the present study was to demonstrate whether generalized muscle hyperalgesia can develop within minutes of acute low back pain using a new experimental model of lumbar facet joint pain. Thirteen healthy volunteers were included and baseline pressure pain thresholds were assessed at eight separate sites, outside the area of evoked low back and referred pain. Using ultrasonography, two electrode needles were placed either side of a lumbar facet joint (right L3-4) and used to induce experimental low back pain for 10 min with continuous stimulation. Thresholds, stimulus-response relationships, distribution and quality of the electrically induced pain were recorded. Electrical facet joint stimulation induced low back pain and pain referral into the anterior leg, ipsilaterally, proximal to the knee, similar to what is observed clinically. Pressure pain thresholds did not change significantly before, during and after facet joint stimulation. In conclusion, we describe a novel model of acute experimental low back pain and demonstrate that generalized hyperalgesia did not develop within minutes of acute low back pain.
Nesbitt, Julian; Moxham, Sian; Ramadurai, Gopinath; Williams, Lucy
Stroke patients can experience a variety of pain. Many stroke patients have co-morbidities such as osteoporosis, arthritis or diabetes causing diabetic neuropathy. As well as pain from other long term conditions, stroke patients can experience central post-stroke pain, headaches, and musculoskeletal issues such as hypertonia, contractures, spasticity, and subluxations. These stroke patients can also have communication difficulties in the form of expressive dysphasia and/or global aphasia. Communication difficulties can result in these patients not expressing their pain and therefore not having it assessed, leading to inadequate pain relief that could impact their rehabilitation and recovery. By implementing an observational measurement of pain such as the Abbey pain scale, patients with communication difficulties can have their pain assessed and recorded. Initially 30% of patients on the acute stroke ward did not have their pain assessed and adequately recorded and 15% of patients had inadequate pain relief. The patient was assessed if they were in pain and therefore not receiving adequate pain relief by measuring their pain on the Abbey pain scale. After introducing the Abbey pain scale and creating a nurse advocate, an improvement was shown such that only 5% of patients did not have their pain recorded and all had adequate pain relief.
Nesbitt, Julian; Moxham, Sian; ramadurai, gopinath; Williams, Lucy
Stroke patients can experience a variety of pain. Many stroke patients have co-morbidities such as osteoporosis, arthritis or diabetes causing diabetic neuropathy. As well as pain from other long term conditions, stroke patients can experience central post-stroke pain, headaches, and musculoskeletal issues such as hypertonia, contractures, spasticity, and subluxations. These stroke patients can also have communication difficulties in the form of expressive dysphasia and/or global aphasia. Communication difficulties can result in these patients not expressing their pain and therefore not having it assessed, leading to inadequate pain relief that could impact their rehabilitation and recovery. By implementing an observational measurement of pain such as the Abbey pain scale, patients with communication difficulties can have their pain assessed and recorded. Initially 30% of patients on the acute stroke ward did not have their pain assessed and adequately recorded and 15% of patients had inadequate pain relief. The patient was assessed if they were in pain and therefore not receiving adequate pain relief by measuring their pain on the Abbey pain scale. After introducing the Abbey pain scale and creating a nurse advocate, an improvement was shown such that only 5% of patients did not have their pain recorded and all had adequate pain relief. PMID:26732690
Kendrick, Cassie; Sliwinski, Jim; Yu, Yimin; Johnson, Aimee; Fisher, William; Kekecs, Zoltán; Elkins, Gary
Clinical evidence for the effectiveness of hypnosis in the treatment of acute, procedural pain was critically evaluated based on reports from randomized controlled clinical trials (RCTs). Results from the 29 RCTs meeting inclusion criteria suggest that hypnosis decreases pain compared to standard care and attention control groups and that it is at least as effective as comparable adjunct psychological or behavioral therapies. In addition, applying hypnosis in multiple sessions prior to the day of the procedure produced the highest percentage of significant results. Hypnosis was most effective in minor surgical procedures. However, interpretations are limited by considerable risk of bias. Further studies using minimally effective control conditions and systematic control of intervention dose and timing are required to strengthen conclusions. PMID:26599994
Kendrick, Cassie; Sliwinski, Jim; Yu, Yimin; Johnson, Aimee; Fisher, William; Kekecs, Zoltán; Elkins, Gary
Clinical evidence for the effectiveness of hypnosis in the treatment of acute procedural pain was critically evaluated based on reports from randomized controlled clinical trials (RCTs). Results from the 29 RCTs meeting inclusion criteria suggest that hypnosis decreases pain compared to standard care and attention control groups and that it is at least as effective as comparable adjunct psychological or behavioral therapies. In addition, applying hypnosis in multiple sessions prior to the day of the procedure produced the highest percentage of significant results. Hypnosis was most effective in minor surgical procedures. However, interpretations are limited by considerable risk of bias. Further studies using minimally effective control conditions and systematic control of intervention dose and timing are required to strengthen conclusions.
Stitt, Rodger Scott; Greenwood, Robert; Laczek, Jeffrey
A 42 year-old African-American woman was admitted for severe acute right upper quadrant pain. Her liver function tests showed a cholestatic pattern of hepatitis. She had no known history of liver disease or sarcoidosis. Imaging of her liver and biliary tree did not reveal any apparent cause for her right upper quadrant pain. A liver biopsy was performed which showed granulomatous disease. This prompted a CT chest that showed mediastinal lymphadenopathy. Biopsy of the mediastinal lymphnode revealed non-caseating granulomas. Despite having no pulmonary symptoms or history of pulmonary sarcoidosis, she was diagnosed with systemic pulmonary sarcoidosis. She was treated with corticosteroids and had complete resolution of symptoms over the next several weeks.
Voelker, M; Schachtel, B P; Cooper, S A; Gatoulis, S C
A recently developed fast-release aspirin tablet formulation has been evaluated in two different pain models. The dental impaction pain model and the sore throat pain model are widely used for assessing analgesia, including acute mild-to-moderate pain. Both studies were double-blind, randomized, parallel group and compared a single dose of 1000 mg aspirin with 1000 mg paracetamol and with placebo and investigated the onset and overall time course of pain relief. Speed of onset was measured by the double-stopwatch method for time to meaningful pain relief and time to first perceptible pain relief. Pain intensity and pain relief were rated subjectively over a 6-h (dental pain) and 2-h (sore throat pain) time period. In both models fast-release aspirin and commercial paracetamol were statistically significantly different from placebo for onset of action, summed pain intensity differences and total pain relief. Meaningful pain relief was achieved within a median of 42.3 and 42.9 min for aspirin and paracetamol, respectively, in the dental pain model. The corresponding numbers in sore throat pain were 48.0 and 40.4 min. All treatments in both studies were safe and well tolerated. No serious adverse events were reported and no subject was discontinued due to an adverse event. Overall the two studies clearly demonstrated efficacy over placebo in the two pain models and a comparable efficacy and safety profile between aspirin and an equivalent dose of paracetamol under the conditions of acute dental pain and acute sore throat pain. Trial registration These trials were registered with ClinicalTrials.gov, registration number: NCT01420094, registration date: July 27, 2011 and registration number: NCT01453400, registration date: October 13, 2011.
Zuccaro, Stefano Maria; Vellucci, Renato; Sarzi-Puttini, Piercarlo; Cherubino, Paolo; Labianca, Roberto; Fornasari, Diego
Despite the availability of effective pain treatments, there are numerous barriers to effective management resulting in a large proportion of patients not achieving optimal pain control. Chronic pain is inadequately treated because of a combination of cultural, societal, educational, political and religious constraints. The consequences of inadequately treated pain are physiological and psychological effects on the patient, as well as socioeconomic implications. Unreasonable failure to treat pain is viewed as unethical and an infringement of basic human rights. The numerous barriers to the clinical management of pain vary depending on whether they are viewed from the standpoint of the patient, the physician, or the institution. Identification and acknowledgement of the barriers involved are the first steps to overcoming them. Successful initiatives to overcome patient, physician and institutional barriers need to be multifaceted in their approach. Multidisciplinary initiatives to improve pain management include dissemination of community-based information, education and awareness programmes to attempt to change attitudes towards pain treatment. A better awareness and insight into the problems caused by unrelieved pain and greater knowledge about the efficacy and tolerability of available pain management options should enable physicians to seek out and adhere to treatment guidelines, and participate in interventional and educational programmes designed to improve pain management, and for institutions to implement the initiatives required. Although much work is underway to identify and resolve the issues in pain management, many patients still receive inadequate treatment. Continued effort is required to overcome the known barriers to effective pain management.
Saini, Shalini; Bhatnagar, Sushma
The World Health Organization estimated that more than 60% of the 14 million new cancer cases worldwide in 2012 were reported in the developing part of the world, including Asia, Africa, Central and South America. Cancer survival rate is poorer in developing countries due to diagnosis at late stage and limited access to timely treatment. Since the disease per se cannot be treated even with the best available treatment modalities, what remains important is symptom management and providing comfort care to these patients. The incidence of pain in advanced stages of cancer approaches 70-80%. Lack of preventive strategies, poverty, illiteracy, and social stigma are the biggest cause of pain suffering and patient presenting in advance stage of their disease. The need for palliative care is expanding due to aging of world's population and increase in the rate of cancer in developed and developing countries. A huge gap remains between demand and current palliative care services. Overcoming barriers to palliative care is a major global health agenda that need immediate attention. Main causes of inadequate pain relief remain lack of knowledge among physician and patients, lack of adequate supply of opioids and other drugs for pain relief, strong bureaucracy involved in terms of procurement, and dispensing of opioids. Beside this, poverty and illiteracy remain the most important factors of increased suffering.
Saini, Shalini; Bhatnagar, Sushma
The World Health Organization estimated that more than 60% of the 14 million new cancer cases worldwide in 2012 were reported in the developing part of the world, including Asia, Africa, Central and South America. Cancer survival rate is poorer in developing countries due to diagnosis at late stage and limited access to timely treatment. Since the disease per se cannot be treated even with the best available treatment modalities, what remains important is symptom management and providing comfort care to these patients. The incidence of pain in advanced stages of cancer approaches 70–80%. Lack of preventive strategies, poverty, illiteracy, and social stigma are the biggest cause of pain suffering and patient presenting in advance stage of their disease. The need for palliative care is expanding due to aging of world's population and increase in the rate of cancer in developed and developing countries. A huge gap remains between demand and current palliative care services. Overcoming barriers to palliative care is a major global health agenda that need immediate attention. Main causes of inadequate pain relief remain lack of knowledge among physician and patients, lack of adequate supply of opioids and other drugs for pain relief, strong bureaucracy involved in terms of procurement, and dispensing of opioids. Beside this, poverty and illiteracy remain the most important factors of increased suffering. PMID:27803557
Mancio, Jennifer; Bettencourt, Nuno; Oliveira, Marco; Pires-Morais, Gustavo; Ribeiro, Vasco Gama
Myocarditis is assumed to involve both ventricles equally. Right ventricular predominant involvement is rarely described. A case of acute viral right ventricular myocarditis presenting with chest pain and syncope, grade 3 atrioventricular block, right ventricular dilatation and free wall hypokinesia is reported. Cardiac MRI showed late enhancement of the right ventricular free wall without involvement of the left ventricle. Anti-Coxsackie A9 virus neutralising IgM-type antibodies titre was elevated. This case emphasises that manifestations of myocarditis can be limited to the right ventricle and should be considered in the differential diagnosis of right ventricular enlargement. PMID:24096068
Philbrick, T H; Kaude, J V; McInnis, A N; Wright, P G
Ultrasonography was performed as the first imaging procedure in 100 patients who presented with acute right upper quadrant pain suggestive of cholecystitis or cholelithiasis. In the final analysis 46 patients were found to have gallbladder disease (40 patients with cholelithiasis, 5 with acalculous cholecystitis, and 1 with a cholesterol polyp in the gallbladder). In 22 of 54 patients with a normal gallbladder, other abdominal disease was found. The error rate for ultrasound was 5%, and in 4 patients ultrasound was not the suitable procedure for the diagnosis. In 91 patients the ultrasonographic diagnosis was correct.
Harvey, A. C.; Moodie, P. F.
A non-sequential Bayesian analysis was deemed a suitable approach to the important clinical problem of analysis of acute abdominal pain in the Emergency Room. Using series reported in the literature as a data source complemented by expert clinical estimates of probabilities of clinical data a program has been established in St. Boniface, Canada. Prior to implementing the program as an online, quickly available diagnostic aid, a prospective preliminary study has shown that the performance of computer plus clinician is significantly better than either clinician or computer alone. A major emphasis has been developing the acceptability of the program in real-life diagnoses in the Emergency Room.
Malanga, Gerard A; Dennis, Robin L
The prescription of medications continues to be one of the mainstays of treatment of acute low back pain episodes. The goals of the pharmacologic treatment for acute low back are reduction of pain and return of normal function. Often, nociception is a result of secondary inflammation and muscle spasm after acute injury of a structure of the spine, which may include muscle, tendon, ligament, disc, or bone. An understanding of the appropriate use of medications to address the underlying pain generator and the current evidence for using these medications is essential for any physician who sees and treats patients with acute low back pain.
Labbé, Elise; Herbert, Donald; Haynes, Johnson
Many physicians believe that patients with sickle cell disease (SCD) are more likely to become addicted to pain medication than are other patient populations. This study hypothesizes that physicians' attitudes towards addiction in patients with SCD affects pain management practices. The Physician Attitudes Survey was sent to 286 physicians at seven National Institutes of Health-funded university-based comprehensive sickle cell centres. The survey assessed demographic information; and physician's attitudes toward and knowledge of pain, pain treatment, and drug addiction and abuse. Significant Pearson product-moment correlations were found between attitudes towards pain and beliefs regarding addiction to prescribed opioids. Physicians reported varied pain management strategies, however, many believe that attitudes toward addiction and to patients in pain crises may result in undertreatment of pain. These results indicate that physicians might benefit from additional education regarding sickle cell disease, addiction to pain medication, the pharmacology of opioids, and the assessment and treatment of pain.
Louis, Martine A.; Lin, Elizabeth; Baek, Ji Yoon; Andoni, Alda; Wang, Xiao Hui
General surgeons are often asked to evaluate acute abdominal pain which has an expanded differential diagnosis in women of childbearing age. Acute appendicitis accounts for many surgical emergencies as a common cause of nongynecologic pelvic pain. In some rare instances, acute appendicitis has been shown to occur simultaneously with a variety of gynecologic diseases. We report a case of concurrent acute appendicitis and ruptured ovarian endometrioma. PMID:28097032
Cole, B Eliot
The occurrence of diabetic peripheral neuropathy (DPN) is linked to poor glycemic control over time. While most people never develop diabetic peripheral neuropathic pain (DPNP) as a consequence of DPN, enough of them do that we must have effective options for the management of this disabling condition. Two years ago there were no formally approved medications for the treatment of DPNP, and now there are two medications with Food and Drug Administration approval for DPNP. One of these medications, duloxetine has been established to significantly improve pain and to address depression by its reuptake inhibition of norepinephrine and serotonin. This article examines the epidemiology of DPNP, its underlying pathogenesis, necessary evaluation methods, and treatment options available with a focus on the role of duloxetine.
Chuang, Alice; Munz, Stephanie M.; Dabiri, Darya
Prenatal oral health extends beyond the oral cavity, impacting the general well-being of the pregnant patient and her fetus. This case report follows a 19-year-old pregnant female presenting with acute liver failure secondary to acetaminophen overdose for management of dental pain following extensive dental procedures. Through the course of her illness, the patient suffered adverse outcomes including fetal demise, acute kidney injury, spontaneous bacterial peritonitis, and septic shock before eventual death from multiple organ failure. In managing the pregnant patient, healthcare providers, including physicians and dentists, must recognize and optimize the interconnected relationships shared by the health disciplines. An interdisciplinary approach of collaborative and coordinated care, the timing, sequence, and treatment for the pregnant patient can be improved and thereby maximize overall quality of health. Continued efforts toward integrating oral health into general healthcare education through interprofessional education and practice are necessary to enhance the quality of care that will benefit all patients. PMID:27847654
Lee, Sarah K Y; Quinonez, Rocio B; Chuang, Alice; Munz, Stephanie M; Dabiri, Darya
Prenatal oral health extends beyond the oral cavity, impacting the general well-being of the pregnant patient and her fetus. This case report follows a 19-year-old pregnant female presenting with acute liver failure secondary to acetaminophen overdose for management of dental pain following extensive dental procedures. Through the course of her illness, the patient suffered adverse outcomes including fetal demise, acute kidney injury, spontaneous bacterial peritonitis, and septic shock before eventual death from multiple organ failure. In managing the pregnant patient, healthcare providers, including physicians and dentists, must recognize and optimize the interconnected relationships shared by the health disciplines. An interdisciplinary approach of collaborative and coordinated care, the timing, sequence, and treatment for the pregnant patient can be improved and thereby maximize overall quality of health. Continued efforts toward integrating oral health into general healthcare education through interprofessional education and practice are necessary to enhance the quality of care that will benefit all patients.
Gordon, Robert M; Corcoran, John R; Bartley-Daniele, Patricia; Sklenar, Dennis; Sutton, Phyllis Roach; Cartwright, Frances
This paper will discuss the transition from multidisciplinary to interdisciplinary and transdisciplinary team approaches to pain management at New York University Langone Medical Center - Rusk Institute of Rehabilitation Medicine. A transdisciplinary team approach to pain management emphasizes mutual learning, training, and education, and the flexible exchange of discipline-specific roles. Clinicians are enabled to implement a unified, holistic, and integrated treatment plan with all members of the team responsible for the same patient-centered goals. The model promotes and empowers patient and family/support system goals within a cultural context. Topics of exploration include the descriptions of three team approaches to patient care, including their practical, philosophical, and historical basis, strengths and challenges, research support, and cultural diversity. Case vignettes will highlight the strengths and limitations of the transdisciplinary team approach to pain management throughout a broad and diverse continuum of care, including acute medical, palliative, and perioperative care and acute inpatient rehabilitation services.
Grant, Lynda D.; Haverkamp, Beth E.
Provides counselors with an introduction to the role of psychosocial processes in the experience of pain and offers assessment and intervention recommendations based on a cognitive-behavioral therapy approach to pain management. (JPS)
Dysvik, Elin; Vinsnes, Anne Guttormsen; Eikeland, Ole-Johan
The aim of this study was to develop and evaluate the effects of a multidisciplinary pain management programme on coping, health-related quality of life and pain intensity. Seventy-six outpatients suffering from chronic pain completed this eight-week programme with the primary aims to increase coping, as measured by the Ways of Coping Checklist, and health-related quality of life, as measured by the Short Form-36 Health Survey. Therapeutic dialogues and education, combined with physical activity, were given in order to increase understanding of and attention to non-medical factors that might affect pain perception. The programme was active, time-limited and structured on the basis of multidisciplinary pain management programmes based on a cognitive-behavioural approach. The findings suggest that this programme has the potential to improve coping skills and health-related quality of life. Additionally, pain intensity, as measured by the Visual Analogue Scale, was reduced. Age and disability were revealed as the prominent predictors of change after treatment. The differences in this sample indicated that the drop-outs tended to be older and reported more health problems, although these findings were non-significant. Clinical and research implications are discussed.
Cheatle, Martin D
Chronic pain affects nearly one-third of the American population. Chronic pain can lead to a variety of problems for a pain sufferer, including developing secondary medical problems, depression, functional and vocational disability, opioid abuse and suicide. Current pain care models are deficient in providing a necessary comprehensive approach. Most patients with chronic pain are managed by primary care clinicians who are typically ill prepared to effectively and efficiently manage these cases. A biopsychosocial approach to evaluate and treat chronic pain is clinically and economically efficacious, but unique delivery systems are required to meet the challenge of access to specialty care.
Manchikanti, Laxmaiah; Hirsch, Joshua A; Falco, Frank JE; Boswell, Mark V
AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain. METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V
Feldman, Jeffrey B
Experimental (Price & Barber, 1987) and neuroimaging studies (Rainville, Carrier, Hofbauer, Bushnell, & Duncan, 1999), suggest that it is the affective dimension of pain as processed in the anterior cingulate cortex (ACC) that is most associated with suffering and autonomic arousal. Conversely, pain related emotions (Rainville, Bao, & Chretien, 2005) and expectations (Koyama, McHaffie, Laurenti, & Coghill, 2005) modulate pain perception and associated pain affect. This paper presents both the scientific background and the general clinical steps involved in a practical hypnotic approach that uses emotion specific wording and the elicitation of prior positive experience to intervene at both the affective and sensory dimensions of pain. Such an approach enables patients to therapeutically use hypnosis to reduce their subjective distress even if they are not able to greatly reduce the sensation of pain. The utilization of positive state dependent learning (Rossi, 1986), following the advice of Milton Erickson to "discover their patterns of happiness" (Parsons-Fein, 2005) is emphasized.
Cheatle, Martin D; Foster, Simmie; Pinkett, Aaron; Lesneski, Matthew; Qu, David; Dhingra, Lara
Chronic pain is associated with symptoms that may impair a patient's quality of life, including emotional distress, fatigue, and sleep disturbance. There is a high prevalence of concomitant pain and sleep disturbance. Studies support the hypothesis that sleep and pain have a bidirectional and reciprocal relationship. Clinicians who manage patients with chronic pain often focus on interventions that relieve pain, and assessing and treating sleep disturbance are secondary or not addressed. This article reviews the literature on pain and co-occurring sleep disturbance, describes the assessment of sleep disturbance, and outlines nonpharmacologic and pharmacologic treatment strategies to improve sleep in patients with chronic pain.
Casazza, Brian A
Acute low back pain is one of the most common reasons for adults to see a family physician. Although most patients recover quickly with minimal treatment, proper evaluation is imperative to identify rare cases of serious underlying pathology. Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required. Although there are numerous treatments for nonspecific acute low back pain, most have little evidence of benefit. Patient education and medications such as nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants are beneficial. Bed rest should be avoided if possible. Exercises directed by a physical therapist, such as the McKenzie method and spine stabilization exercises, may decrease recurrent pain and need for health care services. Spinal manipulation and chiropractic techniques are no more effective than established medical treatments, and adding them to established treatments does not improve outcomes. No substantial benefit has been shown with oral steroids, acupuncture, massage, traction, lumbar supports, or regular exercise programs.
Abdulla, Aza; Adams, Nicola; Bone, Margaret; Elliott, Alison M; Gaffin, Jean; Jones, Derek; Knaggs, Roger; Martin, Denis; Sampson, Liz; Schofield, Pat
This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided
Duong, Vicky; Maher, Chris G; Steffens, Daniel; Li, Qiang; Hancock, Mark J
The aim of this study was to investigate the influence of various weather parameters on pain intensity levels in patients with acute low back pain (LBP). We performed a secondary analysis using data from the PACE trial that evaluated paracetamol (acetaminophen) in the treatment of acute LBP. Data on 1604 patients with LBP were included in the analysis. Weather parameters (precipitation, temperature, relative humidity, and air pressure) were obtained from the Australian Bureau of Meteorology. Pain intensity was assessed daily on a 0-10 numerical pain rating scale over a 2-week period. A generalised estimating equation analysis was used to examine the relationship between daily pain intensity levels and weather in three different time epochs (current day, previous day, and change between previous and current days). A second model was adjusted for important back pain prognostic factors. The analysis did not show any association between weather and pain intensity levels in patients with acute LBP in each of the time epochs. There was no change in strength of association after the model was adjusted for prognostic factors. Contrary to common belief, the results demonstrated that the weather parameters of precipitation, temperature, relative humidity, and air pressure did not influence the intensity of pain reported by patients during an episode of acute LBP.
Kim, Min Sung; Kim, Dong Jin; Na, Chan Ho
Background Although there are several available management strategies for treatment of both acute pain of herpes zoster (HZ) and postherpetic neuralgia (PHN), it is difficult to treat them adequately. Objective The aim of this study was to evaluate the efficacy of intravenously administrated vitamin C on acute pain and its preventive effects on PHN in patients with HZ. Methods Between September 2011 and May 2013 eighty-seven patients who were admitted for HZ were assessed according to age, sex, underlying diseases, duration of pain and skin lesion, dermatomal distribution, and PHN. It was a randomized controlled study, in which 87 patients were randomly allocated into the ascorbic acid group and control group. Each patient received normal saline infusion with or without 5 g of ascorbic acid on days 1, 3, and 5 then answered questionnaires that included side effects and pain severity using visual analogue scale on days 1, 2, 3, 4, and 5. After discharge, the severity of pain was obtained at out-patient clinic or by telephone on weeks 2, 4, 8, and 16. Results There was no differences in severity of pain on patients' age, sex, underlying diseases, duration of pain and skin lesion and dermatomal distribution between two groups (p>0.05). Since 8th week, pain score in ascorbic acid treatment group was significantly lower than control group (p <0.05). The incidence of PHN was significantly lower in the treatment group compared to control group (p=0.014). The changes of overall pain score was significantly different between the two groups (p<0.05). Conclusion Intravenously administered ascorbic acid did not relieve acute HZ pain; but is effective for reducing the incidence of PHN. PMID:27904265
Almoznino, Galit; Benoliel, Rafael; Sharav, Yair; Haviv, Yaron
Chronic craniofacial pain involves the head, face and oral cavity and is associated with significant morbidity and high levels of health care utilization. A bidirectional relationship is suggested in the literature for poor sleep and pain, and craniofacial pain and sleep are reciprocally related. We review this relationship and discuss management options. Part I reviews the relationship between pain and sleep disorders in the context of four diagnostic categories of chronic craniofacial pain: 1) primary headaches: migraines, tension-type headache (TTH), trigeminal autonomic cephalalgias (TACs) and hypnic headache, 2) secondary headaches: sleep apnea headache, 3) temporomandibular joint disorders (TMD) and 4) painful cranial neuropathies: trigeminal neuralgia, post-herpetic trigeminal neuropathy, painful post-traumatic trigeminal neuropathy (PTTN) and burning mouth syndrome (BMS). Part II discusses the management of patients with chronic craniofacial pain and sleep disorders addressing the factors that modulate the pain experience as well as sleep disorders and including both non-pharmacological and pharmacological modalities.
illustrations of a lower incidence of side-effects in the central nervous system. It is therefore possible to conclude that oxycodone represents a valid alternative to morphine in the management of moderate to severe cancer pain, also as first-line treatment.
Fernández, Nicolás; Rodriguez, Santiago; Perez, Jaime
Ovotesticular syndrome (OTS) belongs to the group of disorders of sex development (DSD). We present a case of a patient with OTS presenting with acute labioscrotal pain. A surgical exploration was indicated, and hemorrhage was identified. A gonadectomy was performed and the final pathology report revealed an ovotestis with a bleeding follicle, normal ovarian parenchyma and atrophic testicular parenchyma. After reviewing the literature there is scarce information on this complex topic, but conservative management could be an option if the risk of a gonadal malignancy is low.
Dionne, Raymond A; Gordon, Sharon M
A B S T R A C T The drugs available for the management of acute orofacial pain have changed very little since the introduction of ibuprofen into practice 40 years ago. Orally effective opioids, acetaminophen, aspirin and NSAIDs remain the mainstay of analgesic therapy. Increased recognition of the societal and personal impact of opioid diversion and abuse requires re-examination of the traditional approach of prescribing an opioid-containing analgesic combination to be administered by the patient "as needed" (PRN) starting postoperatively.
Smith, Heather; Youn, Youngwon; Guay, Ryan C; Laufer, Andras; Pilitsis, Julie G
Invasive analgesic therapies provide an alternative to medical management of chronic pain. With the increasing incidence of chronic pain not only in the United States but worldwide, more therapies have evolved to address the growing need for pain relief options. These therapies include spinal injections, nerve blocks, radiofrequency ablation, neurostimulation, and intrathecal drug delivery.
