Faces Pain Scale Scores Research Articles

Effectiveness of Oxycodone, Ibuprofen, or the Combination in the Initial Management of Orthopedic Injury-Related Pain in Children

Orthopedic injuries comprise a majority of the indications for analgesia in the emergency department. Oxycodone and ibuprofen have demonstrated efficacy for this indication, but no studies have compared these drugs in children. Our objective was to investigate the effectiveness of oxycodone, ibuprofen, or their combination for the management of orthopedic injury-related pain in children. This prospective, randomized, double-blinded, clinical trial compared the effectiveness of oxycodone, ibuprofen, and the combination in children (age, 6-18 years), with pain from a suspected orthopedic injury. Subjects were block-randomized to receive 1 of the 3 treatment regimens. Pain was assessed with the Faces Pain Scale (FPS) and Visual Analog Scale at baseline, postimmobilization, 30, 60, 90, and 120 minutes postmedication. The change in the FPS score over time was compared between the 3 treatment groups using a generalized estimating equation model. Although all 3 treatment groups demonstrated a decrease in the FPS score over time, there were no significant differences between the groups. Among the 66 total children enrolled in the 3 treatment groups, there were no statistically significant differences in demographics or injury characteristics. There were 28 subjects with fractures. Immobilization of the injury demonstrated a significant reduction in the FPS score. Subjects in the combination treatment group reported more adverse effects. Oxycodone, ibuprofen, and the combination all provide effective analgesia for mild-to-moderate orthopedic injuries in children. Oxycodone or ibuprofen, alone, can be given, thereby avoiding the increase in adverse effects when given together.

Intramuscular and nerve root stimulation vs lidocaine injection to trigger points in myofascial pain syndrome

To compare the efficacies of an intramuscular stimulation technique and 0.5% lidocaine injection to trigger points in myofascial pain syndrome. Forty-three people with myofascial pain syndrome of the upper trapezius muscle. Twenty-two subjects were treated with intramuscular stimulation and another 21 with 0.5% lidocaine injection at all the trigger points on days 0, 7 and 14. Intramuscular stimulation resulted in a significant reduction in Wong-Baker FACES pain scale scores at all visits and was more effective than trigger point injection. Intramuscular stimulation also resulted in significant improvement on the Geriatric Depression Scale - Short Form. Local twitch responses occurred in 97.7% (42/43) of patients. All the passive cervical ranges of motion were significantly increased. Post-treatment soreness was noted in 54.6% of patients in the intramuscular stimulation group and 38.1% in the trigger point injection group, respectively, and gross subcutaneous haemorrhage (> 4 cm2) was seen in only one patient in the trigger point injection group. In managing myofascial pain syndrome, after one month intramuscular stimulation resulted in more significant improvements in pain intensity, cervical range of motion and depression scales than did 0.5% lidocaine injection of trigger points. Intramuscular stimulation is therefore recommended for myofascial pain syndrome.

Use of the Faces Pain Scale by left and right hemispheric stroke patients

No pain scale is available for stroke patients due to the presence of language or cognitive disorders. However, the Faces Pain Scale (FPS), which was initially developed for children, has been used with success in adults with cognitive impairments. The aim of this study is to test whether the FPS could be used in left or right hemispheric stroke patients (LHSP, RHSP). One hundred twenty-seven stoke patients and 21 controls were recruited in 2 rehabilitation units. Construct validity of FPS was assessed by rating and ranking facial expressions. FPS was correlated to a Visual Analog Scale (VAS) and to a Verbal Rating Scale (VRS) for the assessment of shoulder pain. Reliability was determined by test–retest procedures. Performances of RHSP in the ranking and rating procedures were very poor compared to LHSP and to controls. However, in the assessment of patients’ shoulder pain, FPS scores were highly correlated with VAS and VRS in both stroke groups ( r = 0.65–0.82, p < 10 −3). FPS was more reliable in LHSP than in RHSP. It was preferred to VAS and VRS in LHSP, while in RHSP VAS was the preferred scale. The present study provides preliminary support for the validity and the reliability of FPS in LHSP. However, we do not recommend its sole use in stroke patients. Further studies are needed to determine whether FPS can be used in stroke patients for assessing changes in severity of pain over time.

