Average Pain Numerical Rating Scale Research Articles

Knee mega-prosthesis in the management of complex knee fracture of the elderly : a case series and review of the literature

The management of complicated distal femur fractures (DFF) of the elderly continues to pose a challenge. Knee mega-prosthesis are mostly used for Total knee arthroplasty revision and tumor resection surgery but they can be used for the treatment of complex knee fractures. The purpose of the present study is to examine the short- to mid- term outcomes of their use for complex DFF of the elderly. We retrospectively identified 4 patients with DFF AO33C3 on osteoporotic bone treated by total knee arthroplasty from September 2015 to October 2019. The average age at the time of the surgery was 79,5 years (range, 69 to 95 years). All patients were females and underwent a total knee replacement by one senior surgeon, with the OSS TM Orthopaedic Salvage System (Zimmer Biomet, Warsaw, Indiana, USA). Outcome measures included clinical outcome scores, radiological analyses, reoperation rate and complications. At an average follow-up of 2,3 years (range, 0,6 to 4,2 years), the average Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) was 17,25 (range, 7 to 37), the average Oxford knee score was 35,25 (range, 25 to 41) and the average pain Numerical Rating Scale (NRS) was 0,5 (range, 0 to 1). 3 Patients had postoperative anemia but no implant related complications has been reported. Complex DFF of the elderly treated with mega knee arthroplasty exhibit good clinical outcomes scores. The patients should be selected carefully as the complication rate found in the literature remains high.

Regional pain management for oesophagectomy: Cohort study suggests a viable alternative to a thoracic epidural to enhance recovery after surgery

Ivor Lewis oesophagectomy (ILO) is associated with significant acute postsurgical pain and persistent chronic pain. The purpose of this study was to compare the Concord technique, which involves a combination of a surgeon-inserted paravertebral catheter, a single injection of intrathecal morphine and surgeon-inserted bilateral preperitoneal catheters, with the other available analgesic techniques. The study was designed as a retrospective cohort study and performed at the Concord Repatriation General Hospital, a tertiary teaching hospital affiliated with Sydney University. The participants comprised 60 consecutive patients in whom ILO was undertaken from January 1, 2011 to December 31, 2017, who were retrospectively analysed according to analgesic technique. The maximum, minimum and average pain numerical rating scale (NRS) scores were prospectively recorded daily for 3 days, opioid use for 3 days, and hospital length of stay, intensive care unit (ICU) length of stay, 30-day mortality and postoperative complications were also recorded. The Concord regional anaesthetic technique group had an average NRS pain scores which appeared favourable for day 0 (0.90 vs. 1.42), but no statistical differences were found between either group on day 1 (1.34 vs. 1.54), day 2 (0.94 vs. 1.13) or day 3 (0.94 vs. 1.00). The 30-day mortality, length of stay in hospital and ICU, and postoperative complications were comparable. The Concord regional technique for ILO analgesia appears to provide a simple alternative to other forms of analgesia, with similar analgesic efficacy and with no differences in postoperative complications. This may provide a pathway to enhanced recovery and is suitable to be evaluated in a Randomised control trial (RCT) of techniques.

Knee Mega-Prosthesis in the Management of Complex Knee Fracture of the Elderly a Case Series and Review of the Literature

The management of complicated distal femur fractures (DFF) of the elderly continues to pose a challenge. Knee mega-prosthesis are mostly used for Total knee arthroplasty revision and tumor resection surgery but they can be used for the treatment of complex knee fractures. The purpose of the present study is to examine the short- to mid- term outcomes of their use for complex DFF of the elderly. We retrospectively identified 4 patients with DFF AO33C3 on osteoporotic bone treated by total knee arthroplasty from September 2015 to October 2019. The average age at the time of the surgery was 79,5 years (range, 69 to 95 years). All patients were females and underwent a total knee replacement by one senior surgeon, with the OSS TM Orthopaedic Salvage System (Zimmer Biomet, Warsaw, Indiana, USA). Outcome measures included clinical outcome scores, radiological analyses, reoperation rate and complications. At an average follow-up of 2,3 years (range, 0,6 to 4,2 years), the average Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) was 17,25 (range, 7 to 37), the average Oxford knee score was 35,25 (range, 25 to 41) and the average pain Numerical Rating Scale (NRS) was 0,5 (range, 0 to 1). 3 Patients had postoperative anemia but no implant related complications has been reported. Complex DFF of the elderly treated with mega knee arthroplasty exhibit good clinical outcomes scores. The patients should be selected carefully as the complication rate found in the literature remains high.

