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Improvement of pain treatment after major abdominal surgery by intravenous S+-ketamine.
Argiriadou H, Himmelseher S, Papagiannopoulou P, Georgiou M, Kanakoudis F, Giala M, Kochs E.
Department of Anesthesiology, AHEPA University Hospital, Thessaloniki, Greece. papaziog@med.auth.gr
The use of intraoperative racemic ketamine for pain prevention after abdominal surgery is controversial. We compared one preincisional i.v. injection of S(+)-ketamine with its preincisional and repeated intraoperative use in 45 patients undergoing surgery with epidural and general anesthesia. S(+)-ketamine is a new drug formulation that contains the more potent S(+)-stereoisomer of ketamine. Patients were randomized to receive placebo, 0.5 mg/kg preincisional S(+)ketamine, or 0.5 mg/kg preincisional and 0.2 mg/kg intraoperative S(+)-ketamine repeated at 20-min intervals. In the postoperative period, epidural ropivacaine (2 mg/mL; 0.12 mL.kg(-1).h(-1)) was infused for pain therapy. Patients who received repeated S(+)-ketamine reported smaller pain scores than those who received placebo after awakening and 3 and 6 h later (P < or = 0.05). Fewer patients with repeated S(+)-ketamine required additional analgesics than those with placebo (P < or = 0.05). Cumulative consumption of additional diclofenac and dextropropoxyphene at 24 h was less after single (P < 0.05) and repeated (P < 0.05) S(+)-ketamine versus placebo. After awakening, patients who received repeated S(+)-ketamine reported being in a better mood than those in the other groups (P < 0.05). No psychotomimetic side effects were noted. In conclusion, preincisional and repeated intraoperative small-dose S(+)-ketamine added to general and epidural anesthesia causes better postoperative pain relief than general and epidural anesthesia alone. IMPLICATIONS: After major visceral surgery, preincisional and repeated intraoperative small-dose S(+)-ketamine added to general and epidural anesthesia causes better postoperative pain relief than general and epidural anesthesia alone.
PMID: 15105223 [PubMed - in process]
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The short- and long-term benefit in chronic low back pain through adjuvant electrical versus manual auricular acupuncture.
Sator-Katzenschlager SM, Scharbert G, Kozek-Langenecker SA, Szeles JC, Finster G, Schiesser AW, Heinze G, Kress HG.
Department of Anesthesiology and Intensive Care Medicine (B), Outpatient Pain Center, University of Vienna, Vienna, Austria. sabine.sator@univie.ac.at
Acupuncture is an established adjuvant analgesic modality for the treatment of chronic pain. Electrical stimulation of acupuncture points is considered to increase acupuncture analgesia. In this prospective, randomized, double-blind, controlled study we tested the hypothesis that auricular electroacupuncture (EA) relieves pain more effectively than conventional manual auricular acupuncture (CO) in chronic low back pain patients with insufficient pain relief (visual analogue scale [VAS] > or = 5) treated with standardized analgesic therapy. Disposable acupuncture needles were inserted in the auricular acupuncture points 29, 40, and 55 of the dominant side and connected to a newly developed battery-powered miniaturized stimulator worn behind the ear. Patients were randomized into group EA (n = 31) with continuous low-frequency auricular EA (1 Hz biphasic constant current of 2 mA) and group CO (n = 30) without electrical stimulation (sham-electroacupuncture). Treatment was performed once weekly for 6 wk, and in each group needles were withdrawn 48 h after insertion. During the study period and a 3-mo follow-up, patients were asked to complete the McGill questionnaire. Psychological well being, activity level, quality of sleep, and pain intensity were assessed by means of VAS; moreover, analgesic drug consumption was documented. Pain relief was significantly better in group EA during the study and the follow-up period as compared with group CO. Similarly, psychological well-being, activity, and sleep were significantly improved in group EA versus group CO, the consumption of analgesic rescue medication was less, and more patients returned to full-time employment. Neuropathic pain in particular improved in patients treated with EA. There were no adverse side effects. These results are the first to demonstrate that continuous EA stimulation of auricular acupuncture points improves the treatment of chronic low back pain in an outpatient population. IMPLICATIONS: Continuous electrical stimulation of auricular acupuncture points using the new point stimulation device P-stim significantly decreases pain intensity and improves psychological well-being, activity, and sleep in chronic low back pain patients.
PMID: 15105215 [PubMed - in process]
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Sedation with midazolam leads to reduced pain after dental surgery.
Ong CK, Seymour RA, Tan JM.
Department of Oral & Maxillofacial Surgery, National University of Singapore. cliffong@pacific.net.sg
Our principal objective in this study was to evaluate the potential pain reducing effect of i.v. midazolam in patients undergoing oral surgery. One-hundred-twenty-five patients with impacted mandibular third molars requiring removal under local anesthetic were randomized into 2 groups. The first group (n = 64) was administered i.v. midazolam by titration until a clinical end-point of conscious sedation followed by local anesthetic before surgery; the second group (n = 61) was the control and was administered only local anesthetic before surgery. The surgery was performed in a standardized manner in both groups by the same surgeon. Outcome measures were four primary end-points: pain intensity as assessed by a 100-mm visual analogue scale and a 4-point categorized scale hourly for 8 h, time to first analgesic, total analgesic (ibuprofen) consumption over the first 48 h, and a 5-point categorical patient global assessment scale (0 = poor, 1 = fair, 2 = good, 3 = very good, and 4 = excellent). Throughout the 8-h investigation period, patients in the midazolam group reported significantly lower pain intensity scores than those in the control group (19.0 +/- 13.2 mm versus 28.1 +/- 12.8 mm, P < 0.05). The patients in the midazolam group also reported significantly longer time to first analgesic (165.5 +/- 56.5 min versus 202.2 +/- 79.0 min, P < 0.05), less analgesic consumption (1275 +/- 364 mg versus 1688 +/- 407 mg, P < 0.001) and better patient global assessment (3.34 +/- 0.8 versus 2.4 +/- 0.9, P < 0.001). We conclude that systemically administered midazolam is effective in reducing postoperative pain after third molar surgery. IMPLICATIONS: In this observer blinded study, we found that i.v. midazolam treatment (0.09 mg/kg) has a pain-reducing effect after third molar surgery, thus improving postoperative pain management.
PMID: 15105203 [PubMed - in process]
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Electroanalgesia: does it have a place in the routine management of acute and chronic pain?
White PF.
Publication Types:
PMID: 15105186 [PubMed - in process]
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Tramadol added to 1.5% mepivacaine for axillary brachial plexus block improves postoperative analgesia dose-dependently.
Robaux S, Blunt C, Viel E, Cuvillon P, Nouguier P, Dautel G, Boileau S, Girard F, Bouaziz H.
Department of Anesthesiology and Critical Care Medicine, Hopital Central, Nancy Cedex, Nimes Cedex 9, France.
Adjuncts to local anesthetics for peripheral plexus blockade may enhance the quality and duration of anesthesia and postoperative analgesia. The analgesic, tramadol, has a unique mechanism of action that suggests efficacy as such an adjunct. It displays a central analgesic and peripheral local anesthetic effect. We designed a prospective, randomized, controlled and double-blind clinical trial to assess the effect of tramadol added to brachial plexus anesthesia. One-hundred patients scheduled for carpal tunnel release surgery under brachial plexus anesthesia were randomized into four groups. All patients received 1.5% mepivacaine 40 mL plus a study solution containing either isotonic sodium chloride (Group P, n = 17), tramadol 40 mg (Group T(40), n = 22), tramadol 100 mg (Group T(100), n = 20) or tramadol 200 mg (Group T(200), n = 20). We evaluated the time of onset of anesthesia, duration of sensory and motor blockade, duration and quality of postoperative analgesia, and occurrence of adverse effects. Onset and duration of sensory and motor blocks were not different among groups. The number of patients requesting analgesia in the postoperative period was significantly less in the 3 tramadol groups compared with the placebo group (P = 0.02); this was also noted with the placebo and T(40) groups compared with the T(200) group. No statistical significance was demonstrated between the placebo and the T(40) group or the T(100) group and the T(200) group. Furthermore, there was a significant trend effect among groups applying the Cochran-Armitage tendency test (P = 0.003), suggesting a dose-dependent decrease for additional postoperative analgesia requirements when tramadol was added. Side effects did not differ among groups, although they were more frequently recorded in the T groups. Our study suggests that tramadol added to 1.5% mepivacaine for brachial plexus block enhances in a dose-dependent manner the duration of analgesia with acceptable side effects. However, the safety of tramadol has to be investigated before allowing its use in clinical practice. IMPLICATIONS: Tramadol's unique mechanism of action suggests efficacy as a local anesthetic adjunct for peripheral plexus blockade. Our study demonstrates that tramadol, added to mepivacaine for brachial plexus anesthesia, extends the duration and improves the quality of postoperative analgesia in a dose dependent fashion with acceptable side effects.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041620 [PubMed - indexed for MEDLINE]
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Postoperative epidural anesthesia preserves lymphocyte, but not monocyte, immune function after major spine surgery.
