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Comment on:
Absent from work: nature versus nurture.
Weinstein J.
Publication Types:
PMID: 14734338 [PubMed - indexed for MEDLINE]
 
Population based intervention to change back pain beliefs: three year follow up population survey.
Buchbinder R, Jolley D.
Department of Clinical Epidemiology, Cabrini Hospital and Monash University, Suite 41, Cabrini Medical Centre, 183 Wattletree Road, Malvern, VIC 3144, Australia. rachelle.buchbinder@med.monash.edu.au
PMID: 14764492 [PubMed - in process]
Testing of a new pneumatic device to cause pain in humans.
Schubert HM, Lorenz IH, Zschiegner F, Kremser C, Hohlrieder M, Biebl M, Kolbitsch C, Moser PL.
Department of Trauma Surgery and Sports Medicine, University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
BACKGROUND: Surgical pain typically combines superficial and deep pain. We wished to generate pain that resembled surgical pain, reliably and reproducibly, in volunteers. METHODS: We constructed a computer-controlled pneumatic device to apply pressure to the anterior tibia. The reproducibility of the pain was tested by rating the pressure that caused pain rated 4-5 on a visual analogue scale (VAS) on days 0, 7, and 24 in 10 volunteers. The effect of remifentanil (0.025, 0.05, 0.075, and 0.1 micro g kg(-1) min(-1)) on pain tolerance in another set of volunteers (n=11) was used as an indirect measure of the reliability of pain production. RESULTS: The pressure needed (0.7 (0.3) to 0.9 (0.4) atm (mean (SD)) to induce pain rated 4-5 (VAS) did not vary, showing long-term reproducibility of the method. When pressure was applied to cause increasing pain in volunteers (n=11) 0.05 micro g kg(-1) min(-1) remifentanil increased pain tolerance by 50%. An approximate doubling of the dose (0.1 micro g kg(-1) min(-1)) increased pain tolerance significantly more. The linear logarithmic dose-effect relationship shows that the device causes pain reliably, and this can be reduced with opioid treatment. CONCLUSION: This pneumatic device can apply pain reliably and reproducibly.
PMID: 14766716 [PubMed - as supplied by publisher]
Quality of life and pain relief during treatment with calcitriol and docetaxel in symptomatic metastatic androgen-independent prostate carcinoma.
Beer TM, Eilers KM, Garzotto M, Hsieh YC, Mori M.
Division of Hematology and Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland 97239, Oregon, USA. beert@ohsu.edu
BACKGROUND: The current study evaluated the analgesic activity and impact on quality of life (QOL) of a new chemotherapy regimen of calcitriol and docetaxel in men with androgen-independent prostate carcinoma. METHODS: Analgesic response was defined as a 2-point reduction on the Present Pain Intensity (PPI) scale (or compete relief if baseline PPI was 1) without an increase in analgesic use or a 50% decrease in analgesic medication use without an increase in pain, maintained for > or = 4 weeks. Pain, pain medication consumption, and QOL (measured by the European Organization for Research and Treatment of Cancer QLQ-C30) were evaluated every 4 weeks. RESULTS: Treatment resulted in an analgesic response in 14 of 29 evaluable patients (48%; 95% confidence interval [95% CI], 30-67%). The median time to symptomatic progression in the 14 patients who met criteria for analgesic response was 41 weeks (95% CI, 26-56 weeks). Worsening in physical and role functioning, fatigue, appetite, and global health status and improvement in constipation were detected using the QLQ-C30 QOL questionnaire. CONCLUSIONS: Significant analgesic activity was demonstrated, although worsening in several QOL domains was observed in a patient population with relatively low pain intensity (median PPI, 2). Copyright 2004 American Cancer Society.
PMID: 14770432 [PubMed - in process]
Suicidal Ideation in Outpatients With Chronic Musculoskeletal Pain: An Exploratory Study of the Role of Sleep Onset Insomnia and Pain Intensity.
Smith MT, Perlis ML, Haythornthwaite JA.
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland; dagger Department of Psychiatry, University of Rochester School of Medicine and Dentistry; and double dagger Department of Clinical and Social Psychology, University of Rochester, Rochester, New York.