P.014 OnabotulinumtoxinA-treated cervical dystonia patients report improvements in health-related quality of life in a prospective, observational study: POSTURe

Background: The clinical benefit of onabotulinumtoxinA in cervical dystonia (CD) is proven, but its impact on health-related quality of life (HRQoL) is largely unknown. Methods: Multicentre, prospective, observational study (NCT01655862) of CD patients treated with onabotulinumtoxinA at physician discretion (maximum 9 treatments). Patient-reported HRQoL outcomes and work productivity were collected at baseline, 4- or 8-weeks post-treatment, and final visit (prior to 9th treatment). OnabotulinumtoxinA utilization was assessed. Results: 61 patients received ≥1 treatment; 74.1% completed all treatments. Average total dose/treatment was 186.9U. The splenius capitis was most frequently treated (100% patients). Average pain numeric rating scale score was significantly improved at final visit (2.1) versus baseline (4.6; p<0.001) as were CD impact profile questionnaire-58 scores across all subscales (head/neck symptoms, pain/discomfort, sleep, upper limb activities, walking, annoyance, mood, psychosocial functioning; all p<0.001). Fewer patients (16.0%) reported loss of work productivity at final visit versus baseline (48.4%). 121 AEs were reported by 67.2% patients. 62 AEs in 44.3% patients were treatment-related, the most common being neck pain (18%). One serious AE (not treatment-related) was reported by 1 patient. No new safety signals were identified. Conclusions: Long-term use of onabotulinumtoxinA is a safe, effective treatment for CD, improving HRQoL and work productivity.

Results of a Double-Blind, Randomized, Placebo-Controlled Study of Nabiximols Oromucosal Spray as an Adjunctive Therapy in Advanced Cancer Patients with Chronic Uncontrolled Pain

ContextPrior Phase 2/3 studies found that cannabinoids might provide adjunctive analgesia in advanced cancer patients with uncontrolled pain. ObjectivesTo assess adjunctive nabiximols (Sativex®), an extract of Cannabis sativa containing two potentially therapeutic cannabinoids (Δ9-tetrahydrocannabinol [27 mg/mL] and cannabidiol [25 mg/mL]), in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy. MethodsPhase 3, double-blind, randomized, placebo-controlled trial in patients with advanced cancer and average pain Numerical Rating Scale scores ≥4 and ≤8 despite optimized opioid therapy. Patients randomized to nabiximols (n = 199) or placebo (n = 198) self-titrated study medications over a two-week period, followed by a three-week treatment period at the titrated dose. ResultsMedian percent improvements in average pain Numerical Rating Scale score from baseline to end of treatment in the nabiximols and placebo groups were 10.7% vs. 4.5% (P = 0.0854) in the intention-to-treat population (primary variable) and 15.5% vs. 6.3% (P = 0.0378) in the per-protocol population. Nabiximols was statistically superior to placebo on two of three quality-of-life instruments at Week 3 and on all three at Week 5. In exploratory post hoc analyses, U.S. patients, but not patients from the rest of the world, experienced significant benefits from nabiximols on multiple secondary endpoints. Possible contributing factors to differences in nabiximols efficacy include: 1) the U.S. participants received lower doses of opioids at baseline than the rest of the world and 2) the subgroups had different distribution of cancer pain types, which may have been related to differences in pathophysiology of pain. The safety profile of nabiximols was consistent with earlier studies. ConclusionsAlthough not superior to placebo on the primary efficacy endpoint, nabiximols had benefits on multiple secondary endpoints, particularly in the U.S. patients. Nabiximols might have utility in patients with advanced cancer who receive a lower opioid dose, such as individuals with early intolerance to opioid therapy.

Sativex oromucosal spray as adjunctive therapy in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy: two double-blind, randomized, placebo-controlled phase 3 studies.