Volk T, Schenk M, Voigt K, Tohtz S, Putzier M, Kox WJ.
Departments of Anesthesiology and Intensive Care, University Hospital Charite, Campus Mitte, Humboldt-University, Berlin, Germany. thomas.volk@charite.de
Extensive spine surgery is associated with postsurgical pain. Epidural pain therapy may reduce postoperative stress responses and thereby influence immune functions. In a randomized, controlled, double-blinded prospective trial, 54 patients received either conventional patient-controlled IV analgesia (PCIA; morphine 3 mg/15 min) or patient-controlled epidural analgesia (PCEA; 0.125% ropivacaine plus sufentanil 1 microg/mL at a base rate of 12 mL/h and bolus application of 5 mL/15 min). Circulating cytokines, C-reactive protein (CRP), cortisol, and cell-surface receptor expression of immune cells (cluster of differentiation [CD]14, human leukocyte antigen-DR, CD86, CD71, CD3, CD4, CD8, CD16, and CD19) were measured perioperatively to characterize immunological functions. PCEA, compared with PCIA, had no influence on altered levels of circulating cytokines (interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor-alpha, monocyte chemoattractant protein-1, and macrophage inhibitory factor) or indicators of the stress response (CRP and cortisol). Also, no significant difference was found in monocyte numbers or their human leukocyte antigen-DR, CD86, or CD71 expression. In contrast, the postoperative decrease in B lymphocytes and T-helper cells was significant in the PCEA group. Natural killer cells decreased significantly in patients receiving PCEA compared with PCIA. Therefore, postoperative epidural pain therapy has no influence on monocyte functions but reduces natural killer cells and preserves B-cell and T-helper cell populations. Epidural analgesia thus influences the specific rather than the innate immune system and potentially blunts the postsurgical lymphocyte depression, which is relevant for infectious resistance. IMPLICATIONS:Epidural analgesia affects the immune system. Postoperative epidural analgesia, compared with conventional IV opioid therapy, preserves lymphocyte rather than monocyte functions. An improvement of postoperative immune function by epidural analgesia therefore may improve postoperative resistance to infectious complications or to chronic pain states.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041604 [PubMed - indexed for MEDLINE]
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Analgesic effects of intraarticular sufentanil and sufentanil plus methylprednisolone after arthroscopic knee surgery.
Kizilkaya M, Yildirim OS, Dogan N, Kursad H, Okur A.
Departments of Anesthesiology and Reanimation, The School of Medicine, Ataturk University, Erzurum, Turkey. mkizilkaya65@hotmail.com
We studied the effect of intraarticular saline, sufentanil, or sufentanil plus methylprednisolone after knee arthroscopic meniscectomy. In a double-blind randomized study, 60 patients undergoing knee arthroscopic meniscectomy were allocated to groups receiving intraarticular saline, intraarticular sufentanil 10 microg, or sufentanil 10 microg plus methylprednisolone 40 mg at the end of arthroscopy during general anesthesia. Postoperatively, pain levels at rest and during movement (i.e., active flexion of the knee) were measured by a visual analog scale and were significantly decreased in the sufentanil and sufentanil plus methylprednisolone groups compared with the control group. Moreover, we found that there was a significant reduction in intraarticular sufentanil and sufentanil plus methylprednisolone in the postoperative consumption of analgesics. We also found that the use of intraarticular sufentanil or sufentanil plus methylprednisolone after knee arthroscopic meniscectomy decreases the amount of supplementary analgesic needed for pain relief during the early postoperative period. In addition, we detected that sufentanil provided prolonged pain relief up to 24 h when compared with control, whereas when we combined sufentanil plus methylprednisolone, we found that it further reduced pain and use of analgesics when compared with sufentanil. IMPLICATIONS: The combined use of intraarticular sufentanil (10 microg) and methylprednisolone (40 mg) in arthroscopic meniscectomy surgery reduced both postoperative pain scores and the use of additional analgesics.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041599 [PubMed - indexed for MEDLINE]
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Preoperative ketamine improves postoperative analgesia after gynecologic laparoscopic surgery.
Kwok RF, Lim J, Chan MT, Gin T, Chiu WK.
Department of Anaesthesia and Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong.
In this study, we evaluated the preemptive effect of a small dose of ketamine on postoperative wound pain. In a randomized, double-blinded, controlled trial, we compared the analgesic requirement in patients receiving preincision ketamine with ketamine after skin closure or placebo after gynecologic laparoscopic surgery. One-hundred-thirty-five patients were randomly assigned to receive preincision or postoperative ketamine 0.15 mg/kg or saline IV. Anesthetic technique was standardized. Patients were interviewed regularly up to 4 wk after surgery. Pain score, morphine consumption, side effects, and quality of recovery score were recorded. Patients receiving preincision ketamine had a lower pain score in the first 6 h after operation compared with the postoperative (P = 0.001) or placebo groups (P < 0.001). The mean (95% confidence intervals) time to first request for analgesia in the preincision group, 1.8 h (1.4-2.1), was longer than the postoperative group, 1.2 h (0.9-1.5; P < 0.001), or the placebo group, 0.7 h (0.4-0.9; P < 0.001). The mean +/- SD morphine consumption in the preincision group, 1.5 +/- 2.0 mg, was less than that in the postoperative group, 2.9 +/- 3.1 mg (P = 0.04) and the placebo group, 3.4 +/- 2.7 mg (P = 0.003). There was no significant difference among groups with respect to hemodynamic variables or side effects. No patient complained of hallucinations or nightmares. We conclude that a small dose of ketamine is not only safe, but it also provides preemptive analgesia in patients undergoing gynecologic laparoscopic surgery. IMPLICATIONS: In women undergoing laparoscopic gynecologic surgery, a small preoperative dose of ketamine (0.15 mg/kg) produced preemptive analgesia. There were no significant hemodynamic and psychological side effects with this dose.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15041596 [PubMed - indexed for MEDLINE]
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An epidural hematoma in an adolescent patient after cardiac surgery.
Rosen DA, Hawkinberry DW 2nd, Rosen KR, Gustafson RA, Hogg JP, Broadman LM.
Department of Anesthesiology, Pediatrics, West Virginia University Children's Hospital, West Virginia University School of Medicine, Morgantown 26506-9134, USA. rosend@rcbhsc.wvu.edu
An 18-yr-old patient had a thoracic epidural placed under general anesthesia preceding an uneventful aortic valve replacement with a bioprosthetic valve. On the second postoperative day, he was anticoagulated and also received an antithrombotic medication. While ambulating, he experienced pain in his back, and there was blood in his epidural catheter. The catheter was removed, and he developed motor and sensory loss. Rapid surgical decompression resulted in recovery of his lost neurological function. Management and strategies for preventing this problem are discussed. IMPLICATIONS: Epidural hematoma is a rare complication of epidural anesthesia and has not been reported in pediatric patients undergoing cardiac surgery. The successful treatment of this complication requires swift recognition, diagnosis, and surgical intervention.
Publication Types:
PMID: 15041581 [PubMed - indexed for MEDLINE]
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A review of intrathecal and epidural analgesia after spinal surgery in children.
