Intensive Pain Research Articles

Long-term posttraumatic stress symptoms vary inversely with early opiate dosing in children recovering from serious burns

Children surviving serious burns are at risk for developing posttraumatic stress disorder (PTSD) as a function both of the injury and of its treatment. Short-term studies in such children have demonstrated reduced PTSD symptoms with intensive early pain control. However, the long-term impact of early pain control strategies on posttraumatic stress symptoms in children recovering from serious burn injuries has not been examined. This was a retrospective review of a multiple time point data collection involving a cohort of 147 infants, children, and teenagers with 4 years of follow-up after serious burns conducted at 4 pediatric burn centers to examine the impact of early opiate dosing on long-term posttraumatic stress symptoms. The main outcome measure was the nine-item Short Form Child Stress Disorders Checklist, which is an established and validated assessment. The impact of total opiate dosing during the first 7 days on these scores was assessed. Subjects had an average age of 11 years and average injury size of 22% total body surface area burned (%TBS). The correlation between opiate units (OUs) and %TBS was 0.46 at baseline, OU increasing with increasing %TBS. OUs were strongly predictive of Child Stress Disorders Checklist scores up to 4 years, with higher OU (10 units vs. 6 and 2 units) remaining constantly different up to 4 years in predicting lower stress scores for both smaller and larger burns. Early opiate management of pain associated with acute burn wounds and burn treatment predicts the development and resolution rate of PTSD symptoms in a large multicenter sample of children hospitalized for serious burns. The effect seems to be dose related and durable at least up to 4 years in a range of burn sizes. Prognostic/epidemiologic study, level II.

Efficacy of lycopene‐enriched virgin olive oil for treating burning mouth syndrome: a double‐blind randomised

Burning mouth syndrome (BMS) is an intensive chronic oral mucosal pain condition of unknown aetiology. The aim of this study was to evaluate the clinical performance of lycopene-enriched virgin olive oil used to treat the condition, comparing this with a placebo. This study took the form of a double-bind, randomised clinical trial. A total of 60 patients with BMS were randomly divided into two groups: Group I (n = 30) treated with lycopene-enriched virgin olive oil (300 ppm) (1.5 mL three times a day) and Group II (n=treated with a placebo (1.5 mL three times a day). Evaluations were made before and after 12 weeks of product/placebo application. Symptoms were evaluated by VAS, whilst patient psychological profiles were assessed using the HAD scale and patient quality of life using the Oral Health Impact Profile-14 (OHIP-14) and the Medical Outcome Short Form Health Survey questionnaire (SF36). Fifty patients completed the 12-week treatment (26 in Group I and 24 in Group II). Visual analogue scale pain values improved in both groups but without statistically significant differences between the groups (P = 0.57). Oral quality of life also improved. Four patients in Group I (treatment) left the study and six left Group II (placebo). No patients experienced any adverse effects resulting from treatment at any of the evaluation times. Patients were lost from the sample due to lack of compliance. It was found that the lipid profile did not change during the 3-month study period as a result of the application of lycopene-enriched olive oil (Group I); nor did any change occur in the placebo group (Group II). In this way, the placebo effect was seen to be strong. The topical lycopene-enriched virgin olive oil is a very safe and an effective similar way that the placebo for treating patients with BMS. However, future studies are required to establish the treatment for patients with chronic and painful syndrome.

Adolescent cervical disc degeneration in MRI does not predict adult headache or neck pain: A 5-year follow-up of adolescents with and without headache

The impact of early degenerative changes of the cervical spine on pain in adulthood is unknown. The objective was to determine whether degeneration in adolescence predicts headache or neck pain in young adulthood. As part of a follow-up of schoolchildren with and without headache, 17-year-old adolescents with headache at least three times a month (N = 47) and adolescents with no headache (N = 22) participated in a magnetic resonance imaging (MRI) study of the cervical spine. The same adolescents were re-examined by phone interview at the age of 22 years (N = 60/69, 87%). Mild disc degeneration at the age of 17 years was common, but was not associated with either frequent or intensive headache or neck pain at the age of 22 years. Conclusion: Mild degenerative changes of the cervical spine in 17-year-old adolescents cannot be regarded as a cause of future headache or neck pain.

