Pain Management In Patients Research Articles

Trigeminal neuralgia: a condition to be better understood.

Dear Editor, I read the paper entitled “Trigeminal Neuralgia: Frequency of Occurrence in Different Nerve Branches”, published in your journal (1). The data presented confirms the findings of previous papers (2-4), as was also mentioned by the author. Such findings help the clinicians to diagnose the disease. However, some other points need to be mentioned; even though this study reports no case of bilateral trigeminal neuralgia, previous publications reported that it may affect 1-5% of the patients (5, 6), and another author mentioned that bilateral cases should suggest a systemic involvement, such as multiple sclerosis (MS) or cranial tumor (7). We can conclude that bilateral cases are rare, but not impossible; and a clinician should be suspicious of a systemic condition when examining a patient with bilateral trigeminal neuralgia (TN). Considering that TN is a clinical diagnosis, the clinician should not only rely on the epidemiologic data, even though it might help on the differential diagnosis. Clinical characteristics should be considered during the history taking and clinical examination, and those characteristics can be found on the diagnostic criteria published by the International Headache Society (IHS). The IHS divides TN in two subsets: Classical TN, which is not related to any pathology, but vascular compression. Symptomatic TN, which is caused by an identifiable lesion or pathology. It is known that over 85% of the cases with TN have the classical TN. All clinicians involved on the management of pain patients should be familiar with the diagnostic criteria published by the IHS, which helps to correctly identify patients with TN, as well as differentiate between classical TN and symptomatic TN (8). Although diagnosing TN appears to be easy, many patients have undergone unnecessary dental treatment (9), and about 90% of patients diagnosed with TN experienced pain for more than 1 year before receiving the correct diagnosis (10). Before establishing a long-term treatment, the health care provider should first try to identify the etiology of the TN. As the Bangash’s paper well mentioned, the clinician should closely follow the patients up, in order to select the best treatment, watch for side effects and often evaluate the patient for any change on the medical history (including new intra and extra oral exam). Clinicians should become familiar not only with treatment options, indications and contraindications for each treatment modality, side effects and adverse reactions associated with the treatment, but also with new studies about diagnosis and treatment of TN. As all the other neuropathic pain conditions, TN is not completely understood yet. Finally, further investigations should focus not only on the treatment of TN, but also on the pathogenesis of this condition. Epidemiologic studies as the article published by Bangash on your journal are the first step to develop more specific studies regarding etiology and new treatment options in order to decrease/eliminate the patient’s suffering and clinician’s frustration.

Cement Augmentation of Refractory Osteoporotic Vertebral Compression Fractures

Retrospective cohort. To compare survivorship after cement augmentation of refractory osteoporotic vertebral compression fractures (OVCFs) with traditional inpatient pain management and bracing. OVCFs can cause debilitating pain and functional decline necessitating prolonged bed rest and high-dose narcotics. Vertebroplasty and kyphoplasty are cement augmentation procedures used to control pain and restore function in patients with OVCF's that are refractory to conservative treatment. Early mobilization is associated with improved survival after other fractures in elderly patients. A university hospital database was used to identify all participants treated with primary diagnosis of OVCF between 1993 and 2006. Chart review and imaging studies were used to confirm demographics, comorbidities, diagnosis, and treatment. Survival time was determined using hospital data, national death indices and patient follow-up. Exact Fisher tests, Mann-Whitney tests, and proportional hazards regression models with Kaplan-Meier plots compared patients treated with cement augmentation with controls treated with inpatient pain management and bracing. Patients with high-energy trauma, tumors or age more than 60 years were excluded. Within the past 12 years, 46 patients treated with cement augmentation and 129 matched controls met inclusion criteria. They did not differ with respect to age, sex, and comorbidities. A significant survival advantage was found after cement augmentation compared with controls (P < 0.001; log rank), regardless of comorbidities, age, or the number of fractures diagnosed at the start date (P = 0.565). Controlling simultaneously for covariates, the estimated hazard ratio associated with cementation was 0.10 (95% confidence interval [CI] = 0.02-0.43; P = 0.002) for year 1, 0.15 (95% CI = 0.02-1.12; P = 0.064) for year 2, and 0.95 (95% CI = 0.32-2.79; P = 0.919) for subsequent follow-up. The number of OVCFs at the start time of treatment did not affect survival benefit of cementation (P = 0.44). Cement augmentation of refractory OVCF improves survival for up to 2 years when compared with conservative pain management with bed rest, narcotics, and extension bracing, regardless of age, sex, and number of fractures or comorbidities. Therefore, aggressive management should be considered for refractory OVCFs with intractable back pain.

