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Oligoanalgesia in ED patients with isolated extremity injury without documented fracture.
Pines JM, Perron AD.
Publication Types:
PMID: 16032645 [PubMed - indexed for MEDLINE]
The role of opioids in cancer pain.
Quigley C.
Cancer Centre, Hammersmith Hospital, London W12 0HZ. cquigley@hhnt.nhs.uk
Publication Types:
PMID: 16210282 [PubMed - indexed for MEDLINE]
Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery{dagger}
Vogt A, Stieger DS, Theurillat C, Curatolo M.
Department of Anaesthesiology, Division of Thoracic Surgery, University Hospital of Bern, Inselspital, 3010 Bern, Switzerland.
BACKGROUND: Thoracoscopic surgery can be associated with considerable postoperative pain. While the benefits of paravertebral block on pain after thoracotomy have been demonstrated, no investigations on the effects of paravertebral block on pain after thoracoscopy have been conducted. We tested the hypothesis that a single-injection thoracic paravertebral block, performed preoperatively, reduces pain scores after thoracoscopic surgery. METHODS: Of 45 patients recruited, 40 completed the study. They were randomly allocated to two groups: the paravertebral group received i.v. patient-controlled analgesia (PCA) with morphine plus single-injection thoracic paravertebral block with bupivacaine 0.375% and adrenaline 1:200 000 0.4 ml kg(-1) (n=20). The control group was treated with a back puncture without injection and morphine PCA (n=20). RESULTS: The main outcomes recorded during 48 h after surgery were pain scores using the visual analogue scale (VAS, 0-100). Secondary outcomes were cumulative morphine consumption and peak expiratory flow rate (PEFR). Half an hour and 24 h after surgery, median (25th-75th percentiles) VAS on coughing in the paravertebral group was 31.0 (20.0-55.0) and 30.5 (17.5-40.0) respectively and in the control group it was 70.0 (30.0-100.0) and 50.0 (25.0-75.0) respectively. The difference between the groups over the whole observation period was statistically significant (P<0.05). Twenty-four and 48 h after surgery, median (25th-75th percentiles) cumulative morphine consumption (mg) was 49.0 (38.3-87.0) and 69.3 (38.8-118.5) respectively in the paravertebral group and 51.2 (36.0-84.1) and 78.1 (38.4-93.1) in the control group (statistically not significant). No differences were found in PEFR or the incidence of any side-effects between groups. CONCLUSION: We conclude that single-shot preoperative paravertebral block improves post-operative pain treatment after thoracoscopic surgery in a clinically significant fashion.
PMID: 16199417 [PubMed - as supplied by publisher]
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Concentration-dependent suppression of F-waves by sevoflurane does not predict immobility to painful stimuli in humans{dagger}
Baars JH, Kalisch D, Herold KF, Hadzidiakos DA, Rehberg B.
Department of Anaesthesiology, Charite Campus Mitte, Schumannstrasse 20/21, D-10098 Berlin, Germany.
BACKGROUND: Decreased spinal excitability contributes to the immobilizing effects of halogenated ethers during general anaesthesia. Recurrent spinal responses such as F-waves reflect spinal excitability and are suppressed by volatile anaesthetics. To evaluate whether F-waves are suitable for monitoring immobility, the concentration-dependent effects of sevoflurane on F-waves were compared with effects on the Bispectral Index(TM) (BIS(TM)). The predictive power of all parameters for movement responses to noxious stimuli was tested. In addition, the effect of the noxious stimulus itself on F-waves was investigated. METHODS: In 28 patients, F-waves were recorded during sevoflurane anaesthesia at a frequency of 0.2 Hz at the lower limb. To insert a laryngeal mask, the sevoflurane concentration was initially increased to approximately 4%, which caused a complete extinction of F-waves. The sevoflurane concentration was then reduced until the F-waves recovered. BIS and spectral edge frequency (SEF95) were recorded continuously. The t1/2ke0 and EC50 values of the F-wave persistence and amplitude were calculated using a standard pharmacokinetic-pharmacodynamic model. During decreasing sevoflurane concentration motor responses to tetanic electrical stimulation (50 Hz, 60 mA, 5 s, volar forearm) were tested in seven patients and MACtetanus was calculated using logistic regression. RESULTS: Sevoflurane reduces the F-wave amplitude with an EC50 of 0.79 vol% at a far lower concentration than the calculated MACtetanus (1.5 vol%), whereas the F-wave persistence yields an EC50 of 1.4 vol%. Spinal and EEG parameters predicted the motor responses to movement better than chance alone, but did not differ significantly from each other. CONCLUSION: F-waves, especially the F-wave amplitude, cannot be used to predict movement to noxious stimuli during sevoflurane anaesthesia because they are almost completely suppressed at subclinical sevoflurane concentrations. Either the particular motoneurone pool (the largest motoneurones) assessed by F-waves is not involved in generating movement to painful stimuli or direct effects on motoneurone excitability are not involved in the suppression of movement to painful stimuli by sevoflurane.
PMID: 16199415 [PubMed - as supplied by publisher]
Sacroiliac joint dysfunction: evaluation and management.
Zelle BA, Gruen GS, Brown S, George S.
Department of Orthopaedic Surgery, Division of Orthopaedic Traumatology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
Sacroiliac joint dysfunction is believed to be a significant source of low back and posterior pelvic pain. METHODS: To assess the clinical presentation, diagnostic testing, and treatment options for sacroiliac joint dysfunction, a systematic literature review was performed using MEDLINE. RESULTS: Presently, there are no widely accepted guidelines in the literature for the diagnosis and treatment of sacroiliac instability. Establishing management guidelines for this disorder has been complicated by the large spectrum of different etiologic factors, the variability of patient history and clinical symptoms, limited availability of objective testing, and incomplete understanding of the biomechanics of the sacroiliac joint. CONCLUSIONS: A reliable examination technique to identify the sacroiliac joint as a source of low back pain seems to be pain relief following a radiologically guided injection of a local anaesthetic into the sacroiliac joint. Most patients respond to non-operative treatment. Patients who do not respond to non-operative treatment should be considered for operative sacroiliac joint stabilization.
Publication Types:
PMID: 16093751 [PubMed - indexed for MEDLINE]
Effects of hyperbaric spinal ropivacaine for caesarean section: with or without fentanyl.
Sanli S, Yegin A, Kayacan N, Yilmaz M, Coskunfirat N, Karsli B.