Editorial introductions

Editorial introductions

Treatment of elderly patients with advanced lipedema: a combination of laser-assisted liposuction, medial thigh lift, and lower partial abdominoplasty

BackgroundLipedema is a rare female disorder with a characteristic distribution of adipose tissue hypertrophy on the extremities, with pain and bruising. In advanced stages, reduction of adipose tissue is the only available effective treatment. In elderly patients with advanced lipedema, correction of increased skin laxity has to be considered for an optimal outcome.MethodsWe report on a tailored combined approach to improve advanced lipedema in elderly females with multiple comorbidities. Microcannular laser-assisted liposuction of the upper legs and knees is performed under tumescent anesthesia. Medial thigh lift and partial lower abdominoplasty with minimal undermining are used to correct skin laxity and prevent intertrigo. Postsurgical care with nonelastic flat knitted compression garments and manual lymph drainage are used.ResultsWe report on three women aged 55–77 years with advanced lipedema of the legs and multiple comorbidities. Using this step-by-step approach, a short operation time and early mobilization were possible. Minor adverse effects were temporary methemoglobinemia after tumescent anesthesia and postsurgical pain. No severe adverse effects were seen. Patient satisfaction was high.ConclusionA tailored approach may be useful in advanced lipedema and is applicable even in elderly patients with multiple comorbidities.

Celiac plexus block in a patient with upper abdominal pain caused by diabetic gastroparesis.

Celiac plexus block in a patient with upper abdominal pain caused by diabetic gastroparesis.

Alçı Uygulaması Sonrası Gelişen Kompartman Sendromu: Üç olgu sunumu

Compartment syndrome can occur as a result of the complication of the plaster cast applications ,which are frequently used for fracture stabilization. This syndrome occurs due to increased compartment volume or shrinking of compartment area because of edema, hemorrage or high pressure of tissues. All of these mechanisms causes arteriolar compression, resulting nerve and muscle ischemia. Intensive and continuous pain is common and limits the motions of the patient and increases with passive stretching of the involved muscles. Swelling of limb, change in skin color, peripheral vasculatory failure symptoms such as pallor,weak arterial pulsation and as a result of peripheral nerve damage, sensorimotor deficit can also be observed. Clinical evaluation, measure of pressure within the compartment, and electroneuromyography (ENMG) can be used for the diagnosis. In addition to treatment of to the treatment of etiology and pain, further treatment options such as fasciotomy, physiotherapy modalities, tendon transfers, can be performed. In this case report, we will discuss three patients with nerve lesions as a result of the compartment syndrome that developed due to the plaster casting of bone fractures.

Pediatric pain management: the multidisciplinary approach

Chronic pain in children and adolescents is a growing problem and one that is increasingly being addressed with multidisciplinary treatment teams. This review summarizes different multidisciplinary clinics, focusing specifically on intensive pediatric pain rehabilitation centers. This review offers a summary of the challenges faced by these programs and areas for future study.

Pain Physiology Education Improves Health Status and Endogenous Pain Inhibition in Fibromyalgia

There is evidence that education on pain physiology can have positive effects on pain, disability, and catastrophization in patients with chronic musculoskeletal pain disorders. A double-blind randomized controlled trial (RCT) was performed to examine whether intensive pain physiology education is also effective in fibromyalgia (FM) patients, and whether it is able to influence the impaired endogenous pain inhibition of these patients. Thirty FM patients were randomly allocated to either the experimental (receiving pain physiology education) or the control group (receiving pacing self-management education). The primary outcome was the efficacy of the pain inhibitory mechanisms, which was evaluated by spatially accumulating thermal nociceptive stimuli. Secondary outcome measures included pressure pain threshold measurements and questionnaires assessing pain cognitions, behavior, and health status. Assessments were performed at baseline, 2 weeks, and 3 months follow-up. Repeated measures ANOVAS were used to reveal possible therapy effects and effect sizes were calculated. After the intervention the experimental group had improved knowledge of pain neurophysiology (P<0.001). Patients from this group worried less about their pain in the short term (P=0.004). Long-term improvements in physical functioning (P=0.046), vitality (P=0.047), mental health (P<0.001), and general health perceptions (P<0.001) were observed. In addition, the intervention group reported lower pain scores and showed improved endogenous pain inhibition (P=0.041) compared with the control group. These results suggest that FM patients are able to understand and remember the complex material about pain physiology. Pain physiology education seems to be a useful component in the treatment of FM patients as it improves health status and endogenous pain inhibition in the long term.