SUMMARY: OBJECTIVES Sleep disturbance, depression, and heightened risk of suicide are among the most clinically significant sequelae of chronic pain. While sleep disturbance is associated with suicidality in patients with major depression and is a significant independent predictor of completed suicide in psychiatric patients, it is not known whether sleep disturbance is associated with suicidal behavior in chronic pain. This exploratory study evaluates the importance of insomnia in discriminating suicidal ideation in chronic pain relative to depression severity and other pain-related factors.METHODS Fifty-one outpatients with non-cancer chronic pain were recruited. Subjects completed a pain and sleep survey, the Pittsburgh Sleep Quality Index, the Beck Depression Inventory, and the Multidimensional Pain Inventory. Subjects were classified as "suicidal ideators" or "non-ideators" based on their responses to BDI-Item 9 (Suicide). Bivariate analyses and multivariate discriminant function analyses were conducted.RESULTS Twenty-four percent reported suicidal ideation (without intent). Suicidal ideators endorsed higher levels of: sleep onset insomnia, pain intensity, medication usage, pain-related interference, affective distress, and depressive symptoms (P < 0.03). These 6 variables were entered into stepwise discriminant function analyses. Two variables predicted group membership: Sleep Onset Insomnia Severity and Pain Intensity, respectively. The discriminant function correctly classified 84.3% of the cases (P < 0.0001).DISCUSSION Chronic pain patients who self-reported severe and frequent initial insomnia with concomitant daytime dysfunction and high pain intensity were more likely to report passive suicidal ideation, independent from the effects of depression severity. Future research aimed at determining whether sleep disturbance is a modifiable risk factor for suicidal ideation in chronic pain is warranted.
PMID: 14770051 [PubMed - as supplied by publisher]
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Confirmatory Factor Analysis of the Tampa Scale for Kinesiophobia: Invariant Two-Factor Model Across Low Back Pain Patients and Fibromyalgia Patients.
Goubert L, Crombez G, Van Damme S, Vlaeyen JW, Bijttebier P, Roelofs J.
Faculty of Psychology and Educational Sciences, Ghent University, Belgium; dagger Department of Medical, Clinical and Experimental Psychology, Maastricht University, The Netherlands; and double dagger Department of Psychology, University of Leuven, Belgium.
SUMMARY: OBJECTIVES (1) To investigate the factor structure of the Tampa Scale for Kinesiophobia (TSK) in a Dutch-speaking sample of chronic low back pain (CLBP) patients using confirmatory factor analysis, (2) to examine whether the internal structure of the TSK extends to another group of fibromyalgia (FM) patients, and (3) to investigate the stability of the factor structure in both patient groups using multi-sample analysis.PATIENTS AND METHODS TSK-data from 8 studies collected in Dutch and Flemish chronic pain patients were pooled. For 188 CLBP patients and 89 FM patients, complete data were available. Confirmatory factor analyses were performed to assess 4 models of kinesiophobia, and to examine which factor model provided the best fit. Furthermore, a multi-sample analysis was performed to investigate the stability of the factor structure in both patient groups.RESULTS For both CLBP and FM patients, the 2-factor model containing the factors "activity avoidance" and "pathologic somatic focus" was superior as compared with the 4-factor model containing the factors "harm," "fear of (re)injury." "importance of exercise," and "avoidance of activity". Moreover, the 2-factor model was found to be invariant across CLBP and FM patients, indicating that this model is robust in both pain samples.DISCUSSION As the 2-factor structure provided the best fit of the data in both patient samples, we recommend to use this version of the TSK and its 2 subscales in both clinical practice and research. Based on the content of the items, the subscales were labeled "Harm" and "Fear-avoidance."
PMID: 14770050 [PubMed - as supplied by publisher]
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Hypervigilance to Pain in Fibromyalgia: The Mediating Role of Pain Intensity and Catastrophic Thinking About Pain.
Crombez G, Eccleston C, Van Den Broeck A, Goubert L, Van Houdenhove B.
Department of Experimental-Clinical and Health Psychology, Ghent University, Belgium; dagger Pain Management Unit, University of Bath, The Royal National Hospital for Rheumatic Diseases, United Kingdom; double dagger Department of Psychology, University of Leuven, Belgium; section sign Pain Clinic, Leuven University Hospital, Belgium.
SUMMARY: OBJECTIVE To investigate the mediating role of pain intensity, catastrophic thinking about pain, and negative affectivity in explaining enhanced attention for pain in patients with fibromyalgia.METHODS Sixty-four patients with fibromyalgia and 46 patients with chronic low back pain completed self-report instruments of vigilance to pain, negative affectivity, and catastrophic thinking about pain. These measures, along with diagnostic group and pain intensity, were entered into a partial correlational analysis to investigate which variables mediate the relationship between diagnostic group (fibromyalgia vs. chronic low back pain) and vigilance to pain.RESULTS Fibromyalgia patients reported significantly greater vigilance to pain than patients with chronic low back pain. They also reported higher pain intensity, more negative affectivity, and more catastrophic thinking about pain than patients with chronic low back pain. Vigilance to pain was correlated significantly with pain intensity, negative affectivity, and catastrophic thinking about pain. Further analyses revealed that pain intensity and catastrophic thinking about pain, but not negative affectivity, mediated the relationship between diagnostic group and vigilance to pain.CONCLUSION Fibromyalgia patients report a heightened vigilance to pain. This vigilance is not a unique characteristic of fibromyalgia but is related to the intensity of pain and catastrophic thinking about pain.