Opioids are critical for managing cancer pain, but may provide inadequate relief and/or unacceptable side effects in some cases. To assess the analgesic efficacy of adjunctive Sativex (Δ9-tetrahydrocannabinol (27 mg/mL): cannabidiol (25 mg/mL)) in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy. This report describes two phase 3, double-blind, randomized, placebo-controlled trials. Eligible patients had advanced cancer and average pain numerical rating scale (NRS) scores ≥4 and ≤8 at baseline, despite optimized opioid therapy. In Study-1, patients were randomized to Sativex or placebo, and then self-titrated study medications over a 2-week period per effect and tolerability, followed by a 3-week treatment period. In Study-2, all patients self-titrated Sativex over a 2-week period. Patients with a ≥15% improvement from baseline in pain score were then randomized 1:1 to Sativex or placebo, followed by 5-week treatment period (randomized withdrawal design). The primary efficacy endpoint (percent improvement (Study-1) and mean change (Study-2) in average daily pain NRS scores) was not met in either study. Post hoc analyses of the primary endpoints identified statistically favourable treatment effect for Sativex in US patients <65 years (median treatment difference: 8.8; 95% confidence interval (CI): 0.00-17.95; p = 0.040) that was not observed in patients <65 years from the rest of the world (median treatment difference: 0.2; 95% CI: -5.00 to 7.74; p = 0.794). Treatment effect in favour of Sativex was observed on quality-of-life questionnaires, despite the fact that similar effects were not observed on NRS score. The safety profile of Sativex was consistent with earlier studies, and no evidence of abuse or misuse was identified. Sativex did not demonstrate superiority to placebo in reducing self-reported pain NRS scores in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy, although further exploration of differences between United States and patients from the rest of the world is warranted.

Evaluation of Pulsed Radiofrequency Denervation in the Treatment of Chronic Facetjoint Pain: An Observational Study

Background: Low back disorder is the most common problem in the entire spinal axis. About two-thirds of adults suffer from low back pain (LBP) at some time. Pain generators in the lumbar spine include the annulus of the disc, the posterior longitudinal ligament, a portion of the dural membrane, the facet joints, the spinal nerve roots and ganglia, and the associated paravertebral muscle fascia. There is no doubt that the facet joint is a potential source of chronic LBP. Facet joints are true synovial joints that have a joint space, hyaline cartilage surfaces, a synovial membrane, and a fibrous capsule. Two medial branches of the dorsal rami innervate the facet joints. If conservative measures fail in the treatment of facet joint pain, pulsed radiofrequency (PRF) of the medial branches can be administered. Objectives: The aim of this observational study was to evaluate the efficacy of PRF in the treatment of lumbar chronic facet joint pain. Patients and Methods: In this prospective observational study, we selected 300 patients who suffered from lumbar facet joint pain, were referred to the Pain Therapy Department, and underwent PRF treatment of the lumbar medial branches. We analyzed patients with facet joint pain that was unresponsive to conventional treatment, with a positive response to diagnostic medial branch block, who underwent PRF of the lumbar area for 18 months at San Giovanni Hospital of Rome. Results: Three hundred patients were eligible for the study. After 1 month, 62% of patients (186 patients) reported good pain relief [95% confidence interval (CI) 0.53, 0.7]; 8.6% (26 patients) reported excellent pain relief (95% CI 0.07-0.09); 20. 4% (61 patients) reported poor pain relief (95% CI 0.18-0.22), and 9% (27 patients) reported no pain relief (95% CI 0.08-0.099). The average pain numeric rating scale (NRS) score before the procedure was 6 (range 4-9), decreasing to 2 after the procedure (range 0-4). SF-36 physical and mental parameters improved significantly after the treatment [≥ 1 standard deviation (SD)]. Results after 6 months were similar to those obtained after 1 month. Conclusions: This study suggests that PRF treatment of the lumbar medial branches provides good pain relief for at least 6 months in 70% of patients who suffer from lumbar facet joint pain.

Evaluation of pulsed radiofrequency denervation in the treatment of chronic facetjoint pain: an observational study.

Background:Low back disorder is the most common problem in the entire spinal axis. About two-thirds of adults suffer from low back pain (LBP) at some time. Pain generators in the lumbar spine include the annulus of the disc, the posterior longitudinal ligament, a portion of the dural membrane, the facet joints, the spinal nerve roots and ganglia, and the associated paravertebral muscle fascia. There is no doubt that the facet joint is a potential source of chronic LBP. Facet joints are true synovial joints that have a joint space, hyaline cartilage surfaces, a synovial membrane, and a fibrous capsule. Two medial branches of the dorsal rami innervate the facet joints. If conservative measures fail in the treatment of facet joint pain, pulsed radiofrequency (PRF) of the medial branches can be administered.Objectives:The aim of this observational study was to evaluate the efficacy of PRF in the treatment of lumbar chronic facet joint pain.Patients and Methods:In this prospective observational study, we selected 300 patients who suffered from lumbar facet joint pain, were referred to the Pain Therapy Department, and underwent PRF treatment of the lumbar medial branches. We analyzed patients with facet joint pain that was unresponsive to conventional treatment, with a positive response to diagnostic medial branch block, who underwent PRF of the lumbar area for 18 months at San Giovanni Hospital of Rome.Results:Three hundred patients were eligible for the study. After 1 month, 62% of patients (186 patients) reported good pain relief [95% confidence interval (CI) 0.53, 0.7]; 8.6% (26 patients) reported excellent pain relief (95% CI 0.07-0.09); 20. 4% (61 patients) reported poor pain relief (95% CI 0.18-0.22), and 9% (27 patients) reported no pain relief (95% CI 0.08-0.099). The average pain numeric rating scale (NRS) score before the procedure was 6 (range 4-9), decreasing to 2 after the procedure (range 0-4). SF-36 physical and mental parameters improved significantly after the treatment [≥ 1 standard deviation (SD)]. Results after 6 months were similar to those obtained after 1 month.Conclusions:This study suggests that PRF treatment of the lumbar medial branches provides good pain relief for at least 6 months in 70% of patients who suffer from lumbar facet joint pain.