Danesh, Arash; Onyima, Chiemeka; Dukewich, Matthew; Gupta, Anita
Fluoroquinolones are widely prescribed antibiotics, used for various infectious etiologies. These antibiotics carry the possibility of the serious adverse effect of peripheral neuropathy, with a true incidence not known owing to its rare existence. Recently, the Food and Drug Administration (FDA) has required alterations to drug labels to highlight this adverse effect of fluoroquinolones. This is a case report of a single patient at an inpatient neurology service at an urban academic medical center in the United States. The patient is a 20-year-old male, with well-controlled type 1 diabetes mellitus, presenting with a short duration of bilateral lower extremity pain following a 10-day course of levofloxacin for suspected epididymitis. The patient was initially diagnosed with complex regional pain syndrome and treated with a variety of pain medications, including lidocaine infusions, hydromorphone, methadone, and ketamine infusions. After review of the patient's history and limited response to medical management, the patient's condition was reclassified as an adverse effect from fluoroquinolone treatment. Pain of unknown etiology can be perplexing, both for the physician and the patient. Reporting of similar incidents attributed to medication adverse effects will increase the awareness of this type of neuropathy, avoid future cases of misdiagnosis, and enable early detection and treatment.
Oladosu, Folabomi A.; Maixner, William; Nackley, Andrea G.
Drugs that target G-protein coupled receptors (GPCRs) represent the primary treatment strategy for patients with acute and chronic pain; however, there is substantial individual variability in both the efficacy and adverse side effects associated with these drugs. Variability in drug responses is, in part, due to individuals’ diversity in alternative splicing of pain-relevant GPCRs. GPCR alternative splice variants often exhibit distinct tissue distribution patterns, drug binding properties, and signaling characteristics that may impact disease pathology as well as the size and direction of analgesic effects. Here, we review the importance of GPCRs and their known splice variants to the management of pain. PMID:26250730
McCauley, Jenna L.; Mercer, Mary Ashley; Barth, Kelly S.; Brady, Kathleen T.; Back, Sudie E.
Background Nearly two-thirds of prescription opioid dependent individuals report chronic pain conditions as both an initial and current motivation for prescription opioid use. However, to date, limited information exists regarding perceptions of the adequacy of pain management and pain management behaviors among prescription opioid dependent individuals with a history of treatment for chronic pain. Methods The current study examined perceptions of the medical management of chronic pain among community-recruited individuals (N=39) who met DSM-IV-TR criteria for current prescription opioid dependence and reported a history of treatment for chronic pain. Prescription opioid dependence, symptoms of depression, and pain management perceptions were assessed using the Structured Clinical Interview for DSM Disorders, Beck Depression Inventory, and the Pain Management Questionnaire, respectively. Results Reports of insufficient pain management were common (46.2%), as was utilization of emergency room services for pain management (56.4%). Nearly half reported a physician as their initial source (46.2%) and pain management as their primary initial reason for prescription opioid use (53.8%), whereas 35.9% reported pain relief as their primary reason for current prescription opioid use. Symptoms of depression were common (51.3%), as was comorbid abuse of other substances and history of treatment for substance abuse. Conclusions Results highlight the complicated clinical presentation and prevalent perception of the under-treatment of pain among this population. Findings underscore the importance of interdisciplinary approaches to managing the complex presentation of chronic pain patients with comorbid prescription opioid dependence. Implications for future research are discussed. PMID:25034899
Yuxiang, Li; Lingjun, Zhou; Lu, Tang; Mengjie, Liu; Xing, Ming; Fengping, Shen; Jing, Cui; Xianli, Meng; Jijun, Zhao
Pain is a major problem after burns and researchers continue to report that pain from burns remains undertreated. The inadequate pain control results in adverse sequalae physically and psychologically in the burn victims. A better understanding of a burn patient's experience is important in identifying the factors responsible for undertreated pain and establishing effective pain management guidelines or recommendation in the practice of pain relief for burn injuries. This study sought to explore and describe the experience that patients have about pain related to burn-injury during hospitalization. Semi-structured interviews were conducted on eight patients with moderate to severe pain from burn injuries recruited from a Burn Centre in Northwest China. Data was collected by in-depth interviews and qualitative description after full transcription of each interview. Analysis involved the identification of themes and the development of a taxonomy of patients' experience of burn pain and its management. Three themes were indentified: (1) patients' experience of pain control, (2) patients' perception on burn pain management, and (3) patients' expectation of burn pain management. Findings from this study suggested that patients experience uncontrolled pain both physically and psychologically which may serve as an alert for awareness of health professionals to recognize and establish a multidisciplinary pain management team for burn victims, including surgeons, critical care specialists, anesthesiologists, nurses, psychologists, and social workers to accomplish safe and effective strategies for pain control to reach an optimal level of pain management in burn patients. It also provides insights and suggestions for future research directions to address this significant clinical problem.
Motov, Sergey M; Khan, Abu NGA
Pain is the most common reason people visit emergency rooms. Pain does not discriminate on the basis of gender, race or age. The state of pain management in the emergency department (ED) is disturbing. ED physicians often do not provide adequate analgesia to their patients, do not meet patients’ expectations in treating their pain, and struggle to change their practice regarding analgesia. A review of multiple publications has identified the following causes of poor management of painful conditions in the ED: failure to acknowledge pain, failure to assess initial pain, failure to have pain management guidelines in ED, failure to document pain and to assess treatment adequacy, and failure to meet patient’s expectations. The barriers that preclude emergency physicians from proper pain management include ethnic and racial bias, gender bias, age bias, inadequate knowledge and formal training in acute pain management, opiophobia, the ED, and the ED culture. ED physicians must realize that pain is a true emergency and treat it as such. PMID:21197290
Cho, Young-Hun; Kim, Chang-Kyu; Heo, Kwang-Ho; Lee, Myeong Soo; Ha, In-Hyuk; Son, Dong Wuk; Choi, Byung Kwan; Song, Geun-Sung; Shin, Byung-Cheul
Objectives Acupuncture is commonly used as a complimentary treatment for pain management. However, there has been no systematic review summarizing the current evidence concerning the effectiveness of acupuncture for acute postoperative pain after back surgery. This systematic review aimed at evaluating the effectiveness of acupuncture treatment for acute postoperative pain (≤1 week) after back surgery. Methods We searched 15 electronic databases without language restrictions. Two reviewers independently assessed studies for eligibility and extracted data, outcomes, and risk of bias. Random effect meta-analyses and subgroup analyses were performed. Results Five trials, including 3 of high quality, met our inclusion criteria. The meta-analysis showed positive results for acupuncture treatment of pain after surgery in terms of the visual analogue scale (VAS) for pain intensity 24 hours after surgery, when compared to sham acupuncture (standard mean difference −0.67 (−1.04 to −0.31), P = 0.0003), whereas the other meta-analysis did not show a positive effect of acupuncture on 24-hour opiate demands when compared to sham acupuncture (standard mean difference −0.23 (−0.58 to 0.13), P = 0.21). Conclusion Our systematic review finds encouraging but limited evidence for the effectiveness of acupuncture treatment for acute postoperative pain after back surgery. Further rigorously designed clinical trials are required. PMID:24766648
Thanawala, V; Kadam, V J; Ghosh, R
Management of acute and chronic pain has always been a key area of clinical research. Enkephalinase inhibitors (EIs) seem to be promising as therapeutic agents having antinociceptive action. They additionally possess anticraving, antidiarrhoeal and antidepressant actions. The antinociceptive action of EIs has been reported for over a decade however, their therapeutic potential is yet to be effectively explored. EIs may be broadly classified as endogenous and those that are obtained synthetically. Endogenous EIs include peptides like spinorphin and opiorphin. And compounds like RB 101, RB 120, RB 3007 constitute the synthetically obtained EIs. Endogenous and synthetic inhibitors enkephalin degrading enzymes have been studied in vivo using standard animal models. The potential EI targets appear to be APN (Aminopeptidase N), NEP (Neutral endopeptidase), DPP-III (Dipeptidyl peptidase). EIs possess the advantage that they lack the opioid side effects. This article reviews the mechanisms by which EIs act and elucidates the pathways involved.
Pathmawathi, Subramanian; Beng, Tan Seng; Li, Lee Mei; Rosli, Roshaslina; Sharwend, Supermanian; Kavitha, Rasaiah R; Christopher, Boey Chiong Meng
Breakthrough pain is a significant contributor to much suffering by patients. The experience of intense pain may interfere with, and affect, daily life functioning and has major consequences on patients' well-being if it is not well managed. The area of breakthrough pain has not been fully understood. This study thus aimed to explore the experiences of breakthrough pain among palliative patients. A qualitative study based on a series of open-ended interviews among 21 palliative patients suffering from pain at an urban tertiary hospital in Malaysia was conducted. Five themes were generated: (i) pain viewed as an unbearable experience causing misery in the lives of patients, (ii) deterioration of body function and no hope of recovery, (iii) receiving of inadequate pain management for pain, (iv) insensitivity of healthcare providers toward patients' pain experience, and (v) pain coping experiences of patients. The findings revealed that nonpharmacologic approaches such as psychosocial support should be introduced to the patients. Proper guidance and information should be given to healthcare providers to improve the quality of patient care. Healthcare providers should adopt a sensitive approach in caring for patients' needs. The aim is to meet the needs of the patients who want to be pain free or to attain adequate relief of their pain for breakthrough pain.
Perret, Danielle; Chang, Eric Y; Pang, Winnie; Shinada, Shuntaro; Panush, Richard S
SUMMARY Medical progress is measured by advances in science and technology. The pace of discovery will surely accelerate. We are increasingly challenged not only to assimilate new information, but also to reconcile our learning with our art. We present the common clinical problem of managing pain in osteoarthritis as a paradigm for this dilemma in contemporary patient care. We do not yet have the understanding and interventions to do this optimally for all with osteoarthritis, leaving us with uncertainties as we struggle to care for these patients. In a world of growing complexity and sophistication we must not overlook the person who is our patient. It is easy to be seduced by electronic and informational advances, to be entranced by machinery, and to forget the unique individuality and needs of each patient. Osler taught that “the practice of medicine is an art, based on science”. This doesn't change. PMID:24654815
Reisner-Keller, L A
Pharmacotherapy is a cornerstone in the treatment of pain. Medications are often used to assist in diagnosis of the pain problem because positive or negative responses may delineate the cause of a particular pain. Through rational drug-prescribing habits and education of both patients and physicians, effective regimens can be designed to increase pain control while decreasing untoward drug side effects.
Varner, Joyce McCullers
The elderly are often either untreated or undertreated for pain. The consequences of undertreatment for pain can have a devastating impact on health and quality of life, resulting in depression, anxiety, social isolation, cognitive impairment, immobility, and sleep disturbances. Reasons cited by healthcare professionals for inadequate pain control include lack of training, inappropriate pain assessment, and reluctance to prescribe opioids, however, the undertreatment of pain can be legally considered to constitute neglect, abuse, or negligence. The appropriate treatment of pain is humane and with good diagnostic efforts, proper consideration of appropriate medications and monitoring for adverse effects, healthcare providers can help to successfully control pain.
Huber, Evelyn; Spirig, Rebecca
Chronic musculoskeletal pain in the elderly is very common. The aim of this qualitative study was to gain insight in elderly people's pain medication beliefs. Problem-focused interviews with eight women were conducted. The results show them to be experts in managing pain, which task turns out to be too complex to be described in terms of pain medication beliefs. Using the method of qualitative content analyses five main categories including subcategories were inductively generated and presented in a structured way. The category "to be carried by one's life and illness trajectory" evolved as a basic category in the pain management. It includes the subcategories "to gain experiences from one's life and illness", "to have knowledge of the causes of pain and of their treatment", "to learn how to manage pain in everyday life" as well as "to rely on spiritual well-being". Most important for the women is their every day reality "to live with pain and its physical, psychological, practical and social effects". This leads to "weigh, to combine and to evaluate treatments for pain relief" which includes the subcategories "to be disciplined in carrying out non-pharmacological measures for pain relief", "to use pain medication sparingly but purposefully" and "to cooperate as a partner with health professionals". Some of the participants are challenged by "reaching their limits", which means "to reach the limits of endurable pain", "to experience the limits of failed treatment effects" as well as "to reach the limits of endurable treatment side effects". "To sustain one's quality of life in spite of pain" seems to be the aim of the elderly women's endeavour. The results of this study demand collaborative care in a partnership with elderly people with pain acknowledging their expertise. The results also ask for transdisciplinary efforts to support elderly persons with pain and for the development as well as the evaluation of self-management education programs.
Mathur, Vani A.; Moayedi, Massieh; Keaser, Michael L.; Khan, Shariq A.; Hubbard, Catherine S.; Goyal, Madhav; Seminowicz, David A.
Migraine is a pain disorder associated with abnormal brain structure and function, yet the effect of migraine on acute pain processing remains unclear. It also remains unclear whether altered pain-related brain responses and related structural changes are associated with clinical migraine characteristics. Using fMRI and three levels of thermal stimuli (non-painful, mildly painful, and moderately painful), we compared whole-brain activity between 14 migraine patients and 14 matched controls. Although, there were no significant differences in pain thresholds nor in pre-scan pain ratings to mildly painful thermal stimuli, patients did have aberrant suprathreshold nociceptive processing. Brain imaging showed that, compared to controls, patients had reduced activity in pain modulatory regions including left dorsolateral prefrontal, posterior parietal, and middle temporal cortices and, at a lower-threshold, greater activation in the right mid-insula to moderate pain vs. mild pain. We also found that pain-related activity in the insula was associated with clinical variables in patients, including associations between: bilateral anterior insula and pain catastrophizing (PCS); bilateral anterior insula and contralateral posterior insula and migraine pain intensity; and bilateral posterior insula and migraine frequency at a lower-threshold. PCS and migraine pain intensity were also negatively associated with activity in midline regions including posterior cingulate and medial prefrontal cortices. Diffusion tensor imaging revealed a negative correlation between fractional anisotropy (a measure of white matter integrity; FA) and migraine duration in the right mid-insula and a positive correlation between left mid-insula FA and PCS. In sum, while patients showed lower sensitivity to acute noxious stimuli, the neuroimaging findings suggest enhanced nociceptive processing and significantly disrupted modulatory networks, particularly involving the insula, associated with indices
Simmons, Claribel P.L.; MacLeod, Nicholas; Laird, Barry J.A.
Lung cancer is the most common cancer in the world and pain is its most common symptom. Pain can be brought about by several different causes including local effects of the tumor, regional or distant spread of the tumor, or from anti-cancer treatment. Patients with lung cancer experience more symptom distress than patients with other types of cancer. Symptoms such as pain may be associated with worsening of other symptoms and may affect quality of life. Pain management adheres to the principles set out by the World Health Organization’s analgesic ladder along with adjuvant analgesics. As pain can be caused by multiple factors, its treatment requires pharmacological and non-pharmacological measures from a multidisciplinary team linked in with specialist palliative pain management. This review article examines pain management in lung cancer. PMID:23115483
O'Donnell, Katherine F
The management of pain is one of the greatest clinical challenges for nurses who care for patients during the postoperative period. It can be even more challenging for patients who must manage their own pain after discharge from the health care facility. Research shows that postoperative pain continues to be undermanaged despite decades of education and evidence-based guidelines. Ineffective management of postoperative pain can negatively impact multiple patient outcomes. The purpose of this quality improvement project was to evaluate the effectiveness of a preoperative pain management patient education intervention on improving patients' postoperative pain management outcomes. The project was conducted with patients undergoing same-day laparoscopic cholecystectomy in an outpatient general surgery service at a teaching institution. Patients in the intervention and comparison groups completed the American Pain Society Patient Outcome Questionnaire-Revised during their first postoperative clinic visit 2 weeks after surgery. Results showed that patients who received the preoperative education intervention reported less severe pain during the first 24 hours postoperatively, experienced fewer and less severe pain medication side effects, returned to normal activities sooner, and used more nonpharmacologic pain management methods postoperatively compared with those who did not receive the education.
Davis, Mellar P.
Visceral pain is experienced by 40% of the population, and 28% of cancer patients suffer from pain arising from intra- abdominal metastasis or from treatment. Neuroanatomy of visceral nociception and neurotransmitters, receptors, and ion channels that modulate visceral pain are qualitatively or quantitatively different from those that modulate somatic and neuropathic pain. Visceral pain should be recognized as distinct pain phenotype. TRPV1, Na 1.8, and ASIC3 ion channels and peripheral kappa opioid receptors are important mediators of visceral pain. Mu agonists, gabapentinoids, and GABAB agonists reduce pain by binding to central receptors and channels. Combinations of analgesics and adjuvants in animal models have supra-additive antinociception and should be considered in clinical trials. This paper will discuss the neuroanatomy, receptors, ion channels, and neurotransmitters important to visceral pain and provide a basic science rationale for analgesic trials and management. PMID:22619712
Childs, Susan R; Casely, Emma M; Kuehler, Bianca M; Ward, Stephen; Halmshaw, Charlotte L; Thomas, Sarah E; Goodall, Ian D; Bantel, Carsten
Recent research has confirmed that between 25% and 33% of all hospitalized patients experience unacceptable levels of pain. Studies further indicate that this reduces patient satisfaction levels, lengthens hospital stays, and increases cost. Hospitals are aiming to discharge patients earlier, and this can interfere with adequate pain management. Therefore, the pain service at Chelsea and Westminster Hospital has adapted to this changing model of care. An increasing body of evidence demonstrates that psychological factors are key components of patients’ pain experiences in both acute and chronic pain. Therefore, it is reasonable to suggest a clinical psychologist should be involved in inpatient pain management. This small study discusses three cases that highlight how patient care could be improved by including a clinical psychologist as part of the inpatient pain team. Two cases particularly highlight the active role of the psychologist in the diagnosis and management of common conditions such as fear and anxiety, along with other psychiatric comorbidities. The management therefore employed an eclectic approach adapted from chronic pain and comprising of behavioral, cognitive behavioral, and dialectical behavioral therapeutic techniques blended with brief counseling. The third case exemplifies the importance of nurse-patient interactions and the quality of nurse-patient relationships on patient outcomes. Here, the psychologist helped to optimize communication and to resolve a difficult and potentially risk-laden situation. This small case series discusses the benefits derived from the involvement of a clinical psychologist in the management of inpatient pain, and therefore illustrates the need for novel initiatives for inpatient pain services. However, future research is warranted to validate this approach. PMID:25506221
Lindberg, Maren Falch; Miaskowski, Christine; Rustøen, Tone; Rosseland, Leiv Arne; Paul, Steven M.
Objectives Unrelieved postoperative pain after total knee arthroplasty (TKA) is a significant problem. This longitudinal study investigated how preoperative pain intensity, as well as a comprehensive list of preoperative and perioperative factors, influenced the severity of acute average and worst pain after TKA. Methods Prior to surgery, 203 patients completed a demographic questionnaire, Lee Fatigue Scale, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, and Brief Illness Perception Questionnaire. Brief Pain Inventory was completed prior to surgery as well as through postoperative days (POD) 0 to 4. Clinical data were extracted from medical records. Results Several factors were associated with higher levels of preoperative and postoperative pain. Lower preoperative average and worst pain intensity scores were associated with increases in average and worst postoperative pain from POD1 to POD4. A higher number of comorbidities, higher C-reactive protein values, and higher pain interference with function were associated with higher preoperative levels of average pain. Older age, higher fatigue levels, and higher scores on identity and emotional responses to osteoarthritis (OA) were associated with higher preoperative levels of worst pain. Lower perceived consequences of OA were associated with higher pain from POD1 to POD4. Males and patients with lower preoperative scores for average pain had higher worst pain following surgery. Discussion Patients at higher risk for more severe postoperative pain can be identified through an assessment of pain and other risk factors identified in this study. Future research needs to test the efficacy of interventions that modify patients’ perceptions of living with OA and pain intensity before surgery on short and long term postoperative outcomes. PMID:27583551
Bruehl, Stephen; Chung, Ok Y; Burns, John W
Both trait anger-in (managing anger through suppression) and anger-out (managing anger through direct expression) are related to pain responsiveness, but only anger-out effects involve opioid mechanisms. Preliminary work suggested that the effects of anger-out on postoperative analgesic requirements were moderated by the A118G single nucleotide polymorphism of the mu opioid receptor gene. This study further explored these potential genotypexphenotype interactions as they impact acute pain sensitivity. Genetic samples and measures of anger-in and anger-out were obtained in 87 subjects (from three studies) who participated in controlled laboratory acute pain tasks (ischemic, finger pressure, thermal). McGill Pain Questionnaire (MPQ) Sensory and Affective ratings for each pain task were standardized within studies, aggregated across pain tasks, and combined for analyses. Significant anger-outxA118G interactions were observed (p's<.05). Simple effects tests for both pain measures revealed that whereas anger-out was nonsignificantly hyperalgesic in subjects homozygous for the wild-type allele, anger-out was significantly hypoalgesic in those with the variant G allele (p's<.05). For the MPQ-Affective measure, this interaction arose both from low pain sensitivity in high anger-out subjects with the G allele and heightened pain sensitivity in low anger-out subjects with the G allele relative to responses in homozygous wild-type subjects. No genetic moderation was observed for anger-in, although significant main effects on MPQ-Affective ratings were noted (p<.005). Anger-in main effects were due to overlap with negative affect, but anger-outxA118G interactions were not, suggesting unique effects of expressive anger regulation. Results support opioid-related genotypexphenotype interactions involving trait anger-out.
Ward, Robert J; Weissman, Barbara N; Kransdorf, Mark J; Adler, Ronald; Appel, Marc; Bancroft, Laura W; Bernard, Stephanie A; Bruno, Michael A; Fries, Ian Blair; Morrison, William B; Mosher, Timothy J; Roberts, Catherine C; Scharf, Stephen C; Tuite, Michael J; Zoga, Adam C
Substantial cost, morbidity, and mortality are associated with acute proximal femoral fracture and may be reduced through an optimized diagnostic imaging workup. Radiography represents the primary diagnostic test of choice for the evaluation of acute hip pain. In middle aged and elderly patients with negative radiographs, the evidence indicates MRI to be the next diagnostic imaging study to exclude a proximal femoral fracture. CT, because of its relative decreased sensitivity, is only indicated in patients with MRI contraindications. Bone densitometry (DXA) should be obtained in patients with fragility fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Loeser, John D; Cahana, Alex
The world of health care and the world of business have fundamentally different ethical standards. In the past decades, business principles have progressively invaded medical territories, leading to often unanticipated consequences for both patients and providers. Multidisciplinary pain management has been shown to be more effective than all other forms of health care for chronic pain patients; yet, fewer and fewer multidisciplinary pain management facilities are available in the United States. The amazing increase in interventional procedures and opioid prescriptions has not led to a lessening of the burden of chronic pain patients. Ethical dilemmas abound in the treatment of chronic pain patients: many are not even thought about by providers, administrators, insurance companies, or patients. We call for increased pain educational experiences for all types of health care providers and the separation of business concepts from pain-related health care.
Castillo, Renan C; Raja, Srinivasa N; Frey, Katherine P; Vallier, Heather A; Tornetta, Paul; Jaeblon, Todd; Goff, Brandon J; Gottschalk, Allan; Scharfstein, Daniel O; OʼToole, Robert V
Poor pain control after orthopaedic trauma is a predictor of physical disability and numerous negative long-term outcomes. Despite increased awareness of the negative consequences of poorly controlled pain, analgesic therapy among hospitalized patients after orthopaedic trauma remains inconsistent and often inadequate. The Pain study is a 3 armed, prospective, double-blind, multicenter randomized trial designed to evaluate the effect of standard pain management versus standard pain management plus perioperative nonsteroidal anti-inflammatory drugs or pregabalin in patients of ages 18-85 with extremity fractures. The primary outcomes are chronic pain, opioid utilization during the 48 hours after definitive fixation and surgery for nonunion in the year after fixation. Secondary outcomes include preoperative and postoperative pain intensity, adverse events and complications, physical function, depression, and post-traumatic stress disorder. One year treatment costs are also compared between the groups.
Paolucci, Teresa; Saraceni, Vincenzo Maria; Piccinini, Giulia
Osteoporosis (OP) is a pathological condition that manifests clinically as pain, fractures, and physical disability, resulting in the loss of independence and the need for long-term care. Chronic pain is a multidimensional experience with sensory, affective, and cognitive aspects. Age can affect each of these dimensions and the pain that is experienced. In OP, chronic pain appears to have sensory characteristics and properties of nociceptive and neuropathic pain. Its evaluation and treatment thus require a holistic approach that focuses on the specific characteristics of this population. Pain management must therefore include pharmacological approaches, physiotherapy interventions, educational measures, and, in rare cases, surgical treatment. Most rehabilitative treatments in the management of patients with OP do not evaluate pain or physical function, and there is no consensus on the effects of rehabilitation therapy on back pain or quality of life in women with OP. Pharmacological treatment of pain in patients with OP is usually insufficient. The management of chronic pain in patients with OP is complicated with regard to its diagnosis, the search for reversible secondary causes, the efficacy and duration of oral bisphosphonates, and the function of calcium and vitamin D. The aim of this review is to discuss the most appropriate solutions in the management of chronic pain in OP. PMID:27099529
Paolucci, Teresa; Saraceni, Vincenzo Maria; Piccinini, Giulia
Osteoporosis (OP) is a pathological condition that manifests clinically as pain, fractures, and physical disability, resulting in the loss of independence and the need for long-term care. Chronic pain is a multidimensional experience with sensory, affective, and cognitive aspects. Age can affect each of these dimensions and the pain that is experienced. In OP, chronic pain appears to have sensory characteristics and properties of nociceptive and neuropathic pain. Its evaluation and treatment thus require a holistic approach that focuses on the specific characteristics of this population. Pain management must therefore include pharmacological approaches, physiotherapy interventions, educational measures, and, in rare cases, surgical treatment. Most rehabilitative treatments in the management of patients with OP do not evaluate pain or physical function, and there is no consensus on the effects of rehabilitation therapy on back pain or quality of life in women with OP. Pharmacological treatment of pain in patients with OP is usually insufficient. The management of chronic pain in patients with OP is complicated with regard to its diagnosis, the search for reversible secondary causes, the efficacy and duration of oral bisphosphonates, and the function of calcium and vitamin D. The aim of this review is to discuss the most appropriate solutions in the management of chronic pain in OP.
Esin, Ece; Yalcin, Suayib
Cancer pain is a serious health problem, and imposes a great burden on the lives of patients and their families. Pain can be associated with delay in treatment, denial of treatment, or failure of treatment. If the pain is not treated properly it may impair the quality of life. Neuropathic cancer pain (NCP) is one of the most complex phenomena among cancer pain syndromes. NCP may result from direct damage to nerves due to acute diagnostic/therapeutic interventions. Chronic NCP is the result of treatment complications or malignancy itself. Although the reason for pain is different in NCP and noncancer neuropathic pain, the pathophysiologic mechanisms are similar. Data regarding neuropathic pain are primarily obtained from neuropathic pain studies. Evidence pertaining to NCP is limited. NCP due to chemotherapeutic toxicity is a major problem for physicians. In the past two decades, there have been efforts to standardize NCP treatment in order to provide better medical service. Opioids are the mainstay of cancer pain treatment; however, a new group of therapeutics called coanalgesic drugs has been introduced to pain treatment. These coanalgesics include gabapentinoids (gabapentin, pregabalin), antidepressants (tricyclic antidepressants, duloxetine, and venlafaxine), corticosteroids, bisphosphonates, N-methyl-D-aspartate antagonists, and cannabinoids. Pain can be encountered throughout every step of cancer treatment, and thus all practicing oncologists must be capable of assessing pain, know the possible underlying pathophysiology, and manage it appropriately. The purpose of this review is to discuss neuropathic pain and NCP in detail, the relevance of this topic, clinical features, possible pathology, and treatments of NCP. PMID:24790459
Müller, Monika; Biurrun Manresa, José A; Treichel, Fabienne; Agten, Christoph A; Heini, Paul; Andersen, Ole K; Curatolo, Michele; Jüni, Peter
Low back pain has a life time prevalence of 70% to 85%. Approximately 10% to 20% of all patients experience recurrent episodes or develop chronic low back pain. Sociodemographic, clinical, and psychological characteristics explain the transition from acute to chronic low back pain only to a limited extent. Altered central pain processing may be a contributing mechanism. The measurement of reflex receptive fields (RRF) is a novel method to assess altered central pain processing. The RRF area denotes the area of the foot sole from which spinal nociceptive reflexes can be elicited. It was shown to be enlarged in patients with acute and chronic low back pain compared with pain-free individuals. The aim of the study was to explore the discriminative ability of the RRF to distinguish patients with acute and chronic low back pain with the hypothesis that enlarged RRF are associated with chronic low back pain. We included 214 patients with either acute or chronic low back pain and compared RRF between groups in both univariable and multivariable analyses adjusted for different sociodemographic and clinical characteristics possibly associated with the transition to chronic pain. We found a mean difference between patients with acute and chronic low back pain of -0.01 (95% confidence interval [CI], -0.06 to 0.04) in the crude, -0.02 (95% CI, -0.08 to 0.04) in the age and sex adjusted, and -0.02 (95% CI, -0.09 to 0.05) in the fully adjusted model. Our results suggest that the enlargement of RRF area may not be associated with the transition from acute to chronic low back pain.