PMID: 14770049 [PubMed - as supplied by publisher]
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Expression of Pain in Children With Autism.
Nader R, Oberlander TF, Chambers CT, Craig KD.
Department of Psychology, University of British Columbia, Vancouver, BC, Canada; dagger Division of Developmental Pediatrics, Sunny Hill Health Centre for Children, and Centre for Community Child Health Research, University of British Columbia, Vancouver, BC, Canada; double dagger Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; and section sign Centre for Community Child Health Research, BC Research Institute for Children's and Women's Health, Vancouver, BC, Canada.
SUMMARY: OBJECTIVES Reduced pain sensitivity is widely reported to be a common feature of children with autism, yet this conclusion frequently has been based on anecdotal observations and questionable measures of pain. The aims of the study were to (1) characterize the behavioral response of children with autism experiencing a venepuncture using objective observational measures of pain and distress, (2) examine parents' assessments of pain behavior in children with and without autism, including comparison of the relationship of parental reports with behavioral measures, and (3) compare the behavioral reactions and parental assessments of children with autism with children without autism undergoing venepuncture.METHODS Pain reactions to the invasive procedure of venepuncture were videotaped, systematically described and compared in 21 children with autism (3-7 years old) and 22 nonimpaired children, the latter providing a chronological age and gender equivalent comparison group. Parents provided observer reports of pain, and facial activity was used as an objective behavioral measure of pain.RESULTS The children with autism displayed a significant facial pain reaction in response to the venepuncture procedure. There was a lack of concordance between parental reports of pain and observed pain responses for the children with autism. Behavioral responses of the children with autism were generally similar to the comparison group, except the substantial facial pain reactivity instigated by the venepuncture in the children with autism exceeded that displayed by the nonimpaired comparison children. Parent reports of pain severity did not differ between the autism and comparison groups. The degree of concordance between parental report and observed pain responses was consistently better for the comparison group.DISCUSSION The findings demonstrate that children with autism display a significant behavioral reaction in response to a painful stimulus, and these findings are in sharp contrast to the prevailing beliefs of pain insensitivity described in the literature to date. The findings also raise questions about the appropriateness of parental global report as an assessment tool for pain in children with autism.
PMID: 14770048 [PubMed - as supplied by publisher]
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Pain Flashbacks in Posttraumatic Stress Disorder.
Salomons TV, Osterman JE, Gagliese L, Katz J.
Department of Anesthesia and Pain Management, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada; dagger Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts; paragraph sign Department of Psychology, double dagger School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada; and section sign Department of Anesthesia, University of Toronto, Ontario, Canada.
SUMMARY: OBJECTIVES Surgical patients who regain consciousness while under general anesthesia may develop symptoms of Posttraumatic Stress Disorder (PTSD). One common PTSD symptom is the experiencing of abnormal perceptions during which the patient feels as if the trauma is recurring. The objective of this report is to document the re-occurrence of pain as part of the PTSD sequelae.RESULTS We present two patients who developed PTSD following an episode of awareness under anesthesia. In both cases, posttraumatic sequelae persisted for years and included pain symptoms that resembled, in quality and location, pain experienced during surgery. In addition to their similarity to the original pain, these pain symptoms were triggered by stimuli associated with the traumatic situation, suggesting that they were flashbacks to the episode of awareness under anesthesia.DISCUSSION The similarity between the patients' pain symptoms and pain experienced during trauma, the triggering by traumatic cues, and the associated emotional arousal and avoidance suggest the involvement of a somatosensory memory mechanism.
PMID: 14770047 [PubMed - as supplied by publisher]
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Does Prone or Supine Position Influence Pain Responses in Preterm Infants at 32 Weeks Gestational Age?
Grunau RE, Linhares MB, Holsti L, Oberlander TF, Whitfield MF.
Centre for Community Child Health Research, B.C. Research Institute for Children's & Women's Health, Vancouver, British Columbia, Canada; dagger Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; and double dagger Department of Neurology, Psychiatry and Medical Psychology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, SP, Brazil.