Akdeniz University, Faculty of Medicine, Department of Anaesthesiology, Antalya, Turkey. suatsanli@superonline.com
BACKGROUND AND OBJECTIVE: Adding various opioids to the local anaesthetic solution administrated intrathecally improves the analgesic potency of spinal analgesia. The purpose of this study was to evaluate the efficacy and safety of intrathecal fentanyl 10 microg added to 15 mg hyperbaric ropivacaine in patients undergoing caesarean section under spinal anaesthesia. METHODS: Thirty-seven healthy, full-term parturients were randomly assigned into two groups: Group S (saline group, n=17) received 15 mg hyperbaric ropivacaine in 2.5 mL + 0.5 mL saline; Group F (fentanyl group, n=20) received 15 mg hyperbaric ropivacaine in 2.5 mL + 10 microg fentanyl in 0.5 mL, intrathecally. Characteristics of spinal block, intraoperative quality of spinal anaesthesia, time to first feeling of pain (complete analgesia), time to first request of analgesics postoperatively (effective analgesia), side-effects and fetal outcomes were evaluated. RESULTS: Regression of sensory block to L5 was significantly prolonged in the fentanyl group compared with the saline group (P = 0.001). Time to the first feeling of pain (130.6 +/- 15.8 min vs. 154.3 +/- 31.1 min; P = 0.008) and the first analgesic requirement (161.2 +/- 32.6 min vs. 213.0 +/- 29.3 min; P < 0.001) were significantly shorter in the saline group compared with the fentanyl group. Side-effects, umbilical arterial and venous blood gases did not differ between the groups. Apgar scores were similar in both groups and no infants had an Apgar score < or =7 at 5 min. CONCLUSIONS: The addition of fentanyl 10 microg, to hyperbaric ropivacaine 15 mg, for spinal anaesthesia increased the duration of analgesia in the early postoperative period in patients undergoing caesarean delivery.
Publication Types:
PMID: 15991510 [PubMed - indexed for MEDLINE]
Addition of dexmedetomidine to lidocaine for intravenous regional anaesthesia.
Esmaoglu A, Mizrak A, Akin A, Turk Y, Boyaci A.
Erciyes University Medical Faculty, Department of Anaesthesiology and Reanimation, Kayseri, Turkey. aliye@operamail.com
BACKGROUND AND OBJECTIVE: The aim of this study was to determine the duration of onset and regression time of sensory and motor blocks, the quality of anaesthesia and postoperative analgesia by the addition of dexmedetomidine to local anaesthetic solution in intravenous regional anaesthesia (IVRA). METHODS: Forty patients scheduled for elective hand surgery participated in this prospective randomized double-blind study. The IVRA was achieved using 3 mg kg(-1) lidocaine diluted with saline to a total volume of 40 mL in the control group or 1 microg kg(-1) of dexmedetomidine + 3 mg kg(-1) lidocaine diluted with saline to a total volume of 40 mL in the dexmedetomidine group. The onset and regression times for sensory and motor blocks were recorded. Qualities of anaesthesia, intraoperative and postoperative analgesic requirements were noted. RESULTS: There was no difference between the groups with respect to sensory and motor blocks onset and regression time. The quality of anaesthesia was better in the dexmedetomidine group than the control group and the difference was statistically significant. Intraoperative and postoperative analgesic requirements were greater in the control group than in the dexmedetomidine group. CONCLUSIONS: Addition of dexmedetomidine to local anaesthetic solution in IVRA improved the quality of anaesthesia and decreased analgesic requirements, but had no effect on the sensory and motor blocks onset and regression times.
Publication Types:
PMID: 15991508 [PubMed - indexed for MEDLINE]
Evaluation of a local anaesthesia regimen using a subphrenic catheter after gynaecological laparoscopy.
Ozer Y, Tanriverdi HA, Ozkocak I, Altunkaya H, Demirel CB, Bayar U, Barut A.
Zonguldak Karaelmas University Hospital, Department of Anaesthesiology and Reanimation, Zonguldak, Turkey. yetkin.ozer@tr.net
BACKGROUND AND OBJECTIVE: The purpose of intraperitoneal local anaesthetic administration is to block visceral nociceptive conduction and to provide an additional route of analgesia. The present study evaluates the effects of sequential injections of bupivacaine on postoperative pain through a subphrenic catheter. METHODS: In this double-blinded controlled study, patients scheduled for gynaecological laparoscopy were randomly divided into two groups. One group received 20 mL of saline with 1:200000 epinephrine through a subphrenic catheter before the incision closure and at 4-hourly intervals for the first postoperative 20 h. The second group received 20 mL of bupivacaine 0.125% with 1:200000 epinephrine at the same injection times. Postoperative pain scores and consumption of analgesics were compared. RESULTS: There were no statistical differences in pain scores at rest or incidence of shoulder pain between the two groups, but the patients of the bupivacaine group reported lower pain scores on coughing only in the first hour postoperatively (P = 0.007). Although the patients consumed comparable amounts of metamizole and ondansetron, the number of patients requiring supplemental meperidine and flurbiprofen in the bupivacaine group were significantly lower than in the saline group (P < 0.05). CONCLUSIONS: This study demonstrates that intraperitoneal bupivacaine may reduce pain on coughing in the early postoperative period and the consumption of analgesics postoperatively. The subphrenic catheter technique had no impact upon pain at rest and shoulder-tip pain after gynaecological laparoscopy.
Publication Types:
PMID: 15991507 [PubMed - indexed for MEDLINE]
Postoperative condition after the use of remifentanil with a small dose of piritramide compared with a fentanyl-based protocol in patients undergoing craniotomy.
van der Zwan T, Baerts WD, Perez RS, de Lange JJ.
VU University Medical Centre, Department of Anesthesiology, Amsterdam, The Netherlands. tvdzwan@kabelfoon.nl
BACKGROUND AND OBJECTIVE: The use of remifentanil requires other analgesics for postoperative pain relief compared to fentanyl in patients undergoing craniotomy. This could possibly reduce the postoperative advantages of this short-acting opioid. METHODS: We compared remifentanil and fentanyl-based anaesthesia in a randomized observer and patient blinded trial on patients, undergoing an elective craniotomy. Twenty patients received anaesthesia using remifentanil with a small dose of piritramide (0.1 mg kg(-1)) after closure of the dura mater. Twenty patients underwent a fentanyl-based protocol. In both groups, anaesthesia was induced with thiopental and rocuronium, and maintained with 0.6-1 minimum alveolar concentration (MAC) isoflurane in a nitrous oxide/oxygen mixture 2:1 and rocuronium. Patients received 1 g of paracetamol rectally postoperatively. A visual analogue scale (VAS) for pain, the Glasgow Coma Score, a modified Aldrete Score, arterial carbon dioxide tension (PaCO2) and piritramide consumption were evaluated every half an hour postoperatively. RESULTS: No significant differences were found for pain, Aldrete or Glasgow Coma scores or for PaCO2 between the groups when controlled for age, although the pain and Glasgow Coma Scores were consistently higher and PaCO2 lower in the remifentanil group. Furthermore, 11 out of 20 patients in the remifentanil group requested extra piritramide as opposed to 7 out of 20 in the fentanyl group (P = 0.11). CONCLUSIONS: Despite the intraoperative use of piritramide in the remifentanil group, patients experienced more pain postoperatively. A significant influence of age on pain intensity was found. The use of remifentanil with a small dose of piritramide of 0.1 mg kg(-1) has no evident advantage over the use of fentanyl considering the postoperative conditions after craniotomy.
Publication Types:
PMID: 15991506 [PubMed - indexed for MEDLINE]
Low-dose ketamine failed to spare morphine after a remifentanil-based anaesthesia for ear, nose and throat surgery.
Ganne O, Abisseror M, Menault P, Malhiere S, Chambost V, Charpiat B, Ganne C, Viale JP.