Anzai, Takashi; Hiroshige, Yuu; Nakamura, Masahiro; Iizuka, Takashi; Nakazato, Yuji; Ikeda, Katsuhisa
Most patients complaining of pharyngeal pain have an upper respiratory tract infection or other local explanation for their pain. Here we show 3 rare cases of patients visiting our Otorhinolaryngology Department who had an initial symptom of pharyngeal pain caused by acute coronary syndrome (ACS). An electrocardiogram and a cardiac biomarker test are recommended to exclude ACS with atypical presentation in cases without pharyngolaryngeal findings comparable to pharyngeal pain. PMID:28243429
... That group also strongly recommends that people with low back pain try drug-free remedies -- from simple heat wraps ... back pain can be extremely tough to treat. "Low back pain is one of the top reasons that people ...
Stabbing paroxysmal pain due to neurological disease can often be controlled by anticonvulsants, whereas steady burning pain is often responsive to tricyclic antidepressants, and to neuroleptics. Overuse of opiates may actually aggravate the pain, necessitating detoxification. Transcutaneous electrical nerve stimulation is helpful for conditions in which pain is localized, especially if there is a ‘trigger area’ or neuroma, or if paresthesias can be stimulated within the painful area. Local anesthetic injection, possibly with corticosteroid, relieves painful scars and neuromas, neuritis, and tender trigger points. Sympathetic blocks are used for post-herpetic neuralgia and sympathetic dystrophies. Relaxation therapy is a very useful psychological treatment. PMID:21274032
Schwenkglenks, Matthias; Gerbershagen, Hans J; Taylor, Rod S; Pogatzki-Zahn, Esther; Komann, Marcus; Rothaug, Judith; Volk, Thomas; Yahiaoui-Doktor, Maryam; Zaslansky, Ruth; Brill, Silviu; Ullrich, Kristin; Gordon, Debra B; Meissner, Winfried
Patient ratings of satisfaction with their postoperative pain treatment tend to be high even in those with substantial pain. Determinants are poorly understood and have not previously been studied in large-scale, international datasets. PAIN OUT, a European Union-funded acute pain registry and research project, collects patient-reported outcome data on postoperative day 1 using the self-reported International Pain Outcome Questionnaire (IPO), and patient, clinical, and treatment characteristics. We investigated correlates of satisfaction and consistency of effects across centres and countries using multilevel regression modelling. Our sample comprised 16,868 patients (median age 55 years; 55% female) from 42 centres in 11 European countries plus Israel, USA, and Malaysia, who underwent a wide range of surgical procedures, for example, joint, limb, and digestive tract surgeries. Median satisfaction was 9 (interquartile range 7-10) on a 0-10 scale. Three IPO items showed strong associations and explained 35% of the variability present in the satisfaction variable: more pain relief received, higher allowed participation in pain treatment decisions, and no desire to have received more pain treatment. Patient factors and additional IPO items reflecting pain experience (eg, worst pain intensity), pain-related impairment, and information on pain treatment added little explanatory value, partially due to covariate correlations. Effects were highly consistent across centres and countries. We conclude that satisfaction with postoperative pain treatment is associated with the patients' actual pain experience, but more strongly with impressions of improvement and appropriateness of care. To the degree they desire, patients should be provided with information and involved in pain treatment decisions.
Ferriolo, Angela E; Conlon, Helen Acree
Narcotic pain management is currently a topic of concern in the United States; the latest concerns are both legal and ethical. Narcotics are frequently prescribed medications that, when improperly used or supervised, can cause death. Legal concerns include prescribing narcotics without performing detailed health-related evaluations, not recognizing those seeking drugs for personal recreational use, and clients diverting drugs to others for financial gain. Injured workers need to have pain controlled and be mentally safe to perform their job duties. This article identifies types of pain, comorbidities, and alternative methods of pain management beyond narcotic therapy, as well as discusses guidelines used to initiate narcotic therapy when needed.
Stevens, David L; King, Danielle; Laponis, Ryan; Hanley, Kathleen; Zabar, Sondra; Kalet, Adina L; Gillespie, Colleen
We implemented a pain assessment and management (PAM) curriculum for second year medical students and evaluated long-term skills retention compared to the prior year's class which did not receive the curriculum. The curriculum included pain pathophysiology, assessment and treatment instruction plus feedback on PAM practice with standardized patients. Both cohorts underwent a required end-of-third-year clinical skills examination. Intervention and control group performance on three pain cases (acute, chronic and terminal) was compared. The PAM curriculum was implemented 1.5years before the intervention cohort participated in the clinical skills exam. More intervention students (134/159, 84.3% response rate) obtained basic (87.2% vs. 76.0%, p=.028) and comprehensive (75.2% vs. 60.9%, p=.051) descriptions of acute pain than control students (n=129/174, 74.1% response rate). Intervention students demonstrated superior skills for terminal pain, including: more often asking about impact on functioning (40.7% vs. 25.8%, p=.027), advising change of medication (97.3% vs. 38.7%, p<.001), and providing additional medication counseling (55.0% vs. 27.0%, p<.001). Virtually all students obtained basic descriptions of chronic (intervention vs. control, 98.1% vs. 96.1%, p=.367) and terminal (92.9% vs. 91.7%, p=.736) pain. Surprisingly, more control than intervention students obtained a comprehensive description of chronic pain (94.6% vs. 77.8%, p<.001) and asked about current pain medication in the terminal case (75.6% vs. 55.0%, p=.004). Exposure to the curriculum resulted in durable increases in students' ability to perform PAM skills in patients with acute and terminal pain.
Fragemann, K; Meyer, N; Graf, B M; Wiese, C H R
The care of patients, suffering from acute, chronic, or malignant pain, requires systematic and interprofessional collaboration between all team members to ensure a holistic approach to pain management. In doing so, the different professions are often in a competitive, tense, or dependent relationship resulting from a lack of precise definitions and concepts regarding their responsibilities in the wide field of pain management. Considering pain management as a whole, we can define numerous interfaces concerning competencies and tasks which may open up some new perspectives on concepts of interprofessional education (IPE). Internationally, there have been many attempts to establish concepts of interprofessional education, and it is considered a great challenge to improve continuing medical education. However, interdisciplinary subjects like pain management may benefit from it. Apart from enhancing specialized knowledge, interprofessional education aims to consider the different roles, skills, and responsibilities as well as interprofessional strategies of decision-making. In Germany, only a few efforts have been made with regard to interprofessional pain education. In the following paper, different challenges, tasks, and roles within the field of pain management are discussed in the sense of potential areas of collaboration in the context of interprofessional education. Against this background, the Regensburg model for interprofessional pain management education is described as one national program to enhance the effectiveness of pain management.
Bhatnagar, Sushma; Gupta, Maynak
Intractable cancer pain not amenable to standard oral or parenteral analgesics is a horrifying truth in 10–15% of patients. Interventional pain management techniques are an indispensable arsenal in pain physician's armamentarium for severe, intractable pain and can be broadly classified into neuroablative and neuromodulation techniques. An array of neurolytic techniques (chemical, thermal, or surgical) can be employed for ablation of individual nerve fibers, plexuses, or intrathecalneurolysis in patients with resistant pain and short life-expectancy. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception constitutes the most frequently employed neuromodulation techniques. Lately, there is a rising call for early introduction of interventional techniques in carefully selected patients simultaneously or even before starting strong opioids. After decades of empirical use, it is the need of the hour to head towards professionalism and standardization in order to secure credibility of specialization and those practicing it. Even though the interventional management has found a definite place in cancer pain, there is a dearth of evidence-based practice guidelines for interventional therapies in cancer pain. This may be because of paucity of good quality randomized controlled trials (RCTs) evaluating their safety and efficacy in cancer pain. Laying standardized guidelines based on existing and emerging evidence will act as a foundation step towards strengthening, credentialing, and dissemination of the specialty of interventional cancer pain management. This will also ensure an improved decision-making and quality of life (QoL) of the suffering patients. PMID:26009665
Bhatnagar, Sushma; Gupta, Maynak
Intractable cancer pain not amenable to standard oral or parenteral analgesics is a horrifying truth in 10-15% of patients. Interventional pain management techniques are an indispensable arsenal in pain physician's armamentarium for severe, intractable pain and can be broadly classified into neuroablative and neuromodulation techniques. An array of neurolytic techniques (chemical, thermal, or surgical) can be employed for ablation of individual nerve fibers, plexuses, or intrathecalneurolysis in patients with resistant pain and short life-expectancy. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception constitutes the most frequently employed neuromodulation techniques. Lately, there is a rising call for early introduction of interventional techniques in carefully selected patients simultaneously or even before starting strong opioids. After decades of empirical use, it is the need of the hour to head towards professionalism and standardization in order to secure credibility of specialization and those practicing it. Even though the interventional management has found a definite place in cancer pain, there is a dearth of evidence-based practice guidelines for interventional therapies in cancer pain. This may be because of paucity of good quality randomized controlled trials (RCTs) evaluating their safety and efficacy in cancer pain. Laying standardized guidelines based on existing and emerging evidence will act as a foundation step towards strengthening, credentialing, and dissemination of the specialty of interventional cancer pain management. This will also ensure an improved decision-making and quality of life (QoL) of the suffering patients.
The use of diagnostic laparoscopy in acute abdominal pain, especially when patients have been admitted for acute pain in the lower abdominal quadrants, improves the accuracy of diagnosis and leads to improvements in treatment procedures. A case is reported of a 24-year-old woman admitted under suspicion of appendicitis. The appendix was found to be normal, and a perforation caused by a fishbone was discovered in a Meckel's diverticulum. The diverticulum was resected by a combined laparoscopic and open procedure. Diagnostic laparoscopy should be performed routinely in cases of acute abdominal pain in the lower quadrants of suspected appendiceal origin to avoid overlooking other causes of the symptoms.
Lahoud, Marie José; Kourie, Hampig Raphael; Antoun, Joelle; El Osta, Lana; Ghosn, Marwan
Beside its poor prognosis and its late diagnosis, pancreatic cancer remains one of the most painful malignancies. Optimal management of pain in this cancer represents a real challenge for the oncologist whose objective is to ensure a better quality of life to his patients. We aimed in this paper to review all the treatment modalities incriminated in the management of pain in pancreatic cancer going from painkillers, chemotherapy, radiation therapy and interventional techniques to agents under investigation and alternative medicine. Although specific guidelines and recommendations for pain management in pancreatic cancer are still absent, we present all the possible pain treatments, with a progression from medical multimodal treatment to radiotherapy and chemotherapy then interventional techniques in case of resistance. In addition, alternative methods such as acupuncture and hypnosis can be added at any stage and seems to contribute to pain relief. PMID:27574552
Rettig, Eleni; Tunkel, David E
Acute otitis media (AOM) is a common disease of childhood. AOM is most appropriately diagnosed by careful otoscopy with an understanding of clinical signs and symptoms. The distinction between AOM and chronic otitis media with effusion should be emphasized. Treatment should include pain management, and initial antibiotic treatment should be given to those most likely to benefit, including young children, children with severe symptoms, and those with otorrhea and/or bilateral AOM. Tympanostomy tube placement may be helpful for those who experience frequent episodes of AOM or fail medical therapy. Recent practice guidelines may assist the clinician with such decisions.
Evans, Daniel R.; Eisenlohr-Moul, Tory A.; Button, Daniel F.; Baer, Ruth A.; Segerstrom, Suzanne C.
Training in mindfulness is a well-supported therapeutic strategy for pain conditions, though short-term mindfulness training for acute pain is not always effective. To explore the possibility that initial attempts at mindfulness in people without previous training may drain self-regulatory resources, the current study used a student sample (N=63) to test the hypothesis that brief instruction in mindfulness would lead to reduced pain tolerance on a cold pressor task (CPT), compared to more familiar strategies for coping with acute pain. We also investigated whether high heart rate variability (HRV), a physiological indicator of self-regulatory capacity, would predict pain tolerance. Higher HRV predicted greater pain tolerance only in the control group, suggesting that applying unfamiliar mindfulness strategies while attempting to tolerate pain more rapidly sapped self-regulatory strength. PMID:25843972
Evans, Daniel R; Eisenlohr-Moul, Tory A; Button, Daniel F; Baer, Ruth A; Segerstrom, Suzanne C
Training in mindfulness is a well-supported therapeutic strategy for pain conditions, though short-term mindfulness training for acute pain is not always effective. To explore the possibility that initial attempts at mindfulness in people without previous training may drain self-regulatory resources, the current study used a student sample (N=63) to test the hypothesis that brief instruction in mindfulness would lead to reduced pain tolerance on a cold pressor task (CPT), compared to more familiar strategies for coping with acute pain. We also investigated whether high heart rate variability (HRV), a physiological indicator of self-regulatory capacity, would predict pain tolerance. Higher HRV predicted greater pain tolerance only in the control group, suggesting that applying unfamiliar mindfulness strategies while attempting to tolerate pain more rapidly sapped self-regulatory strength.
Peeters, P; Verbist, J; Keirse, K; Deloose, K; Bosiers, M
Acute limb ischemia (ALI) refers to a rapid worsening of limb perfusion resulting in rest pain, ischemic ulcers or gangrene. With an estimated incidence of 140 million/year, ALI is serious limb-threatening and life-threatening medical emergency demanding prompt action. Three prospective, randomized clinical trials provide data on trombolytic therapy versus surgical intervention in patients with acute lower extremity ischemia. Although they did not give us the final answer, satisfactory results are reported for percutaneous thrombolysis compared with surgery. Moreover, they suggest an important advantage of thrombolysis in acute bypass graft occlusions. Therefore, we believe thrombolytic therapy should be a part of the vascular surgeon's armamentarium to safely and successfully treat ALI patients.
Pak, Sok Cheon; Micalos, Peter S.; Maria, Sonja J.; Lord, Bill
Paramedicine and the emergency medical services have been moving in the direction of advancing pharmaceutical intervention for the management of pain in both acute and chronic situations. This coincides with other areas of advanced life support and patient management strategies that have been well researched and continue to benefit from the increasing evidence. Even though paramedic practice is firmly focused on pharmacological interventions to alleviate pain, there is emerging evidence proposing a range of nonpharmacological options that can have an important role in pain management. This review highlights literature that suggests that paramedicine and emergency medical services should be considering the application of complementary and alternative therapies which can enhance current practice and reduce the use of pharmacological interventions. PMID:25918548
Kames, L D; Rapkin, A J; Naliboff, B D; Afifi, S; Ferrer-Brechner, T
Chronic pelvic pain has rarely been discussed in the pain management literature, although it is extremely common in general gynecological practice and often refractory to traditional medical and surgical therapy. A chronic pelvic pain program was developed to offer an alternative treatment approach for women for whom standard gynecological procedures were inappropriate or unsuccessful. Sixteen subjects completed the full 6-8 week interdisciplinary program, which included both somatic and behavioral therapies. Compared to a waiting list control the results showed a dramatic decrease in reported levels of pain following treatment. Anxiety and depression also decreased and psychosocial functioning improved, including return to work, increased social activities, and improved sexual activity. The outcome suggests that the interdisciplinary pain management approach is effective for the treatment of chronic pelvic pain.
Belfer, Inna; Greco, Carol M.; Lokshin, Anna; Vulakovich, Katie; Landsittel, Douglas; Dai, Feng; Crossett, Lawrence; Chelly, Jacques E.
Objective Total knee replacement (TKR) is the treatment option of choice for the millions of individuals whose osteoarthritis pain can no longer be managed through non-invasive methods. Over 500,000 TKRs are performed annually in the United States. Although most patients report improvement in pain and functioning following TKR, up to 30% report persistent pain that interferes with daily function. However, the reasons for poor outcomes are not clear. To best determine which patients are at risk for pain post TKR, a detailed and comprehensive approach is needed. In this article, we present the methodology of a study designed to identify a set of genetic, proteomic, clinical, demographic, psychosocial, and psychophysical risk factors for severe acute and chronic pain post TKR. Design Prospective longitudinal observational study. Setting University Hospital System. Subjects Patients scheduled for unilateral TKR with a target number of 150. Methods Prior to surgery, we collect demographic, psychosocial, and pain data. Biological data, including blood samples for genetic analyses, and serum, urine, and joint fluid for cytokine assessment are collected intraoperatively. Pain assessments as well as medication use are collected during each of the three days postsurgery. Additionally, pain and psychosocial information is collected 6 and 12 months following surgery. Conclusions This study, for the first time, captures the information on both genetic and “environmental” risk factors for acute and chronic pain post-TKR and has the potential to lead to the next step—multicenter large-scale studies on predictors and biomarkers of poor TKR outcomes as well as on tailored interventions and personalized medicine approaches for those at risk. PMID:25040948
Haas, Mitchell; Nyiendo, Joanne; Aickin, Mikel
Clinicians use patients' recall of pain and disability relief as indicators of therapeutic effectiveness. Recall can change over time, however, and is influenced by factors other than true relief, including current health status. We have determined the trend in the relative contribution of current pain/disability and actual relief (current-baseline score) to relief recall over the course of 1 year. Self-referred patients (n=1182) seeking treatment from primary-care medical doctors and chiropractors in community-based clinics were asked to record present pain and disability, as well as perceived relief at five follow-up time points from 2 weeks to 12 months after initial consultation for acute and chronic low back pain (LBP). Multiple regression analysis was performed at each time point and over the five follow-up time points. We found a clear logarithmic time trend of increasing dependence of pain relief recall on present pain (P<0.0001) and a concomitant pattern of decreasing dependence on actual pain relief (P<0.0001). The patterns are fairly consistent for acute and chronic patients. The principal independent predictor of perceived pain/disability relief appears to be present pain/disability with actual relief playing a smaller role at all time points (P<0.0001) except for disability relief recall at 2 weeks (P=0.103). The findings are robust in LBP sufferers. Complaint characteristics including LBP chronicity, sciatica, LBP history, and comorbidity; psychosocial variables including stress, depression, and well being; sociodemographics; and treating provider type are not important independent predictors of pain and disability relief recall in ambulatory LBP patients. Perceived relief is too weakly related to present pain and disability to be accurate enough for use as a clinical assessment tool for individual patients. Physicians may need to use objective relief data to give the patient a realistic idea of actual improvement.
The management of chronic pain, particularly neuropathic pain, still has significant unmet needs. In addition to inadequate symptomatic relief, there are concerns about adverse effects and addiction associated with treatments. The transplantation of cells that secrete neuroactive substances with analgesic properties into the central nervous system has only become of practical interest in more recent years, but provides a novel strategy to challenge current approaches in treating chronic pain. This review covers pre-clinical and clinical studies from both allogeneic and xenogeneic sources for management of chronic refractory pain.
Malanga, Gerard; Paster, Zorba
People aged 65 years and over make up the fastest growing demographic in the United States. By the year 2040 they will comprise approximately one fourth of the US population. The elderly patient in need of chronic pain therapy presents challenges best met with an enlightened and effective treatment strategy. Practice standards must include a thorough pain assessment and formation of a multimodal care plan, which applies knowledge of pain management in an objective and scientific manner. In this article, a patient case study illustrates how the appropriate management of chronic pain in an elderly patient can lead to better clinical outcomes.
Faramarzalian, Ali; Armitage, Keith B.; Kapoor, Baljendra; Kalva, Sanjeeva P.
The rapid expansion of minimally invasive image-guided procedures has led to their extensive use in the interdisciplinary management of patients with vascular, hepatobiliary, genitourinary, and oncologic diseases. Given the increased availability and breadth of these procedures, it is important for physicians to be aware of common complications and their management. In this article, the authors describe management of select common complications from interventional radiology procedures including tumor lysis syndrome, acute on chronic postprocedural pain, and venous thromboembolism. These complications are discussed in detail and their medical management is outlined according to generally accepted practice and evidence from the literature. PMID:26038627
Samuels, Joanne G; Kritter, Dawn
Pain management documentation, consisting of assessment, interventions, and reassessment, can help provide an important means of communication among practitioners to individualize care. Standard-setting organizations use pain management documentation as a key indicator of quality. Adoption of the electronic medical record alters the presentation of pain management documentation data for clinical and quality evaluation use. The purpose of this study was to describe pain management documentation output from the electronic medical record to gain an understanding of its presentation and evaluate the quantity and quality of the output. After institutional review board approval, data were abstracted from 51 electronic records of postsurgical patients in a 100-bed community hospital. Time-variant pain assessments, interventions, and reassessments were organized into pain management episodes to provide clinically interpretable data for evaluation. Data sources were identified. Data generated 1499 episodes for analysis. Analysis of variance results implied that pain management documentation changes with pain severity. Despite legibility and date and time stamping, inconsistencies and omitted and duplicated documentation were identified. Inconsistent data origination posed difficulty for interpreting clinically relevant associations. Improvements are required to streamline fields and consolidate entries to allow for output in alignment with care.
Namvongprom, Ampaporn; Mazaheri, Monir
Pain management is a core nursing function, and it plays a key role in postoperative care. It is important to understand the cultural context of nursing practices and how this affects effective pain management. The aim of this study was to describe the professional and cultural framework within which pain management is practiced on a Thai surgical ward. Spradley's ethnographic methodology was used. Data were collected through 98.5 hours of field observations and interviews at a surgical ward in Thailand. Three themes were constructed that describe the way Thai nurses practiced pain management: (i) complex communications system to address pain and to respond to it, (ii) the essence of Thai-ness, and (iii) a passive approach to pain management. The results indicate that, in the response to discomfort and pain, better pain management will result if there is a shift from functional to patient-centered care. The nursing culture needs to be further researched and discussed, in order to set priorities in line with the goals of national and international organizations for improving postoperative care and promoting patient comfort. PMID:28044071
Bell, Liz; Duffy, Anita
Although postoperative pain assessment and management is an integral part of surgical nursing practice, it remains ad hoc despite numerous costly empirical research studies. Patients have a right to pain relief; however, the barriers to assessing and managing patient pain in practice have not as yet been overcome. A literature review to establish the main barriers to effective postoperative pain relief in clinical practice was carried out. The findings suggest that time management, and attitudes and beliefs of both patients and nurses are significant factors hampering practice. The authors conclude that future research in this area is futile, and suggest that nurses should focus on auditing their own practice to improve the effectiveness of pain management in practice and enhance standards of care.
Running, Alice; Seright, Teresa
For the projected 1,638,910 patients with a diagnosis of cancer this year, the great majority of them (75-90 %) will experience cancer-related pain. A growing number of these patients will turn to complementary and alternative therapies to assist with the management of their pain and other cancer-related symptoms. The World Health Organization's suggested approach to pain management begins with the use of time honored opioids, but recommends the use of adjuvant therapies early in the management process. Complementary and alternative therapies are being used by more patients each year to assist with the management of their pain. Practitioners and researchers must be aware of the evidence that exists to support or refute the use of these therapies. In this manuscript we review evidence from the recent past on complementary and alternative therapies for pain with emphasis on more common modalities including acupuncture, bio-energy, massage, and music.
Hallstrand, Teal S; Fahy, John V
All asthma patients are at risk for acute asthma exacerbations. Moderate to severe exacerbations account for many emergency department visits and subsequent hospitalizations each year. Recent studies have advanced our understanding of the pathogenesis and treatment of acute asthma. The purpose of this review is to provide practical guidance in the assessment and treatment of adults with acute asthma in the hospital setting. Managing patients with acute asthma involves assessing the severity of the exacerbation, implementing measures to rapidly reverse airflow limitation, and instituting therapies that limit the progression of airway inflammation. Some patients may benefit from other supportive measures such as heliox and noninvasive ventilation. If the patient continues to deteriorate and requires mechanical ventilation, then ventilator settings that minimize the risk of hyperinflation should be chosen. After an episode of acute asthma, long-term preventive medications, especially inhaled corticosteroids, should be prescribed and education should be provided to prevent future episodes.
Bravo Matus, Carlos A; Flores Zúñiga, Rosa María
Postoperative pain is a subjective symptom that has been extensively studied in adults, but only minimally in children. In children, use of low analgesic doses and failure to document the pain and its management are common concerns. In newborns and infants pain is difficult to interpret. This was a double-blind, prospective, multicenter observational study conducted in four public Mexican hospitals to identify analgesic use. One hundred subjects were enrolled at each institution and monitored for 24 to 48 hours following surgery. Data were collected on 152 girls and 248 boys ranging in age from newborns to 14 years. Nearly 300 (290) underwent major procedures; 110 had short stay surgery. The most common analgesics used were paracetamol and dipyrone at low doses. Less frequently ibuprofen or another anti-inflammatory was used. Many children received no analgesic, including 30 newborns, and others received only one or two analgesic doses. Fifteen burn patients received ketorolac. The occurrence and characteristics of the pain were poorly documented in all four hospitals. Postoperative pain causes suffering and can prolong hospital stays. Graphic pain intensity scales exist to evaluate pain, but use of them was not documented in medial records. Nurses and doctors in training did not have the skills needed to evaluate pain. The study revealed errors in pain management and fear among staff in using high doses of common analgesics. The study results document patterns of care in most Mexican hospitals today and indicate a need for pain management training for Mexican doctors and nurses.
Treatment of chronic, nonmalignant pain syndromes has been largely suboptimal and the most debilitating conditions--such as LBP, arthritis, and neuropathic pain--continue to pose a significant burden to individuals and society. Although significant scientific advances in delineating pathophysiologic mechanisms have facilitated the development of targeted pharmacologic and interventional treatments, the integral role played by psychologic, behavioral, and social factors in generating, perpetuating, and individualizing the pain experience has been largely ignored. Consequently, adequate pain relief may still be an achievable goal, but one that is often realized only with a concomitant, cognitive, behaviorally based, functional restoration approach. A multidisciplinary integrative approach that places equal emphasis on understanding the cellular and molecular mechanisms underlying pain, as well as the multidimensional interplay of cognitive, behavioral, and environmental influences is essential to improving outcomes. Although there are presently a paucity of data that identify specific characteristics that define which individuals will benefit from any particular modality, evidence clearly demonstrates that the MPC setting offers patients an opportunity to achieve both adequate pain relief and improved physical, behavioral, and psychologic function. A key challenge for clinicians lies in changing the approach to pain "treatment" and in bridging the gap between the current evolving understanding of pain mechanisms and clinical management. Physiatrists' focus on maximal functional restoration is a critical contribution to cost-effective pain medicine practice. Wisely combining effective pain management techniques within a functional restoration program has the best chance of improving the quality of life for patients with chronic pain disorders and diseases.
Agrawal, Alka M.; Tripathi, Prem Siddharth; Shankhwar, Amit; Naveen, C.