Tobias JD.
Departments of Child Health and Anesthesiology, The University of Missouri, Columbia, Missouri 65212, USA. Tobiasj@health.missouri.edu
In view of the overall experience regarding regional anesthetic techniques to control postoperative pain in infants and children, it is feasible that a similar efficacy and safety profile can be obtained when using such techniques after major orthopedic procedures such as anterior or posterior spinal fusion. I reviewed previous reports regarding the use of neuraxial techniques to provide analgesia after spine surgery in the pediatric population. Variations in both the surgical procedure and the analgesic technique may make the comparison among studies somewhat impractical. Variations of the analgesic technique include 1). the dose of the medications used; 2). the route of delivery (intrathecal or epidural); 3). the mode of delivery (single dose, intermittent bolus dosing, and continuous infusion); 4). the number of epidural catheters used (one versus two); 5). the medications infused (opioids, local anesthetics, or both); 6). the opioid used (morphine, fentanyl, hydromorphone); and 7). the analgesic regimen of the control group (intermittent "as needed" morphine or patient-controlled analgesia). Although limited data are available to document the analgesic superiority of these techniques over parenteral opioids, clinical data offer evidence of other benefits, including decreased intraoperative blood loss and quicker return of gastrointestinal function.
Publication Types:
PMID: 15041580 [PubMed - indexed for MEDLINE]
Spinal manipulation for low back pain.
Childs JD, Flynn TW.
Publication Types:
PMID: 15096345 [PubMed - in process]
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Spinal manipulation for low back pain.
Shapiro CM.
Publication Types:
PMID: 15096344 [PubMed - in process]
It's not just about rubbing--topical capsaicin and topical salicylates may be useful as adjuvants to conventional pain treatment.
Tramer MR.
Division of Anaesthesiology, Geneva University Hospitals, CH-1211 Geneva 14, Switzerland. martin.tramer@hcuge.ch
Publication Types:
PMID: 15105325 [PubMed - in process]
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Extracephalic yawning pain.
Jacome D.
Franklin Medical Center, Department of Medicine, Greenfield, MA and Dartmouth-Hitchcock Medical Center, Division of Neurology, Lebanon, NH, USA.
Jacome DE. Extracephalic yawning pain. Cephalalgia 2004. London. ISSN 0333-1024The aim of this study was to report on two patients with recurrent, paroxysmal, extracephalic pain triggered by yawning. Pain with yawning may occur in several conditions (secondary yawning pain) or develop in the absence of precipitating lesions (primary yawning pain). Primary yawning pain is normally of cephalic location. Methods used were clinical neurological examinations, magnetic resonance imaging of the brain, computerized head tomography, electroencephalogram, blink reflex studies and Panorex X-ray views of the skull. The first patient had intense right shoulder pain and brief apnea for 2 years triggered by yawning. The second patient had yawning pain referred to an area of the neck where a thyroid tumour (Hurthle cell carcinoma) was later found. Neither of the two patients could precipitate their pain with imitation of yawning and neither had evidence of Eagle syndrome. Only the second patient had a history of migraine. Yawning pain may have an extratrigeminal and extracephalic distribution. It rarely serves to identify a lesion underlying the area where the pain is perceived.
PMID: 15096231 [PubMed - as supplied by publisher]
Language bias in a systematic review of chronic pain: how to prevent the omission of non-english publications?
Kovacs FM, Abraira V.
Scientific Department, Kovacs Foundation, Palma de Mallorca, Spain; Unit of Clinical Biostatistics, Hospital Ramon y Cajal, Madrid, Spain.
PMID: 15100600 [PubMed - in process]
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The intravenous administration of ketoprofene: a suitable alternative for acute postoperative pain management in developing countries.
Domi R.
Department of Anesthesia and Intensive Care University Hospital, Center "Mother Theresa", Tirane, Albania.
PMID: 15100598 [PubMed - in process]
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Oral Transmucosal Fentanyl Citrate in the Outpatient Management of Severe Cancer Pain Crises: A Retrospective Case Series.
Burton AW, Driver LC, Mendoza TR, Syed G.
*Section of Cancer Pain Management, Department of Anesthesiology, University of Texas M.D. Anderson Cancer Center, Houston, TX; and daggerDepartment of Symptom Research, University of Texas M.D. Anderson Cancer Center, Houston, TX.
OBJECTIVE:: This retrospective chart review evaluated the efficacy of oral transmucosal fentanyl citrate (OTFC) in an outpatient cancer pain center for patients experiencing severe exacerbations of pain that exceed usual breakthrough pain levels. PATIENTS:: Records were reviewed for all patients who received OTFC at M.D. Anderson's outpatient pain clinic over a three-month time period. OTFC was used in thirty-nine patients experiencing a recent onset of severe pain (>/=7 on a 0-10 scale). All patients had cancer, cancer-related pain syndromes, and were opioid tolerant with an oral morphine equivalent daily dosage (MEDD) of >/=40 mg/day. RESULTS:: Prior to OTFC treatment, all patients reported a mean pain intensity of 9.0 (SD = 1.2). After OTFC treatment, patients reported a mean intensity of 3.0 (SD = 1.4), a significant reduction in pain intensity (P < 0.001). In most cases, OTFC averted the need for an emergency center visit, parenteral opioids, and hospital admission, which suggests that OTFC may be an effective alternative over intravenous opioids to rapidly titrate analgesia in selected opioid-tolerant cancer patients experiencing severe pain.
PMID: 15100597 [PubMed - as supplied by publisher]
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Amenorrhea in a Patient After Treatment With Gabapentin for Complex Regional Pain Syndrome Type II.
Berger JJ.
Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL.
: A 35-year-old woman suffered a traumatic injury to her right sciatic nerve requiring nerve exploration and external neurolysis. Following the surgery, the patient developed complex regional pain syndrome (CRPS) type II and was treated with gabapentin for pain control. Three months after the initiation of gabapentin therapy (1800 mg/day), the patient reported complete cessation of her menses. Based on hormonal tests, her gynecologist concluded that her amenorrhea was secondary to gabapentin therapy. The patient was weaned off the gabapentin over 6 days with return of her menses 2 weeks later. I conclude that gabapentin has the potential to cause amenorrhea with return of menses occurring after discontinuation of the drug.
PMID: 15100596 [PubMed - in process]
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Obesity and the Impact of Chronic Pain.
Marcus DA.
Pain Medicine, Pittsburgh, PA.
OBJECTIVE:: To evaluate obesity as a marker for increased pain severity, disability, and psychologic distress in treatment-seeking, mixed chronic pain patients. METHODS:: Three hundred seventy-two consecutive chronic pain patients seeking evaluation at a university pain clinic were divided into 3 weight categories, based on body mass index (BMI): normal (BMI < 25 kg/m ), overweight (BMI between 25 kg/m and 30 kg/m ), and obese (BMI >/=30 kg/m ). Patients completed questionnaires to identify pain severity, disability, depression, anxiety, and quality of life. RESULTS:: Pain severity and days per week with pain were similar among the weight groups. Disability was related to increasing weight status, with increased BMI associated with more days per week with both reduced activity and complete disability. Depressive symptoms were also related to weight category, with an average Beck Depression Inventory score of 11.81 +/- 7.55 in normal, 12.88 +/- 11.64 in overweight, and 15.78 +/- 9.88 in obese patients. Anxiety scores were similar among the weight categories. Physical function domain of quality of life was also reduced in relation to weight. CONCLUSIONS:: Weight is associated with co-morbid disability, depression, and reduced quality of life for physical function in chronic pain patients. Calculation of the BMI should become a routine part of the screening evaluation for chronic pain patients, with additional screening for disability and psychologic distress in patients with elevated BMIs.
PMID: 15100595 [PubMed - as supplied by publisher]
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Efficacy of Oxcarbazepine in the Treatment of Painful Diabetic Neuropathy.
Beydoun A, Kobetz SA, Carrazana EJ.
*University of Michigan Health System, Ann Arbor, Michigan; daggerNeurologic Center of South Florida, Miami, FL; and double daggerNovartis Pharmaceuticals, East Hanover, NJ.