Hopital de Villefranche-sur-Saone, Department of Anaesthesiology, Villefranche-sur-Saone, France.
BACKGROUND: Ketamine has been claimed to prevent acute opioid tolerance and hyperalgesia following acute exposure to opioids and its use has been proposed to decrease postoperative morphine consumption. METHODS: We conducted a randomized, double-blind, controlled study to evaluate the effect of intravenous (i.v.) ketamine on postoperative pain for 48 h after major ear, nose and throat (ENT) surgery. Thirty-one patients received i.v. ketamine 0.15 mg kg(-1) before induction and 2 microg kg(-1) min(-1) during anaesthesia, and 31 patients were administered placebo in a similar manner. Anaesthesia was standardized with remifentanil and propofol, but without nitrous oxide. Standardized postoperative analgesia included paracetamol, methylprednisolone and morphine administered via a patient controlled analgesia (PCA) device. RESULTS: Intra-operative remifentanil consumption was not different between the ketamine group (0.25 +/- 0.07 microg kg(-1) min(-1)) and the control group (0.22 +/- 0.07 microg kg(-1) min(-1)). In the postoperative period, both groups experienced an identical pain course evolution. Cumulative morphine consumption was not significantly different between groups: at 24 h it was 33.3 +/- 14.9 with ketamine and 31.9 +/- 15.3 mg in controls, at 48h it was 40.4 +/- 20.6 mg with ketamine and 42.5 +/- 25.9 mg in controls. CONCLUSION: Low-dose ketamine added to a remifentanil-based propofol anaesthesia did not reduce morphine consumption after major ENT surgery.
Publication Types:
PMID: 15991504 [PubMed - indexed for MEDLINE]
Extracephalic tenderness and pressure pain threshold in children with headache.
Metsahonkala L, Anttila P, Laimi K, Aromaa M, Helenius H, Mikkelsson M, Jappila E, Viander S, Sillanpaa M, Salminen J.
Department of Child Neurology, Helsinki University Hospital, Helsinki, Finland.
BACKGROUND: Sensitisation of the pain detection system has been suggested to be involved in the pathogenesis of recurrent headache. In adults, increased sensitivity to pain has been found in patients with chronic tension type headache. Children with migraine or with unspecific headache report non-headache pains and interictal pericranial muscular tenderness more often than headache-free children. OBJECTIVE: To study if children with different types of headache report non-headache pain more often than children with no headache and if extracephalic muscular tenderness is different in children with headache in comparison to headache-free children. To find out if interval to the headache episode has influence on the extracranial muscular tenderness. DESIGN: A population-based sample of 13-year-old children with migraine (n=48), episodic tension type headache (61) or no headache (59) were interviewed for the occurrence and characteristics of headache and fulfilled a questionnaire on non-headache pain. A structured manual palpation test on muscular tenderness and a pain threshold measurement were done on seven cephalic and three extracephalic points. RESULTS: Children with migraine reported other pains, especially stomach pain and limb pain more often than children with episodic tension type or no headache. There were no significant differences in the extracephalic muscular tenderness or in the pressure pain thresholds between the three groups. CONCLUSIONS: Children with migraine experience more non-headache pains than children with episodic tension type headache and with no headache. However, neither children with migraine nor children with episodic tension type headache show increased interictal extracephalic muscular sensitivity for palpation.
PMID: 16203164 [PubMed - as supplied by publisher]
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HKF-R 10 - Screening for predicting chronicity in acute low back pain (LBP): A prospective clinical trial.
Neubauer E, Junge A, Pirron P, Seemann H, Schiltenwolf M.
Orthopedic University Clinic, Schlierbacher Landstrasse 200a, Heidelberg 69118, Germany.
STUDY DESIGN: Prospective cohort study. OBJECTIVES: To develop a short instrument to reliably predict chronicity in low back pain (LBP). SUMMARY OF BACKGROUND DATA: Health care expenditures on the treatment of low back pain continue to increase. It is therefore important to prevent the development of chronicity. In Germany, there is at present no early risk assessment tool to predict the risk of developing chronic LBP for patients presenting with acute LBP. Undertaken in an orthopedic practice setting, this study examined known risk factors for chronicity. It resulted in the development of a short questionnaire that successfully predicted the course of chronicity with an accuracy of 78%. METHODS: A cohort of 192 orthopaedic outpatients was assessed for clinical, behavioral, emotional, and cognitive parameters bsed on a self-report test battery of 167 established items predictive for chronicity in LBP. Chronicity was defined as back pain persisting for longer than six months. Logistic regression analysis was performed to evaluate the predictive value of all items significantly associated with the dependent variable. RESULTS: The study found the following items to have the strongest predictive value in the development of chronicity: "How strong was your back pain during the last week when it was most tolerable?" and the question "How much residual pain would you be willing to tolerate while still considering the therapy successful?" These were followed by the variables for "Duration of existing LBP" (more than eight days), the patient's educational level (low levels are related to higher risks of chronicity) and pain being experienced elsewhere in the body. Other significant factors were five items assessing depression (Zung) and the palliative effect of therapeutic massage (where a positive correlation was found). Female patients have a higher risk for chronicity, as do patients with a high total score on the scales assessing "catastrophizing thoughts" and thoughts of "helplessness". CONCLUSION: Using the items listed above, the study was able to predict a patient's risk of developing chronic LBP with a probability of 78%. These items were assembled in a brief questionnaire and were paired with a corresponding evaluative tool. This enables practitioners to assess an individual patient's risk for chronicity by means of a simple calculator in just a few minutes. A validation study for the questionnaire is currently being prepared. MINI ABSTRACT: The objective of this study was the development of a brief questionnaire to assess the risk for chronicity for LBP.
PMID: 16202634 [PubMed - as supplied by publisher]
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Do fundamental fears differentially contribute to pain-related fear and pain catastrophizing? An evaluation of the sensitivity index.
Vancleef LM, Peters ML, Roelofs J, Asmundson GJ.
Department of Medical, Clinical and Experimental Psychology, Maastricht University, Universiteitssingel 50, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
Three fundamental fears - anxiety sensitivity (AS), injury/illness sensitivity (IS) and fear of negative evaluation (FNE) - have been proposed to underlie common fears and psychopathological conditions. In pain research, the relation between AS and (chronic) pain processes was the subject of several studies, whereas the possible role of IS has been ignored. The current research examines the role of IS with respect to various pain-related variables in two studies. In the first study, 192 healthy college students completed the Sensitivity Index (SI; a composite measure assessing the three fundamental fears) and various pain-related questionnaires. In a second study, 60 students out of the original sample took part in a pain induction procedure and completed the SI as well. We first examined the properties of the SI. Factor analysis on the SI replicated the proposed factor structure [Taylor S. The structure of fundamental fears, J Behav Ther Exp Psychiat 1993;24:289-99]. However, some items of the ASI did show problematic loadings and were therefore excluded in subsequent analyses. The main hypothesis of the current study states that IS is a stronger predictor than AS of pain catastrophizing and fear of pain as assessed by self-report measures, and of pain tolerance and anticipatory fear of pain as assessed in a pain induction study. This hypothesis could be confirmed for all variables, except for pain tolerance, which was not predicted by any of the three fundamental fears. The current study can be considered as an impetus for devoting attention to IS in future pain research.