Background and Objective: An acute scrotum is defined as acute pain with or without scrotal swelling, may be accompanied by local signs or general symptoms. Acute scrotal pain is a medical emergency. Depending on cause, the management is entirely different. Torsion of testis and strangulated hernia are surgical emergency; whereas, epididymo-orchitis is treated by medicines. Testicular trauma and obstructed hernia can be differentiated by taking history from patient. Physical examination adds only a little information. Color Doppler ultrasound (US) is the modality of choice to differentiate testicular torsion from inflammatory conditions and can thus help in avoiding unnecessary surgical explorations. Subjects and Methods: A study on 50 patients was conducted who were referred with history of acute scrotal pain to our department between January 2013 and January 2014. Trauma and scrotal mass were excluded from the study. The clinical presentation, outcome, and US results were analyzed. Results: Color Doppler sonography yielded a positive and negative predictive value (PPV and NPV) of 100% each for torsion, whereas, 93.9 and 70.6% for epididymo-orchitis, respectively; a sensitivity and specificity of 100% for torsion, whereas, for epididymo-orchitis it was found to be 86.1 and 85.7%, respectively. In cases of incomplete or early torsion, some residual perfusion may be detected leading to false-negative results. Conclusion: We therefore conclude that color Doppler sonography can reliably rule out testicular torsion and can thus help in avoiding unnecessary surgical explorations. Hence, it can significantly improve outcome and decrease morbidity of patient. It is an accurate, rapid, nonexpensive, nonionizing, important adjunct to clinical assessment of scrotum. PMID:25657954
Tracy, Lincoln M; Georgiou-Karistianis, Nellie; Gibson, Stephen J; Giummarra, Melita J
In an acute environment pain has potential protective benefits. However when pain becomes chronic this protective effect is lost and the pain becomes an encumbrance. Previously unheralded substances are being investigated in an attempt to alleviate the burden of living with chronic pain. Oxytocin, a neuropeptide hormone, is one prospective pharmacotherapeutic agent gaining popularity. Oxytocin has the potential to modulate the pain experience due to its ubiquitous involvement in central and peripheral psychological and physiological processes, and thus offers promise as a therapeutic agent. In this review, we discuss previous effective applications of oxytocin in pain-free clinical populations and its potential use in the modulation of pain experience. We also address the slowly growing body of literature investigating the administration of oxytocin in clinical and experimentally induced pain in order to investigate the potential mechanisms of its reported analgesic actions. We conclude that oxytocin offers a potential novel avenue for modulating the experience of pain, and that further research into this area is required to map its therapeutic benefit.
Harik, Nada S; Smeltzer, Mark S
In children, osteomyelitis is primarily hematogenous in origin and acute in nature. The principal cause of osteomyelitis in children is Staphylococcus aureus, and both the epidemiology and pathogenesis of S. aureus infections, including osteomyelitis, have changed in recent years owing to the emergence of community-associated methicillin-resistant S. aureus. This review focuses on advances in the diagnosis and overall management of acute hematogenous osteomyelitis in children with these changes in mind. PMID:20109047
McCleary, Lynn; Ellis, Jacqueline A; Rowley, Betty
Pain resource nurses (PRNs), who act as pain management coaches or mentors for their colleagues, can contribute to effective pain management. The PRN's role has not been well evaluated in the context of pediatric nursing. Therefore, the objective of this study was to examine the PRN's role in a pediatric setting and, more specifically, to describe the role in terms of the activities PRNs engage in, the challenges they face, and the supports that help them fulfill their role. This research was part of an evaluation of the implementation of a comprehensive pain management program in a pediatric hospital. Focus groups were conducted with 18 PRNs six months after implementation of the PRN role. The essence of the role is to provide support for best-practice pain management to nurses and the multidisciplinary team. The PRNs described seven components of their role and specific strategies to operationalize their role. In addition, the PRNs faced challenges, including feeling disappointed when their expectations for better pain management were not met, experiencing difficulty fitting the activities into their busy workdays, facilitating their colleagues' improved pain management without also alienating them, and maintaining their enthusiasm and energy for the role. Pediatric nursing staff can effectively fill the role of the PRN. The role is multifaceted, and maintaining the role required commitment and enthusiasm on the part of the nurses, as well as commitment by their related institutions.
Quinlan, Joanna; Hughes, Richard; Laird, David
Context/background: The Pain Management Plan (PP) is a brief cognitive behavioural therapy (CBT) self-management programme for people living with persistent pain that can be individually facilitated or provided in a group setting. Evidence of PP efficacy has been reported previously by the pain centres involved in its development. Objectives: To provide a fully independent evaluation of the PP and compare these with the findings reported by Cole et al. Methods: The PP programme was delivered by the County Durham Pain Team (Co. Durham PT) as outlined in training sessions led by Cole et al. Pre- and post-quantitative/patient experience measures were repeated with reliable and clinical significant change determined and compared to the original evaluation. Results: Of the 69 participants who completed the programme, 33% achieved reliable change and 20% clinical significant change using the Pain Self-Efficacy Questionnaire (PSEQ). Across the Brief Pain Inventory (BPI) interference domains between 11% and 22% of participants achieved clinical significant change. There were high levels of positive patient feedback with 25% of participants scoring 100% satisfaction. The mean participant satisfaction across the population was 88%. Conclusion: The results from this evaluation validate those reported by Cole et al. It demonstrates clinically significant improvement in pain and health functioning and high patient appreciation results. Both evaluations emphasise the potential of this programme as an early intervention delivered within a stratified care pain pathway. This approach could optimise the use of finite resources and improve wider access to pain management. PMID:27867506
Moore, RA; Derry, S; Straube, S; Ireson-Paine, J; Wiffen, PJ
Background Previous analysis of a single data set in acute pain following third molar extraction demonstrated a strong relationship between the speed of reduction of pain intensity and overall pain relief, as well as need for additional analgesia. Methods Individual patient data analysis of a single randomized, double-blind trial of placebo, paracetamol 1000 mg, ibuprofen sodium 400 mg and ibuprofen-poloxamer 400 mg following third molar extraction. Visual analogue scale pain intensity (VASPI) and other measurements were made at baseline, every 5–45 min, and at 60, 90, 120, 180, 240, 300 and 360 min. Results Most patients produced consistent VASPI results over time. For placebo and paracetamol, few patients achieved low VASPI scores and maintained them. For both ibuprofen formulations, VASPI scores fell rapidly during the first hour and were then typically maintained until later re-medication. Analysis of all patients showed that rapid VASPI reduction in the first hour was strongly correlated with good overall pain relief (high total pain relief over 0–6 h), and with lesser need for additional analgesia within 6 h. Results for this analysis were in very good agreement with a previous analysis, validating the relationship between fast initial pain intensity reduction and overall good pain relief in this setting. Conclusions In acute pain following third molar extraction, faster acting analgesic formulations provide earlier onset of pain relief, better overall pain relief and a less frequent need for additional analgesia, indicating longer lasting pain relief. PMID:24848990
Hogan, Francesca; McCullough, Chris; Rahman, Asif
A 38-year-old man presented with pleuritic chest pain that was present on waking and localised to the left costal margin with no radiation. He was otherwise asymptomatic and denied preceding trauma, heavy lifting, coughing or recent vomiting. Observations and examination were unremarkable; however, a chest radiograph showed a pneumomediastinum. Spontaneous pneumomediastinum (SPM) is a rare condition that tends to follow a benign clinical course. A CT of the chest is generally only indicated if the chest X-ray fails to show an SPM in patients for whom there is a high index of clinical suspicion. A contrast-enhanced swallow study is only indicated if there is suspicion of an oesophageal tear or rupture. Evidence suggests that patients with SPM can be managed conservatively and observed for 24 h. PMID:25432910
Waxman, Jordana A.; Pillai Riddell, Rebecca R.; Tablon, Paula; Schmidt, Louis A.; Pinhasov, Angelina
Background. Cardiovascular indices of pain are pervasive in the hospital setting. However, no prospective research has examined the development of cardiac responses to acutely painful procedures in the first year of life. Objectives. Our main goal was to synthesize existing evidence regarding the development of cardiovascular responses to acutely painful medical procedures over the first year of life in preterm and term born infants. Methods. A systematic search retrieved 6994 articles to review against inclusion criteria. A total of 41 studies were included in the review. Results. In response to acutely painful procedures, most infants had an increase in mean heart rate (HR) that varied in magnitude both across and within gestational and postnatal ages. Research in the area of HR variability has been inconsistent, limiting conclusions. Conclusions. Longitudinal research is needed to further understand the inherent variability of cardiovascular pain responses across and within gestational and postnatal ages and the causes for the variability. PMID:27445630
Cooper, Stephen A; Desjardins, Paul J; Turk, Dennis C; Dworkin, Robert H; Katz, Nathaniel P; Kehlet, Henrik; Ballantyne, Jane C; Burke, Laurie B; Carragee, Eugene; Cowan, Penney; Croll, Scott; Dionne, Raymond A; Farrar, John T; Gilron, Ian; Gordon, Debra B; Iyengar, Smriti; Jay, Gary W; Kalso, Eija A; Kerns, Robert D; McDermott, Michael P; Raja, Srinivasa N; Rappaport, Bob A; Rauschkolb, Christine; Royal, Mike A; Segerdahl, Märta; Stauffer, Joseph W; Todd, Knox H; Vanhove, Geertrui F; Wallace, Mark S; West, Christine; White, Richard E; Wu, Christopher
This article summarizes the results of a meeting convened by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) on key considerations and best practices governing the design of acute pain clinical trials. We discuss the role of early phase clinical trials, including pharmacokinetic-pharmacodynamic (PK-PD) trials, and the value of including both placebo and active standards of comparison in acute pain trials. This article focuses on single-dose and short-duration trials with emphasis on the perioperative and study design factors that influence assay sensitivity. Recommendations are presented on assessment measures, study designs, and operational factors. Although most of the methodological advances have come from studies of postoperative pain after dental impaction, bunionectomy, and other surgeries, the design considerations discussed are applicable to many other acute pain studies conducted in different settings.
Hunnicutt, Jacob N; Ulbricht, Christine M; Tjia, Jennifer; Lapane, Kate L
Prior studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set (MDS) 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after these important initiatives of: 1) prevalence and correlates of persistent pain; and 2) prevalence and correlates of untreated or undertreated persistent pain.We identified 1,387,405 long-stay residents in United States NHs between 2011-2012 with 2 MDS assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios estimates (APR) and 95% confidence intervals (CI).The prevalence of persistent and intermittent pain was 19.5% and 19.2% respectively but varied substantially by age, gender, race/ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated or undertreated. Racial/ethnic minorities (non-Hispanic blacks vs. whites, APR=1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs. no/mild APR=1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain.One in five NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.
Background Upside-down stomach (UDS) is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. Symptoms may vary heavily as they are related to reflux and mechanically impaired gastric emptying. UDS is associated with a risk of incarceration and volvulus development which both might be complicated by acute gastric outlet obstruction, advanced ischemia, gastric bleeding and perforation. Case presentation A 32-year-old male presented with acute intolerant epigastralgia and anterior chest pain associated with acute onset of nausea and vomiting. He reported on a previous surgical intervention due to a hiatal hernia. Chest radiography and computer tomography showed an incarcerated UDS. After immediate esophago-gastroscopy, urgent laparoscopic reduction, repair with a 360° floppy Nissen fundoplication and insertion of a gradually absorbable GORE® BIO-A®-mesh was performed. Conclusion Given the high risk of life-threatening complications of an incarcerated UDS as ischemia, gastric perforation or severe bleeding, emergent surgery is indicated. In stable patients with acute presentation of large paraesophageal hernia or UDS exhibiting acute mechanical gastric outlet obstruction, after esophago-gastroscopy laparoscopic reduction and hernia repair followed by an anti-reflux procedure is suggested. However, in cases of unstable patients open repair is the surgical method of choice. Here, we present an exceptionally challenging case of a young patient with a giant recurrent hiatal hernia becoming clinically manifest in an incarcerated UDS. PMID:24228771
Dyson, Doris H
Pain exists; however, we can prevent it, and we can treat it. The fallacy that pain is protective and must be allowed to avoid risk for damage after surgery needs to be eradicated. Preoperative and postoperative analgesia is directed at aching pain, whereas sharp pain associated with inappropriate movements persists. Analgesia provides much more benefit than concern. This article provides suggestions for development of an analgesic plan from the point of admission to discharge. These guidelines can then be adjusted according to the patient's needs and responses.
Physical and emotional pain are an inevitable part of human existence and are without natural antidotes. In view of this, and in the light of increasing professional reluctance to depend on analgesics, this paper proposes the widespread application of autogenic training, a relaxation technique which has been seen to confront pain very effectively, and also to reduce substantially drugs dependency. It analyses autogenic training in respect of some of the more common pain-allied disorders such as childbirth, headaches and migraines, back pain, cancer and palliative care, and cardiology.
Beygui, Farzin; Castren, Maaret; Brunetti, Natale Daniele; Rosell-Ortiz, Fernando; Christ, Michael; Zeymer, Uwe; Huber, Kurt; Folke, Fredrik; Svensson, Leif; Bueno, Hector; Van't Hof, Arnoud; Nikolaou, Nikolaos; Nibbe, Lutz; Charpentier, Sandrine; Swahn, Eva; Tubaro, Marco; Goldstein, Patrick
Chest pain and acute dyspnoea are frequent causes of emergency medical services activation. The pre-hospital management of these conditions is heterogeneous across different regions of the world and Europe, as a consequence of the variety of emergency medical services and absence of specific practical guidelines. This position paper focuses on the practical aspects of the pre-hospital treatment on board and transfer of patients taken in charge by emergency medical services for chest pain and dyspnoea of suspected cardiac aetiology after the initial assessment and diagnostic work-up. The objective of the paper is to provide guidance, based on evidence, where available, or on experts' opinions, for all emergency medical services' health providers involved in the pre-hospital management of acute cardiovascular care.
Shuman, W P; Mack, L A; Rudd, T G; Rogers, J V; Gibbs, P
A group of 75 patients with acute right upper quadrant pain was evaluated with both sonography and cholescintigraphy. Accuracy in screening for gallbladder disease was significantly greater with sonography (96%) than with cholescintigraphy (74%). For selecting patients with acute cholecystitis from this population that included acute and chronic cholecystitis as well as nonbiliary pathology, PIPIDA was less accurate (77%) than might be expected based on previous reports primarily due to false positive nonvisualization caused by chronic cholecystitis. Of patients with nonbiliary pathology, sonography was able to detect the cause of the right upper quadrant pain in 21%. Patients with acute right upper quadrant pain should first be screened with sonography. If cholescintigraphy is subsequently used for suspected acute cholecystitis, positive results should be interpreted with caution before surgery is planned.
Shuman, W.P.; Mack, L.A.; Rudd, T.G.; Rogers, J.V.; Gibbs, P.
A group of 75 patients with acute right upper quadrant pain was evaluated with both sonography and cholescintigraphy. Accuracy in screening for gallbladder disease was significantly greater with sonography (96%) than with cholescintigraphy (74%). For selecting patients with acute cholecystitis from this population that included acute and chronic cholecystitis as well as nonbiliary pathology, PIPIDA was less accurate (77%) than might be expected based on previous reports primarily due to false positive nonvisualization caused by chronic cholecystitis. Of patients with nonbiliary pathology, sonography was able to detect the cause of the right upper quadrant pain in 21%. Patients with acute right upper quadrant pain should first be screened with sonography. If cholescintigraphy is subsequently used for suspected acute cholecystitis, positive results should be interpreted with caution before surgery is planned.
Introduction: Acute low back pain is one of the most common health problems especially in industrialized countries where 75 per cent of the population develop it at least once during their life. This study examined the efficacy of thermotherapy and cryotherapy, alongside a routine pharmacologic treatment, on pain relief in patients with acute low back pain referring an orthopedic clinic in Shahrekord, Iran. Materials and Methods: This clinical trial study was conducted on 87 patients randomly assigned to three (thermotherapy and cryotherapy as intervention, and naproxen as control) groups of 29 each. The first (thermotherapy) group underwent treatment with hot water bag and naproxen, the second (cryotherapy) group was treated with ice and naproxen, and the naproxen group was only treated with naproxen, all for one week. All patients were examined on 0, 3rd, 8th, and 15th day after the first visit and the data gathered by McGill Pain Questionnaire. The data were analyzed by SPSS software using paired t-test, ANOVA, and chi-square. Results: In this study, mean age of the patients was 34.48 (20–50) years and 51.72 per cent were female. Thermotherapy patients reported significantly less pain compared to cryotherapy and control (p≤0.05). In thermotherapy and cryotherapy groups, mean pain in the first visit was 12.70±3.7 and 12.06±2.6, and on the 15th day after intervention 0.75±0.37 and 2.20±2.12, respectively. Conclusion: The results indicated that the application of thermo–therapy and cryotherapy accompanied with a pharmacologic treatment could relieve pain in the patients with acute low back pain. PMID:25386469
McCarberg, B H; Argoff, C E
Acute pain caused by musculoskeletal disorders is very common and has a significant negative impact on quality-of-life and societal costs. Many types of acute pain have been managed with traditional oral non-steroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase-2 inhibitors (coxibs). Data from prospective, randomised controlled clinical trials and postmarketing surveillance indicate that use of oral traditional NSAIDs and coxibs is associated with an elevated risk of developing gastrointestinal, renovascular and/or cardiovascular adverse events (AEs). Increasing awareness of the AEs associated with NSAID therapy, including coxibs, has led many physicians and patients to reconsider use of these drugs and look for alternative treatment options. Treatment with NSAIDs via the topical route of administration has been shown to provide clinically effective analgesia at the site of application while minimising systemic absorption. The anti-inflammatory and analgesic potency of the traditional oral NSAID diclofenac, along with its physicochemical properties, makes it well suited for topical delivery. Several topical formulations of diclofenac have been developed. A topical patch containing diclofenac epolamine 1.3% (DETP, FLECTOR® Patch), approved for use in Europe in 1993, has recently been approved for use in the United States and is indicated for the treatment of acute pain caused by minor strains, sprains and contusions. In this article, we review the available clinical trial data for this product in the treatment of pain caused by soft tissue injury. PMID:20666849
Wright, Kerri; Adeosum, Omolola
Sickle cell disease (SCD) is a long-term condition that would benefit from a long-term conditions approach to its care and management. SCD is growing in prevalence, affecting 10,000-12,000 people in the UK, with SCD sufferers having an increased life expectancy from in the past. The most problematic aspect of managing SCD is management of the pain from vaso-occlusive crises. Vaso-occlusive pain is the most common reason for hospital admissions in people with SCD and accounts for large numbers of accident and emergency (A&E) attendances. A literature review was carried out to examine the management of vaso-occlusive pain in SCD. The review identified three main barriers to effective pain management in SCD: the manifestation of vaso-occlusive pain, the sociocultural factors affecting pain assessment, and the concerns regarding addiction and pseudo-addiction. Addressing these barriers will allow people with SCD to have their pain managed more effectively, improve their quality of life and potentially reduce A&E attendances and admissions to hospital.
Rutledge, Dana N; Cantero, Patricia J; Ruiz, Jeanette E
Objectives In group interviews, we examined strategies used to manage chronic pain from the perspective of the individual. Methods Sixteen low income overweight Latino adults participated in two group interviews facilitated by a trained moderator who inquired about the type of chronic pain suffered by participants, followed by more specific questions about pain management. Interviews were audio-recorded, transcribed verbatim (Spanish), back-translated into English, and analyzed using thematic analysis. Results Participants’ pain varied in type, location, and intensity. Participants discussed pain-related changes in activities and social life, and difficulties with health care providers, and as a result, we discovered five major themes: Pain-related Life Alterations, Enduring the Pain, Trying Different Strategies, Emotional Suffering, and Encounters with Health Care System/Providers. Discussion Findings indicated that there are opportunities for providers to improve care for low income overweight Latinos with chronic pain by listening respectfully to how pain alters their daily lives and assisting them in feasible self management strategies. PMID:23129787
Benyamin, Ramsin M; Datta, Sukdeb; Falco, Frank J E
Interventional pain management now stands at the crossroads at what is described as "the perfect storm." The confluence of several factors has led to devastating results for interventional pain management. This article seeks to provide a perspective to various issues producing conditions conducive to creating a "perfect storm" such as use and abuse of interventional pain management techniques, and in the same context, use and abuse of various non-interventional techniques. The rapid increase in opioid drug prescribing, costs to health care, large increases in death rates, and random and rampant drug testing, can also lead to increases in health care utilization. Other important aspects that are seldom discussed include medico-legal and ethical perspectives of individual and professional societal opinions and the interpretation of diagnostic accuracy of controlled diagnostic blocks. The aim of this article is to discuss the impact of several factors on interventional pain management and overuse, abuse, waste, and fraud; inappropriate application without evidence-based literature support (sometimes leading to selective use or non-use of randomized or observational studies for proving biased viewpoints - post priori rather than a priori), and issues related to multiple professional societies having their own agendas to push rather than promulgating the science of interventional pain management. This perspective is based on a review of articles published in this issue of Pain Physician, information in the public domain, and other relevant articles. Based on the results of this review, various issues of relevance to modern interventional pain management are discussed and the viewpoints of several experts debated. In conclusion, supporters of interventional pain management disagree on multiple aspects for various reasons while detractors claim that interventional pain management should not exist as a speciality. Issues to be addressed include appropriate use of evidence
Nageswaran, H; Dunkley, A
A case is presented of severe abdominal pain around a healed scar following fracture of a heterotopically formed bone. This should be considered an unusual differential diagnosis in patients with acute pain of unknown origin who had open abdominal surgery in the past. To our knowledge, we have also reported the first case of hetertopic bone formation incorporating a prolene mesh.
Valle Feijóo, M L; Bermúdez Sanjurjo, J R; González Vázquez, L; Rey Martínez, M; de la Fuente Aguado, J
Acute intermittent porphyria (AIP) is a rare condition characterized by abdominal pain and a wide range of nonspecific symptoms. We report the case of a woman with abdominal pain and syndrome of inappropriate antidiuretic hormone secretion (SIADH) as clinical presentation of AIP. The diagnosis was achieved through the etiologic study of the SIADH.
Vachon-Presseau, Etienne; Martel, Marc O; Roy, Mathieu; Caron, Etienne; Jackson, Philip L; Rainville, Pierre
The shared-representation model of empathy suggests that vicarious pain processes rely partly on the activation of brain systems underlying self-pain in the observer. Here, we tested the hypothesis that self-pain may be facilitated by the vicarious priming of neural systems underlying pain perception. Pictures illustrating painful agents applied to the hand or the foot (sensory information), or painful facial expressions (emotional information) were shown to 43 participants to test the effects of vicarious pain on the nociceptive flexion reflex (NFR) of the lower limb and pain intensity and unpleasantness produced by transcutaneous electrical stimulation applied over the sural nerve. Results confirmed the expected priming effects of vicarious pain on spinal and perceptual processes. However, for comparable pain intensity and arousal evoked by the pain pictures, the facilitation of the NFR and the self-pain unpleasantness measurements was more robust in response to pictures depicting pain sensory compared to emotional information. Furthermore, the facilitation of the NFR by pain pictures was positively correlated with the empathy trait of the observer. In contrast, the change in perceived shock-pain intensity was negatively correlated with empathic traits. This dissociation implies that low-level vicarious priming processes underlying pain facilitation may be downregulated at higher pain-processing stages in individuals reporting higher levels of empathy. We speculate that this process contributes to reducing self-other assimilation and is necessary to adopt higher-order empathic responses and altruistic behaviors.
Kirkaldy-Willis, W.H. )
This book contains 26 chapters. Some of the titles are: Magnetic resonance imaging of the lumbar spine; Diagnostic techniques; The site and nature of the lesion; The anatomy of the lumbosacral spine; The perception of pain; Differential diagnosis of low back pain; and A comprehensive outline of treatment.
Hong, Su Jin
Esophageal pain that manifests as heartburn or chest pain, is a prevalent problem. Esophageal chest pain is most often caused by gastroesophageal reflux disease (GERD), but can also result from inflammatory processes, infections involving the esophagus, and contractions of the esophageal muscle. The mechanisms and pathways of esophageal chest pain are poorly understood. Vagal and spinal afferent pathways carry sensory information from the esophagus. Recently, esophageal hypersensitivity is identified as an important factor in the development of esophageal pain. A number of techniques are available to evaluate esophageal chest pain such as endoscopy and/or proton-pump inhibitor trial, esophageal manometry, a combined impedance-pH study, and esophageal ultrasound imaging. Proton pump inhibitors (PPIs) have the huge success in the treatment of GERD. Other drugs such as imipramine, trazadone, sertraline, tricyclics, and theophylline have been introduced for the control of esophageal chest pain in partial responders to PPI and the patients with esophageal hypersensitivity. Novel drugs which act on different targets are anticipated to treat esophageal pain in the future.
Bookout, Michelle L; Staffileno, Beth A; Budzinsky, Christine M
Patient-centered care is a key driver for the nation's health system, yet patient experience surveys indicate that hospitals are far from achieving favorable outcomes. Partnering with patients and families through a patient and family advisory council (PFAC) advances the practice of patient-centered care to improve outcomes and experiences. This article describes the process of implementing a PFAC and presents outcomes related to patients' perception of pain management in the acute care hospital setting.
Stone, Christopher I.
Traditional medical interventions for the management of pain have consisted largely of either pharmacological treatments or surgery to interrupt the involved neural pathways. The results of these procedures have been largely unsatisfactory because of debilitating side effects and recurrence of pain. Investigations of a host of psychological…
Carey, Erin T; Till, Sara R; As-Sanie, Sawsan
Chronic pelvic pain (CPP) is a multifaceted condition that often has both peripheral and central generators of pain. An understanding of neurobiology and neuropsychology of CPP should guide management. Successful treatment of CPP is typically multimodal, and pharmacologic treatment strategies include analgesics, hormonal suppression, anesthetics, antidepressants, membrane stabilizers, and anxiolytics. Evidence for these and other emerging pharmacologic therapies is presented in this article.
Rivera Domínguez, A; Mora Jurado, A; García de la Oliva, A; de Araujo Martins-Romeo, D; Cueto Álvarez, L
Acute pelvic pain is a common condition in emergency. The sources of acute pelvic pain are multifactorial, so it is important to be familiar with this type of pathologies. The purpose of this article is review the main causes of gynecological acute pelvic pain and their radiologic appearances to be able to make an accurate diagnosis and provide objective criteria for patient management.
Musey, Paul I; Linnstaedt, Sarah D; Platts-Mills, Timothy F; Miner, James R; Bortsov, Andrey V; Safdar, Basmah; Bijur, Polly; Rosenau, Alex; Tsze, Daniel S; Chang, Andrew K; Dorai, Suprina; Engel, Kirsten G; Feldman, James A; Fusaro, Angela M; Lee, David C; Rosenberg, Mark; Keefe, Francis J; Peak, David A; Nam, Catherine S; Patel, Roma G; Fillingim, Roger B; McLean, Samuel A
Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas, in May 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine and the pain research field reviewed the current literature and identified eight candidate priority areas. At the conference, these eight areas were reviewed and all eight were ratified using a nominal group technique to build consensus. These priority areas were: 1) gender differences in the pharmacological and nonpharmacological interventions for pain, including differences in opioid tolerance, side effects, or misuse; 2) gender differences in pain severity perceptions, clinically meaningful differences in acute pain, and pain treatment preferences; 3) gender differences in pain outcomes of ED patients across the life span; 4) gender differences in the relationship between acute pain and acute psychological responses; 5) the influence of physician-patient gender differences and characteristics on the assessment and treatment of pain; 6) gender differences in the influence of acute stress and chronic stress on acute pain responses; 7) gender differences in biological mechanisms and molecular pathways mediating acute pain in ED populations; and 8) gender differences in biological mechanisms and molecular pathways mediating chronic pain development after trauma, stress, or acute illness exposure. These areas represent priority areas for future scientific inquiry, and gaining understanding in these will be essential to improving our understanding of sex and gender
Efficacy and safety profile of combination of tramadol-diclofenac versus tramadol-paracetamol in patients with acute musculoskeletal conditions, postoperative pain, and acute flare of osteoarthritis and rheumatoid arthritis: a Phase III, 5-day open-label study
Chandanwale, Ajay S; Sundar, Subramanian; Latchoumibady, Kaliaperumal; Biswas, Swati; Gabhane, Mukesh; Naik, Manoj; Patel, Kamlesh
Objective We aimed to evaluate the safety and efficacy of a fixed-dose combination (FDC) of tramadol and diclofenac versus a standard approved FDC of tramadol and paracetamol, in patients with acute moderate to severe pain. Methods A total of 204 patients with moderate to severe pain due to acute musculoskeletal conditions (n=52), acute flare of osteoarthritis (n=52), acute flare of rheumatoid arthritis (n=50), or postoperative pain (n=50) were enrolled in the study at baseline. Each disease category was then randomized to receive either of two treatments for 5 days: group A received an FDC of immediate-release tramadol hydrochloride (50 mg) and sustained-release diclofenac sodium (75 mg) (one tablet, twice daily), and group B received an FDC of tramadol hydrochloride (37.5 mg) and paracetamol (325 mg) (two tablets every 4–6 hours, up to a maximum of eight tablets daily). The primary efficacy end points were reductions in pain intensity from baseline at day 3 and day 5 as assessed by a Visual Analog Scale (VAS) score. Results Group A showed a significant reduction in the VAS score for overall pain from baseline on day 3 (P=0.001) and day 5 (P<0.0001) as compared with group B. The combination of tramadol-diclofenac resulted in few mild to moderate adverse events (nausea, vomiting, epigastric pain, and gastritis), which required minimal management, without any treatment discontinuation. The number of adverse events in group A was nine (8.82%) compared with 22 (21.78%) in group B, after 5 days of treatment. Conclusion An FDC of tramadol-diclofenac showed a significantly greater reduction in pain intensity and was well tolerated compared with tramadol-paracetamol, resulting in better analgesia in patients suffering from moderate to severe pain due to acute musculoskeletal conditions, postoperative pain following orthopedic surgery, or acute flare of osteoarthritis and rheumatoid arthritis. PMID:25152629
Syrjala, Karen L.; Jensen, Mark P.; Mendoza, M. Elena; Yi, Jean C.; Fisher, Hannah M.; Keefe, Francis J.