Inpatient-based intensive interdisciplinary pain treatment for highly impaired children with severe chronic pain: Randomized controlled trial of efficacy and economic effects

Pediatric chronic pain, which can result in deleterious effects for the child, bears the risk of aggravation into adulthood. Intensive interdisciplinary pain treatment (IIPT) might be an effective treatment, given the advantage of consulting with multiple professionals on a daily basis. Evidence for the effectiveness of IIPT is scarce. We investigated the efficacy of an IIPT within a randomized controlled trial by comparing an intervention group (IG) (n=52) to a waiting-list control group (WCG) (n=52). We made assessments before treatment (PRE), immediately after treatment (POST), as well as at short-term (POST6MONTHS) and long-term (POST12MONTHS) follow-up. We determined a combined endpoint, improvement (pain intensity, disability, school absence), and investigated 3 additional outcome domains (anxiety, depression, catastrophizing). We also investigated changes in economic parameters (health care use, parental work absenteeism, subjective financial burden) and their relationship to the child’s improvement. Results at POST showed that significantly more children in the IG than in the WCG were assigned to improvement (55% compared to 14%; Fisher P<.001; 95% confidence interval for incidence difference: 0.21% to 0.60%). Although immediate effects were achieved for disability, school absence, depression, and catastrophizing, pain intensity and anxiety did not change until short-term follow-up. More than 60% of the children in both groups were improved long-term. The parents reported significant reductions in all economic parameters. The results from the present study support the efficacy of the IIPT. Future research is warranted to investigate differences in treatment response and to understand the changes in economic parameters in nonimproved children.

Retrospective Outcome Analyses for Headaches in a Pain Rehabilitation Interdisciplinary Program

Incapacitating chronic migraine and other severe headaches can have significant impact on peoples' lives, including family and occupational functioning. Although a number of reports have investigated the prevalence and medical treatment of chronic headache, few have reported on the efficacy of treating these disorders within a comprehensive, intensive chronic pain rehabilitation program (CPRP), instead of a headache-specific program. CPRPs provide treatment of headache by focusing not only on physical pain, but also its association with impaired mood and function. We examined the efficacy of CPRP in patients with chronic headache via a retrospective analysis of 123 patients (76.4% female), ages 21 to 85, who completed the CPRP at the Cleveland Clinic between January 2007 and December 2011, and were diagnosed using International Classification of Headache Disorders, 2nd edition and International Classification of Headache Disorders, 2nd edition revision, with migraine or headache as a major complaint. Outcome measures included: pain intensity scores present at the moment of questioning where 10 is the maximal (0-10/10), Depression Anxiety Stress Scale (DASS) scores, (measuring mood), and Pain Disability Index scores (measuring function). Repeated measures t-tests were used. Average pain score on admission was 6.4, and 3.4 upon discharge. Average function on admission was moderately impaired, and normalized on discharge. The average depression score was in the moderate range, and had normalized on discharge. The average anxiety score on admission was in the severe range and was in the mild range on discharge. Results indicate that individuals had statistically and clinically meaningful improvement in pain, mood, and function. Data suggest that an interdisciplinary CPRP approach for patients diagnosed with headache can be effective in helping to decrease pain, as well as normalize mood and function. Thus, CPRPs serve as an alternative treatment to multidisciplinary headache programs, interventional pain techniques, and primary care standard headache care.

Myopericarditis: under a mask of acute coronary syndrome

The aim of the study was to evaluate the prevalence rate, clinical features and outcomes of myopericarditis in patients, hospitalized with initial diagnosis of ST-elevation Acute Coronary Syndrome (ACS). Methods: 634 pts with ST-elevation ACS were included. They underwent emergency Coronary Angiography (CAG), ECG, echo and laboratory testing (cardiac troponin level, inflammatory markers). Contrast-enhanced Magnetic Resonance Imaging (MRI) was used to verify the diagnosis of myopericarditis. Results: Among 634 pts with typical clinical characteristics of ACS, elevated troponin and persistent ST-elevation on ECG, myopericarditis was diagnosed in 4 cases (0.6%), mean age 27.5±5.2 yrs, all were males. Presumable etiology remained unknown, but 2 patients recently had viral infection and one patient underwent toxic effect of hydrogen sulphide before admission. All of them had intensive chest pain and exertional dyspnea, 3 patients experienced shortness of breath and dizziness at rest. In two patients the course of acute myopericarditis was complicated by pulmonary edema. Other complaints included arrhythmia (25%), pre-syncope (25%) and low-grade fever (75%). ST-elevation on ECG was predominantly localized in inferior (75%) and lateral leads (25%). Three patients had inferolateral wall hypokinesis during echocardiography, other parameters (heart size, global contractility and pulmonary artery systolic pressure) were normal. Mean EF was 53.7±7.2%. All patients diagnosed with acute myopericarditis received anti-inflammatory drugs, diuretics and symptomatic treatment and remained hemodinamically stable in hospital period. During 12-month follow up period after acute myopericarditis we didn't register fatal outcomes or major adverse cardiovascular events. Conclusions: The difficulty in diagnostics of inflammatory myocardial diseases lies in the poor specificity and sensitivity of the various diagnostic techniques used. Our report illustrates that patients with suspected acute myocardial infarction but normal coronary angiography may have likely myocarditis. Confusing factors are typical angina, elevated cardiac troponin level and ST-segment elevation on ECG, suggestive of acute myocardial infarction. Pathogenetic anti-inflammatory treatment contributed to considerable improvement of the clinical and functional status of patients.