SUMMARY: OBJECTIVE The purpose of this study was to examine the influence of prone and supine position in preterm infants during acute pain of blood collection.SETTING Level III Neonatal Intensive Care Unit (NICU).STUDY DESIGN Thirty-eight preterm infants (birthweight 1339 [590-2525] g, GA 29 [25- 32] wks) were in 2 groups depending on their position in the isolette prior to and during heel lance at 32 weeks post-conceptional age. The study design was a comparison between groups (Prone, Supine) during 2 events (Baseline, Heel lance).OUTCOME MEASURE Pain measures were multidimensional, including behavioral (sleep-wake state and facial activity) and physiological (heart rate) responses measured continuously prior to (Baseline) and during blood collection (Lance).RESULTS Both groups of infants displayed statistically significant shifts in sleep-wake state to greater arousal, and increased facial activity and heart rate, from Baseline to Lance. Prone position was associated with significantly more deep sleep during Baseline, compared with Supine position, but there were no differences in sleep-wake state during Lance. Minor increased facial activity was shown in some time segments of Baseline for infants in Supine compared with Prone, but did not differ overall between positions. Prone and Supine position did not affect heart rate significantly during Baseline or Lance events.CONCLUSIONS Prone position promotes deep sleep in preterm neonates at 32 weeks post-conceptional age when they are undisturbed. However, placement in prone position is not a sufficient environmental comfort intervention for painful invasive procedures such as heel lance for blood sampling in the NICU. Neonates require other environmental supports to promote coping with this stressful event.
PMID: 14770046 [PubMed - as supplied by publisher]
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Quantitative Assessment of Chronic Postsurgical Pain Using the McGill Pain Questionnaire.
Bruce J, Poobalan AS, Smith WC, Chambers WA.
Department of Public Health, University of Aberdeen, Polwarth Building, Medical School, Foresterhill, Aberdeen, United Kingdom AB25 2ZD; dagger Department of Public Health, University of Aberdeen, Polwarth Building, Medical School, Foresterhill, Aberdeen, United Kingdom, AB25 2ZD; double dagger Department of Public Health, University of Aberdeen, Polwarth Building, Medical School, Foresterhill, Aberdeen, United Kingdom, AB25 2ZD; and section sign Consultant in Anaesthesia and Pain Management, Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, United Kingdom.
SUMMARY: OBJECTIVES The McGill Pain Questionnaire (MPQ) provides a quantitative profile of 3 major psychologic dimensions of pain: sensory-discriminative, motivational-affective, and cognitive-evaluative. Although the MPQ is frequently used as a pain measurement tool, no studies to date have compared the characteristics of chronic post-surgical pain after different surgical procedures using a quantitative scoring method.METHODS Three separate questionnaire surveys were administered to patients who had undergone surgery at different time points between 1990 and 2000. Surgical procedures selected were mastectomy (n = 511 patients), inguinal hernia repair (n = 351 patients), and cardiac surgery via a central chest wound with or without saphenous vein harvesting (n = 1348 patients). A standard questionnaire format with the MPQ was used for each survey. The IASP definition of chronic pain, continuously or intermittently for longer than 3 months, was used with other criteria for pain location. The type of chronic pain was compared between the surgical populations using 3 different analytical methods: the Pain Rating Intensity score using scale values, (PRI-S); the Pain Rating Intensity using weighted rank values multiplied by scale value (PRI-R); and number of words chosen (NWC).RESULTS The prevalence of chronic pain after mastectomy, inguinal herniorrhaphy, and median sternotomy with or without saphenectomy was 43%, 30%, and 39% respectively. Chronic pain most frequently reported was sensory-discriminative in quality with similar proportions across different surgical sites. Average PRI-S values after mastectomy, hernia repair, sternotomy (without postoperative anginal symptoms), and saphenectomy were 14.06, 13.00, 12.03, and 8.06 respectively. Analysis was conducted on cardiac patients who reported anginal symptoms with chronic post-surgical pain (PRI-S value 14.28). Patients with moderate and severe pain were more likely to choose more than 10 pain descriptors, regardless of the operative site (P < 0.05).DISCUSSION The prevalence and characteristics of chronic pain was remarkably similar across different operative groups. This study is the first to quantitatively compare chronic post-surgical pain using similar methodologies in heterogeneous post-surgical populations.
PMID: 14770045 [PubMed - as supplied by publisher]
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Pain-Related Fear, Lumbar Flexion, and Dynamic EMG Among Persons With Chronic Musculoskeletal Low Back Pain.
Geisser ME, Haig AJ, Wallbom AS, Wiggert EA.
Spine Program, Department of Physical Medicine and Rehabilitation and dagger Department of Surgery, University of Michigan, Health System, Ann Arbor, Michigan.