Methadone use in children and young adults at a cancer center: A retrospective study

To augment the literature on methadone applications in pediatric oncology, the authors reviewed the use of methadone at a pediatric cancer center over a 5-year period. Forty-one patients received methadone for inpatient or outpatient pain management. The authors retrospectively reviewed their demographic characteristics, diagnoses, type of pain (nociceptive, neuropathic, or mixed) and causes of pain, and the indications, dose regimens, adverse effects, and outcomes of methadone treatment. There were four types of clinical uses for methadone in 41 patients (10 patients had two): nociceptive pain unresponsive to other opioids (17 patients, 33.3 percent), neuropathic pain (20 patients, 39.2 percent), facilitation of weaning from opioids (11 patients, 21.6 percent), and end-of-life pain management (3 patients, 5.9 percent). The mean age of the 24 males (58.5 percent) and 17 females (41.5 percent) at the start of treatment was 15.7 years (range, 0.6-23 years). The most common diagnoses were leukemia (n = 10, 24.4 percent), osteosarcoma (n = 7, 17.0 percent), and rhabdomyosarcoma (n = 5, 12.2 percent). The causes of pain were bone marrow transplant (n = 13, 31.7 percent), amputation (n = 6, 14.6 percent), chemotherapy (n = 5, 12.2 percent), tumor (n = 5, 12.2 percent), limb-sparing surgery (n = 4, 9.8 percent), and other (n = 8, 19.5 percent). Efficacy was assessed at the end (or after 6 months) of methadone treatment. For many patients (43.1 percent), methadone showed efficacy in achieving the purpose for which it was prescribed, including reduction of nociceptive or neuropathic pain and prevention of opioid withdrawal. Sedation was the most common side effect (24.4 percent). Methadone was effective for pediatric patients with neuropathic pain or nociceptive pain unresponsive to other opioids, and it effectively prevented opioid withdrawal.

Responsiveness of the cervical Northern American Spine Society questionnaire (NASS) and the Short Form 36 (SF-36) in chronic whiplash

Objective: To determine and compare the sensitivity to change of the condition-specific cervical Northern American Spine Society (NASS) and the generic Short Form 36 (SF-36). Design: Prospective cohort study. Subjects: One hundred and seventy five patients after whiplash injury. Interventions: Four-week inpatient interdisciplinary pain management programme. Main measures, analysis: Responsiveness of the NASS and the SF-36 was quantified by effect size and standardized response mean and compared within the same construct by the modified Jacknife test. Ability to detect improvement was compared using sensitivities determined from receiver operating characteristics curves. Results: In pain, the NASS was comparable responsive to the SF-36 at the one-month follow-up (n = 175): effect sizes: 0.62 (NASS) versus 0.61 (SF-36), P = 0.914. The NASS was less responsive than the SF-36 in function: 0.23 versus 0.63, P < 0.001 and in pain+function: 0.35 versus 0.58 (P = 0.001). These relationships remained consistent using standardized response means, at the six-month follow-up (n = 103), and in the comparison of the sensitivities. Sensitivities at one month, pain: 70% (NASS) versus 62% (SF-36), P = 0.234; function: 65% versus 80%, P = 0.002; pain+function: 68% versus 78%, P = 0.035. The six-month data were similar. Conclusions: The generic SF-36 was more responsive in function and equally responsive in pain when compared to the condition-specific NASS. The SF-36 can be recommended as a responsive instrument for measurement of pain and function in chronic whiplash syndrome.