Is permanent maxillary tooth removal without palatal injection possible?

The aim of the present study was to demonstrate if articaine HCl could provide palatal anesthesia in maxillary tooth removal without the need for a second palatal injection. Of 53 patients, 23 had bilateral and 30 had unilateral extractions. In the study group 2 mL of 4% articaine/HCl with 1:100,000 epinephrine was injected into the buccal vestibule of the tooth. After 5 min the extraction was performed. 27 subjects were controls and subjected to the same protocol with palatal injection. All patients completed a Faces Pain Scale (FPS) and a 100-mm Visual Analogue Scale (VAS) after extraction. According to VAS and FPS scores, when permanent maxillary tooth removal with palatal injection (97.5%) and without palatal injection (96.8%) were compared the difference was not statistically significant (P > .05) [corrected]. Permanent removal of maxillary teeth without palatal injection is possible by depositing 2 mL articaine/HCl to the buccal vestibule of the tooth.

PI-44Correlation of CYP2D6 genotype with response to oxycodone in orthopedic injury related pain

BACKGROUND Inter-individual variability in response and adverse effects to oxycodone in pediatric patients may be due to CYP2D6 enzyme genetic variation. Intermediate or poor metabolizer (IM, PM) genotypes have impaired oxymorphone formation and may have altered response to oxycodone. This study assessed clinical response and presence of adverse events of oxycodone treatment as a function of CYP2D6 genotype. METHODS Randomized double blind prospective clinical trial in a tertiary care emergency department. 66 children (6–18 y) with orthopedic injuries were randomized to single dose oxycodone (0.1, 0.15 or 0.2 mg/kg). DNA was obtained via buccal swab and CYP2D6 genotype determined. Pain was assessed by Faces Pain Scale (FPS) at baseline, and 20, 40 and 60 minutes post-dose. RESULTS Dose groups were comparable for demographics and baseline FPS scores. Each group had effective analgesia as evidenced by significant reduction of FPS scores from baseline (p < 0.001). No FPS score differences were demonstrated between dose groups at any time point. No significant adverse events occurred. One patient was a PM (mean FPS = 5.5). IM (n=15, FPS = 3.4 ± 2.6) reported lower FPS scores than extensive metabolizers (EM) reported (n=36, FPS = 4.7 ± 3.0). A GEE model accounted for repeated measures, and found the difference between EM and IM was non-significant (model coefficient 0.88 (-0.20, 1.97), p = 0.11). CONCLUSION Findings suggest clinical response to oxycodone varies with CYP2D6 genotype but further study is indicated. Clinical Pharmacology & Therapeutics (2005) 79, P18–P18; doi: 10.1016/j.clpt.2005.12.065