OBJECTIVES:: To evaluate the safety, tolerability, and efficacy of oxcarbazepine in the treatment of painful diabetic neuropathy. METHODS:: This was an open-label, 9-week trial, consisting of a 1-week prospective Screening Phase followed by an 8-week Treatment Phase. Treatment with oxcarbazepine was initiated at 150 mg/day, and the daily dose was doubled on a weekly basis and titrated to tolerability over 4 weeks, up to 1200 mg/day. This was followed by a 4-week fixed-dose Maintenance Phase, during which patients were maintained on oxcarbazepine at 1200 mg/day or highest tolerated dose. The primary efficacy variable was the change in the weekly pain rating assessed on the Visual Analog Scale (VAS) of the short-form McGill Pain Questionnaire between the Screening Phase and the Treatment Phase. All analyses were performed on the intent-to-treat population. RESULTS:: Thirty patients were enrolled in the trial. The mean daily oxcarbazepine dose during the Maintenance Phase was 814 mg. The mean VAS score dropped from 66.3 during the Screening Phase to 34.3 at the end of the trial (P = 0.0001), for a mean reduction of 48.3%. In addition, there were significant improvements in the total pain score and present pain intensity. Oxcarbazepine was well tolerated, with the most common adverse events consisting of drowsiness and dizziness. DISCUSSION:: The results suggest that oxcarbazepine administered as monotherapy is an efficacious and safe option for the symptomatic treatment of pain associated with symmetrical diabetic neuropathy. These results will need to be confirmed in large, double-blind, placebo-controlled, randomized clinical trials.
PMID: 15100593 [PubMed - as supplied by publisher]
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Path Model of Psychological Antecedents to Pain Experience: Experimental and Clinical Findings.
Sullivan MJ, Thorn B, Rodgers W, Ward LC.
*Departement de Psychologie, Universite de Montreal, Montreal, Quebec, Canada; daggerDepartment of Psychology, University of Alabama, Tuscaloosa, AL; double daggerFaculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada; and section signVA Medical Center, Tuscaloosa, AL.
OBJECTIVES:: Two studies are described addressing how anxiety, fear of pain, and catastrophizing impact on pain experience. METHODS:: In study 1, 66 undergraduates (34 men, 32 women) completed measures of state and trait anxiety, fear of pain, and catastrophizing prior to participating in a cold pressor procedure. In study 2, 60 undergraduates (30 men, 30 women) completed the same measures and participated in dental hygiene treatment and rated the pain they experienced during a scaling procedure (removing deposits from the tooth surface). RESULTS:: In both studies, fear of pain and catastrophizing were significantly correlated with pain intensity ratings, and fear of pain and catastrophizing were correlated with each other. Trait anxiety was correlated with catastrophizing but not with fear of pain or pain. Path analyses revealed significant paths from trait anxiety to state anxiety, from trait anxiety to catastrophizing, and from catastrophizing to pain intensity ratings. DISCUSSION:: The findings suggest that although fear of pain and catastrophizing are related constructs, catastrophizing provides unique predictive ability for pain ratings, while fear of pain does not. Clinical and theoretical implications of these findings are discussed.
PMID: 15100592 [PubMed - as supplied by publisher]
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Evaluating Pain Induced by Venipuncture in Pediatric Patients With Developmental Delay.
Benini F, Trapanotto M, Gobber D, Agosto C, Carli G, Drigo P, Eland J, Zacchello F.
*Department of Pediatrics, University of Padua, Italy and daggerCollege of Nursing, University of Iowa, Ames, IA.
OBJECTIVES:: Little attention has been paid to the assessment of pain in children with developmental delay. The aim of this study was to explore several methods for assessing pain during venipuncture in this population of children, using classic and modified scales to evaluate the children's response to simplified tools. METHODS:: Sixteen children with mild or moderate developmental delay were evaluated using three standard self-rating scales (Visual Analog Scale [VAS], Eland Scale, and Faces Scale) and three modified methods (Cube Test, Modified Eland Scale, and Modified Faces Scale), recording subjective self-ratings and behavioral expressions of pain during a venipuncture procedure, apart from the initial fear. The children's pain and reaction time were assessed by an outside observer, while their pain and fear were also evaluated by the parents. RESULTS:: The VAS was used without difficulty by all the children and revealed a good consistency with the Cube Test. The parents' and neutral observer's indirect pain assessment was also consistent with the child's evaluations. The Eland Scale proved difficult to use, especially for Down's syndrome children, while its modified version was easier. Results emerging from the original and modified Faces Scales were inconsistent. Frightened children attributed higher pain scores, demonstrating that negative emotions exacerbate the experience of pain in developmentally delayed children. The patients showed a limited capacity for verbal and behavioral expression in reaction to the painful stimulus (especially the Down's cases). DISCUSSION:: These findings support the conviction that even developmentally delayed children can use self-rating methods effectively. This sector demands further, more extensive study, including the development of simplified tools, to ensure an adequate pain assessment and optimal antalgic approach to this particular pediatric population.
PMID: 15100591 [PubMed - as supplied by publisher]
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A Randomized, Double-Blind, Parallel-Group Study Comparing the Analgesic Effect of Etoricoxib to Placebo, Naproxen Sodium, and Acetaminophen With Codeine Using the Dental Impaction Pain Model.
Malmstrom K, Kotey P, Coughlin H, Desjardins PJ.
*Department of Clinical Immunology & Analgesia and Department of Biostatistics, Merck Research Laboratories, Rahway, NJ; and daggerScirex Corporation, Austin, TX.
OBJECTIVE:: To compare the overall analgesic effect, including time to onset, peak and duration of effect for etoricoxib 120 mg, a new COX-2 selective inhibitor, in patients with acute pain to that of placebo. Naproxen sodium 550 mg and acetaminophen/codeine 600/60 mg were the active comparators. METHODS:: A total of 201 patients with moderate to severe pain following surgical extraction of >/=2 third molars, of which at least the mandibular tooth was impacted, were randomly allocated to receive single oral doses of placebo (n = 50), etoricoxib 120 mg (n = 50), naproxen sodium 550 mg (n = 51), or acetaminophen/codeine 600/60 mg (n = 50). The endpoints included total pain relief over 8 hours (TOPAR8, primary end point), sum of pain intensity difference over 8 hours, patient's global evaluation, onset, peak, and duration of analgesia. RESULTS:: Etoricoxib 120 mg had a significantly greater least squares (LS) mean TOPAR8 score than placebo (20.9 vs 5.4; P < 0.001) and acetaminophen/codeine 600/60 mg (20.9 vs 11.5; P < 0.001), and a similar LS mean TOPAR8 score to naproxen sodium 550 mg (20.9 vs 21.3). All three active treatments had rapid onset of analgesia, median time ~30 minutes. The duration of analgesic effect, defined as median time to rescue medication use, was >24 hours for etoricoxib, 20.8 hours for naproxen sodium, 3.6 hours for acetaminophen/codeine, and 1.6 hours for placebo. DISCUSSION:: Etoricoxib is a new COX-2 selective inhibitor under development for treatment of osteoarthritis, rheumatoid arthritis, and acute pain. In this study, etoricoxib 120 mg provided rapid and long-lasting pain relief to patients with moderate-to-severe postdental surgery pain. Etoricoxib was generally well tolerated.
PMID: 15100590 [PubMed - as supplied by publisher]
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Long-Term Peripheral Nerve Stimulation for Painful Nerve Injuries.
Eisenberg E, Waisbrod H, Gerbershagen HU.
*Pain Relief Unit, Rambam Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa Pain Research Group, Israel; daggerHaifa, Israel; and double daggerRed Cross Pain Center, Mainz, Germany.