Differences in pain, function and coping in Multidimensional Pain Inventory subgroups of chronic back pain: a one-group pretest-posttest study

BackgroundPatients with non-specific back pain are not a homogeneous group but heterogeneous with regard to their bio-psycho-social impairments. This study examined a sample of 173 highly disabled patients with chronic back pain to find out how the three subgroups based on the Multidimensional Pain Inventory (MPI) differed in their response to an inpatient pain management program.MethodsSubgroup classification was conducted by cluster analysis using MPI subscale scores at entry into the program. At program entry and at discharge after four weeks, participants completed the MPI, the MOS Short Form-36 (SF-36), the Hospital Anxiety and Depression Scale (HADS), and the Coping Strategies Questionnaire (CSQ). Pairwise analyses of the score changes of the mentioned outcomes of the three MPI subgroups were performed using the Mann-Whitney-U-test for significance.ResultsCluster analysis identified three MPI subgroups in this highly disabled sample: a dysfunctional, interpersonally distressed and an adaptive copers subgroup. The dysfunctional subgroup (29% of the sample) showed the highest level of depression in SF-36 mental health (33.4 ± 13.9), the interpersonally distressed subgroup (35% of the sample) a modest level of depression (46.8 ± 20.4), and the adaptive copers subgroup (32% of the sample) the lowest level of depression (57.8 ± 19.1). Significant differences in pain reduction and improvement of mental health and coping were observed across the three MPI subgroups, i.e. the effect sizes for MPI pain reduction were: 0.84 (0.44 - 1.24) for the dysfunctional subgroup, 1.22 (0.86 - 1.58) for the adaptive copers subgroup, and 0.53 (0.24 - 0.81) for the interpersonally distressed subgroup (p = 0.006 for pairwise comparison). Significant score changes between subgroups concerning activities and physical functioning could not be identified.ConclusionsMPI subgroup classification showed significant differences in score changes for pain, mental health and coping. These findings underscore the importance of assessing individual differences to understand how patients adjust to chronic back pain.

Improved Postoperative Pain Control and Function After Inpatient Pain Consultation on an Orthopedic Unit

A quality improvement project was initiated on an orthopedic unit at a tertiary Midwestern hospital by the inpatient pain management consult service. Several factors drove this initiative, including low patient satisfaction scores for pain management and increased staff awareness regarding pain management practices. After receiving Institutional Review Board approval, a pilot study was initiated in an attempt to improve postoperative pain management. Data were collected on a convenience sample of postoperative patients seen by the inpatient pain management consulting service over a 4-month period.

Behandlung chronischer Schmerzen in der Schweiz: wissenschaftliche Evidenz

Chronic pain is often seen in the lower back region (lumbar spine). It usually influences different aspects of health and wellbeing, is often treated inadequately and causes important economic costs. Various biopsychosocial factors influence chronic pain and the outcome of medical treatment. This has lead to multidisciplinary treatment strategies. The scientific evaluation of interdisciplinary inpatient pain management programs in Switzerland shows moderate to large changes in various health dimensions in subjects with chronic non-specific back pain, fibromyalgia, chronic widespread pain, and after whiplash injury. These short- to mid-term results are confirmed by international scientific evidence. The effects of an interdisciplinary pain management program are higher than those of the standard rehabilitation. Complementary, subgroup-specific pain treatment could optimize these results.

Psychiatric aspects of burn

ABSTRACTBurn injuries and their subsequent treatment cause one of the most excruciating forms of pain imaginable. The psychological aspects of burn injury have been researched in different parts of the world, producing different outcomes. Studies have shown that greater levels of acute pain are associated with negative long-term psychological effects such as acute stress disorder, depression, suicidal ideation, and post-traumatic stress disorder for as long as 2 years after the initial burn injury. The concept of allostatic load is presented as a potential explanation for the relationship between acute pain and subsequent psychological outcomes. A biopsychosocial model is also presented as a means of obtaining better inpatient pain management and helping to mediate this relationship.