This review examines evidence for psychological factors that affect pain across the cancer continuum from diagnosis through treatment and long-term survivorship or end of life. Evidence is convincing that emotional distress, depression, anxiety, uncertainty, and hopelessness interact with pain. Unrelieved pain can increase a desire for hastened death. Patients with cancer use many strategies to manage pain, with catastrophizing associated with increased pain and self-efficacy associated with lower pain reports. A variety of psychological and cognitive behavioral treatments can reduce pain severity and interference with function, as indicated in multiple meta-analyses and high-quality randomized controlled trials. Effective methods include education (with coping skills training), hypnosis, cognitive behavioral approaches, and relaxation with imagery. Exercise has been tested extensively in patients with cancer and long-term survivors, but few exercise studies have evaluated pain outcomes. In survivors post-treatment, yoga and hypnosis as well as exercise show promise for controlling pain. Although some of these treatments effectively reduce pain for patients with advanced disease, few have been tested in patients at the end of life. Given the clear indicators that psychological factors affect cancer pain and that psychological and behavioral treatments are effective in reducing varying types of pain for patients with active disease, these methods need further testing in cancer survivors post-treatment and in patients with end-stage disease. Multidisciplinary teams are essential in oncology settings to integrate analgesic care and expertise in psychological and behavioral interventions in standard care for symptom management, including pain. PMID:24799497
Syrjala, Karen L; Jensen, Mark P; Mendoza, M Elena; Yi, Jean C; Fisher, Hannah M; Keefe, Francis J
This review examines evidence for psychological factors that affect pain across the cancer continuum from diagnosis through treatment and long-term survivorship or end of life. Evidence is convincing that emotional distress, depression, anxiety, uncertainty, and hopelessness interact with pain. Unrelieved pain can increase a desire for hastened death. Patients with cancer use many strategies to manage pain, with catastrophizing associated with increased pain and self-efficacy associated with lower pain reports. A variety of psychological and cognitive behavioral treatments can reduce pain severity and interference with function, as indicated in multiple meta-analyses and high-quality randomized controlled trials. Effective methods include education (with coping skills training), hypnosis, cognitive behavioral approaches, and relaxation with imagery. Exercise has been tested extensively in patients with cancer and long-term survivors, but few exercise studies have evaluated pain outcomes. In survivors post-treatment, yoga and hypnosis as well as exercise show promise for controlling pain. Although some of these treatments effectively reduce pain for patients with advanced disease, few have been tested in patients at the end of life. Given the clear indicators that psychological factors affect cancer pain and that psychological and behavioral treatments are effective in reducing varying types of pain for patients with active disease, these methods need further testing in cancer survivors post-treatment and in patients with end-stage disease. Multidisciplinary teams are essential in oncology settings to integrate analgesic care and expertise in psychological and behavioral interventions in standard care for symptom management, including pain.
Ko, Hyoung-Gon; Oh, Seog-Bae; Zhuo, Min; Kaang, Bong-Kiun
Autism spectrum disorder is a debilitating mental illness and social issue. Autism spectrum disorder patients suffer from social isolation, cognitive deficits, compulsive behavior, and sensory deficits, including hyposensitivity to pain. However, recent studies argued that autism spectrum disorder patients show physiological pain response and, in some cases, even extremely intense pain response to harmless stimulation. Recently, Shank gene family was reported as one of the genetic risk factors of autism spectrum disorder. Thus, in this study, we used Shank2(-) (/) (-) (Shank2 knock-out, KO) mice to investigate the controversial pain sensitivity issue and found that Shank2 KO mice showed reduced tactile perception and analgesia to chronic pain.
Jeon, Young Hoon
Spinal cord stimulation has become a widely used and efficient alternative for the management of refractory chronic pain that is unresponsive to conservative therapies. Technological improvements have been considerable and the current neuromodulation devices are both extremely sophisticated and reliable in obtaining good results for various clinical situations of chronic pain, such as failed back surgery syndrome, complex regional pain syndrome, ischemic and coronary artery disease. This technique is likely to possess a savings in costs compared with alternative therapy strategies despite its high initial cost. Spinal cord stimulation continues to be a valuable tool in the treatment of chronic disabling pain.
Hemming, Laureen; Maher, David
Pain is the major source of anxiety and distress at the end of life, particularly in cases of end-stage cancer. However, pain management is not always effective or effectively implemented. This article identifies several barriers to effective pain relief in terminal cancer--the complexity of pain; difficulties in physical, emotional and spiritual assessment; difficulties in the delivery of medication--that challenge the skills of all professionals involved in palliative care. There are no simple answers, but awareness of the breadth of the issues may help focus nurses' minds on the patient in every encounter.
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Vasseljen, Ottar; Woodhouse, Astrid; Bjørngaard, Johan Håkon; Leivseth, Linda
In this prospective cohort study we aimed to describe the natural course of acute neck and low back pain in a general population of Norway. We screened 9056 subjects aged 20-67 years who participated in a general health survey for a new episode of neck or low back pain the previous month. The screening identified 219 subjects who formed the cohort for this study. Pain intensity was reported on a numeric rating scale (0-10) at 1, 2, 3, 6, and 12 months after start of the new pain episode. The course of pain was described for neck and low back pain, different baseline pain levels, age groups, and number of pain sites at baseline. Use of medication and health care was described and associations between pain intensity and seeking health care were estimated. Pain declined rapidly within 1 month after a new pain episode, with a reduction of 0.91 (95% confidence interval [CI] 0.50-1.32) for neck pain and 1.40 (95% CI 0.82-1.99) for low back pain with little change thereafter. However, pain remained unchanged over the follow-up year for those with equal pain in the neck and low back areas at baseline and for those reporting 4 or more pain sites at baseline. Only 1 in 5 sought health care for their complaints. Still, the course of pain was comparable to effect sizes reported in interventional studies. This study thus contributes natural course reference data for comparisons of pain outcome in clinical trials and practice.
Schäfers, Maria; Sommer, Claudia
Cytokine activation or dysregulation is implied in a variety of painful disease states. Numerous experimental studies provide evidence that proinflammatory cytokines induce or facilitate neuropathic pain. Cytokine levels are rapidly and markedly upregulated in the peripheral nerves, dorsal root ganglia, spinal cord and in particular regions of the brain, after peripheral nerve injuries. Direct receptor-mediated actions on afferent nerve fibers as well as cytokine effects involving further mediators have been reported. Whereas direct application of exogenous proinflammatory cytokines induces pain, blockade of these cytokines or application of anti-inflammatory cytokines reduces pain behavior in most experimental paradigms. Cytokine measurements may identify patients at risk of developing chronic pain associated with their neuropathic conditions, as in the examples of peripheral neuropathies and postherpetic neuralgia. Anticytokine agents currently on the market are effective for the treatment of mostly inflammatory pain conditions, and are starting to be introduced for neuropathic pain states; however, their use is limited by potential life-threatening complications. Owing to the pleiotropy and redundancy of the cytokine system, the successful approach may not be inhibition of one particular cytokine but strategies shifting the balance between pro- and anti-inflammatory cytokines in properly selected patients. Agents that specifically target downstream signaling molecules may provide hope for safer and more specific therapies.
Bagshaw, Kyle R; Hanenbaum, Curt L; Carbone, Erica J; Lo, Kevin WH; Laurencin, Cato T; Walker, Joseph; Nair, Lakshmi S
Acute and chronic pain control is a significant clinical challenge that has been largely unmet. Local anesthetics are widely used for the control of post-operative pain and in the therapy of acute and chronic pain. While a variety of approaches are currently used to prolong the duration of action of local anesthetics, an optimal strategy to achieve neural blockage for several hours to days with minimal toxicity has yet to be identified. Several drug delivery systems such as liposomes, microparticles and nanoparticles have been investigated as local anesthetic delivery vehicles to achieve prolonged anesthesia. Recently, injectable responsive hydrogels raise significant interest for the localized delivery of anesthetic molecules. This paper discusses the potential of injectable hydrogels to prolong the action of local anesthetics. PMID:25690085
Schurtz, Guillaume; Lamblin, Nicolas; Bauters, Christophe; Goldstein, Patrick; Lemesle, Gilles
Over the past two decades, the use of multiple biomarkers has changed cardiovascular disease management. Recently, several trials have assessed the diagnostic and prognostic performances of copeptin, especially in patients with heart failure or acute coronary syndromes. Primary results are interesting, with copeptin looking promising for: the management of patients who present at emergency departments early after chest pain onset and the risk stratification of patients with heart failure. The purpose of this article is to review the data on the place of copeptin in the management of patients with chest pain or heart failure.
Park, Juyoung; Hirz, Christina E; Manotas, Karen; Hooyman, Nancy
As key players in multidisciplinary health care systems, geriatric social workers must understand the dynamics of pain management among older adults with chronic pain. This study identified perceived barriers to, and facilitators for, utilizing nonpharmacological pain management through face-to-face interviews with 44 ethnically diverse community-dwelling older adults. Constant comparative analysis identified barriers not recognized in prior studies: (a) embarrassment/self-consciousness, (b) unavailability of certain treatments, and (c) lack of faith in effectiveness of nonpharmacological treatments. Most frequently reported facilitators were (a) social support, (b) positive attitude, and (c) available resources. Social workers can provide counseling to motivate older adults to exercise to manage chronic pain and refer them to exercise programs tailored for older adults. To resolve the most frequently reported barrier-transportation-social workers can link older adults with transportation services offered by senior centers or other nonprofit agencies.
Altman, Roy; Daniels, Stephen; Young, Clarence L
Although frequently prescribed to relieve acute pain in patients, non-steroidal anti-inflammatory drugs (NSAIDs) are associated with dose-related gastrointestinal, cardiovascular, and renal complications. Investigational, submicron particle NSAIDs are being developed that could provide effective pain relief at lower doses than currently available oral NSAIDs. This is the first phase 3 study evaluating the analgesic efficacy and safety of lower-dose indomethacin submicron particle capsules in patients following elective surgery. This multicenter, double-blind study enrolled patients aged 18 to 68 years who underwent bunionectomy under regional anesthesia. Patients with a pain intensity rating of ≥40 mm on a 100-mm Visual Analog Scale were randomized to receive indomethacin submicron particle capsules (40 mg 3 times daily [TID], 40 mg twice daily [BID], or 20 mg TID), celecoxib (400 mg loading dose, then 200 mg BID), or placebo. The primary efficacy parameter was the overall (summed) pain intensity difference measured by a Visual Analog Scale during a period of 48 hours. Scheduled assessments measured secondary efficacy parameters such as patient pain intensity differences. Indomethacin submicron particle capsules 40 mg 3 times daily (509.6 ± 91.9 overall [summed] pain intensity difference), 40 mg twice daily (328.0 ± 92.9 overall [summed] pain intensity difference), and 20 mg 3 times daily (380.5 ± 92.9 overall [summed] pain intensity difference) reduced pain intensity from 0 to 48 hours (P ≤ 0.046 for all 3 groups) compared with placebo (67.8 ± 91.4 overall [summed] pain intensity difference). There was some evidence of patient analgesia for celecoxib (279.4 ± 91.9 overall [summed] pain intensity difference; P = 0.103). Some evidence of pain control was observed in patients as early as 2 hours following administration of indomethacin submicron particle capsules and was sustained throughout the treatment period. Indomethacin submicron particle capsules were
Albeldawi, Mazen; Qadeer, Mohammed A; Vargo, John J
Acute upper gastrointestinal (GI) bleeding is common and potentially life-threatening and needs a prompt assessment and aggressive medical management. All patients need to undergo endoscopy to diagnose, assess, and possibly treat any underlying lesion. In addition, patients found to have bleeding ulcers should receive a proton pump inhibitor, the dosage and duration of treatment depending on the endoscopic findings and clinical factors.
Mehling, Wolf E.; Gopisetty, Viranjini; Acree, Michael; Pressman, Alice; Carey, Tim; Goldberg, Harley; Hecht, Frederick; Avins, Andrew L
Study Design Prospective cohort study Objective to establish outcome measures for recovery and chronic pain for studies with patients that present with recent-onset acute low back pain in primary care Summary of Background Data Among back pain researchers, no consensus exists about outcome definitions or how to identify primary-care patients as not-recovered from an episode of low back pain. Cut points for outcome scales have mostly been arbitrarily chosen. Theoretical models for establishing minimal important change (MIC) values in studies of patients with low back pain have been proposed and need to be applied to real data. Methods In a sample of 521 patients which presented with acute low back pain (<4 weeks) in primary care clinics and were followed for 6 months, scores for pain and disability were compared with ratings on a global perceived effect scale. Using multiple potential “gold standards” as anchors (reference standards), the receiver operating characteristics method was used to determine optimal cut points for different ways of defining non-recovery from acute low back pain. Results MIC values and upper limits for pain and disability scores as well as minimal important percent changes are presented for five different definitions of recovery. A previously suggested 30% change from baseline scores does not accurately discriminate between recovered and not recovered patients in patients presenting with acute low back pain in primary care. Conclusions Outcome definitions that combine ratings from perceived recovery scales with pain and disability measures provide the highest accuracy in discriminating recovered from non-recovered patients. PMID:21311400
Merlin, Jessica S.; Walcott, Melonie; Kerns, Robert; Bair, Matthew J.; Burgio, Kathryn L.; Turan, Janet M.
Objective Chronic pain in individuals with HIV is a common, impairing condition. Behavioral interventions for chronic pain specifically tailored to this population have yet to be developed. We assert that understanding self-management strategies already used by persons living with these conditions is an essential first step, and is the objective of this investigation. Design We conducted a thematic analysis of qualitative data from 25 in-depth interviews with individuals with HIV and chronic pain. Results The primary pain self-management strategies articulated by participants were: physical activity; cognitive and spiritual strategies; spending time with family and friends and social support; avoidance of physical/social activity; medication-centric pain management; and substance use. Conclusions Some of these strategies may be viewed as beneficial and overlap with known HIV self-management strategies (cognitive strategies), whereas others may have negative health consequences (substance use). Interventions that incorporate healthy self-management strategies may be particularly effective in improving both HIV and pain outcomes. PMID:25645646
Lambert, Gavin; Elam, Mikael; Friberg, Peter; Lundborg, Christopher; Gao, Sinsia; Bergquist, Jonas; Nitescu, Petre
Continuous intracisternal infusion of bupivacaine for the management of intractable pain of the head and neck is effective in controlling pain in this patient group. With the catheter tip being located at the height of the C1 vertebral body, autonomic regulatory information may also be influenced by the infusion of bupivacaine. By combining direct sampling of cerebrospinal fluid (CSF), via a percutaneously placed catheter in the cisterna magna, with a noradrenaline and adrenaline isotope dilution method for examining sympathetic and adrenal medullary activity, we were able to quantify the release of brain neurotransmitters and examine efferent sympathetic nervous outflow in patients following intracisternal administration of bupivacaine. Despite severe pain, sympathetic and adrenal medullary activities were well within normal range (4.2 ± 0.6 and 0.7 ± 0.2 nmol min−1, respectively, mean ± s.e.m.). Intracisternal bupivacaine administration caused an almost instantaneous elevation in mean arterial blood pressure, increasing by 17 ± 7 mmHg after 10 min (P < 0.01). Heart rate increased in parallel (17 ± 5 beats min−1), and these changes coincided with an increase in sympathetic nervous activity, peaking with an approximately 50% increase over resting level 10 min after injection (P < 0.01). CSF levels of GABA were reduced following bupivacaine (P < 0.05). CSF catecholamines and serotonin, and EEG, remained unaffected. These results show that acutely administered bupivacaine in the cisterna magna of chronic pain sufferers leads to an activation of the sympathetic nervous system. The results suggest that the haemodynamic consequences occur as a result of interference with the neuronal circuitry in the brainstem. Although these effects are transient, they warrant caution at the induction of intracisternal local anaesthesia. PMID:16254013
Colloca, Luana; Grillon, Christian
Placebo analgesia makes individuals experience relief of their pain simply by virtue of the anticipation of a benefit. A reduction of pain can occur also when placebos follow the administration of active and effective painkillers. In fact, studies indicate that placebos mimic the action of active treatments and promote the endogenous release of opioids in both humans and animals. Finally, social support and observational learning also lead to analgesic effects. Thus, different psychological factors and situations induce expectations of analgesia facilitating the activation of the top-down systems for pain control along with the release of endogenous mediators crucially involved in placebo-induced benefits. Recent scientific investigation in the field of brain imaging is opening new avenues to understanding the cognitive mechanisms and neurobiological substrates of expectation-induced pain modulation. Gaining deeper knowledge of top-down mechanisms of pain modulation has enormous implications for personalizing and optimizing pain management. PMID:24771206
Pham, Phuong-Chi T.; Toscano, Edgar; Pham, Phuong-Mai T.; Pham, Phuong-Anh T.; Pham, Son V.; Pham, Phuong-Thu T.
Pain has been reported to be a common problem in the general population and end-stage renal disease (ESRD) patients. Although similar data for pre-ESRD patients are lacking, we recently reported that the prevalence of pain is also very high (>70%) among pre-ESRD patients at a Los Angeles County tertiary referral centre. The high prevalence of pain in the CKD population is particularly concerning because pain has been shown to be associated with poor quality of life. Of greater concern, poor quality of life, at least in dialysis patients, has been shown to be associated with poor survival. We herein discuss the pathophysiology of common pain conditions, review a commonly accepted approach to the management of pain in the general population, and discuss analgesic-induced renal complications and therapeutic issues specific for patients with reduced renal function. PMID:25949305
Sherwood, Gwen; McNeill, Jeanette
Effective pain management continues to baffle clinicians in spite of numerous evidence-based guidelines and standards, focused clinical interventions and standardized assessments. Reflective practice is a mindful approach to practice that grounds clinicians in the moment with the individual patient to ask questions and then to listen to the patient's message about their pain experience. Reflective practice helps meld theoretical knowledge with lessons from experience to rethink mechanistic responses to patient pain. The subjective nature of pain means no two patients have the same experience, and, evidence based best practices are to be applied within the patient's preferences and context. The paper uses a case study to illustrate how to apply reflective practice to integrate the interprofessional quality and safety competencies to provide patient-centered pain management. Applying reflective questions throughout the care experience by all members of the healthcare team provides a mindful approach that focuses care on the individual patient.
Sung, Won; Abraham, Mathew; Plastaras, Christopher; Silfies, Sheri P.
Background Context A subgroup of patients with acute/sub-acute low back pain (LBP) presenting with trunk movement control deficits, pain provocation with segmental testing, and segmental hypermobility have been clinically identified as having movement coordination impairments (MCI) of the trunk. It is hypothesized that these patients have proprioceptive, postural and movement control impairments of the trunk associated with LBP. While, trunk control impairments have been identified in patients with chronic LBP, they have not been investigated in this subgroup or closer to symptom onset. Purpose To identify trunk motor control (postural control and movement precision) impairments in a subgroup of patients with acute/sub-acute LBP who have been clinically identified to have MCI and determine association of these impairments with pain and fear of movement. Study Design/Setting Observational design; University biomechanics lab and clinical practice. Patient Sample Thirty-three patients with acute/sub-acute LBP identified with trunk MCI and 33 gender, age, and BMI matched healthy controls. Outcome Measures Self-report Measures Numeric Pain Rating Scale, Oswestry Disability Questionnaire, Fear Avoidance Beliefs Questionnaire. Physiologic Measures Postural control, Movement precision Methods Center of pressure movement was measured while subjects attempted to volitionally control trunk posture and movement while sitting on a platform with a hemisphere mounted underneath. This created an unstable surface that required coordinated trunk control to maintain an upright-seated posture. Postural control was tested using eyes-open and eyes-closed balance protocols. Movement precision was tested with a dynamic control test requiring movement of the center of pressure along a discrete path. Group trunk motor control performance was compared with ANOVA and t-Test. Performance association with pain and fear of movement were assessed with Pearson’s Correlations. Funding for this
Tamaddonfard, Esmaeal; Khalilzadeh, Emad; Hamzeh-Gooshchi, Nasrin; Seiednejhad-Yamchi, Sona
In conscious rats implanted with an intracerebroventricular (icv) cannula, effect of icv injections of histamine, chlorpheniramine (H(1)-receptor antagonist) and ranitidine (H(2)-receptor blocker) was investigated in a rat model of acute trigeminal pain. Acute trigeminal pain was induced by putting a drop of 5 M NaCl solution on the corneal surface of the eye and the numbers of eye wipes were counted during the first 30 s. Histamine (20, 40 microg) and chlorpheniramine (80 microg) significantly decreased the numbers of eye wipes. Ranitidine alone had no effect. Pretreatment with chlorpheniramine did not change the histamine-induced analgesia, whereas the histamine effect on pain was inhibited with ranitidine pretreatment. These results indicate that the brain histamine, through central H(2) receptors, may be involved in the modulation of the acute trigeminal pain in rats.
Marchettini, P; Teloni, L; Formaglio, F; Lacerenza, M
Painful diabetic peripheral neuropathy (DPN) is described as a superficial burning pain associated with other positive and/or negative sensory systems affecting the feet and lower extremities. It is one of the most commonly encountered neuropathic pain syndromes in clinical practice. Presentation may be complicated by multiple symptoms, including allodynia, hyperalgesia, other less well characterized dysesthesias, and serious disruption of social functioning and mood. Peripheral nerve function may deteriorate, which can account for patient reports of diminution of pain after several years of follow-up. Although current understanding holds that the pathogenesis of DPN is multifactorial in nature, long-term studies have shown that rigorous glycemic control is the most relevant factor in clinical intervention and can delay the onset and slow the progression of neuropathy. In addition to glycemic control, other treatment approaches must be examined in order to restore quality of life for patients experiencing painful DPN. Differential diagnosis is required to isolate DPN from other unexplained chronic pain. Neurologic testing in painful DPN is an area of active research and is used to assess the neurologic pathways giving rise to the pain, the degree of neural damage and the degree of subclinical damage. Current treatment options for DPN include mainly antidepressants and anticonvulsants, with other agents such as tramadol, dextromethorphan and memantine being employed or studied. This review article includes a case study of a patient with painful DPN to demonstrate the current management strategies for this neuropathic pain syndrome.
Alvarez, Pedro; Gear, Robert W.; Green, Paul G.; Levine, Jon D.
The function of populations of nociceptors in muscle pain syndromes remain poorly understood. We compared the contribution of two major classes, isolectin B4-positive (IB4(+)) and IB4-negative (IB4(−)) nociceptors, in acute and chronic inflammatory and ergonomic muscle pain. Baseline mechanical nociceptive threshold was assessed in the gastrocnemius muscle of rats treated with IB4-saporin, which selectively destroys IB4(+) nociceptors. Rats were then submitted to models of acute inflammatory (intramuscular carrageenan)- or ergonomic intervention (eccentric exercise or vibration)-induced muscle pain, and each of the three models also evaluated for the transition from acute to chronic pain, manifest as prolongation of prostaglandin E2 (PGE2)-induced hyperalgesia, after recovery from the hyperalgesia induced by acute inflammation or ergonomic interventions. IB4-saporin treatment did not affect baseline mechanical nociceptive threshold. However, compared to controls, IB4-saporin treated rats exhibited shorter duration mechanical hyperalgesia in all three models and attenuated peak hyperalgesia in the ergonomic pain models. And, IB4-saporin treatment completely prevented prolongation of PGE2-induced mechanical hyperalgesia. Thus, IB4(+) and IB4(−) neurons contribute to acute muscle hyperalgesia induced by diverse insults. However, only IB4+ nociceptors participate in the long term consequence of acute hyperalgesia. Finally, using retrograde labelling we found that approximately 70% of sensory neurons innervating the gastrocnemius muscle are IB4(+). PMID:22206923
Bush, Francis M.
Review of the literature indicates that most routine orofacial dysfunctions are characterized by deep pain. Various disorders of the masticatory systems, particularly musculoskeletal conditions, are thought to be triggered by occlusal disharmonies. The pain component develops following a pattern of bruxism, muscle hyperactivity, fatigue and spasm. Treatment for most disorders has been to modify the occlusion, although the rational for doing so appears questionable. Critical issues in the field of occlusion related to orofacial pain are reviewed: occlusal disharmonies, coincidence of retruded-intercuspal contact positions, non-working side interferences, maximum intercuspation of teeth, occlusal adjustment, and occlusal appliances. The studies reviewed fail to support the clinical objective of obtaining equal contact at retruded and intercuspal positions and that the lateral pterygoid muscles stabilize the temporomandibular joint. The relationship between non-working side interferences and pain dysfunction is also not readily supported by controlled studies. Occlusal adjustment appears to be unsatisfactory as a modality for management of pain: not all patients improved following treatment, some relapse occurs even with the most stable contacts, and other treatments such as intra-articular injections of corticosteroids reduced symptoms more readily. Occlusal splints seem to reduce most clinical signs and symptoms on both a short-term and long-term basis. Placement of mandibular orthopedic repositioning appliances results in reduction of pain in some patients, but usually this treatment is followed by extensive rehabilitation. Six major areas are suggested for clinical studies that attempt to relate occlusion to management of orofacial pain. These include: establishment of an ideal jaw position, sequencing of symptoms in the pain history, relationship of pain to other symptoms, development of physiological methods to assess how occlusal modification affects pain
Dear, B F; Gandy, M; Karin, E; Ricciardi, T; Langman, N; Staples, L G; Fogliati, V J; Sharpe, L; McLellan, L F; Titov, N
There is significant interest in the potential of Internet-delivered pain management programs for adults with chronic pain. Understanding the characteristics of people who do and do not benefit from Internet-delivered programs will help to guide their safe and effective use. Using a large sample from a previous randomised controlled trial of an established Internet-delivered pain management program, the Pain Course, this study (n = 463) examined whether several demographic, clinical, psychological, and treatment-related variables could be used to predict clinical response in levels of disability, depression, anxiety, or average pain. Multiple univariate and multivariate stepwise logistic regressions were used to identify unique predictors of clinical improvement, which, consistent with recommendations, was defined as a ≥30% reduction in symptoms or difficulties from baseline. Several unique predictors of clinical improvement were found. However, no particularly decisive or dominant predictors emerged that were common across time points or across the outcome domains. Reflecting this, the identified predictors explained only 18.1%, 13.7%, 7.6%, and 9.5% of the variance in the likelihood of making a clinical improvement in disability, depression, anxiety, and average pain levels, respectively. The current findings suggest that a broad range of patients may benefit from emerging Internet-delivered pain management programs and that it may not be possible to predict who will or will not benefit on the basis of patients' demographic, clinical, and psychological characteristics.
Allegaert, Karel; van den Anker, John N
Inadequate pain management but also inappropriate use of analgesics in early infancy has negative effects on neurodevelopmental outcome. As a consequence, neonatal pain management is still in search for the Holy Grail. At best, effective pain management is based on prevention, assessment, and treatment followed by a re-assessment of the pain to determine if additional treatment is still necessary. Unfortunately, epidemiological observations suggest that neonates are undergoing painful procedures very frequently, unveiling the need for effective preventive, non-pharmacological strategies. In addition, assessment is still based on validated, multimodal, but subjective pain assessment tools. Finally, in neonatal intensive care units, there is a shift in clinical practices (e.g., shorter intubation and ventilation), and this necessitates the development and validation of new pharmacological treatment modalities. To illustrate this, a shift in the use of opioids to paracetamol has occurred and short-acting agents (remifentanil, propofol) are more commonly administered to neonates. In addition to these new modalities and as part of a more advanced approach of the developmental pharmacology of analgesics, pharmacogenetics also emerged as a tool for precision medicine in neonates. To assure further improvement of neonatal pain management the integration of pharmacogenetics with the usual covariates like weight, age and/or disease characteristics is needed.