BACKGROUND:: Although peripheral nerve stimulation (PNS) has been used in the treatment of pain since 1965, only a few follow-up studies have been published. The aim of the present retrospective study was to carefully assess the long-term efficacy and safety of PNS in the treatment of painful nerve injuries. METHODS:: Patients suffering from intractable pain due to peripheral nerve injuries underwent PNS after careful selection. Long-term results were evaluated based upon patients' reports of pain intensity on a visual analog scale (VAS) and their consumption of analgesics. Two categories of results were chosen: good, referring to 50% or more relief of pain with abstinence from analgesic medications; and poor, with less than 50% improvement. RESULTS:: Of 154 referred patients, 46 (26 women and 20 men) were found suitable for PNS. Four etiologic factors were identified, the most common being nerve lesion following an operation in the region of the hip or knee. Other etiologies included entrapment neuropathy, pain following nerve graft, and painful neuropathy following a traumatic injection. The follow-up period was 3-16 years. Of the 46 patients who underwent surgery, the results were classified as good in 36 (78%) patients and as poor in 10 (22%) patients. Overall, pain intensity dropped from a VAS of 69 +/- 12 before surgery to 24 +/- 28 postoperatively (P < 0.001). CONCLUSIONS:: PNS can produce good pain relief in the majority of carefully selected patients suffering from isolated painful neuropathies.
PMID: 15100589 [PubMed - as supplied by publisher]
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Comparison of the Redundancy, Reliability, and Responsiveness to Change Among SF-36, Oswestry Disability Index, and Multidimensional Pain Inventory.
Wittink H, Turk DC, Carr DB, Sukiennik A, Rogers W.
*Pain Management Program, Tufts-New England Medical Center, Boston, MA; daggerJohn and Emma Bonica Professor of Anesthesiology & Pain Research, Department of Anesthesiology, University of Washington, Seattle, WA; double daggerSaltonstall Professor of Pain Research, Pain Management Program, Tufts-New England Medical Center, Boston, MA; section signPain Management Program, Tufts-New England Medical Center, Boston, MA; and paragraph signDepartment of Clinical Care Research, the Health Institute, Tufts-New England Medical Center, Boston, MA.
OBJECTIVE:: To compare the Medical Outcomes Trust Short-Form-36 (SF-36), the Multidimensional Pain Inventory (MPI), and the Oswestry Disability Index (ODI) measures on internal consistency, domain overlap, and responsiveness in detecting changes following multidisciplinary pain treatment. METHODS:: 424 patients with chronic pain referred to a multidisciplinary pain center were assessed. Of these, 87 patients were assessed prior to and following treatment. Cronbach's alphas were calculated for each SF-36 and MPI domain, and for the ODI. Canonical correlation and regression analyses (R) described overlap. Responsiveness to change was computed from treatment effect size and significance. RESULTS:: Cronbach's alpha ranged from 0.69-0.92 for MPI domains, from 0.79-0.91 for SF-36 domains, and was 0.86 for the ODI. Three domains overlapped but several were unique (eg, the MPI "significant other" domains; R range 0.03-0.16). Significant changes following treatment were observed for the MPI Pain Severity, Interference and Outdoor Work Activities, the SF-36 Physical and Social Functioning, Bodily Pain, and the ODI. CONCLUSION:: The MPI, SF-36, and ODI each have good psychometric properties. Three domains overlapped between the MPI and the SF-36: pain, Interference/Social functioning, and mental health. The MPI and the SF-36 each contributed unique domains such as the SF-36 General Health and Vitality domains and the MPI "significant other" and physical activity domains. Several of the MPI domains were among the most sensitive to change. Because of its large normative sample and samples of patients with diverse medical disorders, the SF-36 may be particularly useful to compare chronic pain patients to those with other medical conditions. The ODI has the lowest respondent burden. The MPI and SF-36, although containing much overlapping information, both make unique and complementary contributions to assessing patients with chronic pain.
PMID: 15100588 [PubMed - as supplied by publisher]
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Analgesics for Acute Pain: Meeting the United States Food and Drug Administration's Requirements for Proof of Efficacy.
Ridgway D.
Lineberry Research Associates, Research Triangle Park, NC.
OBJECTIVE:: To examine the United States Food and Drug Administration's (FDA) standards for reviews of the scientific basis for efficacy claims for newly approved oral analgesics. METHODS:: Comparison of the trial methodologies and results provided by the FDA's medical reviewer in the Summary Bases of Approval (SBA) for the 9 oral acute analgesics approved in the last 10 years: ketorolac, diclofenac potassium, bromfenac, tramadol, hydrocodone/ibuprofen fixed combination, celecoxib, rofecoxib, tramadol/acetaminophen, and valdecoxib. RESULTS:: For all 9 new analgesics, studies were conducted in patients with postoperative dental pain and nondental surgical pain. The relief of gynecologic pain was examined for 5 of the new drugs. No studies in other pain models (such as infection, neuropathy, and nonsurgical trauma) supported claims of efficacy for any of the new drugs. The overall designs of the dental and nondental surgical studies, including timing of the single dose of trial drug, timing of evaluations, scales used for evaluations, and the use of both measured and derived outcome variables, were similar across the 8 development programs fully described in SBAs. Other characteristics of the trials, including choice of population for efficacy analyses, methods of carrying forward pain intensity and pain relief scores, and the length of time patients were encouraged to refrain from use of rescue medication differed across the development programs. CONCLUSION:: The requirements for approval of new analgesics in the United States encourage the pharmaceutical industry to perform efficacy studies using stylized designs in dental and nondental surgical pain. Studies of the efficacy of new analgesics in other common clinical settings are rarely or never included in development programs.
PMID: 15100587 [PubMed - as supplied by publisher]
Comment on:
Pre-emptive analgesia produced by interscalene blockade. What failed: the block or the methods?
Blumenthal S, Nadig M, Borgeat A.
Publication Types:
PMID: 14649349 [PubMed - indexed for MEDLINE]
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Perioperative intravenous adenosine infusion to extend postoperative analgesia in brachial plexus block.
Apan A, Ozcan S, Buyukkocak U, Anbarci O, Basar H.
Department of Anaesthesiology, Kirikkale University Faculty of Medicine, Kirikkale, Turkey. alpaslanapan@doctor.com
BACKGROUND AND OBJECTIVE: Adenosine infusions have been shown to reduce requirements of anaesthetics, to decrease the need for postoperative analgesics and to attenuate hyperaesthesia related to neuropathic pain. We decided to investigate the effects, beneficial or otherwise, of an adenosine infusion administered during surgery. A brachial plexus block was used to produce anaesthesia for the surgery. METHODS: Sixty adults undergoing upper extremity surgery were included in the study. Brachial plexus block was performed via an axillary approach with lidocaine 1.25% and epinephrine 1/200 000 (40 mL). Patients were randomly assigned to two groups. During surgery, saline (control) or adenosine 80 microg kg min was infused intravenously in a double-blind fashion for 1 h. Visual analogue scores every 4 h, analgesic consumption, time to first spontaneous pain sensation, time to first rescue analgesic and adverse effects were noted during the first 24 h. RESULTS: Vital signs were stable in both groups throughout surgery. During the adenosine infusion, one patient fainted while another complained of palpitations and tightness of the chest; both patients were excluded from further analyses. The time to first sensation of pain was significantly longer in the adenosine group compared to the control group (438 +/- 387 vs. 290 +/- 227 min, P = 0.02). The time to first rescue analgesic, the visual analogue scale scores and analgesic consumption in the postoperative period were similar. CONCLUSIONS: In patients undergoing surgery with an axillary plexus block, a perioperative adenosine infusion prolongs the duration of postoperative analgesia to some extent. However, the time to first rescue analgesic, total analgesic requirements and pain scores were unchanged; the risk of potentially serious adverse effects is high. This therapy cannot be recommended.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14649345 [PubMed - indexed for MEDLINE]
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Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial.
Naja MZ, Ziade MF, Lonnqvist PA.