The study of multimodal analgesia on postoperative delirium in elder patients with hip fracture

Objective To study effects of multimodal analgesia on postoperative delirium (POD)in elder patients with hip fracture.Methods One hundred and eight elder patients with hip fractures were gathered in a prospective study.Fifty-nine cases were included in the group of multimodal analgesia (25 males,34 females),with an average age of 72.91±5.42 years,and 35 were treated with hip replacements,the other 24 were internal fixations.Forty-nine cases were in the group of conventional analgesia (22 males,27 females),with an average age of 72.14±4.93 years,29 were treated with hip replacements,20 were internal fixations.Assessments of delirium were based on confusion assessment method.Local infiltrated anesthesia,patient control intravenous analgesia,and intravenous nonsteroid anti-inflammatory drug were applied in the group of multimodal analgesia.For the other group,morphine would be given only when patient complained pain or there was POD.Postoperatively,visual analogue scale (VAS),onset of delirium,other correlative data were recorded by an independent researcher.All patients underwent POD were managed with intensive pain management,and then reevaluated.Results VAS in multimodal analgesia group [Day1:2.10±1.43(resting),4.74±1.45 (active) and Day 3:1.01±0.92 (resting),3.31±1.36 (active)] were significandy lower than that in the other group [Day1:4.67±1.33 (resting),7.44±1.59 (active)and Day 3:2.24±1.39 (resting),5.06±1.46 (active)].PODs were detected in 15 (30.6％) in group of conventional analgesia; while in group of multimodal analgesia,there were 7 (11.9％).All POD were given intensive pain managements by injection of 10 mg morphine and achieved relief of deliriums.Conclusion Postoperative multimodal analgesia may reduce the incidence of POD.First aid of intensive pain management may help to control POD. Key words: Analgesia; Hip; Fractures, bone; Delirium; Aged

Postoperative Beschwerden

Women report more severe postoperative complaints than men (e.g. nausea and pain) and expectations of complaints prior to surgery influence the postoperative complaints. Therefore, the aim of this study was to explore if gender differences in complaint expectation can account for differences in postoperative complaints. A further objective was to investigate the effective load of complaints and to look for gender differences. In total 281 patients (128 men and 153 women) were included in the study and all patients underwent elective general surgery. Patients were asked for symptom expectations and symptom experiences prior to surgery. After surgery they answered the Anesthesiological Questionnaire (ANP) a validated self-rating method for the assessment of postoperative symptoms and complaints. The symptoms referred to in the questionnaire included sensation of cold, sensation of heat, nausea and vomiting, tickly throat, croakiness, dry mouth and thirst, difficulty in breathing, sore throat, pain in the area of surgery, pain in the area of infusion, muscle pain, back pain, headache, difficulties in urination, difficulty in awakening and feeling of somatic discomfort. In addition patients rated the affective load of the postoperative complaints. In previous surgery women reported experiencing more postoperative somatic complaints than men. Sex-related differences were significant (p < 0.05) for sensation of cold, nausea and vomiting, tickly throat, croakiness, sore throat, pain and the feeling of somatic discomfort. Likewise, women expected more intensive postoperative complaints following the forthcoming operation. After surgery women reported significantly more severe complaints in negative symptoms of the ANP (e.g. nausea and vomiting, pain and somatic discomfort). Effect sizes of sex-related differences varied according to the symptom (e.g. for pain effect strength d = 0.50, for nausea d = 0.60 and for thirst d = 0.13). Effect sizes decreased when the effect of expectation was statistically controlled. Logistic regression revealed that expectation was an independent predictor for the sensation of severe nausea (odds ratio OR 4.3] and intensive postoperative pain (OR 2.6). Regardless of gender, postoperative pain, nausea and dry mouth/thirst were symptoms with the highest affective load. Preoperative expectations increase gender differences in somatic complaints following surgery. Anesthesiological education of patients should influence dysfunctional expectations. Postoperative pain, nausea and thirst should be the main targets of interventions to improve patient complaints.

AB0601 Risk factors for early osteoarthritis progression

BackgroundOsteoarthritis (OA) is one of the most common joint pathologies, which is a result of cartilage or subchondral bone damage.Objectivesto determine the risk factors of structural progression of knee OA...