PMID: 16202633 [PubMed - as supplied by publisher]
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Expectancy, fear and pain in the prediction of chronic pain and disability: A prospective analysis.
Boersma K, Linton SJ.
Department of Occupational and Environmental Medicine, Orebro University Hospital, Orebro 701 85, Sweden; Department of Behavioral, Social and Legal Sciences - Psychology, Orebro University, Orebro, Sweden.
Studies with (sub) acute back pain patients show that negative expectancies predict pain and disability at a one-year follow up. Yet, it is not clear how expectations relate to other factors in the development of chronic disability such as pain and fear. This study investigates the relationship between expectations, pain-related fear and pain and studies how these variables are related to the development of chronic pain and disability. Subjects (N=141) with back and/or neck pain (duration <1 year) were recruited via primary care. They completed measures on pain, expectancy, pain-related fear (pain-related negative affect and fear avoidance beliefs) and function. A one-year follow up was conducted with regard to pain and function. It was found that pain, expectancy, pain-related fear and function were strongly interrelated. In the cross-sectional analyses negative expectancies were best explained by frequent pain and a belief in an underlying and serious medical problem. Prospectively, negative expectancy, negative affect and a belief that activity may result in (re) injury or increased pain, explained unique variance in both pain and function at one-year follow up. In conclusion, expectancy, negative affect and fear avoidance beliefs are interrelated constructs that have predictive value for future pain and disability. Clinically, it can be helpful to inquire about beliefs, expectancy and distress as an indication of risk as well as to guide intervention. However, the strong interrelations between the variables call for precaution in treating them as if they were separate entities existing in reality.
PMID: 16199189 [PubMed - as supplied by publisher]
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The NK(1)-receptor antagonist TKA731 in painful diabetic neuropathy: A randomised, controlled trial.
Sindrup SH, Graf A, Sfikas N.
Department of Neurology, Odense University Hospital, DK-5000 Odense C, Denmark.
Substance P is one of the neurotransmitters released by primary nociceptive neurons in the dorsal horn of the spinal cord and it binds postsynaptically to NK(1)-receptors. This receptor is therefore an obvious target for analgesic drugs. The aim of this multicenter, randomised, double-blind, placebo-controlled and parallel-group study was to test if the non-peptide NK(1)-receptor antagonist TKA731 would relieve painful diabetic polyneuropathy. Eighty-seven patients completed a treatment period of 2 weeks' duration with TKA731 (150mg daily) or placebo preceded by one week for baseline observations. There was no significant difference between TKA731 and placebo in change in pain rating from baseline to study end neither for rating of total pain (mean -13.4mm vs. -11.6mm, p=0.664) nor for change in ratings of different pain symptoms (touch- or pressure-evoked pain, pain paroxysms, steady burning or deep aching pain) (p=0.169-0.834).
PMID: 16199188 [PubMed - as supplied by publisher]
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An animal model of chronic inflammatory pain: Pharmacological and temporal differentiation from acute models.
Wilson AW, Medhurst SJ, Dixon CI, Bontoft NC, Winyard LA, Brackenborough KT, Alba JD, Clarke CJ, Gunthorpe MJ, Hicks GA, Bountra C, McQueen DS, Chessell IP.
Department of Pain Research, Neurology and Gastrointestinal CEDD, GlaxoSmithKline Research and Development Ltd., Third Avenue, Harlow, Essex CM19 5AW, UK.
Clinically, inflammatory pain is far more persistent than that typically modelled pre-clinically, with the majority of animal models focussing on short-term effects of the inflammatory pain response. The large attrition rate of compounds in the clinic which show pre-clinical efficacy suggests the need for novel models of, or approaches to, chronic inflammatory pain if novel mechanisms are to make it to the market. A model in which a more chronic inflammatory hypersensitivity phenotype is profiled may allow for a more clinically predictive tool. The aims of these studies were to characterise and validate a chronic model of inflammatory pain. We have shown that injection of a large volume of adjuvant to the intra-articular space of the rat knee results in a prolonged inflammatory pain response, compared to the response in an acute adjuvant model. Additionally, this model also results in a hypersensitive state in the presence and absence of inflammation. A range of clinically effective analgesics demonstrate activity in this chronic model, including morphine (3mg/kg, t.i.d.), dexamethasone (1mg/kg, b.i.d.), ibuprofen (30mg/kg, t.i.d.), etoricoxib (5mg/kg, b.i.d.) and rofecoxib (0.3-10mg/kg, b.i.d.). A further aim was to exemplify the utility of this chronic model over the more acute intra-plantar adjuvant model using two novel therapeutic approaches; NR2B selective NMDA receptor antagonism and iNOS inhibition. Our data shows that different effects were observed with these therapies when comparing the acute model with the model of chronic inflammatory joint pain. These data suggest that the chronic model may be more relevant to identifying mechanisms for the treatment of chronic inflammatory pain states in the clinic.
PMID: 16199187 [PubMed - as supplied by publisher]
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Pain and pain-related fear are associated with functional and social disability in an occupational setting: Evidence of mediation by pain-related fear.
Gheldof EL, Vinck J, Van den Bussche E, Vlaeyen JW, Hidding A, Crombez G.
Research Group of Health Psychology, Hasselt University, Campus Diepenbeek, Agoralaan - Gebouw D, 3590 Diepenbeek, Belgium.
This study examined the role of work-related, psychosocial and psychological factors in predicting functional and social disability in working employees. In a cross-sectional design, 890 working employees (reporting at least 1 day of back pain during the past year) completed self-report measures of back pain, disability, pain-related fear, negative and positive affectivity, job satisfaction, job stress and physical work load. Regression analyses revealed that pain intensity was a strong predictor of functional (beta=.69, p<.001) and social disability (beta=.67, p<.001). Fear of (re)injury due to movement (beta=.25, p<.001; beta=.28, p<.001) had additional predictive value in both models. Further, (singular) mediation tests indicated that fear for (re)injury partially mediated the relation between pain intensity and disability, and between negative affectivity and disability. Finally, path analyses revealed both fear and pain intensity as mediators between negative affectivity and disability. Overall, our findings point at the relevance of the cognitive-behavioral model of avoidance in occupational settings.
PMID: 16199186 [PubMed - as supplied by publisher]
Comment on:
A vaccine to prevent herpes zoster.
Carroll I, Gaeta R, Mackey S.
Publication Types:
PMID: 16196123 [PubMed - indexed for MEDLINE]
Comment on:
A vaccine to prevent herpes zoster.
Kessler KM.
Publication Types:
PMID: 16192493 [PubMed - indexed for MEDLINE]
Images in clinical medicine. Cullen's and Turner's signs.
Mookadam F, Cikes M.
Mayo Clinic, Rochester, MN 55905, USA.
Publication Types:
PMID: 16192483 [PubMed - indexed for MEDLINE]
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A cannabinoid pharmacotherapy for chemotherapy-evoked painful peripheral neuropathy.