SUMMARY: OBJECTIVES The purpose of this study was to examine the relationship between pain-related fear, lumbar flexion, and dynamic EMG activity among persons with chronic musculoskeletal low back pain. It was hypothesized that pain-related fear would be significantly related to decreased lumbar flexion and specific patterns of EMG activity during flexion and extension.STUDY DESIGN Data was obtained from subjects who, on a single day, completed self-report measures of pain and pain-related fear, and were interviewed to determine demographic and pain information. Subjects then underwent a dynamic EMG evaluation for which they were asked to stand, then bend forward as far as possible, stay fully flexed, and return to standing. Lumbar EMG and angle of flexion were recorded during this time. A flexion-relaxation ratio (FRR) was computed by comparing maximal EMG while flexing to the average EMG in full flexion.SUBJECTS Seventy-six persons with chronic musculoskeletal low back pain.RESULTS Zero-order correlations indicated that pain-related fear was significantly related to reduced lumber flexion (r = -0.55), maximum EMG during flexion (r = -0.38) and extension (r = -0.51), and the FRR (r = -0.40). When controlling for pain and demographic factors, pain-related fear continued to be related to reduced lumbar flexion. Using a path-analytic model to examine whether angle of flexion mediated the relationship between fear and EMG activity, the models examining maximal EMG during flexion and extension supported the notion that pain-related fear influences these measures indirectly through its association with decreased range of motion. Conversely, pain-related fear was independently related to higher average EMG in full flexion, while angle of flexion was not significantly related. Pain-related fear was directly related to a smaller FRR, as well as indirectly through angle of flexion.CONCLUSIONS Pain-related fear is significantly associated with reduced lumbar flexion, greater EMG in full flexion, and a smaller FRR. The relationship between pain-related fear and EMG during flexion and extension appears to be mediated by reduced lumbar flexion. These results suggest that pain-related fear is directly associated with musculoskeletal abnormalities observed among persons with chronic low back pain, as well as indirectly through limited lumbar flexion. These musculoskeletal abnormalities as well as limited movement may be involved in the development and maintenance of chronic low back pain. In addition, changes in musculoskeletal functioning and flexion associated with pain-related fear may warrant greater attention as part of treatment.
PMID: 14770044 [PubMed - in process]
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Comparison between bupivacaine 0.125% and ropivacaine 0.2% for epidural administration to outpatients with chronic low back pain.
Lierz P, Gustorff B, Markow G, Felleiter P.
Marienkrankenhaus Soest, Department of Anaesthesiology and Intensive Care Medicine, Soest, Germany. dr.lierz@marienkrankenhaus-soest.de
BACKGROUND AND OBJECTIVE: Epidural blocks should provide good analgesia for the treatment of chronic low back pain without any motor block to allow active physiotherapy. Epidural ropivacaine is known to produce less motor block compared to bupivacaine at anaesthetic concentrations. This prospective, randomized double blind study compares the analgesic, motor block, and haemodynamic effects of single shot epidural injections of ropivacaine 0.2% 10 mL with bupivacaine 0.125% in outpatients suffering from chronic low back pain. METHODS: Forty patients were assigned to receive either ropivacaine 0.2% (n = 20) or bupivacaine 0.125% (n = 20) within a series of eight single shot epidural blocks. RESULTS: Thirty-six patients received either ropivacaine 0.2% (n = 18) or bupivacaine 0.125% (n = 18) within a series of eight single shot epidural blocks. Both groups showed no significant differences either in analgesia, or in motor blockade or haemodynamic changes. Thus ropivacaine 0.2% did not reduce the incidence of motor block (9.0% of patients with motor block Bromage scores 1, 2 or 3 in ropivacaine or bupivacaine). The combination of repeated epidural analgesia and physiotherapy reduced the median pain-scores (visual analogu scale, 0-10) from 7 (SD +/- 1.6) at the beginning of the study to 4.1 (SD +/- 1.7) at the end of the series. CONCLUSIONS: Both bupivacaine 0.125% and ropivacaine 0.29% appear suitable for epidural administration to outpatients with chronic low back pain attending for epidural analgesia associated with physiotherapy (physical therapy).
PMID: 14768921 [PubMed - in process]
Comment on:
Loss of productive time due to pain.
Roy S.
Publication Types:
PMID: 14871911 [PubMed - indexed for MEDLINE]
Chest pain? Cause.
Hallani H, Eslick GD, Cox M, Wyatt JM, Lee CH.
Department of Cardiology, Liverpool Hospital, Liverpool, Australia.
PMID: 14962526 [PubMed - in process]
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The lonely world of the inpatient family.
Noble D.
Publication Types:
PMID: 14683667 [PubMed - indexed for MEDLINE]
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Anaesthesia, surgery, and challenges in postoperative recovery.
Kehlet H, Dahl JB.
Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark. henrik.kehlet@hh.hosp.dk
Surgical injury can be followed by pain, nausea, vomiting and ileus, stress-induced catabolism, impaired pulmonary function, increased cardiac demands, and risk of thromboembolism. These problems can lead to complications, need for treatment in hospital, postoperative fatigue, and delayed convalescence. Development of safe and short-acting anaesthetics, improved pain relief by early intervention with multimodal analgesia, and stress reduction by regional anaesthetic techniques, beta-blockade, or glucocorticoids have provided important possibilities for enhanced recovery. When these techniques are combined with a change in perioperative care a pronounced enhancement of recovery and decrease in hospital stay can be achieved, even in major operations. The anaesthetist has an important role in facilitating early postoperative recovery by provision of minimally-invasive anaesthesia and pain relief, and by collaborating with surgeons, surgical nurses, and physiotherapists to reduce risk and pain.
Publication Types:
PMID: 14667752 [PubMed - indexed for MEDLINE]
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Is the diagnosis important for the treatment of patients with shoulder complaints?
Smidt N, Green S.
Institute for Research in Extramural Medicine, VU Medical Centre, 1081 BT, Amsterdam, Netherlands. n.smidt.emgo@med.vu.nl
PMID: 14667738 [PubMed - indexed for MEDLINE]
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Leading the way in African home-based palliative care. Free oral morphine has allowed expansion of model home-based palliative care in Uganda.
Ramsay S.
Publication Types:
PMID: 14661621 [PubMed - indexed for MEDLINE]
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Distant skip level discitis and vertebral osteomyelitis after caudal epidural injection: a case report of a rare complication of epidural injections.
Yue WM, Tan SB.
Department of Orthopaedic Surgery, Singapore General Hospital, Singapore. yuewm@singnet.com.sg
STUDY DESIGN: A case report of distant discitis and vertebral osteomyelitis involving skip levels after caudal epidural steroid injection. OBJECTIVES: To report and investigate the occurrence of distant infective discitis and vertebral osteomyelitis involving skip levels after epidural injection. SUMMARY OF THE BACKGROUND DATA: Distant discitis and vertebral osteomyelitis is a serious but rare complication after epidural injection. A case involving skip levels and without the occurrence of epidural abscess formation has apparently not been previously reported in the literature. METHODS: An elderly woman presenting with clinical, radiologic, and magnetic resonance imaging evidence of spinal canal stenosis involving L3/4 and L4/5 levels and degenerative spondylolisthesis of the L4/5 level was given an epidural injection of steroids and lignocaine via the caudal route. A month later, she presented with worsened low back pain, elevated serum acute phase reactants, and plain radiographic evidence of L4/5 infective discitis. Magnetic resonance imaging and microbiologic examination of computed tomographically guided biopsy specimens confirmed infective discitis involving L2/3 and L4/5 intervertebral levels, together with adjacent vertebral osteomyelitis. RESULTS: The patient was successfully treated with antibiotics targeted at Pseudomonas aeruginosa, which was isolated in the culture of the biopsy specimens. Follow-up improvements in the clinical condition, serum acute phase reactants levels, radiographs, and magnetic resonance imaging were noted. CONCLUSIONS: Distant discitis and vertebral osteomyelitis involving skip levels and without the occurrence of epidural abscess formation is a serious but rare complication after epidural injection.
Publication Types:
PMID: 12782996 [PubMed - indexed for MEDLINE]
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Risk factors for failure and complications of intradiscal electrothermal therapy: a pilot study.
Cohen SP, Larkin T, Abdi S, Chang A, Stojanovic M.
Pain Management Center, Department of Anesthesia, Walter Reed Army Medical Center, Washington, DC, USA. Steven.Cohen@med.nyu.edu
STUDY DESIGN: A bi-institutional, retrospective clinical data analysis. OBJECTIVES: To determine risk factors for failure and complications of intradiscal electrothermal therapy, a treatment for discogenic back pain. SUMMARY OF THE BACKGROUND DATA: Intradiscal electrothermal therapy is a relatively new treatment for discogenic back pain. Though previous studies have shown it to be an effective treatment, there are few published studies examining complications and none examining risk factors for failure. METHODS: The authors treated 79 patients with discogenic back pain using intradiscal electrothermal therapy. Complications were assessed by patient report and, when indicated, further diagnostic testing. Success or failure was determined by visual analogue pain scores at 6-month follow-up. Variables examined for their relationship to failure and complications were age, sex, duration of pain, number of levels heated, smoking history, diabetes, obesity, leg pain, and previous back surgery. RESULTS: Forty-eight percent of patients reported more than 50% pain relief at their 6-month follow-up. There were eight complications (10%), most of which were self-limited and transient. The only risk factor associated with intradiscal electrothermal therapy failure was obesity (P = 0.01). Whereas 54% of nonobese patients reported good pain relief at 6 months, only one out of 10 obese patients had successful intradiscal electrothermal therapy. The obese patients in our study were more likely to have a complication from intradiscal electrothermal therapy than they were to obtain pain relief. CONCLUSION: The only risk factor found to be associated with IDET outcome was obesity, which was a strong predictor of failure. Obesity should be considered a relative contraindication to performing IDET.