PEDIATRICS

Study objective: We compare the effectiveness of intravenous ketorolac and intravenous prochlorperazine in the treatment of pediatric migraine headaches. Methods: We performed a prospective, randomized, double‐blind clinical trial in two pediatric emergency departments (EDs) within children's hospitals. Children aged 5 to 18 years presenting to the ED with migraine headaches were eligible for the study. Contraindications to either medication or the inability to complete the pain score resulted in exclusion. Children were randomized to receive intravenous ketorolac (.5 mg per kilogram; maximum 30 mg) or intravenous prochlorperazine (.15 mg per kilogram; maximum 10 mg). All children also received a normal saline solution bolus. Successful treatment was defined as a 50% or greater reduction in the Nine Faces Pain Scale score at 60 minutes. If a less than 50% improvement occurred by 60 minutes, the child received the other medication. Forty‐eight‐hour follow‐up telephone calls were made to each family to assess recurrence and late side effects. Results: Sixty‐two children were enrolled: 33 initially received prochlorperazine, and 29 initially received ketorolac. By 60 minutes, 16 (55.2%) of 29 children who received ketorolac and 28 (84.8%) of 33 children who received prochlorperazine were successfully treated (difference = 30%; 95% confidence interval [CI] 8% to 52%). Fifty‐six (93.3%) of the 60 children who completed the study were successfully treated by the study's conclusion. Approximately 30% of each group had a recurrence of some headache symptoms. Only two children reported side effects, both mild and self‐limited. Conclusion: In children, intravenous prochlorperazine is superior to intravenous ketorolac in the acute treatment of migraine headaches. Comments: Neuroleptics do work in terminating migraine (Wang SJ, Silberstein SD, Young WB. Droperidol treatment of status migrainosus and refractory migraine. Headache. 1997; 37:377‐382), and this may be related to a dopaminergic accelerator hypothesized by Dr. Stephen Peroutka (Peroutka SJ. Dopamine and migraine. Neurology. 1997;49:650‐656). Stewart J. Tepper We would have difficulty using intravenous prochloperazine (UK trademark STEMETIL) in the United Kingdom since the parental formulation is licensed only for intramuscular use in both adults and children. Furthermore, our national formulary recommends only oral dosing of prochlorperazine children, due to a high frequency of extrapyramidal effects {http://www.bnf.org/bnf/index.html}. I assume both ketorolac and prochlorperazine are licensed for i.v. use in North America, but are there any more pediatric data? David S. Millson

Treatment of pediatric migraine headaches: A randomized, double-blind trial of prochlorperazine versus ketorolac

Study objective We compare the effectiveness of intravenous ketorolac and intravenous prochlorperazine in the treatment of pediatric migraine headaches. Methods We performed a prospective, randomized, double-blind clinical trial in 2 pediatric emergency departments (EDs) within children's hospitals. Children aged 5 to 18 years presenting to the ED with migraine headaches were eligible for the study. Contraindications to either medication or the inability to complete the pain score resulted in exclusion. Children were randomized to receive intravenous ketorolac (0.5 mg/kg; maximum 30 mg) or intravenous prochlorperazine (0.15 mg/kg; maximum 10 mg). All children also received a normal saline solution bolus. Successful treatment was defined as a 50% or greater reduction in the Nine Faces Pain Scale score at 60 minutes. If a less than 50% improvement occurred by 60 minutes, the child received the other medication. Forty-eight-hour follow-up telephone calls were made to each family to assess recurrence and late side effects. Results Sixty-two children were enrolled: 33 initially received prochlorperazine, and 29 initially received ketorolac. By 60 minutes, 16 (55.2%) of 29 of those who received ketorolac and 28 (84.8%) of 33 of those who received prochlorperazine were successfully treated (difference=30%; 95% confidence interval [CI] 8% to 52%). Fifty-six (93.3%) of the 60 children who completed the study were successfully treated by the study's conclusion. Approximately 30% of each group had a recurrence of some headache symptoms. Only 2 children reported side effects, both mild and self-limited. Conclusion In children, intravenous prochlorperazine is superior to intravenous ketorolac in the acute treatment of migraine headaches.

The efficacy of pre‐ versus postsurgical axillary block on postoperative pain in paediatric patients

We compared the effects of pre- and postsurgical axillary block on pain after hand and forearm surgery in 55 children in a double-blind randomized study. The successful blocks are reported here (n=49). Children aged 1-11 years and ASA I or II were allocated randomly to receive axillary block with 2 mg.kg-1 of 0.25% bupivacaine, either after induction but before the surgery (presurgical group, n=25) or immediately after surgery, before the end of anaesthesia (postsurgical, n=24). In all patients, a standard general anaesthesia technique was used. The Faces Pain Scale (FPS) and analgesic requirements were recorded for 24 h at various times after operation. Eight patients (32%) in the presurgical group and 20 patients (83.33%) in the postsurgical group did not require additional analgesic within the first 24 h after operation (P< 0.05). In patients who had pain during the observation period, the pain started 13.66+/-2.61 h in the presurgical group and 13.14+/-2.34 h in the postsurgical group after performing block (P> 0.05). The FPS scores were similar in both groups during the first 8 h in the postoperative period (P> 0.05). There was a significant difference at 10 h after surgery (P< 0.05). Cumulative FPS score was higher in the presurgical group (10.50+/-1.06) than in the postsurgical group (9.45+/-1.28) (P< 0.05), but both groups had effective analgesia overall, the mean FPS score being less than 2. Additional analgesic consumption was similar in these patients in both groups. A lower isoflurane concentration was used in the presurgical group (0.68% vs 1.72%, P< 0.001). We did not demonstrate the superiority of preemptive analgesia, but our results indicate that presurgical axillary block with 0.25% bupivacaine allows the use of inhalational anaesthetics at lower concentrations while providing a reasonably painless postoperative period.