Hohmann AG.
Neuroscience and Behavior Program, Department of Psychology, The University of Georgia, Athens, GA 30602, USA.
Publication Types:
PMID: 16203094 [PubMed - as supplied by publisher]
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A prospective study of acceptance of pain and patient functioning with chronic pain.
McCracken LM, Eccleston C.
Pain Management Unit, Royal National Hospital for Rheumatic Diseases, The University of Bath, Bath BA1 1RL, UK.
Acceptance of chronic pain is emerging as an important concept in understanding ways that chronic pain sufferers can remain engaged with valued aspects of life. Recent studies have relied heavily on cross-sectional investigations at a single time point. The present study sought to prospectively investigate relations between acceptance of chronic pain and patient functioning. A sample of adults referred for interdisciplinary treatment of severe and disabling chronic pain was assessed twice, an average of 3.9 months apart. Results showed that pain and acceptance were largely unrelated. Pain at Time 2 was weakly related to measures of functioning at Time 2. On the other hand, acceptance at Time 1 was consistently related to patient functioning at Time 2. Those patients who reported greater acceptance at Time 1 reported better emotional, social, and physical functioning, less medication consumption, and better work status at Time 2. These data suggest that willingness to have pain, and to engage in activity regardless of pain, can lead to healthy functioning for patients with chronic pain. Treatment outcome and process studies may demonstrate the potential for acceptance-based clinical methods for chronic pain management.
PMID: 16203093 [PubMed - as supplied by publisher]
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Motor cortex stimulation-effective for neuropathic pain but the mode of action remains illusive.
Meyerson B.
Section of Neurosurgery, Department of Clinical Neuroscience, Karolinska Institute/Karolinska University Hospital, SE-17176 Stockholm, Sweden.
Publication Types:
PMID: 16202535 [PubMed - as supplied by publisher]
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Estrogen-dependent abdominal hyperalgesia induced by ovariectomy in adult mice: A model of functional abdominal pain.
Sanoja R, Cervero F.
Anesthesia Research Unit (Faculty of Medicine), Faculty of Dentistry and McGill Center for Pain Research, McGill University, Montreal, Que, Canada.
Some abdominal pain syndromes are characterized by persistent pain without demonstrable pathology. Many of them are prevalent in women and it is known that sex hormones are associated with differences in pain perception between males and females. To model a process of functional abdominal pain in females we studied the time course and estrogen dependency of a hyperalgesic state induced by ovariectomy in adult mice. Three groups of C57/BL6 mice were used: virgin mice, proven breeders (2 or 3 successful pregnancies) and retired breeders (more than three successful pregnancies). Within each group, a third of the mice were ovariectomized (OVX), a third received sham surgery and a third were controls. OVX mice, but not sham or controls, developed a robust mechanical hyperalgesia and allodynia in the abdomen, hindlimbs and proximal tail, but not in the forelimbs, that was established 4 weeks after OVX and lasted for the 7 weeks of the experiment. Increases in visceral sensitivity were also observed in OVX mice. Thermal pain thresholds (hot plate) remained unchanged. The reproductive history of the animals had no influence on the hyperalgesia. In another series of experiments a slow release pellet containing 17beta-estradiol was implanted in half of the OVX mice and a similar pellet without the hormone in the other half. Hormone replacement prevented the development of hyperalgesia in OVX animals but did not stop the involution of the internal reproductive organs. We conclude that OVX in mice provides a useful model for a hormonally dependent hyperalgesic state resembling functional pain.
PMID: 16202534 [PubMed - as supplied by publisher]
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Iontophoretic administration of S(+)-ketamine in patients with intractable central pain: A placebo-controlled trial.
Vranken JH, Dijkgraaf MG, Kruis MR, van Dasselaar NT, van der Vegt MH.
Department of Anesthesiology, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100f DE Amsterdam, The Netherlands.
The efficacy of 50 and 75mg S(+)-ketamine administered daily by an iontophoresis-assisted transdermal drug delivery system was tested against placebo in a randomized, double-blind design in 33 patients with central neuropathic pain. At baseline and 1 week after the start of treatment subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analog scale (VAS), health status (Pain Disability Index and EQ-5D) and quality of life (SF-36). Safety assessment included incidence and intensity of adverse events. No significant differences in pain scores (VAS) were observed between the ketamine groups and placebo during the course of the trial. Corrected for baseline levels, daily 50mg S(+)-ketamine did not improve patient's health status or quality of life compared with placebo treatment. However, daily 75mg S(+)-ketamine showed significant improvements on the Pain Disability Index, on the EQ-5D, and on the SF-36 except for the role-physical functioning and general health perception. Iontophoretic administration of S(+)-ketamine was well tolerated with a low incidence of adverse events (mild and transient in nature, resolving spontaneously). Iontophoretic administration of S(+)-ketamine was not more effective than placebo treatment in reducing pain scores in patients with severe central neuropathic pain. However, iontophoretic administration of 75mg S(+)-ketamine improved the health status and the quality of life in these patients.
PMID: 16202531 [PubMed - as supplied by publisher]
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Ethnic differences in thermal pain responses: A comparison of South Asian and White British healthy males.
Watson PJ, Latif RK, Rowbotham DJ.
Department of Health Sciences, School of Medicine, University of Leicester, Gwendolen Road, Leicester LE5 4PW, UK.
The expression and report of pain is influenced by social environment and culture. Previous studies have suggested ethnically determined differences in report of pain threshold, intensity and affect. The influence of ethnic differences between White British and South Asians has remained unexplored. Twenty age-matched, male volunteers in each group underwent evaluation. Cold and warm perception and cold and heat threshold were assessed using an ascending method of limits. Magnitude estimation of pain unpleasantness and pain intensity were investigated with thermal stimuli of 46, 47, 48 and 49 degrees C. Subjects also completed a pain anxiety questionnaire. Data was analysed using t-test, Mann-Whitney and repeated measures analysis of variance as appropriate. There were no differences in cold and warm perception between the two groups. There was a statistically significant difference between the two groups for heat pain threshold (P=0.006) and heat pain intensity demonstrated a significant effect for ethnicity (F=13.84, P=0.001). Although no group differences emerged for cold pain threshold and heat unpleasantness, South Asians demonstrated lower cold pain threshold and reported more unpleasantness at all temperatures but this was not statistically significant. Our study shows that ethnicity plays an important role in heat pain threshold and pain report, South Asian males demonstrated lower pain thresholds and higher pain report when compared with matched White British males. There were no differences in pain anxiety between the two groups and no correlations were identified between pain and pain anxiety Haemodynamic measures and anthropometry did not explain group differences.
PMID: 16202529 [PubMed - as supplied by publisher]
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Trigeminal pain under vagus nerve stimulation.
Carius A, Schulze-Bonhage A.
Epilepsy Center, University Hospital of Freiburg, Breisacher Strasse 64, D-79106 Freiburg, Germany.