Department of Anesthesia and Intensive Care, Makassed General Hospital, Beirut, Lebanon. zouhnaja@yahoo.com
BACKGROUND AND OBJECTIVE: Different anaesthetic techniques are used during breast surgery but are frequently associated with unsatisfactory postoperative analgesia. Paravertebral nerve blockade has recently been proposed as a favourable alternative for this type of surgical procedure, providing excellent pain relief and a reduced incidence of postoperative nausea and vomiting. The aim of the present study was to compare the use of a nerve-stimulator guided paravertebral nerve blockade technique to regular general anaesthesia for breast surgery. METHODS: Sixty patients were prospectively randomized to receive either paravertebral nerve blockade or general anaesthesia for breast surgery. The primary end-point of the study was to assess postoperative analgesia (visual analogue scale and supplemental opioid requirements); the incidence of postoperative nausea and vomiting and length of hospital stay were considered as secondary outcome measures. RESULTS: Visual analogue scores both at rest and at movement, as well as the need for supplemental opioid administration during the first 3 days postoperatively, were significantly lower in patients handled with para-vertebral nerve blockade compared to patients receiving general anaesthesia (P < 0.05). The number of patients free from nausea and vomiting after operation was significantly higher in the paravertebral nerve blockade group (93%) compared to the general anaesthesia group (67%) (P < 0.05). The use of paravertebral nerve blockade was also associated with a significantly shorter hospital stay (median 1 day) compared to general anaesthesia (2 days) (P < 0.01). Both the performance of the block and the intraoperative conditions was well accepted by the vast majority of patients treated by paravertebral nerve blockade (97%). CONCLUSION: The use of paravertebral nerve blockade was associated with improved postoperative pain relief, a reduced incidence of nausea and vomiting after operation and a shorter duration of hospital stay compared to general anaesthesia in patients undergoing breast surgery.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14649342 [PubMed - indexed for MEDLINE]
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Levobupivacaine 0.25% compared with ropivacaine 0.25% by the caudal route in children.
Astuto M, Disma N, Arena C.
Policlinico Universitario, Department of Anaesthesia, Catania, Italy. astmar@tiscalinet.it
BACKGROUND AND OBJECTIVE: Levobupivacaine is the most recently introduced local anaesthetic into clinical practice. In a randomized double-blinded study, the onset, intraoperative tolerance, postoperative analgesic effect, motor blockade and any adverse reactions produced by levobupivacaine were compared with ropivacaine. METHODS: Sixty children, ASA I-II, 2-6 yr old, undergoing elective minor surgery, received a single caudal injection of 1 mL kg(-1) of either levobupivacaine 0.25% or ropivacaine 0.25%. Caudal blocks were performed after induction of inhalation general anaesthesia using sevoflurane; anaesthesia was maintained via a laryngeal mask airway using a mixture of sevoflurane, oxygen and air. RESULTS: Onset time, intraoperative tolerance, postoperative analgesic effect and motor blockade were comparable between the two groups. The mean onset of the block was 8.2 +/- 2.2 min for levobupivacaine and 8.5 +/- 3.0 min for ropivacaine (P = 0.66). Additional analgesics during operation were not required in any of the children. No significant difference was found for mean time to requirement of additional analgesia with rectal acetaminophen (paracetamol) (302 +/- 29 min for the levobupivacaine group and 230 +/- 38 min for the ropivacaine group (P = 0.32)). During the first 4 h after placement of caudal block, the pain assessment score (according to the Children Hospital Eastern Ontario Pain Scale) was comparable for the two groups. No motor block was observed in any group on awakening, nor during the observation period. CONCLUSIONS: We conclude that levobupivacaine 0.25% 1 mL kg(-1) provides caudal block of comparable onset and duration, as produced by the same volume and concentration of ropivacaine.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14580053 [PubMed - indexed for MEDLINE]
Comment on:
Risk to the coronary arteries of intracoronary stem cell infusion and G-CSF cytokine therapy.
Matsubara H.
Department of Cardiovascular Medicine, Kyoto Prefectural University School of Medicine, Translational Research Center, Kyoto University Hospital, Kyoto, Japan. matsubah@koto.kpu-m.ac.jp
Publication Types:
PMID: 15016481 [PubMed - indexed for MEDLINE]
Comment on:
Intensive statin therapy--a sea change in cardiovascular prevention.
Topol EJ.
Publication Types:
PMID: 15007111 [PubMed - indexed for MEDLINE]
Comment in:
Intensive versus moderate lipid lowering with statins after acute coronary syndromes.
Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, Joyal SV, Hill KA, Pfeffer MA, Skene AM; Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators.
Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA. cpcannon@partners.org
BACKGROUND: Lipid-lowering therapy with statins reduces the risk of cardiovascular events, but the optimal level of low-density lipoprotein (LDL) cholesterol is unclear. METHODS: We enrolled 4162 patients who had been hospitalized for an acute coronary syndrome within the preceding 10 days and compared 40 mg of pravastatin daily (standard therapy) with 80 mg of atorvastatin daily (intensive therapy). The primary end point was a composite of death from any cause, myocardial infarction, documented unstable angina requiring rehospitalization, revascularization (performed at least 30 days after randomization), and stroke. The study was designed to establish the noninferiority of pravastatin as compared with atorvastatin with respect to the time to an end-point event. Follow-up lasted 18 to 36 months (mean, 24). RESULTS: The median LDL cholesterol level achieved during treatment was 95 mg per deciliter (2.46 mmol per liter) in the standard-dose pravastatin group and 62 mg per deciliter (1.60 mmol per liter) in the high-dose atorvastatin group (P<0.001). Kaplan-Meier estimates of the rates of the primary end point at two years were 26.3 percent in the pravastatin group and 22.4 percent in the atorvastatin group, reflecting a 16 percent reduction in the hazard ratio in favor of atorvastatin (P=0.005; 95 percent confidence interval, 5 to 26 percent). The study did not meet the prespecified criterion for equivalence but did identify the superiority of the more intensive regimen. CONCLUSIONS: Among patients who have recently had an acute coronary syndrome, an intensive lipid-lowering statin regimen provides greater protection against death or major cardiovascular events than does a standard regimen. These findings indicate that such patients benefit from early and continued lowering of LDL cholesterol to levels substantially below current target levels. Copyright 2004 Massachusetts Medical Society
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
PMID: 15007110 [PubMed - indexed for MEDLINE]
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Primary care involvement and outcomes of care in patients with a workers' compensation claim for back pain.
Atlas SJ, Wasiak R, van den Ancker M, Webster B, Pransky G.
General Medicine Division and the Clinical Epidemiology Unit, Medical Services, MA General Hospital, Harvard Medical School, Boston, MA 02114, USA. satlas@partners.org
STUDY DESIGN: A retrospective case series of primary care patients receiving Workers' Compensation (WC) for back pain. OBJECTIVE: To describe the extent of primary care provider (PCP) involvement in work-related low back pain (WRLBP), and whether PCP involvement is a significant determinant of patterns of care or outcomes. SUMMARY OF BACKGROUND DATA: In general, WRLBP has inferior outcomes compared with nonoccupational LBP. Although it has been suggested that better outcomes are achieved when care for WRLBP involves specialists such as occupational medicine physicians rather than a PCP, limited evidence supports this claim. METHODS: Adult patients were identified by electronic records from four hospital-affiliated PCP practices in fiscal years 1996 to 1998. Those with a WRLBP claim filed during the same time period were identified by searching a WC claims database. Medical records were reviewed to assess past medical history, the extent of prior PCP contacts for any visits before and for visits 2 years after the reported onset of the WRLBP claim, and detailed information on visits for this condition. Disability outcomes (total costs and days of work disability) were obtained from the WC database. RESULTS: Among 68,710 individuals with a PCP practice visit, 118 with a WRLBP claim were identified. The final study sample included 87 patients with a WRLBP claim and at least 1 documented PCP practice visit during the study period. Seventy-eight percent of patients saw the PCP at least once in the 2 years after the claim onset date, but only 34 patients (39%) visited the PCP for their WRLBP, and 20 (23%) had more than 1 visit. Although almost all patients with a PCP visit for WRLBP saw a physician (not the PCP in 79% of cases) within a week of the claim onset date, the median number of days between the onset date and the first WRLBP visit to the PCP was 47.5. Patients with a prior history of back problems were more likely to have a PCP visit for WRLBP (odds ratio 2.9, 95% confidence interval 1.1-7.7). Patients with PCP visits for WRLBP had higher total and medical costs than those without PCP visits, but a similar number of paid disability days. After controlling for other potential predictors, involvement of the PCP was not a significant predictor of the total cost of the WRLBP claim. CONCLUSIONS: Many individuals with a WC claim do not have a stable PCP relationship around the onset of their WRLBP episode. Those with PCP relationships uncommonly involve the PCP in their WRLBP, and if they do, it is usually later in the course because of persistent or recurrent symptoms. Disability outcomes appear to be similar regardless of whether a PCP was involved. However, PCP involvement is associated with greater medical costs, which may reflect confounding based on duration of symptoms rather than the nature of the care provided. Additional research is needed to understand how different patterns of care for patients with a WRLBP claim relate to outcomes and how these patients compare with individuals without such a claim, as well as the factors that lead patients to involve their PCP or not.