Publication Types:
PMID: 12782982 [PubMed - indexed for MEDLINE]
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Sitting with adjustable ischial and back supports: biomechanical changes.
Makhsous M, Lin F, Hendrix RW, Hepler M, Zhang LQ.
Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois 60611, USA. m-makhsous2@northwestern.edu
STUDY DESIGN: The seat and back contact force, pressure distribution, lumbar lordosis, and low back muscle activities associated with a new seat design with adjustable ischial support and backrest were investigated using kinematic, kinetic, electromyographic, and radiographic measurements. OBJECTIVES: To investigate the biomechanical effects of adjusting ischial and backrest supports during sitting. SUMMARY OF THE BACKGROUND DATA: Sitting may induce posterior rotation of the pelvis, reduction of lumbar lordosis, and increases in muscle tension, disc pressure, and pressure on the ischium and coccyx, which may be associated with low back pain. A device that reduces the ischial load and maintains lumbar lordosis may help increase seating comfort and reduce low back pain. METHODS: Fifteen office workers with no known low back pain history were tested. Contact pressure distributions, reaction forces between the buttock-thighs and seat and between the back and backrest, load carried by the seat pan and backrest, sacral inclination, lumbar lordosis, intervertebral space of lumbar spine, and muscular activity in stabilizing the trunk were measured for sitting with and without ischial support and with adjustable back support. RESULTS: When the ischial support was relieved, the center of the force on the seat and on the legs of the chair, and the peak center of pressure on the seat, were significantly (P < 0.002) shifted forward toward the thighs. The total contact area on the seat pan and on the backrest was significantly decreased and increased, respectively (P < 0.001). The sacral inclination, total and segmental lumbar lordosis, and lumbar spine disc height were significantly increased for sitting upright with backrest, with the lumbar curve close to that during standing. CONCLUSIONS: Sitting with reduced ischial support and fitted backrest to the lower spine altered the contact area, reduced peak pressure under the ischia, reduced muscular activity, maintained total and segmental lumbar lordosis, rotated the sacrum forward, and increased lumbar intervertebral disc heights, which could potentially reduce low back pain.
PMID: 12782977 [PubMed - indexed for MEDLINE]
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Efficacy of cervical endplay assessment as an indicator for spinal manipulation.
Haas M, Groupp E, Panzer D, Partna L, Lumsden S, Aickin M.
Division of Research, Western States Chiropractic College, Portland, Oregon 97230, USA. mhaas@wschiro.edu
STUDY DESIGN: Double-blind, randomized, placebo-controlled trial. OBJECTIVES: To evaluate the effect of manual endplay assessment on neck pain and stiffness outcomes in neck pain patients receiving spinal manipulation. SUMMARY OF THE BACKGROUND DATA: There have been no studies on the efficacy of palpation used as an indicator for manipulation in the management of back and neck pain. METHODS: Neck pain patients (n = 104) were randomly assigned to two groups. The study group received manipulation targeted to individual cervical vertebrae according to endplay restriction noted by the examining clinician. The control group received manipulation determined by sham, computer-generated examination findings; endplay examination was ignored and served as a placebo assessment. Treatment was rendered on a single occasion by a chiropractor. Outcomes were neck pain and stiffness assessed before and after manipulation and at least 5 hours following treatment. RESULTS: The study and control groups showed clinically important improvement in neck pain and stiffness. However, there were no clinically important or statistically significant differences between the study and control groups in terms of pain or stiffness outcomes. Findings were robust across patient, complaint, and treatment characteristics. CONCLUSIONS: Endplay assessment in and of itself did not contribute to the same-day pain and stiffness relief observed in neck pain patients receiving spinal manipulation. The impact on a longer course of treatment remains to be investigated. The data suggest that pain modulation may not be limited to mechanisms associated with manipulation of putative motion restrictions.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 12782973 [PubMed - indexed for MEDLINE]
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Tumor necrosis factor-alpha monoclonal antibody, infliximab, used to manage severe sciatica.
Karppinen J, Korhonen T, Malmivaara A, Paimela L, Kyllonen E, Lindgren KA, Rantanen P, Tervonen O, Niinimaki J, Seitsalo S, Hurri H.