Krok, Jessica L; Baker, Tamara A
This study examines the relationship of personality traits and affect on cancer-related pain in 150 older adults receiving outpatient treatment at a comprehensive cancer center. Regression analyses revealed extraversion as a significant predictor of current pain, with openness to experience as a significant indicator of average pain. Similarly, positive affect and negative affect were significant predictors of self-efficacy for pain management. Moderation models showed that conscientiousness and extraversion were significant moderators in the relationship between self-efficacy for pain management and worst pain. These findings suggest that different personality types may influence perceptions of pain severity.
Phillip, Veit; Steiner, Jörg M; Algül, Hana
Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis. PMID:25133018
Wu, Xiao-Liang; Lu, Bin; Sun, Jian-Hua; Ai, Bing-Wei; Bao, Chao; Wu, Wen-Zhong; Li, Jian-Bing; Liu, Lan-Ying; Wu, Wen-Yun; Pei, Li-Xia; Zhou, Jun-Ling; Li, Yan-Cai; Qin, Shan
The clinical experiences and proven cases of distinguished doctor of TCM, professor WU Xu, on acupuncture for acute upper abdominal pain is introduced. Professor WU's manipulation characteristics of acupuncture for acute upper abdominal pain, including acute cholecystitis, kidney stone, acute stomach pain, are one-hand shape but both hands in nature, moving like Tai Chi, force on the tip of needle, movement of qi mainly. The main technique posture is one-hand holding needle with middle finger for pressing, the needle is hold by thumb and index finger, and is assisted by middle finger. The special acupuncture experience of emergency is treatment according to syndrome differentiation, combination of acupuncture and moxibustion, selecting acupoint based on experience, blood-letting acupuncture therapy and so on.
Baba, Mika; Gomwo, Ikuo
Cancer pain consists of continuous pain lasting almost all day and transient exacerbation of pain called breakthrough pain. Breakthrough pain is classified as somatic pain and visceral pain, neuropathic pain according to the character of pain. Although the immediate release opioid is used as the first treatment of choice to breakthrough pain, the effect is not enough when it shows the character of neuropathic pain. Pregabalin has become the first medicine for the treatment of neuropathic pain, and it sometimes reveals prompt analgesic effect based on its pharmacological profile. It has also been reported that pregabalin used with oxycodine reveals analgesic effect with smaller dosage than pregabalin alone. We experienced a young patient with lung cancer suffering from sudden exacerbation of symptomatic sciatica, whose pain was markedly reduced within 30 minutes by taking immediate release oxycodone 5 mg and pregabalin 75 mg simultaneously. Conclusions : Pregabalin with immediate release oxycodone simultaneously may be able to improve acute exacerbation of neuropathic cancer pain rapidly.
Buruck, Gabriele; Wendsche, Johannes; Melzer, Marlen; Strobel, Alexander; Dörfel, Denise
Psychosocial stress affects resources for adequate coping with environmental demands. A crucial question in this context is the extent to which acute psychosocial stressors impact empathy and emotion regulation. In the present study, 120 participants were randomly assigned to a control group vs. a group confronted with the Trier Social Stress Test (TSST), an established paradigm for the induction of acute psychosocial stress. Empathy for pain as a specific subgroup of empathy was assessed via pain intensity ratings during a pain-picture task. Self-reported emotion regulation skills were measured as predictors using an established questionnaire. Stressed individuals scored significantly lower on the appraisal of pain pictures. A regression model was chosen to find variables that further predict the pain ratings. These findings implicate that acute psychosocial stress might impair empathic processes to observed pain in another person and the ability to accept one's emotion additionally predicts the empathic reaction. Furthermore, the ability to tolerate negative emotions modulated the relation between stress and pain judgments, and thus influenced core cognitive-affective functions relevant for coping with environmental challenges. In conclusion, our study emphasizes the necessity of reducing negative emotions in terms of empathic distress when confronted with pain of another person under psychosocial stress, in order to be able to retain pro-social behavior. PMID:24910626
Buruck, Gabriele; Wendsche, Johannes; Melzer, Marlen; Strobel, Alexander; Dörfel, Denise
Psychosocial stress affects resources for adequate coping with environmental demands. A crucial question in this context is the extent to which acute psychosocial stressors impact empathy and emotion regulation. In the present study, 120 participants were randomly assigned to a control group vs. a group confronted with the Trier Social Stress Test (TSST), an established paradigm for the induction of acute psychosocial stress. Empathy for pain as a specific subgroup of empathy was assessed via pain intensity ratings during a pain-picture task. Self-reported emotion regulation skills were measured as predictors using an established questionnaire. Stressed individuals scored significantly lower on the appraisal of pain pictures. A regression model was chosen to find variables that further predict the pain ratings. These findings implicate that acute psychosocial stress might impair empathic processes to observed pain in another person and the ability to accept one's emotion additionally predicts the empathic reaction. Furthermore, the ability to tolerate negative emotions modulated the relation between stress and pain judgments, and thus influenced core cognitive-affective functions relevant for coping with environmental challenges. In conclusion, our study emphasizes the necessity of reducing negative emotions in terms of empathic distress when confronted with pain of another person under psychosocial stress, in order to be able to retain pro-social behavior.
Kubilius, Ricardas; Sabalys, Gintautas; Guzeviciene, Vesta
The general causes of upper dental plexus injury are tooth disturbances and the periodontal tissues diseases, the pathology of maxillary sinus, various traumatically manipulations in the area of tooth and maxilla as well. The main symptom of upper tooth neural plexus injury is acute and chronic pain in the alveolar sprout of maxilla, gums or in the area of singly tooth, which rarely spreads into neighboring maxillofacial areas. The authors recommend that the acute pain syndrome would be called the inflammation of upper tooth plexus, and the chronic pain syndrome--plexopathia of upper tooth. Study presents the differential diagnosis according to character of facial pain syndrome and the data of sensority disorders research and investigation of pain thresholds as well. The recommendations for treatment tactic and methods of analyzed indispositions are suggested.
Bawa, Monika; Mahajan, Jai K; Aggerwal, Neel; Sundaram, Jegadeesh; Rao, K L N
The appropriate pain management in neonates and children is lacking. Factors that prevent the execution of proper pain relief vary from center to center. We studied the factors responsible for it in a surgical unit. We conducted a survey at a tertiary-level institute among the resident doctors and nursing staff by means of an informal questionnaire analyzing their basic knowledge. The questions pertained mainly to pain assessment, analgesic usage, role of opioids, and formal training, and the responses so obtained were analyzed under these four headings. Seventy-three percent (22/30) of the residents and 74% (26/35) of the nursing staff knew about pain assessment scoring system in pediatric patients. However, assessment of pain in emergency cases was always done by only 6.6% of the residents. Effect of analgesia on severity of pain was never recorded by 33% (10/30) of the residents. Eighty-six percent (26/30) of the residents and 91% (32/35) of the nursing staff had adequate knowledge about analgesic dosage and interval for routine use. Ten of the 30 (33%) residents believed that analgesic administration in an acute abdomen, before definitive diagnosis, will always mask the symptoms. During a minor procedure, 56% (17/30) of the residents always used analgesia. Only 3.3% (1/30) of residents and 2.8% (1/35) of the nursing staff had received a structured training for pain management. Although, 93% (28/30) of the residents claimed to know about the safety of use of opioids, only 46% (14/30) used them routinely as analgesics. Pain management in surgical neonates and children is often ignored. Lack of formal training, inadequate knowledge, and standard protocols are the barriers in our setup, which may in turn be due to overwhelming attention given to the surgical condition.
Kwekkeboom, K L
Many people with cancer will experience pain when they are outside of structured care settings. Patients must provide their own self-care, drawing on instructions from healthcare providers and on independently developed plans for pain management. With growing interest in complementary therapies, the scope of nonpharmacologic interventions used by patients with cancer to manage pain may be very different than 10-15 years ago. The purpose of this study was to describe steps taken by patients with breast and gynecologic cancer to manage pain after discharge from a surgical hospitalization. A secondary analysis was completed using data from 34 women who participated in a randomized trial of guided imagery. Techniques used included positioning, distraction, relaxation, heat, and eating/drinking. Compared to results of previous studies, increased use of relaxation strategies (breathing, imagery, music, meditation) was noted in the current study. The majority of participants used nonpharmacologic strategies in addition to analgesic medications. Pain-related outcomes were similar among persons who used analgesic medications alone and those who used a combination of analgesics and nonpharmacologic strategies. Nurses may benefit from knowing which pain management strategies patients find helpful so that they can encourage their use and teach similar strategies to the patients who find them useful.
Lara-Solares, Argelia; Ahumada Olea, Marisol; Basantes Pinos, Amparito de Los Ángeles; Bistre Cohén, Sara; Bonilla Sierra, Patricia; Duarte Juárez, Eva Rossina; Símon Escudero, Omar A; Santacruz Escudero, Juan Guillermo; Flores Cantisani, José Alberto
Cancer is a major public health issue. Poor pain management has devastating consequences that seriously affect quality of life, diminish functionality and place a huge emotional burden on patients and their relatives. A group of Latin American opinion leaders were invited to participate in a meeting to discuss areas associated with cancer pain. The expert panel reviewed the latest literature to draft region-specific guidelines for effective pain management. The guidelines make recommendations on tailoring treatment to the specific type of pain and provide local physicians with the state-of-the art findings in the field. Management should be with pharmacological approaches (nonopioid, adjuvant and opioid analgesics, as well as oncologic therapies and interventional procedures) and nonpharmacological approaches.
Kahn, S R; Shapiro, S; Ducruet, T; Wells, P S; Rodger, M A; Kovacs, M J; Anderson, D; Tagalakis, V; Morrison, D R; Solymoss, S; Miron, M-J; Yeo, E; Smith, R; Schulman, S; Kassis, J; Kearon, C; Chagnon, I; Wong, T; Demers, C; Hanmiah, R; Kaatz, S; Selby, R; Rathbun, S; Desmarais, S; Opatrny, L; Ortel, T L; Galanaud, J-P; Ginsberg, J S
Acute deep venous thrombosis (DVT) causes leg pain. Elastic compression stockings (ECS) have potential to relieve DVT-related leg pain by diminishing the diameter of distended veins and increasing venous blood flow. It was our objective to determine whether ECS reduce leg pain in patients with acute DVT. We performed a secondary analysis of the SOX Trial, a multicentre randomised placebo controlled trial of active ECS versus placebo ECS to prevent the post-thrombotic syndrome.The study was performed in 24 hospital centres in Canada and the U.S. and included 803 patients with a first episode of acute proximal DVT. Patients were randomised to receive active ECS (knee length, 30-40 mm Hg graduated pressure) or placebo ECS (manufactured to look identical to active ECS, but lacking therapeutic compression). Study outcome was leg pain severity assessed on an 11-point numerical pain rating scale (0, no pain; 10, worst possible pain) at baseline, 14, 30 and 60 days after randomisation. Mean age was 55 years and 60% were male. In active ECS patients (n=409), mean (SD) pain severity at baseline and at 60 days were 5.18 (3.29) and 1.39 (2.19), respectively, and in placebo ECS patients (n=394) were 5.38 (3.29) and 1.13 (1.86), respectively. There were no significant differences in pain scores between groups at any assessment point, and no evidence for subgroup interaction by age, sex or anatomical extent of DVT. Results were similar in an analysis restricted to patients who reported wearing stockings every day. In conclusion, ECS do not reduce leg pain in patients with acute proximal DVT.
Rafati, Foozieh; Soltaninejad, Maryam; Aflatoonian, Mohamad Reza; Mashayekhi, Fatemeh
Background: Pain is one of the most common symptoms experienced by patients after surgeries. Inadequate postoperative pain management is an international problem and the need to improve its management is well documented. The aim of the study was to assess nursing reports related to the patients’ pain intensity and quality, concomitant symptoms, use of scales in pain assessment, and compliance with the national guideline after surgery. Methods: This study was a retrospective cohort; samples were nurse records of patients who had elective surgery. Result: Only 6% of the patients’ pain records included pain intensity which was not measured with standard scales. More than half of all injections were opioid analgesic which is in contrast to the guidelines of the Iranian Ministry of Health. Pain assessment was higher in women and by nurses with more than 15 years of working experience. Conclusion: to conclude, the patients’ pain was not assessed properly in terms of intensity, quality, and associated symptoms. Therefore, training and motivating nurses is very important in this context and should be incorporated in nurses’ academic and continuous educational courses. PMID:27047265
Sorosky, Susan; Stilp, Sonja; Akuthota, Venu
Many interventions for the management of low back pain exist, however most have modest efficacy at best, and there are few with clearly demonstrated benefits once pain becomes chronic. Therapeutic exercise, on the other hand, does appear to have significant benefits for managing patients with chronic low back pain (CLBP) in terms of decreasing pain and improving function. In addition, because chronic pain is complex and does not fit a simple model, there have also been numerous trials investigating and demonstrating the efficacy of multidisciplinary pain programs for CLBP. It follows that interventions that treat more than one aspect of LBP would have significant benefits for this patient population. Yoga and Pilates which have, both been gaining in popularity over the last decade are two mind-body exercise interventions that address both the physical and mental aspects of pain with core strengthening, flexibility, and relaxation. There has been a slow evolution of these nontraditional exercise regimens into treatment paradigms for LBP, although few studies examining their effects have been published. The following article will focus on the scientific and theoretical basis of using yoga and Pilates in the management of CLBP.
Satija, Aanchal; Ahmed, Syed Mehmood; Gupta, Rahul; Ahmed, Arif; Rana, Shiv Pratap Singh; Singh, Suraj Pal; Mishra, Seema; Bhatnagar, Sushma
Breast cancer is one of the most prevalent cancers amongst women in the world. Unfortunately, even after adequate treatment, some patients experience severe pain either due to disease progression or due to treatment related side effects. The persistent pain causes a negative physical and psychosocial impact on patients’ lives. Current rational pain management is patient-centred and requires a thorough psychological assessment. Usually adequate analgesia is achieved by adopting the WHO's three step analgesic ladder. As the disease progresses, the pain experienced by the patient also increases. This necessitates the administration of opioids and adjuvant analgesics to the breast cancer patients experiencing severe pain. However, opioid use is associated with intolerable side effects like constipation, nausea, vomiting, fear of dependence, and tolerance. Concomitant medications are required to combat these unacceptable side effects. Adjuvant analgesics need to be added to provide adequate and satisfactory analgesia. These factors worsen the psychological state of patients and deteriorate their quality of life. Hence, there is a need to develop therapeutic modalities to provide adequate analgesia with minimum side effects. This review article focuses on the current treatments available for cancer pain management, their limitations, and novel targets and non-pharmacological measures under investigation which have the potential to produce a radical change in pain management measures for the breast cancer patients. PMID:24718395
Tamanini, José Tadeu Nunes; Salzani, Vagner Tadeu; Tamanini, Juliana Milhomem; Iessenco, Filipe; Reis, Leonardo O.
ABSTRACT Report case (s) relevant aspects: Man, 27 years old, complaining of acute testicular pain by 2 hours in the remaining left testicle. Denies fever, lower urinary tract symptoms such as dysuria, urinary frequency, concommitant or prior urethral discharge to the painful condition. He underwent right orchiectomy 13 years ago by testicular torsion. He is a chronic user of cocaine for 15 years and during the last three days the drug use was continuous and intense. Proposed premise substantiating case (s) description: Initial diagnostic hypothesis: Syndromic: Acute Scrotum Syndrome (SEA) Main Etiologic (testicular torsion)Secondary Etiologic (acute orchiepididymitis) Briefly delineates what might it add? Lines of research That Could be Addressed: In this challenging clinical case we presented an alternative and new etiologic diangosis for the acute scrotum which the main etiologic factor remains testicular torsion. This new diangosis is acute testicular ischemia as a complication of cocaine abuse. PMID:27583357
Jacobsen, Ramune; Samsanaviciene, Jurgita; Liubarskiene, Zita; Sjøgren, Per; Møldrup, Claus; Christrup, Lona; Sciupokas, Arunas; Hansen, Ole Bo
The prevalence of cancer-related pain is high despite available guidelines for the effective assessment and management of that pain. Barriers to the use of opioid analgesics partially cause undertreatment of cancer pain. The aim of this study was to compare pain management outcomes and patient-related barriers to cancer pain management in patient samples from Denmark and Lithuania. Thirty-three Danish and 30 Lithuanian patients responded to, respectively, Danish and Lithuanian versions of the Brief Pain Inventory pain scale, the Barriers Questionnaire II, the Hospital Anxiety and Depression Scale, the Specific Questionnaire On Pain Communication, and the Medication Adherence Report Scale. Emotional distress and patient attitudes toward opioid analgesics in cancer patient samples from both countries explained pain management outcomes in the multivariate regression models. Pain relief and pain medication adherence were better in Denmark, and the country of origin significantly explained the difference in the regression models for these outcomes. In conclusion, interventions in emotional distress and patient attitudes toward opioid analgesics may result in better pain management outcomes generally, whereas poor adherence to pain medication and poor pain relief appear to be more country-specific problems.
Dryden, Donna M.; Chordiya, Pritam; Johnson, David W.; Plint, Amy C.; Stang, Antonia
Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings. Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model. Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone. Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials. PMID:28077923
Stock, Matthew L; Baldridge, Sarah L; Griffin, Dee; Coetzee, Johann F
Dehorning or disbudding in cattle is performed for a variety of reasons using various methods. Pain associated with this procedure has been mostly evaluated through behavioral, physiologic, and neuroendocrine changes following dehorning. Analgesics, including local nerve blockades, anti-inflammatories, and opioids have demonstrated an effective attenuation of the cortisol response. The administration of sedatives with analgesic properties has been indicated in the attenuation of the acute phase of pain associated with dehorning. Following a literature review, this article recommends a multimodal approach to analgesia for dehorning procedures, including the use of a local anesthetic and anti-inflammatory and, when possible, a sedative-analgesic.
Fernández-de-Las-Peñas, César; Layton, Michelle; Dommerholt, Jan
Thoracic spine pain is as disabling as neck and low back pain without receiving the same level of attention in the scientific literature. Among the different structures that can refer pain to the thoracic spine, muscles often play a relevant role. Trigger points (TrPs) from neck, shoulder and spinal muscles can induce pain in the region of the thoracic spine. There is a lack of evidence reporting the presence of TrPs in the region of the thoracic spine, but clinical evidence suggests that TrPs can be a potential source of thoracic spine pain. The current paper discusses the role of TrPs in the thoracic spine and dry needling (DN) for the management of TrPs in the thoracic multifidi and longissimus thoracis. This paper also includes a brief discussion of the application of DN in other tissues such as tendons, ligaments and scars.
Fernández-de-las-Peñas, César; Layton, Michelle; Dommerholt, Jan
Thoracic spine pain is as disabling as neck and low back pain without receiving the same level of attention in the scientific literature. Among the different structures that can refer pain to the thoracic spine, muscles often play a relevant role. Trigger points (TrPs) from neck, shoulder and spinal muscles can induce pain in the region of the thoracic spine. There is a lack of evidence reporting the presence of TrPs in the region of the thoracic spine, but clinical evidence suggests that TrPs can be a potential source of thoracic spine pain. The current paper discusses the role of TrPs in the thoracic spine and dry needling (DN) for the management of TrPs in the thoracic multifidi and longissimus thoracis. This paper also includes a brief discussion of the application of DN in other tissues such as tendons, ligaments and scars. PMID:26309385
Parker, Michael; Rodgers, Antony
Assessment and management of pain in pre-hospital care settings are important aspects of paramedic and clinical team roles. As emergency department waiting times and delays in paramedic-to-nurse handover increase, it becomes more and more vital that patients receive adequate pre-hospital pain relief. However, administration of analgesia can be inadequate and can result in patients experiencing oligoanalgesia, or under-treated pain. This article examines these issues along with the aetiology of trauma and the related socioeconomic background of traumatic injury. It reviews validated pain-assessment tools, outlines physiological responses to traumatic pain and discusses some of the misconceptions about the provision of effective analgesia in pre-hospital settings.
Dewey, Stephen L.; Brodie, Jonathan D.; Ashby, Jr., Charles R.
The present invention provides a composition for treating pain. The composition includes a pharmaceutically acceptable analgesic and a GABAergic agent, such as gamma vinyl GABA, effective in reducing or eliminating the addictive liability of the analgesic. The invention also includes a method for reducing or eliminating the addictive
Shah, Shalini; Banh, Esther T.; Koury, Katharine; Bhatia, Gaurav; Nandi, Roneeta; Gulur, Padma
Nonobstetrical causes of pain during pregnancy are very common and can be incapacitating if not treated appropriately. Recent reports in the literature show that a significant percentage of pregnant women are treated with opioids during pregnancy. To address common pain conditions that present during pregnancy and the available pharmacological and nonpharmacological treatment options, for each of the pain conditions identified, a search using MEDLINE, PubMed, Embase, and Cochrane databases was performed. The quality of the evidence was evaluated in the context of study design. This paper is a narrative summary of the results obtained from individual reviews. There were significant disparities in the studies in terms of design, research and methodology, and outcomes analyzed. There is reasonable evidence available for pharmacological approaches; however, these are also associated with adverse events. Evidence for nonpharmacological approaches is limited and hence their efficacy is unclear, although they do appear to be primarily safe. A multimodal approach using a combination of nonpharmacological and pharmacological options to treat these pain conditions is likely to have the most benefit while limiting risk. Research trials with sound methodology and analysis of outcome data are needed. PMID:26448875
Blount, Ronald L.; Piira, Tiina; Cohen, Lindsey L.; Cheng, Patricia S.
This article reviews the various settings in which infants, children, and adolescents experience pain during acute medical procedures and issues related to referral of children to pain management teams. In addition, self-report, reports by others, physiological monitoring, and direct observation methods of assessment of pain and related constructs…
Greenberg, Joshua A.; Hsu, Jonathan; Bawazeer, Mohammad; Marshall, John; Friedrich, Jan O.; Nathens, Avery; Coburn, Natalie; May, Gary R.; Pearsall, Emily; McLeod, Robin S.
There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone–induced pancreatitis. Une hausse de l’incidence de pancréatite aiguë a été constatée à l’échelle mondiale. Malgré l’amélioration de l’accès aux soins et aux techniques d’imagerie et d’intervention, la pancréatite aiguë est toujours associée à une morbidité et une mortalité importantes. Bien qu’il existe des guides de pratique clinique pour la prise en charge de la pancréatite aiguë, des études récentes sur la vérification de la prise en charge clinique de cette affection révèlent des lacunes importantes dans la conformité aux recommandations fondées sur des données probantes. Ces résultats mettent en relief l’importance de formuler des recommandations compréhensibles et applicables pour le diagnostic et la prise en charge de la pancréatite aiguë. La présente ligne directrice vise à fournir des recommandations fondées sur des données probantes pour la prise en charge de la pancréatite aiguë, qu’elle soit bénigne ou grave, ainsi que de ses complications et de celles de la pancréatite causée par un calcul biliaire. PMID:27007094
Rubin, Jay J
At least 40 to 60 percent of women and at least 20 percent of men with chronic pain disorders report a history of being abused during childhood and/or adulthood. This incidence of abuse is two to four times higher than in the general population. Patients with more severe or frequent abuse, usually during childhood and worse if sexual in nature. often develop specific syndromes or combinations of syndromes. These syndromes include posttraumatic stress disorder, fibromyalgia, and other conditions characterized by repression, somatization, and increased utilization of medical care. Psychosomatic symptoms and dysfunctional behaviors may emerge as these patients seek attention and validation of their suffering, while paradoxically repressing painful memories of trauma. Behavioral observations and key features of the physical examination may greatly help the clinician identify both the presence and severity of psychosomatic disease. In addition, it is very interesting that various studies document physiologic changes in the brains of patients with a history of abuse and in patients with a diagnosis of fibromyalgia. These studies suggest that abuse may physiologically and developmentally increase a person's susceptibility to pain and that some organic changes may be associated with psychogenic disease. Diagnosis and treatment of even the most challenging patients with chronic pain is much more effective if it includes (a) careful inquiry about any history of past or present abuse or other severe trauma, (b) empathy and constructive validation of disease and suffering, (c) recognition of dysfunctional pain behaviors and personality traits, (d) documentation of nonanatomic as well as anatomic features on examination, (e) multidisciplinary treatments including psychotherapy whenever indicated, and (f) noninvasive procedures and alternatives to potentially habit-forming medications whenever possible and appropriate. Furthermore, it has been shown that helping patients gain
van der Velde, J; Linehan, L; Cusack, S
We conducted a survey of Irish Coast Guard Search and Rescue Helicopter winchmen to establish if their pain management scope of practice was adequate for their working environment. We surveyed 17 SAR personnel. 88% of winchmen have experienced scenarios where they were unable to reduce pain scores below 6/10. In seeking solutions within current Irish Prehospital Clinical Practice Guidelines, repeated descriptions of operations in extreme weather and sea conditions were given which were entirely incompatible with the dexterity required to break a glass ampoule and draw up solution, let alone site an intravenous (IV) line or administer a drug via intramuscular (IM) injection. Irish Coast Guard Search and Rescue Helicopter winchmen encounter polytrauma patients in extreme pain in uniquely challenging environments. Novel solutions to pain management within this tightly governed system are urgently required.
Hwang, Peter H
Acute rhinosinusitis is a common ailment accounting for millions of office visits annually, including that of Mrs D, a 51-year-old woman presenting with 5 days of upper respiratory illness and facial pain. Her case is used to review the diagnosis and treatment of acute rhinosinusitis. Acute viral rhinosinusitis can be difficult to distinguish from acute bacterial rhinosinusitis, especially during the first 10 days of symptoms. Evidence-based clinical practice guidelines developed to guide diagnosis and treatment of acute viral and bacterial rhinosinusitis recommend that the diagnosis of acute rhinosinusitis be based on the presence of "cardinal symptoms" of purulent rhinorrhea and either facial pressure or nasal obstruction of less than 4 weeks' duration. Antibiotic treatment generally can be withheld during the first 10 days of symptoms for mild to moderate cases, given the likelihood of acute viral rhinosinusitis or of spontaneously resolving acute bacterial rhinosinusitis. After 10 days, the likelihood of acute bacterial rhinosinusitis increases, and initiation of antibiotic therapy is supported by practice guidelines. Complications of sinusitis, though rare, can be serious and require early recognition and treatment.
Deltito, J. A.
Emergency ward physicians are presented daily with patients in pain. Provisions of safe, quick pain control remains one of their major duties. Hypnosis can be used as an effective adjunct or substitute for analgesic medications when these drugs prove to be ineffective or contraindicated. Four such illustrative cases of attempted pain control are presented. The psychological foundations of pain and its assessment are discussed. The emergency ward physician can obtain facility in hypnotic techniques with only modest training. Hypnosis may then become a valuable tool in helping him provide safe and effective pain management. PMID:6728748
Ormandy, Elisabeth H; Griffin, Gilly
When asked about the use of animals in biomedical research, people often state that the research is only acceptable if pain and distress are minimised. However, pain is caused when the aim is to study pain itself, resulting in unalleviated pain for many of the animals involved. Consequently, the use of animals in pain research is often considered contentious. To date, no research has explored people's views toward different types of animal-based pain research (e.g. chronic or acute pain). This study used a web-based survey to explore people's willingness to support the use of mice in chronic versus acute pain research. The majority of the participants opposed the use of mice for either chronic (68.3%) or acute (63.1%) pain research. There was no difference in the levels of support or opposition for chronic versus acute pain research. Unsupportive participants justified their opposition by focusing on the perceived lack of scientific merit, or the existence of non-animal alternatives. Supporters emphasised the potential benefits that could arise, with some stating that the benefits outweigh the costs. The majority of the participants were opposed to pain research involving mice, regardless of the nature and duration of the pain inflicted, or the perceived benefit of the research. A better understanding of public views toward animal use in pain research may provide a stronger foundation for the development of policy governing the use of animals in research where animals are likely to experience unalleviated pain.