PMID: 15105679 [PubMed - in process]
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Factors related to the onset and persistence of chronic back pain in the community: results from a general population follow-up study.
Smith BH, Elliott AM, Hannaford PC, Chambers WA, Smith WC.
Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Aberdeen, UK. blairsmith@abdn.ac.uk
INTRODUCTION: We compared the prevalence of chronic back pain (CBP) at two points 4 years apart and examined socio-demographic, health, and pain-related factors associated with its onset and persistence. METHOD: A random population sample of 2,184 adults was surveyed in 1996 and resurveyed in 2000. The questionnaire included chronic pain case definition questions (pain for 3 months or longer); the cause (1996) or site (2000) of any chronic pain; the Chronic Pain Grade questionnaire; the Level of Expressed Need (LEN) questionnaire; the SF-36 general health questionnaire; and demographic questions. Those with CBP in 1996 and 2000 had "persistent" CBP; those with CBP in 1996 but not 2000 had "recovered" CBP; those with CBP in 2000 but not 1996 had "new" CBP. RESULTS: Corrected response rates were 82.3% (1996) and 83.0% (2000). The sample prevalence of CBP was 16% (1996) and 27% (2000). Factors in 1996 independently associated with "persistent" compared with "recovered" CBP were preexisting arthritis, high LEN, poor mental health, and not living alone. Factors independently predicting "new" CBP compared with no previous CBP were previous chronic pain elsewhere and poor physical health. "Persistent" CBP was associated with more severe pain, higher LEN, and poorer general health than "new" CBP. DISCUSSION: CBP is a common and lasting problem, whose persistence and onset are predicted by clinical (especially pain) and help-seeking behavior factors, rather than socio-demographic. Prevention should focus on these factors.
PMID: 15105678 [PubMed - in process]
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Do primary-care clinicians think that nonspecific low back pain is one condition?
Kent P, Keating J.
School of Physiotherapy, La Trobe University, Melbourne, Victoria, Australia. peter.kent@latrobe.edu.au
STUDY DESIGN: Postal survey. OBJECTIVES.: To determine whether Australian primary-care clinicians think that nonspecific low back pain (NSLBP) is one condition or a number of conditions (subgroups), and whether this belief influences their management of NSLBP. SUMMARY OF BACKGROUND DATA: Most low back pain (LBP) remains a diagnostic enigma and results in approximately 80% of primary care LBP presentations being most accurately labeled as "nonspecific LBP." Manual therapy clinicians (chiropractors, osteopaths, physiotherapists) are trained to think that subgroups exist within the NSLBP population. This research sought to identify the extent to which these beliefs are widely held in primary care. METHODS: A survey was conducted of 1,093 primary-contact clinicians from six professional disciplines (physiotherapists, manipulative physiotherapists, chiropractors, osteopaths, general medical practitioners, and musculoskeletal medicine practitioners). RESULTS: Completed questionnaires were returned by 651 (60%) clinicians. Of the primary-contact clinicians who responded, 93% do not think NSLBP is one condition. Seventy-four percent think that it is currently possible to recognize NSLBP subgroups. Ninety-three percent treat NSLBP differently based on patterns of signs and symptoms. The proportions of clinicians who hold these views were highest for physiotherapists and manipulative physiotherapists, and smallest for general medical practitioners and musculoskeletal medicine practitioners. CONCLUSIONS: Although assigning NSLBP patients to subgroups has not been validated, it is common in primary-care settings and influences case management. If subgroups exist within the NSLBP population, there are implications for research into the effects of treatment. Further research into the validity of subgroups is warranted.
PMID: 15105677 [PubMed - in process]
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Variation in back pain between countries: the example of Britain and Germany.
Raspe H, Matthis C, Croft P, O'Neill T; European Vertebral Osteoporosis Study Group.
Institute for Social Medicine, Medical University of Lubeck, Lubeck, Germany. heiner.raspe@sozmed.mu-luebeck.de
STUDY DESIGN: Cross-sectional survey with personal interviews. OBJECTIVE: To study national differences in subjective health, back pain, and self-perceived disability between the United Kingdom and Germany. SUMMARY OF BACKGROUND DATA: Back pain is a leading health problem in most Western populations, causing enormous costs to the national health systems. Different prevalence rates were reported from many countries, but rarely as a result of a direct comparison based on an identical study design. METHODS: A total of 6,235 male and female participants 50 to 79 years of age (population-based stratified random samples) were recruited in 6 British and 8 German study centers. The interviewer administered standardized questionnaire included a section about presence and severity of back pain. RESULTS: Past and current back pain was more frequent among German participants and different between East and West German centers. The differences in back pain prevalence rates could not be explained by less favorable risk profiles among German respondents. CONCLUSIONS: Intercultural differences in perceiving or reporting back pain can be hypothesized as the most likely explanation of the markedly different prevalence rates of the disorder in the United Kingdom and East and West Germany.
PMID: 15105675 [PubMed - in process]
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Triple pelvic ring fixation in patients with severe pregnancy-related low back and pelvic pain.
van Zwienen CM, van den Bosch EW, Snijders CJ, van Vugt AB.
University Hospital Rotterdam, Department of Traumatology, Rotterdam, The Netherlands.
STUDY DESIGN: Single-group prospective follow-up study. OBJECTIVES: To assess the functional outcome of internal fixation of the pelvic ring in patients with severe pregnancy-related low back and pelvic pain (PLBP) in whom all other treatments failed. BACKGROUND DATA: More than half of all pregnant women experience PLBP. In most cases, the pain disappears after childbirth. In some, however, the pain becomes chronic and patients may be wheelchair-bound or bedridden. After failure of all conservative treatment, surgical fixation of the pelvic ring seems to be the only remaining option for those severe cases. MATERIALS AND METHODS: The postsurgical functional outcome of 58 severe PLBP patients was evaluated with the Majeed score and endurance of walking, sitting, and standing. Inclusion criteria were serious disability and failure of all conservative treatment. The surgical technique consisted of a symphysiodesis and bilateral percutaneous placement of two sacroiliac screws under fluoroscopic guidance. RESULTS: With a follow-up of an average of 2.1 years, the difference between preoperative and postoperative Majeed score indicated that an improvement of more than 10 points was achieved in 69.8% and 89.3% of the patients at 12 and 24 months, respectively. The most important complications were irritation of nerve roots (8.6%), nonunion of the symphysis (15.5%), failure of the symphyseal plate (3.4%), and pulmonary embolism (1.7%). CONCLUSIONS: In this preliminary study, surgical fixation of the pelvic ring yielded satisfactory results in severe PLBP patients in terms of pain relief and improvement in ADL functions. These results should be confirmed in a randomized clinical trial.
PMID: 15094546 [PubMed - in process]
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Low back pain among endurance athletes with and without specific back loading--a cross-sectional survey of cross-country skiers, rowers, orienteerers, and nonathletic controls.
Bahr R, Andersen SO, Loken S, Fossan B, Hansen T, Holme I.