Multimodal analgesic approach incorporating paravertebral blocks for open radical retropubic prostatectomy: a randomized double-blind placebo-controlled study

Perioperative pain management influences both the quality as well as the speed of recovery following surgery. This was a randomized double-blind placebo-controlled study designed to assess the effectiveness of a multimodal analgesic approach (MMA) vs patient-controlled analgesia (PCA) alone in patients undergoing open prostatectomy. Prior to surgery, paravertebral blocks (PVBs) were performed with either 0.5% ropivacaine in the MMA group or saline in the PCA group. Patients in the MMA group also received celecoxib (400 mg po prior to surgery and 200 mg po bid for seven days following surgery) and ketamine 10 mg iv. Following surgery, every patient had free access to morphine PCA. A pain numerical rating scale (NRS) at 24 hr was chosen as the primary endpoint. Secondary endpoints included morphine consumption at 24 hr and SF-36 (36-Item Short-Form Health Survey) scores from two weeks to 24 weeks following surgery. The primary endpoint, average pain NRS at 24 hr, was 2.6 in the MMA group compared with 3.9 in the PCA group (difference = -1.6, 95% confidence interval [CI]: -2.3 to -0.4; P = 0.01). The average morphine consumption at 24 hr was 4.8 mg in the MMA group compared with 10.5 mg in the PCA group (difference = -5.7, 95% CI: -13.0 to 0.5; P = 0.01). Higher SF-36 scores at two, four, eight, and 12 weeks were observed in the MMA group compared with the PCA group, but no statistically significant (P < 0.05) between-group difference was found after Bonferroni correction of comparisons conducted repeatedly over time. Postoperative adverse effects included low episodes of postoperative nausea and vomiting, bladder spasms, constipation, and pruritus. This study demonstrates that PVBs combined with celecoxib and ketamine provide better immediate postoperative pain control and facilitate earlier functional recovery in patients undergoing an open radical prostatectomy when compared with PCA alone.

How do changes in pain severity levels correspond to changes in health status and function in patients with painful diabetic peripheral neuropathy?

The current analysis compares changes in pain with changes in function and health status in individuals with painful diabetic peripheral neuropathy (DPN). The post hoc analysis is based on a 12week, multinational, placebo-controlled trial of pregabalin in which 401 patients were randomized to treatment. Study measures included the Brief Pain Inventory short-form (BPI-sf), EQ-5D and other patient-reported outcomes. Cutpoints were derived on the BPI-sf 0–10 average pain numeric rating scale [NRS] to classify pain grades of “mild” (1–3), moderate (4–6) and severe (7–10), adjusting for geographical regions where data were collected. Two different metrics were used to classify the importance of change in pain severity from baseline to 12weeks: changes in pain severity grades (defined by cutpoint categories) and percent reduction in the NRS (categories ranging from 0–9% to ⩾50%). An improvement in one pain grade or a ⩾30% reduction in the NRS served as determinants of a clinically important difference. Patients with a one-grade reduction in pain severity, either from “severe-to-moderate” or “moderate-to-mild,” had a 3-point improvement the BPI-sf Pain Interference Index (PII; a composite measure of function); a reduction from “severe-to-mild” pain corresponded to a 6-point improvement in the PII. Similarly, a reduction in the NRS of ⩾30% and ⩾50% corresponded to a 3-point and a 5-point improvement in the PII, respectively. Changes in pain were also associated with changes in health status. Results suggest that patients whose pain is not reduced to a mild level of severity can still experience clinically important changes in function and health status.