Assessment of the results of laminectomy for lumbar disc lesions is unsatisfactory, but it seems that some degree of recurrent pain is virtually inevitable. The clinical features and incidence of the various painful syndromes seen in these patients, including one, the sacro-spinalis insertion syndrome, which has not previously been described, are outlined and the management of each is discussed with reference to two personal series, one of 98 patients consecutively undergoing laminectomy and the other of 35 patients referred because of recurrent pain following laminectomy. Finally, problems of prophylaxis are considered. PMID:6454375
Wedmore, Ian S; Johnson, Troy; Czarnik, Jim; Hendrix, Steve
The wilderness and operational setting places unique constraints on one's ability to treat pain. In this article we will discuss methods for treating pain both in the wilderness and operational setting. By operational we mean the austere deployed military setting, to include both noncombat and combat operations. The authors combined experience with wartime trauma pain management consists of experience in Operation "Just Cause" (Panama Invasion), Operation "Desert Storm" (Persian Gulf War), Operation "Uphold Democracy" (Haiti liberation), Operation "Enduring Freedom" (Afghanistan conflict), and Operation "Iraqi Freedom" (Iraq conflict).
Grimmer-Somers, Karen; Prior, Mathew; Robertson, Jim
Background Despite its high prevalence, most acute low back pain (ALBP) is nonspecific, self-limiting with no definable pathology. Recurrence is prevalent, as is resultant chronicity. Psychosocial factors (yellow flags comprising depression and anxiety, negative pain beliefs, job dissatisfaction) are associated with the development of chronic LBP. Methods A national insurer (Accident Compensation Corporation, New Zealand [NZ]), in conjunction with a NZ primary health organization, piloted a strategy for more effective management of patients with ALBP, by following the NZ ALBP Guideline. The guidelines recommend the use of a psychosocial screening instrument (Yellow Flags Screening Instrument, a derivative of Örebro Musculoskeletal Pain Questionnaire). This instrument was recommended for administration on the second visit to a general medical practitioner (GP). This paper tests whether published cut-points of yellow flag scores to predict LBP claims length and costs were valid in this cohort. Results Data was available for 902 claimants appropriately enrolled into the pilot. 25% claimants consulted the GP once only, and thus were not requested to provide a yellow flag score. Yellow flag scores were provided by 48% claimants who consumed two or more GP services. Approximately 60% LBP presentations resolved within five GP visits. Yellow flag scores were significantly and positively associated with treatment costs and service use, although the association was nonlinear. Claimants with moderate yellow flag scores were similarly likely to incur lengthy claims as claimants with at-risk scores. Discussion Capturing data on psychosocial factors for compensable patients with ALBP has merit in predicting lengthy claims. The validity of the published yellow flag cut-points requires further testing. PMID:21197284
Salomoni, Sauro; Tucker, Kylie; Hug, François; McPhee, Megan; Hodges, Paul
Although maximal voluntary contraction (MVC) force is reduced during pain, studies using interpolated twitch show no consistent reduction of voluntary muscle drive. The present study aimed to test if the reduction in MVC force during acute experimental pain could be explained by increased activation of antagonist muscles, weak voluntary activation at baseline, or changes in force direction. Twenty-two healthy volunteers performed maximal voluntary isometric knee extensions before, during, and after the effects of hypertonic (pain) and isotonic (control) saline injections into the infrapatellar fat pad. The MVC force, voluntary activation, electromyographic (EMG) activity of agonist, antagonist, and auxiliary (hip) muscles, and pain cognition and anxiety scores were recorded. MVC force was 9.3% lower during pain than baseline (p < 0.001), but there was no systematic change in voluntary activation. Reduced MVC force during pain was variable between participants (SD: 14%), and was correlated with reduced voluntary activation (r = 0.90), baseline voluntary activation (r = − 0.62), and reduced EMG amplitude of agonist and antagonist muscles (all r > 0.52), but not with changes in force direction, pain or anxiety scores. Hence, reduced MVC force during acute pain was mainly explained by deficits in maximal voluntary drive. PMID:27559737
Cheong, Benjamin Y.C.; Lufschanowski, Roberto
We present the case of a 63-year-old woman with a remote history of supraventricular tachycardia and hyperlipidemia, who presented with recurrent episodes of acute-onset chest pain. An electrocardiogram showed no evidence of acute coronary syndrome. A chest radiograph revealed a prominent right-sided heart border. A suspected congenital pericardial cyst was identified on a computed tomographic chest scan, and stranding was noted around the cyst. The patient was treated with nonsteroidal anti-inflammatory drugs, and the pain initially abated. Another flare-up was treated similarly. Cardiac magnetic resonance imaging was then performed after symptoms had resolved, and no evidence of the cyst was seen. The suspected cause of the patient's chest pain was acute inflammation of a congenital pericardial cyst with subsequent rupture and resolution of symptoms. PMID:28100978
Van Hulle Vincent, Catherine; Wilkie, Diana J; Wang, Edward
We evaluated feasibility of the Internet-based Relieve Children's Pain (RCP) protocol to improve nurses' management of children's pain. RCP is an interactive, content-focused, and Kolb's experiential learning theory-based intervention. Using a one-group, pretest-posttest design, we evaluated feasibility of RCP and pretest-posttest difference in scores for nurses' beliefs, and simulated and actual pain management practices. Twenty-four RNs completed an Internet-based Pain Beliefs and Practices Questionnaire (PBPQ, alpha=.83) before and after they completed the RCP and an Acceptability Scale afterward. Mean total PBPQ scores significantly improved from pretest to posttest as did simulated practice scores. After RCP in actual hospital practice, nurses administered significantly more ibuprofen and ketorolac and children's pain intensity significantly decreased. Findings showed strong evidence for the feasibility of RCP and study procedures and significant improvement in nurses' beliefs and pain management practices. The 2-hr RCP program is promising and warrants replication with an attention control group and a larger sample.
Bech, N. H.; Hulst, A. H.; Spuijbroek, J. A.; van Leuken, L. L. A.; Haverkamp, D.
Hip arthroscopy is a fast growing orthopedic field of expertise. As in any field of surgery adequate postoperative pain management regimes are of utmost importance. The purpose of this review is to provide an overview of current knowledge on anesthetic options for perioperative pain management for hip arthroscopy. We searched the Pubmed/Medline and Embase database for literature and included 10 studies for our analysis. Because of the variety of pain scales and different ways of measured pain no meta-analysis could be performed and a descriptive review is performed. There are several types of pain regimens that can mostly be divided in two groups: local anesthetics and nerve blocks. Included studies show a rather large variation in reported visual analogue scale scores, post anesthesia care unit admission time and opioid usage. There are several anesthetic options available for hip arthroscopy. Different studies use different dosages, anesthetic regimens and different protocols; this partly explains the differences between studies with similar techniques. Peripheral nerve blocks seems promising but regarding current literature no clear recommendation can be made about what the best perioperative pain management option is, an overview of all reported techniques is given. PMID:27583156
... for Pain Management Providers SUMMARY: Under the provisions of Section 3507(a)(1)(D) of the Paperwork... Collection Title: Web Based Training for Pain Management Providers. Type of Information Collection Request... Based Training for Pain Management Providers, via the Web site PainAndAddictionTreatment.com ,...
... Training for Pain Management Providers Under the provisions of section 3507(a)(1)(D) of the Paperwork... Collection Title: Web Based Training for Pain Management Providers. Type of Information Collection Request... Based Training for Pain Management Providers, via the Web site PainAndAddictionTreatment.com ,...
Melzack, R; Wall, P D; Ty, T C
Features of acute pain were examined in patients at an emergency clinic. Patients who had severe, life-threatening injuries or who were agitated, drunk, or 'in shock' were excluded from the study. Of 138 patients who were alert, rational and coherent, 51 (37%) stated that they did not feel pain at the time of injury. The majority of these patients reported onset of pain within an hour of injury, although the delays were as long as 9 h or more in some patients. The predominant emotions of the patients were embarrassment at appearing careless or worry about loss of wages. None expressed any pleasure or indicated any prospect of gain as a result of the injury. The occurrence of delays in pain onset was related to the nature of the injury. Of 46 patients whose injuries were limited to skin (lacerations, cuts, abrasions, burns), 53% had a pain-free period. Of 86 patients with deep-tissue injuries (fractures, sprains, bruises, amputation of a finger, stabs and crushes), only 28% had a pain-free period. The McGill Pain Questionnaire was administered to patients who felt pain immediately after injury or after a delay, and revealed a normal distribution of sensory scores but very low affective scores compared to patients with chronic pain. The results indicate that the relationship between injury and pain is highly variable and complex.
This article provides an overview of the role of the nurse in the assessment and management of five ocular conditions that give rise to an acute red eye in older people. The conditions discussed are acute closed angle glaucoma, acute iritis, acute conjunctivitis, herpes zoster ophthalmicus and bacterial corneal ulcer.
Goldstein, Stuart L
Fluid management in critical illness has undergone extensive reevaluation in the past decade. Since a significant percentage of critically ill patients develop acute kidney injury (AKI), optimal fluid management is even more paramount to prevent the ill effects of either underhydration or overhydration. The concepts of early goal-directed fluid therapy (EGDT) and conservative late fluid management permeate current clinical research, and the independent association between fluid accumulation and mortality has been repeatedly demonstrated. A number of prospective randomized trials are planned to provide an adequately powered assessment of the effect of EGDT or earlier renal replacement therapy initiation in patients with, or at risk for AKI. The aim of this analytical review is to use existing clinical and physiological studies to support a 3-phase model of fluid management in the critically ill patient with AKI.
The Self-Management Programme for People with Arthritis aims to teach patients to manage their condition, improve their understanding, and communicate effectively with health professionals. The focus is on developing self-efficacy and peer teaching. (SK)
Sørensen, Jan; Vach, Werner; Christensen, Henrik Wulff; Høilund-Carlsen, Poul Flemming; Hartvigsen, Jan
Aims To assess whether primary sector healthcare in the form of chiropractic care is cost-effective compared with self-management in patients with musculoskeletal chest pain, that is, a subgroup of patients with non-specific chest pain. Methods and results 115 adults aged 18–75 years with acute, non-specific chest pain of musculoskeletal origin were recruited from a cardiology department in Denmark. After ruling out acute coronary syndrome and receiving usual care, patients with musculoskeletal chest pain were randomised to 4 weeks of community-based chiropractic care (n=59) or to a single information session aimed at encouraging self-management as complementary to usual care (n=56). Data on resource use were obtained from Danish national registries and valued from a societal perspective. Patient cost and health-related quality-adjusted life years (QALYs; based on EuroQol five-dimension questionnaire (EQ-5D) and Short Form 36-item Health Survey (SF-36)) were compared in cost-effectiveness analyses over 12 months from baseline. Mean costs were €2183 lower for the group with chiropractic care, but not statistically significant (95% CI −4410.5 to 43.0). The incremental cost-effectiveness ratio suggested that chiropractic care was cost-effective with a probability of 97%, given a threshold value of €30 000 per QALY gained. In both groups, there was an increase in the health-related quality of life, and the mean increases were similar over the 12-month evaluation period. The mean differences in QALYs between the groups were negligible. Conclusions Chiropractic care was more cost-effective than self-management. Therefore, chiropractic care can be seen as a good example of a targeted primary care approach for a subgroup of patients with non-specific chest pain. Trial registration number NCT00462241. PMID:27175285
Jakobsen, Markus D.; Jay, Kenneth; Colado, Juan Carlos
Topical menthol gels are classified “topical analgesics” and are claimed to relieve minor aches and pains of the musculoskeletal system. In this study we investigate the acute effect of topical menthol on carpal tunnel syndrome (CTS). We screened 645 slaughterhouse workers and recruited 10 participants with CTS and chronic pain of the arm/hand who were randomly distributed into two groups to receive topical menthol (Biofreeze) or placebo (gel with a menthol scent) during the working day and 48 hours later the other treatment (crossover design). Participants rated arm/hand pain intensity during the last hour of work (scale 0–10) immediately before 1, 2, and 3 hours after application. Furthermore, global rating of change (GROC) in arm/hand pain was assessed 3 hours after application. Compared with placebo, pain intensity and GROC improved more following application of topical menthol (P = 0.026 and P = 0.044, resp.). Pain intensity of the arm/hand decreased by −1.2 (CI 95%: −1.7 to −0.6) following topical menthol compared with placebo, corresponding to a moderate effect size of 0.63. In conclusion, topical menthol acutely reduces pain intensity during the working day in slaughterhouse workers with CTS and should be considered as an effective nonsystemic alternative to regular analgesics in the workplace management of chronic and neuropathic pain. PMID:25298894
Sundstrup, Emil; Jakobsen, Markus D; Brandt, Mikkel; Jay, Kenneth; Colado, Juan Carlos; Wang, Yuling; Andersen, Lars L
Topical menthol gels are classified "topical analgesics" and are claimed to relieve minor aches and pains of the musculoskeletal system. In this study we investigate the acute effect of topical menthol on carpal tunnel syndrome (CTS). We screened 645 slaughterhouse workers and recruited 10 participants with CTS and chronic pain of the arm/hand who were randomly distributed into two groups to receive topical menthol (Biofreeze) or placebo (gel with a menthol scent) during the working day and 48 hours later the other treatment (crossover design). Participants rated arm/hand pain intensity during the last hour of work (scale 0-10) immediately before 1, 2, and 3 hours after application. Furthermore, global rating of change (GROC) in arm/hand pain was assessed 3 hours after application. Compared with placebo, pain intensity and GROC improved more following application of topical menthol (P = 0.026 and P = 0.044, resp.). Pain intensity of the arm/hand decreased by -1.2 (CI 95%: -1.7 to -0.6) following topical menthol compared with placebo, corresponding to a moderate effect size of 0.63. In conclusion, topical menthol acutely reduces pain intensity during the working day in slaughterhouse workers with CTS and should be considered as an effective nonsystemic alternative to regular analgesics in the workplace management of chronic and neuropathic pain.
Kuppusamy, Shanggar; Gillatt, David
Acute urinary retention (AUR) is more than ten times more common in men than women. In men it tends to occur in the elderly; the risk of AUR is higher in men > 70 years. The causes in men can be divided into precipitated or occurring spontaneously. These can be further divided according to the mechanism i.e. obstructive, neurological and myogenic. Spontaneous AUR, caused by progression of BPH leading to a mechanical obstruction of the bladder outlet, is the most common cause of AUR. The typical presentation of AUR is a patient complaining of a sudden inability to urinate associated with progressive abdominal distension which is usually painful. The pain increases in intensity with increasing distension of the bladder. An abdominal examination should reveal a distended bladder which can be confirmed by a dull percussion note. A digital rectal examination is vital to gain information on prostatic enlargement (benign or malignant), faecal load in rectum, anal tone and presence of other masses. Urinalysis and culture should be carried out on a sample obtained after catheterisation to rule out infection. Renal function should be assessed to see if there has been damage to the upper tracts. It is better not to perform a PSA test in this situation as it will invariably be raised due to distension of the bladder and catheter insertion. If catheter insertion fails then a urological consultation is required for insertion of a suprapubic catheter. Admission is essential if the patient is: unwell with urosepsis; has abnormal renal function needing investigation and fluid monitoring; has acute neurological problems; or cannot take care of the catheter. Trial without catheter needs to be planned and the ideal time to do this is within 2-3 days so that the patient can pass urine naturally.
Pandher, Dilbans Singh; Boparai, Randhir Singh; Kapila, Rajesh
The case report highlights an unusual case of posterolateral knee pain after total knee arthroplasty. Tendinitis of the patellar tendon or pes anserinus is a common complication after total knee arthroplasty; however, there is no report in the literature regarding the biceps femoris tendinitis causing acute pain in the early postoperative period. In this case, the biceps tendinitis was diagnosed and treated by ultrasound-guided injection into the tendon sheath.
Background Pain management is a critical but complex issue for the relief of acute pain, particularly for postoperative pain and severe pain in cancer patients. It also plays important roles in promoting quality of care. The introduction of pain management decision support systems (PM-DSS) is considered a potential solution for addressing the complex problems encountered in pain management. This study aims to investigate factors affecting acceptance of PM-DSS from a nurse anesthetist perspective. Methods A questionnaire survey was conducted to collect data from nurse anesthetists in a case hospital. A total of 113 questionnaires were distributed, and 101 complete copies were returned, indicating a valid response rate of 89.3%. Collected data were analyzed by structure equation modeling using the partial least square tool. Results The results show that perceived information quality (γ=.451, p<.001), computer self-efficacy (γ=.315, p<.01), and organizational structure (γ=.210, p<.05), both significantly impact nurse anesthetists’ perceived usefulness of PM-DSS. Information quality (γ=.267, p<.05) significantly impacts nurse anesthetists’ perceptions of PM-DSS ease of use. Furthermore, both perceived ease of use (β=.436, p<.001, R2=.487) and perceived usefulness (β=.443, p<.001, R2=.646) significantly affected nurse anesthetists’ PM-DSS acceptance (R2=.640). Thus, the critical role of information quality in the development of clinical decision support system is demonstrated. Conclusions The findings of this study enable hospital managers to understand the important considerations for nurse anesthetists in accepting PM-DSS, particularly for the issues related to the improvement of information quality, perceived usefulness and perceived ease of use of the system. In addition, the results also provide useful suggestions for designers and implementers of PM-DSS in improving system development. PMID:23360305
Cleary, Daniel R; Heinricher, Mary M
Despite similar behavioral hypersensitivity, acute and chronic pain have distinct neural bases. We used intraplantar injection of complete Freund's adjuvant to directly compare activity of pain-modulating neurons in the rostral ventromedial medulla (RVM) in acute vs chronic inflammation. Heat-evoked and von Frey-evoked withdrawal reflexes and corresponding RVM neuronal activity were recorded in lightly anesthetized animals either during the first hour after complete Freund's adjuvant injection (acute) or 3 to 10 days later (chronic). Thermal and modest mechanical hyperalgesia during acute inflammation were associated with increases in the spontaneous activity of pain-facilitating ON-cells and suppression of pain-inhibiting OFF-cells. Acute hyperalgesia was reversed by RVM block, showing that the increased activity of RVM ON-cells is necessary for acute behavioral hypersensitivity. In chronic inflammation, thermal hyperalgesia had resolved but mechanical hyperalgesia had become pronounced. The spontaneous discharges of ON- and OFF-cells were not different from those in control subjects, but the mechanical response thresholds for both cell classes were reduced into the innocuous range. RVM block in the chronic condition worsened mechanical hyperalgesia. These studies identify distinct contributions of RVM ON- and OFF-cells to acute and chronic inflammatory hyperalgesia. During early immune-mediated inflammation, ON-cell spontaneous activity promotes hyperalgesia. After inflammation is established, the antinociceptive influence of OFF-cells is dominant, yet the lowered threshold for the OFF-cell pause allows behavioral responses to stimuli that would normally be considered innocuous. The efficacy of OFF-cells in counteracting sensitization of ascending transmission pathways could therefore be an important determining factor in development of chronic inflammatory pain.
Donaldson, James; Haddad, Behrooz; Khan, Wasim S
Acute compartment syndrome (ACS) is a surgical emergency warranting prompt evaluation and treatment. It can occur with any elevation in interstitial pressure in a closed osseo-fascial compartment. Resultant ischaemic damage may be irreversible within six hours and can result in long-term morbidity and even death. The diagnosis is largely clinical with the classical description of 'pain out of proportion to the injury'. Compartment pressure monitors can be a helpful adjunct where the diagnosis is in doubt. Initial treatment is with the removal of any constricting dressings or casts, avoiding hypotension and optimizing tissue perfusion by keeping the limb at heart level. If symptoms persist, definitive treatment is necessary with timely surgical decompression of all the involved compartments. This article reviews the pathophysiology, diagnosis and current management of ACS.
Kossaify, Antoine; Garcia, Annie; Succar, Sami; Ibrahim, Antoine; Moussallem, Nicolas; Kossaify, Mikhael; Grollier, Gilles
Biomarkers in acute cardiac care are gaining increasing interest given their clinical benefits. This study is a review of the major conditions in acute cardiac care, with a focus on biomarkers for diagnostic and prognostic assessment. Through a PubMed search, 110 relevant articles were selected. The most commonly used cardiac biomarkers (cardiac troponin, natriuretic peptides, and C-reactive protein) are presented first, followed by a description of variable acute cardiac conditions with their relevant biomarkers. In addition to the conventional use of natriuretic peptides, cardiac troponin, and C-reactive protein, other biomarkers are outlined in variable critical conditions that may be related to acute cardiac illness. These include ST2 and chromogranin A in acute dyspnea and acute heart failure, matrix metalloproteinase in acute chest pain, heart-type fatty acid binding protein in acute coronary syndrome, CD40 ligand and interleukin-6 in acute myocardial infarction, blood ammonia and lactate in cardiac arrest, as well as tumor necrosis factor-alpha in atrial fibrillation. Endothelial dysfunction, oxidative stress and inflammation are involved in the physiopathology of most cardiac diseases, whether acute or chronic. In summary, natriuretic peptides, cardiac troponin, C-reactive protein are currently the most relevant biomarkers in acute cardiac care. Point-of-care testing and multi-markers use are essential for prompt diagnostic approach and tailored strategic management. PMID:24046510
Damasceno, Marina B M V; de Melo Júnior, José de Maria A; Santos, Sacha Aubrey A R; Melo, Luana T M; Leite, Laura Hévila I; Vieira-Neto, Antonio E; Moreira, Renato de A; Monteiro-Moreira, Ana Cristina de O; Campos, Adriana R
Orofacial pain is a highly prevalent clinical condition, yet difficult to control effectively with available drugs. Much attention is currently focused on the anti-inflammatory and antinociceptive properties of lectins. The purpose of this study was to evaluate the antinociceptive effect of frutalin (FTL) using rodent models of inflammatory and neuropathic orofacial pain. Acute pain was induced by formalin, glutamate or capsaicin (orofacial model) and hypertonic saline (corneal model). In one experiment, animals were pretreated with l-NAME and naloxone to investigate the mechanism of antinociception. The involvement of the lectin domain in the antinociceptive effect of FTL was verified by allowing the lectin to bind to its specific ligand. In another experiment, animals pretreated with FTL or saline were submitted to the temporomandibular joint formalin test. In yet another, animals were submitted to infraorbital nerve transection to induce chronic pain, followed by induction of thermal hypersensitivity using acetone. Motor activity was evaluated with the rotarod test. A molecular docking was performed using the TRPV1 channel. Pretreatment with FTL significantly reduced nociceptive behaviour associated with acute and neuropathic pain, especially at 0.5 mg/kg. Antinociception was effectively inhibited by l-NAME and d-galactose. In line with in vivo experiments, docking studies indicated that FTL may interact with TRPV1. Our results confirm the potential pharmacological relevance of FTL as an inhibitor of orofacial nociception in acute and chronic pain mediated by TRPA1, TRPV1 and TRPM8 receptor.
Moore, R Andrew; Edwards, Jayne; Derry, Sheena; McQuay, Henry J
Background This is an updated version of the original Cochrane review published in Issue 2, 2000. Dihydrocodeine is a synthetic opioid analgesic developed in the early 1900s. Its structure and pharmacokinetics are similar to that of codeine and it is used for the treatment of postoperative pain or as an antitussive. It is becoming increasingly important to assess the relative efficacy and harm caused by different treatments. Relative efficacy can be determined when an analgesic is compared with control under similar clinical circumstances. Objectives To quantitatively assess the analgesic efficacy and adverse effects of single-dose dihydrocodeine compared with placebo in randomised trials in moderate to severe postoperative pain. Search methods Published reports were identified from electronic databases (MEDLINE, EMBASE, CENTRAL, the Oxford Pain Relief Database in December 2007, the original search was conducted in October 1999). Additional studies were identified from the reference lists of retrieved reports. Selection criteria Inclusion criteria: full journal publication, clinical trial, random allocation of participants to treatment groups, double blind design, adult participants, baseline pain of moderate to severe intensity, postoperative administration of study drugs, treatment arms which included dihydrocodeine and placebo and either oral or injected (intramuscular or intravenous) administration of study drugs. Data collection and analysis Data collection and analysis: summed pain intensity and pain relief data over four to six hours were extracted and converted into dichotomous information to yield the number of participants obtaining at least 50% pain relief. This was used to calculate relative benefit and number-needed-to-treat-to-benefit (NNT) for one participant to obtain at least 50% pain relief. Single-dose adverse effect data were collected and used to calculate relative risk and number-needed-to-treat-to-harm (NNH). Main results Fifty-two reports
Gilhooly, D; McGarvey, B; O'Mahony, H; O'Connor, T C
A 39-year-old para 3 woman presented for elective caesarean section (lower segment caesarean section (LSCS)) for breech presentation. The patient had a strong history of atopy and anaphylaxis to paracetamol, codeine, penicillin and latex. The patient was asthmatic, triggered by aspirin. Epidural anaesthesia was unsuccessful and LSCS was carried out under spinal anaesthesia. Postoperatively the patient was unwilling to take analgesic medication due to fear of an allergic reaction. Three 5% lidocaine patches were applied to the wound for postoperative analgesia. This reduced the patient's visual analogue scale pain score from 10/10 to 5/10 at rest and 10/10 to 7/10 with movement. Transcutaneous electrical nerve stimulation was added and this improved associated back pain, reducing the pain further to 2/10. This is the first description of lignocaine patch 5% for postoperative LSCS pain. It is suggested that this method of delivery of local anaesthetic, which is easy to apply and has minimal side effects, should be considered not as a sole agent but as part of a multimodal technique to address postoperative LSCS pain.
Abdel Shaheed, Christina; Maher, Christopher G; Williams, Kylie A; McLachlan, Andrew J
Pharmacists have the potential to take a lead role in the primary care management of people with acute low back pain. The aim of this study was to investigate pharmacists' views on implementing a care program for people with acute low back pain in the community pharmacy. Recruitment of pharmacists for this study took place between July 2012 and March 2013. A convenience sample of 30 pharmacists who collaborated in recruiting participants for a low back pain clinical trial in Sydney (n=15 pharmacist recruiters and n=15 non-recruiters) completed an open-ended questionnaire. There was no marked variation in responses between the two groups. Participating pharmacists were receptive to the idea of implementing a care program for people with low back pain, highlighting the need for adequate reimbursement and adequate training of staff to ensure it is successful. Pharmacists identified that the follow up of people receiving such a service is dependent on several factors such as effective reminder systems and the proximity of patients to the pharmacy.
Guevara-López, Uría; Covarrubias-Gómez, Alfredo; Elías-Dib, Jorge; Reyes-Sánchez, Alejandro; Rodríguez-Reyna, Tatiana Sofía
It has been documented that pain in its diverse modalities is the most common cause of medical attention. In Mexico, an increase in its frequency has promoted its consideration in several health programs. On the other hand, inadequate pain management will cause severe physical, psychoaffective, and socioeconomic repercussions for patients, families, and public health services. Despite this panorama, there has not been an agreement to establish better diagnostic and therapeutic methods for the management of chronic pain. A consensus group was reunited and was integrated by medical experts from private and public institutions and from various states of the Mexican Republic. To assure the development of these practice guidelines, these experts had experience in the assessment and treatment of conditions causing pain. With the guidelines used by other consensus groups, meetings were held to analyze and discuss published literary evidence for the management of low back pain. The recommendations were classified according to their methodological strength. As a result of this meeting, consensus recommendations were based on evidence and operational conclusions of such proactive educational plans, institutional policies and diagnostic recommendations for pharmacological and nonpharmacological treatment in order for Mexican physicians to provide a better therapeutic approach to low back pain.
Schlett, Christopher L; Hoffmann, Udo; Geisler, Tobias; Nikolaou, Konstantin; Bamberg, Fabian
Coronary computed tomography angiography (CCTA) is recommended for the triage of acute chest pain in patients with a low-to-intermediate likelihood for acute coronary syndrome. Absence of coronary artery disease (CAD) confirmed by CCTA allows rapid emergency department discharge. This article shows that CCTA-based triage is as safe as traditional triage, reduces the hospital length of stay, and may provide cost-effective or even cost-saving care.