Three epilepsy patients treated by cyclic continuous vagus nerve stimulation (VNS) experienced trigeminal pain during the periods of stimulation, which was reported as toothache in the left lower jaw, ipsilateral to the side of stimulation. The symptom occurred with a latency of days to weeks following an increase in stimulation current intensity (SCI). Trigeminal pain was reversible with decrease in SCI, or subsided due to habituation. These findings show that clinically relevant effects of VNS on nociception may occur. Because of the late onset and variable form of this side effect, trigeminal pain may not be regarded as VNS-related which may result in unnecessary diagnostic and therapeutic procedures.
PMID: 16202528 [PubMed - as supplied by publisher]
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Botulinum toxin A versus bupivacaine trigger point injections for the treatment of myofascial pain syndrome: A randomised double blind crossover study.
Graboski CL, Shaun Gray D, Burnham RS.
Glenrose Rehabilitation Hospital, 10230 111Ave, Edmonton Ab, TSG 0B7, Canada.
The treatment of myofascial pain syndrome (MPS) is diverse and includes trigger point injections of various substances including local anesthetics, steroids and Botulinum toxin A (BTX A). The purpose of this study was to compare the effectiveness of trigger point injections using BTX A versus bupivacaine, both in combination with a home-based rehabilitation program. To be enrolled, subjects first had to demonstrate responsiveness to bupivacaine trigger point injection. In this single center, double blind, randomized, cross-over trial, 18 patients with MPS received trigger point injections of either 25 units Botulinum toxin A or 0.5ml of 0.5% bupivacaine per trigger point. A maximum of eight trigger points were injected per subject. Subjects were followed until their pain returned to 75% or more of their pre-injection pain for two consecutive weeks, after which there was a 2 week wash-out period. The subjects then crossed over and had the same trigger points injected with the other agent. All subjects participated in a home exercise program involving static stretches of the affected muscles. Both treatments were effective in reducing pain when compared to baseline (P=0.0067). There was, however, no significant difference between the BTX A and 0.5% bupivacaine groups in duration or magnitude of pain relief, function, satisfaction or cost of care (cost of injectate excluded). Considering the high cost of BTX A, bupivacaine is deemed a more cost-effective injectate for MPS.
PMID: 16202527 [PubMed - as supplied by publisher]
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Persistent idiopathic facial pain exists independent of somatosensory input from the painful region: findings from quantitative sensory functions and somatotopy of the primary somatosensory cortex.
Lang E, Kaltenhauser M, Seidler S, Mattenklodt P, Neundorfer B.
Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany; Pain Center, University of Erlangen-Nuremberg, Krankenhausstrasse 12, D-91054 Erlangen, Germany.
In 14 patients with unilateral persistent idiopathic facial pain (PIFP), classified according to the criteria of the International Headache Society, and 16 age-matched control subjects sensory functions were examined on the face by quantitative sensory testing (QST). Additionally, the somatotopy of the primary somatosensory cortex (SI) to tactile input from the pain area was evaluated by means of magnetoencephalography. Previously reported abnormalities in PIFP as a dishabituation of the R2 component of the blink reflex and psychiatric disturbances were co-evaluated. Psychiatric evaluation included a Structured Clinical Interview for axis-I DSM IV disorders (SCID-I) and employment of the SCL-90-R and a depression scale (ADS). Thresholds to touch, pin prick, warm, cold, heat and pressure pain as well as the pain ratings to single and repetitive (perceptual wind up) painful pin prick stimuli did not indicate a significant sensory deficit or hyperactivity in the pain area when compared with the asymptomatic side nor when compared with the values of healthy control subjects. QST results were not significantly altered in patients (n=4) that showed an abnormal dishabituation of the R2 component of the blink reflex. The interhemispheric difference in distance between the cortical representation of the lip and the index finger did not differ between patients and control subjects. Psychiatric evaluation did not disclose significant abnormalities at a group level. It is concluded that PIFP is maintained by mechanisms which do not involve somatosensory processing of stimuli from the pain area.
PMID: 16202526 [PubMed - as supplied by publisher]
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The Bath Adolescent Pain Questionnaire (BAPQ): Development and preliminary psychometric evaluation of an instrument to assess the impact of chronic pain on adolescents.
Eccleston C, Jordan A, McCracken LM, Sleed M, Connell H, Clinch J.
Pain Management Unit, University of Bath, Level 7, Wessex House, Bath BA2 7AY, UK; Royal National Hospital for Rheumatic Diseases, NHS Trust, Bath, UK.
Chronic pain causes significant problems in the lives of many adolescents, considerably affecting their physical, psychological and social functioning. The assessment of the multidimensional impact of chronic pain is an essential clinical task. This study reports on the development and psychometric evaluation of the Bath Adolescent Pain Questionnaire (BAPQ); an assessment tool designed specifically for use with adolescents who experience chronic pain. A sample of 222 adolescents (11-18 years) experiencing chronic pain completed the 109-item draft inventory. Participants were recruited from two different UK clinics. All participants responded to items using a 5-point frequency scale. Psychometric evaluation of the data resulted in a reduced inventory length of 61 items. Internal consistency of all seven questionnaire subscales was established using Cronbach's alpha. Comparative validity was undertaken by comparison of all individual subscales with existing validated measures (SCAS, CDI-S, FDI, Brief FAM. PCS and CASAFS). The temporal reliability of each inventory subscale was established using a sub-sample of 30 adolescent participants over a 17-day period. Psychometric evaluation of the data suggests the inventory yields both a reliable and valid assessment of the impact of chronic pain on the lives of adolescents. The BAPQ may offer a comprehensive way to assess the widespread deleterious impact of adolescent chronic pain in both a research and clinical setting. Further investigation is needed on the predictive validity of the subscales. Additional data from samples of patients with diagnoses that are not musculoskeletal in origin would be of great assistance.
PMID: 16202524 [PubMed - as supplied by publisher]
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Self-pain enmeshment and the perception of pain.
Macdonald MR.
Department of Psychiatry, University of Western Ontario, London, Ont., Canada N6C5Z9.
Publication Types:
PMID: 16202521 [PubMed - as supplied by publisher]
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Impairment of pain inhibition in chronic tension-type headache.
Pielsticker A, Haag G, Zaudig M, Lautenbacher S.
Department of Physiological Psychology, University of Bamberg, Markusplatz 3, 96045 Bamberg, Germany; Psychosomatic Hospital Windach, Windach, Germany.
Evidence has been accumulated suggesting that a dysfunction in pain inhibitory systems, i.e. in 'diffuse noxious inhibitory controls' (DNIC)-like mechanisms, might be-amongst other factors-responsible for the development of anatomically generalized chronic pain like fibromyalgia. The aim of the present study was to look for similar impairments in chronic tension-type headache (CTTH) as a regionally specific pain syndrome. Twenty-nine CTTH patients and 25 age- and sex-matched healthy control subjects participated in the study. After baseline assessment of electrical detection and pain thresholds, tonic heat stimuli were concurrently applied by a thermode to the thigh to induce DNIC-like pain inhibition. Tonic heat stimuli were applied either slightly above ('pain' condition) or slightly below ('heat' condition) pain threshold. For determination of electrical detection and pain thresholds, electrocutaneous stimuli were administered either to the forearm (extra-cranial site) or to the temple (cranial site), using a multiple staircase procedure. The increase in the electrical detection and pain thresholds induced by concurrent tonic heat stimulation was significantly smaller in the CTTH patients than in the control subjects. This group difference was present during the 'pain' as well as the 'heat' condition. Furthermore, the electrical detection and pain thresholds were affected in this group-specific manner both at the forearm and at the temple. These findings suggest that patients with CTTH suffer from deficient DNIC-like pain inhibitory mechanisms in a similar manner, as do patients with anatomically generalized chronic pain like fibromyalgia.