Pyomyositis in the course of acute lymphoblastic leukemia

Pyomyositis is a term used to asses pyogenic infection of the skeletal muscle and develops as the result of bacteriemia and occurs most commonly in patients with various immunosuppressive diseases. Pyomyositis should be considered in the differential diagnosis in patients complaining of intensive muscle pain and fever. The usual causative organism is Staphylococcus aureus. We present a 3-year-old boy with acute lymphoblastic leukemia (ALL) and pyomyositis caused by Pseudomonas aeruginosa diagnosed in the course of induction therapy. The diagnosis of pyomyositis in the crural muscles of both legs was given based on imaging examinations: ultrasonography and magnetic resonance.

Opioid wean does not increase chronic pain

The purpose of this study was to investigate if opioid weaning was associated with pain and depression outcomes in a group of chronic pain patients that completed an intensive 5-week interdisciplinary pain rehabilitation program. Patients were categorized into three groups based on setting and opiate weaning status. Patients were administered the Medical College of Virginia’s Pain Questionnaire (MCVPQ) and Beck Depression Inventory (BDI) at admission and discharge. Group differences on demographic and clinical variables were tested with one-way ANOVA and chi-square analyses.

Development of efficacy-tolerability composite measures integrating measures of pain reduction and the severity and duration of AEs

Development of efficacy-tolerability composite measures integrating measures of pain reduction and the severity and duration of AEs

Chronic pain and anxiety: a treatment outcome comparison of patients with anxiety in an interdisciplinary pain rehabilitation program

Anxiety symptoms are often overlooked or deemphasized for chronic pain patients, and research on effective treatments for patients with both chronic pain and anxiety is minimal. This study attempts to determine the prevalence of various anxiety disorders within this population, and compare treatment outcomes of those with or without anxiety following an intensive (3-week) interdisciplinary pain rehabilitation program. Mayo Clinic IRB approved this retrospective study comparing patients with and without anxiety from March 2009 to Dec. 2011. The presence of an anxiety disorder was determined by diagnoses given from responses to the Mini-International Neuropsychiatric Interview. Pain-related anxiety and pain catastrophizing were assessed with the Pain-Anxiety Symptoms Scale and the Pain Catastrophizing Scale. Pain severity, mood and functioning were assessed with the Multidimensional Pain Inventory, Pain Catastrophizing Scale, SF-36 Health Survey and Center for Epidemiological Studies-Depression scale. Significant differences in age, gender, ethnicity, andmarital statuswere foundbetween anxiety and non-anxiety groups.Within this sample, panic disorder (with andwithout agoraphobia; 16%) was the most prevalent anxiety disorder. Upon admission significant differences were found in most treatment outcomes with chronic pain patients with anxiety faring worse. Upon discharge, those with anxiety significantly scored worse than those without anxiety in pain-anxiety symptoms (p<.01), pain catastrophizing (p<.05), depression (p<.001), and life control (p<.05). Upon follow-up, significant differences in depression (p<.001) were found with the anxiety group rating higher. This study concludes that patients with the presence of anxiety or an anxiety disorder responded favorably with improved functioning following interdisciplinary rehabilitation pain treatment. Yet, those with anxiety tended to show poorer outcomes than those without the presence of an anxiety disorder. Interdisciplinary pain rehabilitation programs should address anxiety disorders and provide tools for patients to manage and cope with anxiety in healthy ways to further improve outcomes.

The effects of intraarticular opioids in pain relief after arthroscopic menisectomy:A randomized clinical trial study

Knee arthroscopy is a painful procedure which if untreated will cause intensive and prolonged pain that may prevent rehabilitation of patients. This study was designed to compare the analgesic effects of different opioids in the early post operative period in comparison to control group. One hundred forty patients were prospectively assigned to four groups randomly. After arthroscopic menisectomy all patients received an intraarticular injection containing 9.5 ml bupivacaine 0.5% with 1:200000 epinephrine in a 10 ml syringe. The remainder of syringe was filled with one of the study solutions. Group I: 5mg methadone, group II: 5mg morphine, group III: 5 ml normal saline, group IV: 50 mg meperidine. At three stages in the ealy post operative period the need for analgesics was recorded. A statistical comparison was done afterwards. Results : In morphine group (group II), the analgesic usage in hospitalized and outpatients compared with other groups was significantly low(P<0.05). Morphine in comparison to meperidine or methadone is more beneficial in reducing pain or analgesic need when is added to bupivacain injection following arthroscopic menisectomy.