Department of Physical Medicine and Rehabilitation, Oulu University Hospital, Finland. jaro.karppinen@occuphealth.fi
STUDY DESIGN: An open-label study was conducted. OBJECTIVE: To evaluate the efficacy and safety of infliximab, a monoclonal chimeric antibody, against tumor necrosis factor-alpha (TNFalpha) for the treatment of severe sciatica. SUMMARY OF BACKGROUND DATA: Evidence from animal studies indicates that TNFalpha plays a role in the pathophysiology of sciatica. Anti-TNFalpha therapy has not been previously evaluated in sciatic patients. METHODS: In this study, 10 patients with disc herniation-induced severe sciatica received infliximab (Remicade 3 mg/kg) intravenously over 2 hours. The outcome was assessed at 1 hour, 1 week, 2 weeks, 1 month, and 3 months after the infusion and compared to historical control subjects consisting of 62 patients who received saline in a trial of periradicular infiltration for sciatica. Leg pain was the primary outcome, with more than a 75% decrease from the baseline score constituting a painless state. Fisher's exact test and repeated measures analysis of variance were used for statistical analysis. RESULTS: At 1 hour after the infusion, leg pain had decreased by 50%. At 2 weeks, 60% of the patients in the infliximab group were painless, as compared with 16% of the control patients (P = 0.006). The difference was sustained at 3 months (90% vs 46%; P = 0.014). Infliximab was superior over the whole follow-up period in terms of leg pain (P = 0.003) and back-related disability (P = 0.004). At 1 month, every patient in the infliximab group had returned to work, whereas 38% of the control subjects still were on sick leave (P = 0.02). None of the patients treated with infliximab underwent surgery during the follow-up period. No immediate or delayed adverse drug reactions and no adverse effects related to medication were observed. CONCLUSIONS: Anti-TNFalpha therapy is a promising treatment option for sciatica. There is an urgent need for a randomized controlled trial to evaluate whether thesepromising early results can be confirmed.
Publication Types:
- Clinical Trial
- Controlled Clinical Trial
PMID: 12698115 [PubMed - indexed for MEDLINE]
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Prospective randomized clinical trial comparing patient-controlled intravenous analgesia with patient-controlled epidural analgesia after lumbar spinal fusion.
Fisher CG, Belanger L, Gofton EG, Umedaly HS, Noonan VK, Abramson C, Wing PC, Brown J, Dvorak MF.
Combined Neurosurgical and Orthopaedic Spine Program, Department of Orthopaedics, University of British Columbia, Vancouver Hospital and Health Sciences Centre. cfisher@vanhosp.bc.ca
STUDY DESIGN: A prospective, randomized, double-blind clinical trial was conducted. OBJECTIVE: To compare the efficacy of patient-controlled analgesia (PCA) with that of patient-controlled epidural analgesia (PCEA) in terms of overall patient satisfaction with postoperative pain management after lumbar spine fusion. SUMMARY OF BACKGROUND DATA: In numerous surgical disciplines, PCEA and PCA have proved to be effective methods of postoperative pain control. The literature states that with PCEA, less opioid use is required during the immediate postoperative period to maintain equivalent pain control compared to PCA. Continuous epidural infusion has been assessed in spine fusion patients, but PCEA has not been evaluated. Furthermore, this is the first prospective randomized clinical trial to assess overall patient satisfaction while stratifying patients for both anxiety level and preoperative opioid use. METHODS: For this study, 74 patients were assigned randomly to one of two treatment groups, with PCA and PCEA administered in a double-blind manner for a 3-day postoperative course. All the patients received both PCA and PCEA delivery systems. Assessment was by a blinded, independent observer. Overall patient satisfaction with pain management was assessed by a visual analog scale at the end of postoperative day 3. Secondary measures included: three scales from the Functional Independence Measure instrument; opioid quantity; side effects; and length of hospital stay. RESULTS: Thirty-eight patients were randomized to PCA, and 36 were randomized to PCEA. No baseline variable differences between the groups were observed. The results showed no difference between the groups on the following measures: overall patient satisfaction with pain management, ambulation, and length of stay. The PCA patients used significantly more opioid than the PCEA patients. CONCLUSIONS: Both postoperative analgesic regimens provided good overall patient satisfaction. The only clinical advantage of PCEA over PCA for spine fusion patients was the lower amount of opioid consumed, although the PCEA group experienced significantly more side effects than the PCA group. There were no other significant differences. Therefore, patient or physician preference could select either postoperative pain management delivery system.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 12698113 [PubMed - indexed for MEDLINE]
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