Haanstra, Tsjitske M; Kamper, Steven J; Williams, Christopher M; Spriensma, Alette S; Lin, Chung-Wei Christine; Maher, Christopher G; de Vet, Henrica C W; Ostelo, Raymond W J G
It is believed that patients' expectancies about the effectiveness of treatment influence their treatment outcomes, but the working mechanism is rarely studied in patients with low back pain. Theoretical models suggest that adherence to treatment may be an important pathway. The aim of this study was to assess the mediating role of adherence to treatment in the relationship between expectancies and the outcomes of recovery and pain intensity in patients with acute low back pain. This study used data from a randomized placebo-controlled trial of paracetamol for acute low back pain. Expectancies were measured with the Credibility Expectancy Questionnaire. Adherence was measured with a medication diary. Pain intensity was recorded daily in a diary on a 0 to 10 pain scale, and recovery was defined as the first of 7 consecutive days scoring 0 or 1 on a 6-point pain scale. Cox regression (dependent variable: recovery) and linear mixed-model analyses (dependent variable: daily pain intensity scores) were performed. The "difference in coefficients" approach was used to establish mediation. A total of 1573 participants were included in current analyses. There was a small but highly significant relationship between expectancies and outcomes; 3.3% of the relationship between expectancies and recovery and 14.2% of the relationship between expectancies and pain intensity were mediated by adherence to treatment. This study does not convincingly support the theory that adherence is a key pathway in the relationship between treatment outcome expectancies and recovery and pain intensity in this acute low back pain population.
Wells, Judith; Turner, Barbara; Coombs, Eileen
A descriptive, correlational design was used to evaluate the effectiveness of a chronic cancer pain management education program. The Nurses' Knowledge and Attitude Survey Regarding Pain (NKAS) was used to evaluate the program. A convenience sample of 27 registered nurses was recruited to participate in the study. Analysis of the data revealed a significant difference between pre-test and post-test scores on the NKAS. There were no significant correlations observed between any study variables. The small convenience sample prevents the ability to generalize the findings. It is concluded that the education program was effective in improving knowledge and attitudes related to chronic cancer pain management. Implications for nursing practice, research, education, and administration are suggested.
Fitzcharles, Mary-Ann; Lussier, David; Shir, Yoram
Musculoskeletal pain in the elderly is common and disabling. As the conditions causing rheumatic pain, including osteoarthritis, inflammatory arthritis and soft-tissue conditions such as tendonitis and bursitis, are, for the most part, not curable, pain control is paramount in order to maintain quality of life. Pain management should be multimodal and tailored to the individual patient, and will likely include a combination of both nonpharmacological and pharmacological interventions. Nonpharmacological treatments begin with education of the patient, encouragement to practise self-management strategies and attention to healthy life habits such as weight control and regular physical activity and exercise. Advice in this regard may be effectively given by healthcare professionals other than physicians. Although herbal products and nutritional supplements are commonly used by patients, studies of their efficacy and safety, especially in the elderly, are limited. In contrast, topical applications, and in particular those containing NSAIDs, are being used more frequently, are associated with fewer adverse effects than oral preparations and offer a new and safer treatment alternative. Similarly, intra-articular and soft-tissue injections of corticosteroids provide an easy and cost-effective option for symptom relief with minimal risk. The use of any pharmacological agent in the elderly should be tempered with caution regarding increased sensitivity to medications, drug-drug interactions and associated co-morbidities. Therefore, the elderly will often require down-adjustment of dosage and careful attention to the risk/benefit ratio of the treatment. There is, however, no single ideal pain medication for management of rheumatic pain. The four broad categories of treatments, namely simple analgesics (i.e. paracetamol [acetaminophen]), NSAIDs, stronger analgesics (i.e. opioids) and adjuvant drugs, each have unique and particular concerns regarding their adverse effect
Good, Heidi; Riley-Doucet, Cheryl K; Dunn, Karen S
Pain in long-term care (LTC) is common among older residents despite the vast options available for optimal pain management. Inadequate pain management affects individual health care outcomes. Researcher evidence has shown that nurse practitioners (NPs) improve the quality of care in LTC but are challenged by multiple barriers that inhibit optimal pain control. The purpose of the current pilot study was to explore both the pain management processes used by nurses in LTC and the documented patient outcomes that come from these processes. In addition, factors were identified that may impact the NP role in providing adequate pain control in LTC. This descriptive study used a retrospective, case-controlled research design that incorporated reviewing 55 LTC resident medical records. Results show how the process of pain management in LTC can be improved by expanding the professional role of the NP.
Dworkin, Robert H.; O’Connor, Alec B.; Kent, Joel; Mackey, Sean C.; Raja, Srinivasa N.; Stacey, Brett R.; Levy, Robert M.; Backonja, Miroslav; Baron, Ralf; Harke, Henning; Loeser, John D.; Treede, Rolf-Detlef; Turk, Dennis C.; Wells, Christopher D.
Neuropathic pain (NP) is often refractory to pharmacologic and non-interventional treatment. On behalf of the International Association for the Study of Pain Neuropathic Pain Special Interest Group (NeuPSIG), the authors evaluated systematic reviews, clinical trials, and existing guidelines for the interventional management of NP. Evidence is summarized and presented for neural blockade, spinal cord stimulation (SCS), intrathecal medication, and neurosurgical interventions in patients with the following peripheral and central NP conditions: herpes zoster and postherpetic neuralgia (PHN); painful diabetic and other peripheral neuropathies; spinal cord injury NP; central post-stroke pain; radiculopathy and failed back surgery syndrome (FBSS); complex regional pain syndrome (CRPS); and trigeminal neuralgia and neuropathy. Due to the paucity of high-quality clinical trials, no strong recommendations can be made. Four weak recommendations based on the amount and consistency of evidence, including degree of efficacy and safety, are: (1) epidural injections for herpes zoster; (2) steroid injections for radiculopathy; (3) SCS for FBSS; and (4) SCS for CRPS type 1. Based on the available data, we recommend not to use sympathetic blocks for PHN nor RF lesions for radiculopathy. No other conclusive recommendations can be made due to the poor quality of available of data. Whenever possible, these interventions should either be part of randomized clinical trials or documented in pain registries. Priorities for future research include randomized clinical trials; long-term studies; and head-to-head comparisons among different interventional and non-interventional treatments. PMID:23748119
Dion, Liza; Rodgers, Nancy; Cutshall, Susanne M.; Cordes, Mary Ellen; Bauer, Brent; Cassivi, Stephen D.; Cha, Stephen
Background: Integrative therapies such as massage have gained support as interventions that improve the overall patient experience during hospitalization. Thoracic surgery patients undergo long procedures and commonly have postoperative back, neck, and shoulder pain. Purpose: Given the promising effects of massage therapy for alleviation of pain, we studied the effectiveness and feasibility of massage therapy delivered in the postoperative thoracic surgery setting. Methods: Patients who received massage in the postoperative setting had pain scores evaluated pre and post massage on a rating scale of 0 to 10 (0 = no pain, 10 = worst possible pain). Results: In total, 160 patients completed the pilot study and received massage therapy that was individualized. Patients receiving massage therapy had significantly decreased pain scores after massage (p ≤ .001), and patients’ comments were very favorable. Patients and staff were highly satisfied with having massage therapy available, and no major barriers to implementing massage therapy were identified. Conclusions: Massage therapy may be an important additional pain management component of the healing experience for patients after thoracic surgery. PMID:21847428
Sturgeon, John A
Pain is a complex stressor that presents a significant challenge to most aspects of functioning and contributes to substantial physical, psychological, occupational, and financial cost, particularly in its chronic form. As medical intervention frequently cannot resolve pain completely, there is a need for management approaches to chronic pain, including psychological intervention. Psychotherapy for chronic pain primarily targets improvements in physical, emotional, social, and occupational functioning rather than focusing on resolution of pain itself. However, psychological therapies for chronic pain differ in their scope, duration, and goals, and thus show distinct patterns of treatment efficacy. These therapies fall into four categories: operant-behavioral therapy, cognitive-behavioral therapy, mindfulness-based therapy, and acceptance and commitment therapy. The current article explores the theoretical distinctiveness, therapeutic targets, and effectiveness of these approaches as well as mechanisms and individual differences that factor into treatment response and pain-related dysfunction and distress. Implications for future research, dissemination of treatment, and the integration of psychological principles with other treatment modalities are also discussed.
Dworkin, Robert H; O'Connor, Alec B; Kent, Joel; Mackey, Sean C; Raja, Srinivasa N; Stacey, Brett R; Levy, Robert M; Backonja, Miroslav; Baron, Ralf; Harke, Henning; Loeser, John D; Treede, Rolf-Detlef; Turk, Dennis C; Wells, Christopher D
Neuropathic pain (NP) is often refractory to pharmacologic and noninterventional treatment. On behalf of the International Association for the Study of Pain Neuropathic Pain Special Interest Group, the authors evaluated systematic reviews, clinical trials, and existing guidelines for the interventional management of NP. Evidence is summarized and presented for neural blockade, spinal cord stimulation (SCS), intrathecal medication, and neurosurgical interventions in patients with the following peripheral and central NP conditions: herpes zoster and postherpetic neuralgia (PHN); painful diabetic and other peripheral neuropathies; spinal cord injury NP; central poststroke pain; radiculopathy and failed back surgery syndrome (FBSS); complex regional pain syndrome (CRPS); and trigeminal neuralgia and neuropathy. Due to the paucity of high-quality clinical trials, no strong recommendations can be made. Four weak recommendations based on the amount and consistency of evidence, including degree of efficacy and safety, are: 1) epidural injections for herpes zoster; 2) steroid injections for radiculopathy; 3) SCS for FBSS; and 4) SCS for CRPS type 1. Based on the available data, we recommend not to use sympathetic blocks for PHN nor radiofrequency lesions for radiculopathy. No other conclusive recommendations can be made due to the poor quality of available data. Whenever possible, these interventions should either be part of randomized clinical trials or documented in pain registries. Priorities for future research include randomized clinical trials, long-term studies, and head-to-head comparisons among different interventional and noninterventional treatments.
Sturgeon, John A
Pain is a complex stressor that presents a significant challenge to most aspects of functioning and contributes to substantial physical, psychological, occupational, and financial cost, particularly in its chronic form. As medical intervention frequently cannot resolve pain completely, there is a need for management approaches to chronic pain, including psychological intervention. Psychotherapy for chronic pain primarily targets improvements in physical, emotional, social, and occupational functioning rather than focusing on resolution of pain itself. However, psychological therapies for chronic pain differ in their scope, duration, and goals, and thus show distinct patterns of treatment efficacy. These therapies fall into four categories: operant-behavioral therapy, cognitive-behavioral therapy, mindfulness-based therapy, and acceptance and commitment therapy. The current article explores the theoretical distinctiveness, therapeutic targets, and effectiveness of these approaches as well as mechanisms and individual differences that factor into treatment response and pain-related dysfunction and distress. Implications for future research, dissemination of treatment, and the integration of psychological principles with other treatment modalities are also discussed. PMID:24748826
Hart, Ann Marie
Acute bronchitis is a common respiratory infection seen in primary care settings. This article examines the current evidence for diagnosis and management of acute bronchitis in adults and provides recommendations for primary care clinical practice.
Paolillo, Ciro; Spallino, Ilenia
Up to 10% of all patients at the Emergency Department present for acute abdominal pain. The C-reactive protein (CRP) and white blood cell (WBC) are routinely determined as part of the workup of patients with abdominal pain. Three large prospective cohort studies comprising a total of 2961 adult patients with acute abdominal pain were selected. CRP levels and WBC counts were compared between patients with urgent and nonurgent final diagnoses. These studies conclude that the laboratory values individually are weak discriminators and cannot be used as a triage instrument in the selection of patients with acute abdominal pain requiring additional diagnostic tests.
Lin, Wei-Ching; Lin, Chien-Heng
The accurate diagnosis of pediatric acute abdominal pain is one of the most challenging tasks in the emergency department (ED) due to its unclear clinical presentation and non-specific findings in physical examinations, laboratory data, and plain radiographs. The objective of this study was to evaluate the impact of abdominal multidetector computed tomography (MDCT) performed in the ED on pediatric patients presenting with acute abdominal pain. A retrospective chart review of children aged <18 years with acute abdominal pain who visited the emergency department and underwent MDCT between September 2004 and June 2007 was conducted. Patients with a history of trauma were excluded. A total of 156 patients with acute abdominal pain (85 males and 71 females, age 1-17 years; mean age 10.9 ± 4.6 years) who underwent abdominal MDCT in the pediatric ED during this 3-year period were enrolled in the study. One hundred and eighteen patients with suspected appendicitis underwent abdominal MDCT. Sixty four (54.2%) of them had appendicitis, which was proven by histopathology. The sensitivity of abdominal MDCT for appendicitis was found to be 98.5% and the specificity was 84.9%. In this study, the other two common causes of nontraumatic abdominal emergencies were gastrointestinal tract (GI) infections and ovarian cysts. The most common etiology of abdominal pain in children that requires imaging with abdominal MDCT is appendicitis. MDCT has become a preferred and invaluable imaging modality in evaluating uncertain cases of pediatric acute abdominal pain in ED, in particular for suspected appendicitis, neoplasms, and gastrointestinal abnormalities.
Caraceni, Augusto; Davies, Andrew; Poulain, Philippe; Cortés-Funes, Hernán; Panchal, Sunil J; Fanelli, Guido
The moral imperative to adequately manage pain is being increasingly recognized worldwide. A comprehensive pain management approach that addresses the various presentations of pain in patients with cancer is required, including appropriate management of breakthrough pain. Breakthrough pain commonly occurs in patients with advanced cancer and is disabling to the individual and burdensome to society, yet it is often inadequately managed. Because pain is heterogeneous, the best management of an individual's pain, including breakthrough pain in cancer, requires a thorough assessment to tailor the treatment strategies. Recently developed guidelines support this approach and recommend treating breakthrough pain using rapid- or short-acting opioids with pharmacodynamics that mirror the rapid onset and short duration of the presenting pain. This approach should be part of a comprehensive strategy to treat pain within the context of the primary disease trajectory, offering continuity of care and access to specialized palliative care when appropriate.
Rejeh, Nahid; Ahmadi, Fazlollah; Mohamadi, Eesa; Anoosheh, Moniereh; Kazemnejad, Anooshirvan
This qualitative study describes ethical challenges faced by Iranian nurses in the process of pain management in surgical units. To address this issue, semistructured interviews were conducted with 26 nurses working in surgery units in three large university hospitals in Tehran. An analysis of the transcripts revealed three main categories: institutional limitations; nurses' proximity to and involvement with pain and suffering; and nurses' fallibility. Specific themes identified within the categories were: insufficient resources, medical hierarchy; difficulties with believing patients' complaints regarding pain and suffering; and experiencing the consequences of poor judgments. Our findings lead us to conclude that, as nurses are much closer to patients' pain and suffering than other health professionals, being aware of their ethical problems, and being able to reflect on them and discuss and learn from them, will reduce the burden of the ethical challenges faced. The findings will help nurses in other countries to devise suitable ways to reduce the ethical burdens they bear in their daily practice.
Holland, Wesley C.; Hunold, Katherine M.; Mangipudi, Sowmya A.; Rittenberg, Alison M.; Yosipovitch, Natalie; Platts-Mills, Timothy F.
Objectives Musculoskeletal pain is a common reason for emergency department (ED) visit by older adults. Outpatient pain management following ED visits in this population is challenging as a result of contraindications to, and side effects from, available therapies. Shared decision-making (SDM) between patients and emergency physicians may improve patient experiences and health outcomes. Among older ED patients with acute musculoskeletal pain, we sought to characterize their desire for involvement in the selection of outpatient analgesics. We also sought to assess the impact of SDM on change in pain at 1 week, patient satisfaction, and side effects. Methods This was a prospective study of adults aged 60 years and older presenting to the ED with acute musculoskeletal pain. Participants’ desire to contribute to outpatient analgesic selection was assessed by phone within 24 hours of ED discharge using the Control Preferences Scale and categorized as active, collaborative, or passive. The extent to which SDM occurred in the ED was also assessed within 24 hours of discharge using the 9-item Shared Decision Making Questionnaire, and scores were subsequently grouped into tertiles of low, middle, and high SDM. The primary outcome was change in pain severity between the ED visit and 1 week. Secondary outcomes included satisfaction regarding the decision about how to treat pain at home, satisfaction with the pain medication itself, and side effects. Results Desire of participants (N = 94) to contribute to the decision regarding selection of outpatient analgesics varied: 16% active (i.e., make the final decision themselves), 37% collaborative (i.e., share decision with provider), and 47% passive (i.e., let the doctor make the final decision). The percentage of patients who desired an active role in the decision was higher for patients who were college educated versus those who were not college educated (28% vs. 11%; difference 17%, 95% confidence interval [CI] = 0% to 35
Daeninck, P.; Gagnon, B.; Gallagher, R.; Henderson, J.D.; Shir, Y.; Zimmermann, C.; Lapointe, B.
Breakthrough cancer pain (btcp) represents an important element in the spectrum of cancer pain management. Because most btcp episodes peak in intensity within a few minutes, speed of medication onset is crucial for proper control. In Canada, several current provincial guidelines for the management of cancer pain include a brief discussion about the treatment of btcp; however, there are no uniform national recommendations for the management of btcp. That lack, accompanied by unequal access to pain medication across the country, contributes to both regional and provincial variability in the management of btcp. Currently, immediate-release oral opioids are the treatment of choice for btcp. This approach might not always offer optimal speed for onset of action and duration to match the rapid nature of an episode of btcp. Novel transmucosal fentanyl formulations might be more appropriate for some types of btcp, but limited access to such drugs hinders their use. In addition, the recognition of btcp and its proper assessment, which are crucial steps toward appropriate treatment selection, remain challenging for many health care professionals. To facilitate appropriate management of btcp, a group of prominent Canadian specialists in palliative care, oncology, and anesthesiology convened to develop a set of recommendations and suggestions to assist Canadian health care providers in the treatment of btcp and the alleviation of the suffering and discomfort experienced by adult cancer patients. PMID:27122974
Wang, Yu; Zhao, Hong; Zhou, Zhen; Tian, Ci; Xiao, Hong-Li; Wang, Bao-En
Background: Acute abdominal pain is a common symptom of emergency patients. The severity was always evaluated based on physicians’ clinical experience. The aim of this study was to establish an early risk stratification method (ERSM) for addressing adults with acute abdominal pain, which would guide physicians to take appropriate and timely measures following the established health-care policies. Methods: In Cohort 1, the records of 490 patients with acute abdominal pain that developed within the past 72 h were enrolled in this study. Measurement data and numeration data were compared with analysis of variance and Chi-square test, respectively. Multiple regression analysis calculated odd ratio (OR) value. P and OR values showed the impacts of factors. ERSM was established by clinical experts and statistical experts according to Youden index. In Cohort 2, data from 305 patients with acute abdominal pain were enrolled to validate the accuracy of the ERSM. Then, ERSM was prospectively used in clinical practice. Results: The ERSM was established based on the scores of the patient's clinical characteristics: right lower abdominal pain + 3 × diffuse abdominal pain + 3 × cutting abdominal pain + 3 × pain frequency + 3 × pain duration + fever + 2 × vomiting + 5 × stop defecation + 3 × history of abdominal surgery + hypertension history + diabetes history + hyperlipidemia history + pulse + 2 × skin yellowing + 2 × sclera yellowing + 2 × double lung rale + 10 × unconsciousness + 2 × right lower abdominal tenderness + 5 × diffuse abdominal tenderness + 4 × peritoneal irritation + 4 × bowel sounds abnormal + 10 × suspicious diagnosis + white blood cell count + hematocrit + glucose + 2 × blood urea nitrogen + 3 × creatine + 4 × serum albumin + alanine aminotransferase + total bilirubin + 3 × conjugated bilirubin + amylase. When the score was <18, the patient did not need hospitalization. A score of ≥18 and <38 indicated that the patient should be under
Moore, R Andrew; Derry, Sheena; Moore, Maura; McQuay, Henry J
Background Tiaprofenic acid is a a non-steroidal anti-inflammatory drug (NSAID). It is widely available around the world, with indications for osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, periarticular disorders, and strains and sprains. This review sought to evaluate the efficacy and safety of oral tiaprofenic acid in acute postoperative pain, using clinical studies of patients with established pain, and with outcomes measured primarily over 6 hours using standard methods. This type of study has been used for many decades to establish that drugs have analgesic properties. Objectives To assess the efficacy of single dose oral tiaprofenic acid in acute postoperative pain, and any associated adverse events. Search methods We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to June 2009. Selection criteria Randomised, double blind, placebo-controlled trials of single dose orally administered tiaprofenic acid in adults with moderate to severe acute postoperative pain. Data collection and analysis Two review authors independently assessed trial quality and extracted data. We planned to use area under the “pain relief versus time” curve to derive the proportion of participants with tiaprofenic acid experiencing at least 50% pain relief over 4 to 6 hours, using validated equations; to use number needed to treat to benefit (NNT); the proportion of participants using rescue analgesia over a specified time period; time to use of rescue analgesia; information on adverse events and withdrawals. Main results Not one of eleven studies identified by the searches and examined in detail studied oral tiaprofenic acid against placebo in patients with established postoperative pain and therefore no results are available. Authors’ conclusions In the absence of evidence of efficacy for oral tiaprofenic acid in acute postoperative pain, its use in this indication is not justified at present. Because trials clearly
Ersek, Mary; Polissar, Nayak; Du Pen, Anna; Jablonski, Anita; Herr, Keela; Neradilek, Moni B
Background Unrelieved pain among nursing home (NH) residents is a well-documented problem. Attempts have been made to enhance pain management for older adults, including those in NHs. Several evidence-based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults. Despite the proliferation and dissemination of these practice guidelines, research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting. One promising approach is the embedding of guidelines into explicit protocols and algorithms to enhance decision making. Purpose The goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence-based pain assessment and management practices, decreasing pain and depressive symptoms, and enhancing mobility among NH residents. Methods The study used a cluster-randomized controlled trial (RCT) design in which the individual NH was the unit of randomization. The Roger's Diffusion of Innovations theory provided the framework for the intervention. Outcome measures were surrogate-reported usual pain, self-reported usual and worst pain, and self-reported pain-related interference with activities, depression, and mobility. Results The final sample consisted of 485 NH residents from 27 NHs. The investigators were able to use a staggered enrollment strategy to recruit and retain facilities. The adaptive randomization procedures were successful in balancing intervention and control sites on key NH characteristics. Several strategies were successfully implemented to enhance the adoption of the algorithm. Limitations/Lessons The investigators encountered several methodological challenges that were inherent to
Hagen, Ellen M; Rekand, Tiina
Spinal cord injury (SCI) is an injury to the spinal cord that leads to varying degrees of motor and/or sensory deficits and paralysis. Chronic pain of both neuropathic and nociceptive type is common and contributes to reduced quality of life. The aim of the review is to provide current clinical understanding as well as discuss and evaluate efficacy of pharmacological interventions demonstrated in the clinical studies. The review was based on literature search in PubMed and Medline with words "neuropathic pain" and "spinal cord injury". The review included clinical studies and not experimental data nor case reports. A limited number of randomized and placebo-controlled studies concerning treatment options of neuropathic pain after SCI were identified. Amitriptyline, a tricyclic antidepressant and the antiepileptic drugs, gabapentin and pregabalin, are most studied with demonstrated efficacy, and considered to be the primary choice. Opioids have demonstrated conflicting results in the clinical studies. In addition, administration route used in the studies as well as reported side effects restrict everyday use of opioids as well as ketamine and lidocaine. Topical applications of capsaicin or lidocaine as well as intradermal injections of Botulinum toxin are new treatment modalities that are so far not studied on SCI population and need further studies. Non-pharmacological approaches may have additional effect on neuropathic pain. Management of pain should always be preceded by thorough clinical assessment of the type of pain. Patients need a follow-up to evaluate individual effect of applied measures. However, the applied management does not necessarily achieve satisfactory pain reduction. Further clinical studies are needed to evaluate the effect of both established and novel management options.
Jacob, Eufemia; Hockenberry, Marilyn; Mueller, Brigitta U
The use of hydromorphone is increasing but little is known about its effects during painful episodes in adolescents with sickle cell disease. This pilot study examined the intensity, location, and quality of pain and evaluated the amount of relief and side effects from PCA hydromorphone during acute painful episodes in five adolescents with sickle cell disease. Data suggest that hydromorphone may provide a better alternative than morphine, the most commonly prescribed opioid in patients with sickle cell disease. Hydromorphone may provide improved pain control and recovery from acute painful episodes in patients with sickle cell disease.
Amoza Pais, Sonia; Batlle Marin, Xavi; Oronoz Martinez, Begoña; Balen Ribera, Enrique; Yarnoz Irazabal, Concepción
Purpose The role of surgery in the management of diverticular disease after an episode of acute diverticulitis (AD) managed in a conservative form is evolving. Age, number of episodes of AD, type of episode, and symptoms after the episodes are factors related to the need for elective surgery. The aim of this study is to evaluate the safety of conservative management and the risk factors for emergency surgery after a first episode of AD managed without surgery. Methods We retrospectively evaluated 405 patients diagnosed as having had a first episode of AD. Sixty-nine patients underwent emergency surgery on the first admission, and 69 patients had an elective operation in the follow-up (group A). The remaining 267 patients were managed initially without surgery (group B). Thirteen of these 267 patients needed a further urgent surgical procedure. Factors involved in the decision of elective surgery and the probability of emergency surgery after the first episode of AD managed without surgery were evaluated in relation to demographic factors, risk factors, presence of recurrences, and type of the first episode. Results Patients, mean age was 62.7 years, 71 were aged less than 51, and 151 were males. The mean follow-up for patients with nonoperative management was 91.2 months. An elective operation was performed in 69 patients. Compared to patients in group B, those in group A more frequently had a first episode of complicated acute diverticulitis (CAD) (37.1% vs. 16.4%; P = 0.000) and were more likely to be smokers (46.3% vs. 19.3%; P = 0.000) and to suffer more than one episode of AD (42% vs. 26.9%; P = 0.027). Nonoperative management was chosen for 267 patients, but 13 patients needed an emergency operation later. In the multivariate analysis, we found a significant relation between the presence of CAD in the first episode and the need for emergency surgery. There were no differences in surgical mortality between the patients in the two groups, but patients treated
Bicanovsky, Lesley K; Lagman, Ruth L; Davis, Mellar P; Walsh, Declan
Evaluation of abdominal pain requires an understanding of the possible causes(benign or malignant) and recognition of typical patterns and clinical presentation. Abdominal pain has multiple causes; associated signs and symptoms may aid in the diagnosis. Remember that some patients will not have a textbook presentation, and unusual causes for pain must be considered. Those with chronic pancreatitis with structural complications should be operated on early, whereas those with other types of chronic pancreatitis should receive medical therapy focusing on alleviating symptoms. Control of the most troublesome symptoms will provide the best management for IBS. Pharmacologic success in bowel obstruction depends on the level and degree of obstruction. Decision making is based on reasonable expectations of survival, treatment-related success, performance status, and goals of care. Quality of life will be enhanced by appropriate symptom management.
George, Susan E; Clinton, Susan C; Borello-France, Diane F
The multisystem nature of female chronic pelvic pain (CPP) makes this condition a challenge for physical therapists and other health care providers to manage. This article uses a case scenario to illustrate commonly reported somatic, visceral, and neurologic symptoms and their associated health and participation impact in a female with CPP. Differential diagnosis of pain generators requires an in-depth understanding of possible anatomic and physiologic contributors to this disorder. This article provides a detailed discussion of the relevant clinical anatomy with specific attention to complex interrelationships between anatomic structures potentially leading to the patient's pain. In addition, it describes the physical therapy management specific to this case, including examination, differential diagnosis, and progression of interventions.
Beaudet, Joanne; Rasch, John
Investigated relationship of Beck Depression Inventory (BDI) scores to employment status and time since injury among persons with acute low back pain. Work status was unrelated to BDI scores. Participants 5 to 6 months post-injury scored higher than participants l month post-injury; participants working 5 to 6 months post-injury scored higher than…
Donnelly, Elizabeth H; Nemhauser, Jeffrey B;