Oslo Sports Trauma Research Center, University of Sport & Physical Education, Oslo, Norway. roald@nih.no
STUDY DESIGN: Cross-sectional survey among athletes competing at the national elite level in cross-country skiing, rowing, and orienteering, as well as a matched nonathletic control group. OBJECTIVE: To compare the prevalence of symptoms of low back pain between endurance sports with different loading characteristics on the lumbar region: cross-country skiing, rowing, and orienteering, as well as a nonathletic control group. SUMMARY OF BACKGROUND DATA: Although it is claimed that back pain is a frequent problem in endurance sports loading the lower spine such as rowing or cross-country skiing, the prevalence of low back problems in such sports has not been compared with relevant control groups. METHODS: Self-reported questionnaire on low back pain adapted for sports based on standardized Nordic questionnaires for musculoskeletal symptoms. Responders were 257 cross-country skiers (response rate: 100%), 199 rowers (99.5%), and 278 orienteerers (99.3%), and 197 control subjects (66%). RESULTS: Low back pain was reported to be somewhat more common among cross-country skiers and rowers than orienteerers and nonathletic controls. The prevalence among cross-country skiers of reported low back pain ever (65.4%) and low back pain during the previous 12 months (63.0%) was higher than nonathletic controls (OR [95% CI]: 1.94 [1.29-2.92]). Rowers (25.6%) reported missing training because of low back pain more frequently than orienteerers did (13.7%, OR: 2.16 [1.25-3.74]). The athletes reported more low back pain during periods when training and competition load was higher, and cross-country skiers more frequently reported having low back problems using classic than freestyle skiing techniques. CONCLUSIONS: Low back pain appears to be somewhat more common in endurance sports that specifically load the low back during training and competition. The relationship between seasonal training patterns and specific skiing techniques indicate that there is a relationship between low back pain and the specific loading patterns of skiing and rowing.
PMID: 15094542 [PubMed - in process]
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Outcomes of workers' compensation claimants with low back pain undergoing intradiscal electrothermal therapy.
Webster BS, Verma S, Pransky GS.
Liberty Mutual Center for Disability Research, Hopkinton, MA 01748, USA. barbara.webster@libertymutual.com
STUDY DESIGN: Case series. OBJECTIVE: To describe the outcomes of workers' compensation (WC) claimants who have had a lumbar intradiscal electrothermal therapy (IDET) procedure. SUMMARY OF BACKGROUND DATA: IDET was developed as a less invasive treatment alternative to fusion after failure of conservative treatment for discogenic low back pain (LBP). Initial IDET case series from single practices have reported improved pain, function, and return to work outcomes. Little is known about results when performed by a variety of providers or in WC populations. MATERIALS AND METHODS: LBP cases that underwent IDET between December 1, 1998 and February 29, 2000 were identified from WC records. Data sources included hardcopy claim files, administrative medical billing data, and computerized claim file narrative reports. Outcomes included narcotic use 6 months or more after IDET, additional invasive treatment after IDET (low back injections or surgery), and improved work status 24 months after IDET. RESULTS: One hundred forty-two cases from 23 states were identified, with 97 different providers performing the procedure. Mean duration of symptoms before IDET was 26 months. Mean follow-up duration after IDET was 22 months. Ninety-six (68%) of the cases did not meet one or more of the published inclusion criteria. Seventy-eight cases (55%) received at least two narcotic prescriptions 6 months or more after IDET. Fifty-three (37%) had at least one lumbar injection and 32 (23%) had lumbar surgery after IDET. A total of 55 (39%) were working at 24 months after IDET; of these, 28 (20%) were not working and 27 (19%) were working before IDET. Narcotic use after IDET was associated with narcotic use before IDET, the same provider performing discography and IDET (provider self-referral), and positive signs of radiculopathy (C = 0.80). Need for invasive lumbar procedures after IDET were associated with provider self-referral, narcotic use before IDET, and older age (C = 0.73). Continued work absence after IDET was associated with provider self-referral, male gender, litigation, narcotic use before IDET, and older age (C = 0.83). Conformance with published selection criteria for IDET was not associated with provider self-referral or outcomes, nor was duration before IDET associated with outcomes. CONCLUSION: The procedure may be less effective when performed by a variety of providers than suggested by initial case series performed by single providers or practices in work-related LBP cases. Provider self-referral and narcotic use before IDET are significant risk factors for poor outcomes. Randomized controlled trials are needed to determine whether there is a subset of patients with discogenic back pain who derive substantial and sustained benefit from this procedure.
PMID: 15094540 [PubMed - in process]
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Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish Lumbar Spine Study: a multicenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group.
Fritzell P, Hagg O, Jonsson D, Nordwall A; Swedish Lumbar Spine Study Group.
Department of Orthopedic Surgery, Falun Hospital, Falun, Sweden. peter.fritzell@ltdalarna.se
STUDY DESIGN: A cost-effectiveness study was performed from the societal and health care perspectives. OBJECTIVE: To evaluate the costs-effectiveness of lumbar fusion for chronic low back pain (CLBP) during a 2-year follow-up. SUMMARY OF BACKGROUND DATA: A full economic evaluation comparing costs related to treatment effects in patients with CLBP is lacking. PATIENTS AND METHODS: A total of 284 of 294 patients with CLBP for at least 2 years were randomized to either lumbar fusion or a nonsurgical control group. Costs for the health care sector (direct costs), and costs associated with production losses (indirect costs) were calculated. Societal total costs were identified as the sum of direct and indirect costs. Treatment effects were measured using patient global assessment of improvement, back pain (VAS), functional disability (Owestry), and return to work. RESULTS: The societal total cost per patient (standard deviations) in the surgical group was significantly higher than in the nonsurgical group: Swedish kroner (SEK) 704,000 (254,000) vs. SEK 636,000 (208,000). The cost per patient for the health care sector was significantly higher for the surgical group, SEK 123,000 (60,100) vs. 65,200 (38,400) for the control group. All treatment effects were significantly better after surgery. The incremental cost-effectiveness ratio (ICER), illustrating the extra cost per extra effect unit gained by using fusion instead of nonsurgical treatment, were for improvement: SEK 2,600 (600-5,900), for back pain: SEK 5,200 (1,100-11,500), for Oswestry: SEK 11,300 (1,200-48,000), and for return to work: SEK 4,100 (100-21,400). CONCLUSION: For both the society and the health care sectors, the 2-year costs for lumbar fusion was significantly higher compared with nonsurgical treatment but all treatment effects were significantly in favor of surgery. The probability of lumbar fusion being cost-effective increased with the value put on extra effect units gained by using surgery.
PMID: 15094539 [PubMed - in process]
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The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a randomized controlled trial.
Stuge B, Laerum E, Kirkesola G, Vollestad N.
Section for Health Science, University of Oslo, Oslo, Norway. B.K.Stuge@helsefag.uio.no
STUDY DESIGN: A randomized controlled trial with stratified block design. OBJECTIVES: To evaluate a treatment program focusing on whether specific stabilizing exercises for patients with pelvic girdle pain after pregnancy reduce pain, improve functional status, and improve quality of life. SUMMARY OF BACKGROUND DATA. : The evidence of effectiveness of treatment for pelvic girdle pain is weak. Recent research has focused on the importance of activation of muscles for motor control and stability of the lumbopelvic region. To the authors' knowledge, the efficacy of applying these principles for pelvic girdle pain has not previously been evaluated in a randomized controlled trial. METHODS: Eighty-one women with pelvic girdle pain were assigned randomly to two treatment groups for 20 weeks. One group received physical therapy with a focus on specific stabilizing exercises. The other group received individualized physical therapy without specific stabilizing exercises. Assessments were administered by a blinded assessor, at baseline, after intervention and 1 year post partum. Main outcome measures were pain, functional status and quality of life. RESULTS: There were no dropouts. After intervention and at 1 year post partum, the specific stabilizing exercise group showed statistically and clinically significant lower pain intensity, lower disability, and higher quality of life compared with the control group. Group difference in median values for evening pain after treatment was 30 mm on the Visual Analog Scale. Disability was reduced by more than 50% for the exercise group; changes were negligible in the control group. Significant differences were also observed for physical tests, in favor of the specific exercise group. CONCLUSION: An individualized treatment approach with specific stabilizing exercises appears to be more effective than physical therapy without specific stabilizing exercises for women with pelvic girdle pain after pregnancy.
PMID: 15094530 [PubMed - in process]
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