Preemptive Analgesia in Children: Does It Exist?

Preemptive analgesia has been evident in animals, but few adult human studies exist demonstrating this concept exist, and there are fewer still in children. Caudal epidural blocks with local anesthetics are often placed for postoperative analgesia in children. This study evaluated whether these blocks are more effective when placed prior to surgical incision. Children aged 1-6 years and ASA I and II (n = 51), undergoing elective herniorrhaphy, orchidopexy, or circumcision were randomly assigned to receive a caudal epidural block with 0.6 mL/kg of 0.25% bupivacaine with 1:200,000 epinephrine, either before incision (n = 28) or after surgery (n = 23). In all patients, anesthesia was induced and maintained with oxygen, nitrous oxide, and halothane, and caudal epidural blocks were placed. Postoperative pain was scored by a blinded observer using a Faces Pain Scale in the recovery room and was also assessed at home by the parents. Analgesic requirement during the 24-hour period was recorded. The Faces Pain Scale scores and analgesic requirements did not differ between the groups, either in the recovery room or at home (P > .05). Although preemptive analgesia has been successfully demonstrated in some earlier clinical studies, our results indicate that pre- and postincisional caudal epidural blocks with 0.25% bupivacaine were equally effective in children.

Age-Related Response to Lidocaine-Prilocaine (EMLA) Emulsion and Effect of Music Distraction on the Pain of Intravenous Cannulation

To compare the efficacy of a local anesthetic cream and music distraction in reducing or preventing pain from needle puncture (intravenous cannulation) in children. A secondary aim was to examine the influence of age on the pain report and behavior and on the therapeutic outcome. Children aged 4 to 16 years (N = 180) who were to undergo surgery under general anesthesia via intravenous cannulation were randomly allocated to one of three interventions. The comparison of lidocaine-prilocaine emulsion (EMLA, Astra) and a placebo emulsion was double-blind. Stratification by age group (4 to 6, 7 to 11, 12 to 16) ensured an equal number of children (20) in each intervention/age group category. A global assessment of the behavioral reaction to the procedure was made by the principal investigator, taking into account vocal, verbal, facial, and motor responses. The child was asked to assess pain severity on the Faces Pain Scale (FPS) and a visual analogue toy (VAT). The scales were applied conservatively as ordinal scales: FPS 0 to 6; VAT 0 to 10. Children who received lidocaine-prilocaine emulsion reported less pain (mean FPS score = 1.42) compared with placebo emulsion (mean FPS score = 2.58) and with music distraction (mean FPS = 2.62). There was a highly significant therapeutic effect (P < .001) on the self-report and behavioral scores. Younger children, regardless of intervention, reported significantly more pain than the older children (mean FPS scores: 2.85, 2.33, 1.43 for age groups 4 to 6, 7 to 11, and 12 to 16 respectively; P < .001). The superiority of the local anesthetic emulsion was maximal in the youngest age group (4 to 6) almost eliminating pain-related behavior, and multiple regression analysis confirmed significant age and treatment effects and revealed interaction between therapeutic effect and age. Although a trend favoring the active emulsion was evident in the older children (7 to 11, 12 to 16) the differences were not significant. The pain scores were influenced by the type (gauge) of cannula, but this did not affect the conclusion regarding therapeutic and age effects. There was no influence of sex, experience with venipuncture, or whether the child was anxious on arrival in the operating room. The results show that lidocaine-prilocaine emulsion is highly effective in preventing pain from venipunctures in young children, the group in most need of prevention.