PMID: 16202520 [PubMed - as supplied by publisher]
Efficacy and concerns regarding early analgesia in children with acute abdominal pain.
Vane DW.
Department of Surgery, University of Vermont, Burlington, VT 05401, USA. dennis.vane@vtmednet.org
Publication Types:
PMID: 16199717 [PubMed - in process]
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Analgesia for children with acute abdominal pain: a cautious move to improved pain management.
Armstrong FD.
Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL 33101, USA. darmstrong@miami.edu
Publication Types:
PMID: 16199716 [PubMed - in process]
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Early analgesia for children with acute abdominal pain.
Green R, Bulloch B, Kabani A, Hancock BJ, Tenenbein M.
Department of Emergency Medicine, Dalhousie University, Halifax, Canada.
OBJECTIVES: The objectives of this study were to determine whether the administration of morphine to children with acute abdominal pain would impede the diagnosis of appendicitis and to determine the efficacy of morphine in relieving the pain. METHODS: This was a double-blind, randomized, placebo-controlled trial involving 5- to 16-year-old children who presented to the emergency department of a children's hospital with a chief complaint of acute abdominal pain that was thought by the pediatric emergency attending physician to require a surgical consultation. Subjects were randomized to receive intravenously administered morphine or normal saline solution. Clinical data and the emergency physician's confidence in his or her clinical diagnosis (0-100%) were recorded systematically with a standardized form. This was repeated 15 minutes after administration of the study medication. The surgeon assessed the child within 1 hour and completed a similar data collection sheet. Pain was assessed, with a color analog scale, before and after study medication administration. Each subject was monitored for 2 weeks after enrollment. RESULTS: One hundred eight children were enrolled; 52 received morphine and 56 received a placebo saline solution. There were no differences between groups in demographic variables or the degree of pain. There were no differences between groups in the diagnoses of appendicitis or perforated appendicitis or the number of children who were observed and then underwent laparotomy. The reduction in the mean pain score was significantly greater in the morphine group (2.2 vs 1.2 cm). The emergency physicians' and surgeons' confidence in their diagnoses was not affected by the administration of morphine. CONCLUSIONS: Our data show that morphine effectively reduces the intensity of pain among children with acute abdominal pain and morphine does not seem to impede the diagnosis of appendicitis.
PMID: 16199711 [PubMed - in process]
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Does lidocaine gel alleviate the pain of bladder catheterization in young children? A randomized, controlled trial.
Vaughan M, Paton EA, Bush A, Pershad J.
Division of Emergency Medicine, Department of Pediatrics, University of Tennessee Health Sciences Center, Le Bonheur Children's Medical Center, Memphis, TN, USA.
OBJECTIVE: Bladder catheterization (BC) is a commonly performed, painful procedure in the pediatric emergency department (ED). A survey demonstrated that analgesia is infrequently used for several brief painful procedures, including BC, in pediatric patients. In this study, we evaluated the use of 2% lidocaine gel to alleviate the pain associated with BC in young children (<2 years) in the ED. METHODS: We conducted a randomized, double-blind, placebo-controlled trial comparing pain scores during bladder catheterization with 2% lidocaine gel versus nonanesthetic lubricant. We used a previously validated scale for measuring brief procedure-related pain in preverbal children (Face Legs Arms Cry Consolability Pain Scale [FLACC]). A total of 115 patients were recruited; 56 patients were randomized to the control group, and 59 were randomized to the lidocaine group. Lubricant was applied to both the genital mucosa and the catheter. Pain measurements were recorded at 3 time intervals: before insertion of the catheter, during catheterization, and after catheterization. Interobserver reliability had been previously established in an observational pilot study. RESULTS: The difference in mean FLACC scores between the control (7.55 +/- 2.56) and study groups (7.37 +/- 2.87) during catheterization was not statistically significant. The change in FLACC from time 1 (preprocedure) to time 2 (during procedure) was statistically significant in both groups, suggesting that bladder catheterization is a painful procedure. CONCLUSIONS: Altering the standard practice of use of nonanesthetic lubricant with 2% lidocaine gel as lubricant during bladder catheterization in young children may not be helpful in alleviating the pain associated with the procedure.
PMID: 16199701 [PubMed - in process]
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The treatment of disabling single-level lumbar discogenic low back pain with total disc arthroplasty utilizing the Prodisc prosthesis: a prospective study with 2-year minimum follow-up.
Bertagnoli R, Yue JJ, Shah RV, Nanieva R, Pfeiffer F, Fenk-Mayer A, Kershaw T, Husted DS.
St. Elizabeth Klinikum, Spine Center, Straubing, Germany.
STUDY DESIGN: Prospective, longitudinal minimum 2-year follow-up. OBJECTIVE: To assess the efficacy and safety of the Prodisc implant in patients with disabling single-level discogenic low back pain (LBP). SUMMARY OF BACKGROUND DATA: The treatment of debilitating discogenic LBP has been controversial and varied. To date, a longitudinal prospective study of the treatment of single-level incapacitating discogenic LBP using the Prodisc total disc arthroplasty technique has not been described. METHODS: A prospective analysis was performed on 118 patients treated with single-level lumbar Prodisc total disc arthroplasty. Patients 18 to 60 years of age with disabling and recalcitrant discogenic LBP with or without radicular pain secondary to single-level discogenic LBP from L3 to S1 were included. Patients were assessed before surgery, and outcome measurements were after surgery administered at 3, 6, 12, and 24 months. RESULTS: A total of 104 patients (88%) fulfilled all follow-up criteria. The median age of all patients was 47 years (range, 36-60 years). Statistical improvements in VAS, Oswestry, and patient satisfaction scores occurred 3 months postoperatively. These improvements were maintained at the 24-month follow-up. Radicular pain also decreased significantly. Full-time and part-time work rates increased from 10% to 35% and 3% to 24%, respectively. No additional fusion surgeries were necessary either at the affected or unaffected levels. Radiographic analysis revealed an affected disc height increase from 4 mm to 13 mm (P < 0.001) and an affected disc motion from 3 degrees to 7 degrees (P < 0.004). CONCLUSIONS: Single-level Prodisc lumbar total disc arthroplasty is a safe and efficacious treatment method for debilitating lumbar discogenic LBP. Significant improvements in patient satisfaction and disability scores occurred after surgery by 3 months and were maintained at the 2-year follow-up. No device-related complications occurred. Patients with severe to moderate disc height loss as well as those with symptomatic posterior anular defects with minimal disc height loss achieve functional gains and significant pain relief. Careful and appropriate patient selection is essential in ensuring optimal surgical outcomes.
PMID: 16205353 [PubMed - in process]
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The treatment of disabling multilevel lumbar discogenic low back pain with total disc arthroplasty utilizing the ProDisc prosthesis: a prospective study with 2-year minimum follow-up.
Bertagnoli R, Yue JJ, Shah RV, Nanieva R, Pfeiffer F, Fenk-Mayer A, Kershaw T, Husted DS.
St. Elizabeth Klinikum, Spine Center, Straubing, Germany.
STUDY DESIGN: Prospective, longitudinal minimum 2-year follow-up. OBJECTIVE: To assess the efficacy and safety of the Prodisc implant in patients with disabling multilevel discogenic low back pain (LBP). SUMMARY OF BACKGROUND DATA: Few, if any, alternatives have been proposed to treat recalcitrant and debilitating multilevel lumbar discogenic low back pain. To date, a prospective study specifically examining the use of multilevel Prodisc total disc arthroplasty has not been described. METHODS: A prospective analysis was performed on 25 patients (63 prostheses) treated with multilevel lumbar ProDisc total disc arthroplasty. Minimum follow-up was 2 years. Patients 18 to 60 years of age with disabling discogenic low back pain and minimal radicular pain secondary to multiple level lumbar spondylosis from L1 to S1 were included. Preoperative and postoperative disability and pain scores were measured using Oswestry and visual analog scores. Preoperative and postoperative neurologic, radiographic, and pain medication assessments were also performed at similar postoperative intervals. RESULTS: A total of 29 patients (72 prostheses) were enrolled in the prospective analysis. Twenty-five patients (63 prostheses) fulfilled all follow-up criteria and are included for final analysis. Fifteen bisegmental and 10 trisegmental level cases were performed. Visual analog pain, Oswestry, and patient satisfaction scores were significantly reduced at the 3-month as well as at 48-month follow-up. Radiographic analysis revealed an affected disc height increases from 5 mm to 12 mm (P < 0.05) and affected disc motions from 3 degrees to 7 degrees (P < 0.05). No change in adjacent level disc heights was seen. Complications included a single case of subsidence of the inferior endplate of the L4-L5 segment in a bisegmental L4-L5/L5-S1 case. We also report a delayed case of anterior extrusion of a polyethylene component in a patient who had sustained a fall of a bicycle. CONCLUSIONS: Our preliminary data on multisegmental ProDisc lumbar total disc arthroplasty appear to be a safe and efficacious treatment method for debilitating lumbar spondylosis without significant facet arthropathy. In our select (non-Workers Compensation and/or medical legal) cohort of patients, we demonstrate a patient satisfaction rate of 93%. Careful and appropriate patient selection is essential in ensuring optimal surgical outcomes.
PMID: 16205346 [PubMed - in process]
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Back schools for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group.
Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW.
Department of Public and Occupational Health/EMGO-Institute, VU University Medical Center, Body@Work TNO VUmc, Amsterdam, The Netherlands. mw.heymans@vumc.nl
STUDY DESIGN: A systematic review within the Cochrane Collaboration Back Review Group. OBJECTIVES: To assess the effectiveness of back schools for patients with nonspecific low back pain (LBP). SUMMARY OF BACKGROUND DATA: Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating patients with LBP. However, the content of back schools has changed and appears to vary widely today. METHODS: We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials to November 2004 for relevant trials reported in English, Dutch, French, or German. We also screened references from relevant reviews and included trials. Randomized controlled trials that reported on any type of back school for nonspecific LBP were included. Four reviewers, blinded to authors, institution, and journal, independently extracted the data and assessed the quality of the trials. We set the high-quality level, a priori, at a trial meeting six or more of 11 internal validity criteria. Because data were clinically and statistically too heterogeneous to perform a meta-analysis, we used a qualitative review (best evidence synthesis) to summarize the results. The evidence was classified into four levels (strong, moderate, limited, or no evidence), taking into account the methodologic quality of the studies. We also evaluated the clinical relevance of the studies. RESULTS: Nineteen randomized controlled trials (3,584 patients) were included in this updated review. Overall, the methodologic quality was low, with only six trials considered to be high-quality. It was not possible to perform relevant subgroup analyses for LBP with radiation versus LBP without radiation. The results indicate that there is moderate evidence suggesting that back schools have better short- and intermediate-term effects on pain and functional status than other treatments for patients with recurrent and chronic LBP. There is moderate evidence suggesting that back schools for chronic LBP in an occupational setting are more effective than other treatments and placebo or waiting list controls on pain, functional status, and return to work during short- and intermediate-term follow-up. In general, the clinical relevance of the studies was rated as insufficient. CONCLUSION: There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain and improve function and return-to-work status, in the short- and intermediate-term, compared with exercises, manipulation, myofascial therapy, advice, placebo, or waiting list controls, for patients with chronic and recurrent LBP. However, future trials should improve methodologic quality and clinical relevance and evaluate the cost-effectiveness of back schools.
PMID: 16205340 [PubMed - in process]
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Satisfaction as a predictor of clinical outcomes among chiropractic and medical patients enrolled in the UCLA low back pain study.
Hurwitz EL, Morgenstern H, Yu F.
Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA 90095-1772, USA. ehurwitz@ucla.edu
STUDY DESIGN: Observational study conducted within a randomized clinical trial. OBJECTIVES: The objective of this study is to estimate the effects of patient satisfaction on subsequent changes in pain and disability among low back pain patients randomized to chiropractic or medical care in a managed-care practice setting. SUMMARY OF BACKGROUND DATA: Recent studies of low back pain treatments have shown chiropractic patients to be more satisfied with their care than medical patients. However, little is known about the relation between patient satisfaction and clinical outcomes. METHODS: A total of 681 low back pain patients presenting to three southern California healthcare clinics and screened for serious spinal pathology and contraindications were randomized to medical care with and without physical therapy, and chiropractic care with and without physical modalities, and followed for 18 months. Satisfaction with back care was measured on a 40-point scale and observed at 4 weeks following randomization. The primary outcome variables, observed between 6 weeks and 18 months of follow-up, are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire, and remission from clinically meaningful pain and disability. Perceived change in low back symptoms was a secondary outcome. RESULTS: Greater satisfaction increased the odds of remission from clinically meaningful pain and disability at 6 weeks (adjusted odds ratio [OR] for 10-point increase in satisfaction = 1.61, 95% confidence interval [CI] = 0.99, 2.68), but not at 6, 12, or 18 months (6 months: adjusted OR = 1.05, 95% CI = 0.73, 1.52; 12 months: adjusted OR = 0.94, 95% CI = 0.67, 1.32; 18 months: adjusted OR = 1.07; 95% CI = 0.76, 1.50). Perception of improvement was greater among highly satisfied than less satisfied patients throughout the 18-month follow-up period. The estimated effects of satisfaction on clinical outcomes were similar for medical and chiropractic patients. CONCLUSIONS: Patient satisfaction may confer small short-term clinical benefits for low back pain patients. Long-term perceived improvement may reflect, in part, perceived past improvement as measured by satisfaction.
PMID: 16205336 [PubMed - in process]
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