The Impact of Integrative Medicine on Pain Management in a Tertiary Care Hospital

Optimal inpatient pain management remains a major institutional and therapeutic challenge. Nontoxic, nonpharmacological approaches to treating pain show promise but have not been widely implemented, nor has their effectiveness been evaluated. To evaluate the effectiveness of an inpatient integrative medicine consult service for pain management in 6 settings across an entire tertiary care hospital. Retrospective, observational study. Abbott Northwestern Hospital, a 629-bed tertiary-care hospital in Minneapolis, Minn, that is part of Allina Hospitals & Clinics. Approximately 1837 patients hospitalized between January 1, 2008, and June 30, 2009. Pretreatment and posttreatment pain scores on a verbal scale of 0 to 10. Most patients (66%) had never previously received integrative services. Provision of integrative services had immediate and beneficial effects on pain scores. The average reduction in pain scores was 1.9 points (on a 10-point scale), and the average percentage in pain reduction was approximately 55%. The formal provision of inpatient integrative medicine had a significant impact on pain scores for hospitalized patients, reducing self-reported pain by more than 50%, without placing patients at increased risk of adverse effects. This was true in all 6 settings. Age, previous use of complementary therapies, and sex did not affect results. Future research must define the appropriate dose of the intervention, the duration of the relief, and the identification of patients most likely to respond to these nonpharmacological treatments. Additionally, future research using the electronic health record will allow quantification of any reduction in total costs, pain medication usage, and adverse events.

Psychiatric aspects of burn.

Burn injuries and their subsequent treatment cause one of the most excruciating forms of pain imaginable. The psychological aspects of burn injury have been researched in different parts of the world, producing different outcomes. Studies have shown that greater levels of acute pain are associated with negative long-term psychological effects such as acute stress disorder, depression, suicidal ideation, and post-traumatic stress disorder for as long as 2 years after the initial burn injury. The concept of allostatic load is presented as a potential explanation for the relationship between acute pain and subsequent psychological outcomes. A biopsychosocial model is also presented as a means of obtaining better inpatient pain management and helping to mediate this relationship.

Interdisciplinary rehabilitation after whiplash injury: An observational prospective outcome study

To examine the state of, and change in, biopsycho-social health and quality of life of patients after whiplash injury, before and after an inpatient interdisciplinary pain management programme. Observational, prospective cohort study (n = 103) using medical record data and standardized self-assessments to compare health state with general population norms and to determine effects by means of standardized effect sizes. The therapy programme consisted of drug adaptation, graded activity exercise, relaxation therapies, and behavioural therapy. Compared with population norms, patients' health was significantly deteriorated in all dimensions of the Short Form 36, depression and anxiety at all examined times. After rehabilitation, pain improved by effect sizes up to 0.65, function/role performance up to 0.87, vitality up to 0.67 and coping up to 0.41. At the 6-month follow-up, these effects remained, with effect sizes between 0.45 and 0.87. The median working capacity improved from 8 h per week at baseline to 21 h at follow-ups. The rehabilitation programme showed moderate to large mid-term improvements in important health dimensions, medication reduction and working capacity. Further controlled studies are required to quantify and attribute these improvements more precisely.

A multicenter, randomized, double-blind, placebo- controlled trial of intravenous ibuprofen 400 and 800 mg every 6 hours in the management of postoperative pain

Background: Although opioids are the mainstay of inpatient postoperative pain management, they do not block inflammation. The NSAID ibuprofen has antiinflammatory and analgesic properties, and a multimodal approach may reduce opioid requirements. Objective: This study was conducted to assess the effects of intravenously administered ibuprofen 400 and 800 mg q6h in postoperative pain management. Methods: This multicenter, randomized, doubleblind, placebo-controlled trial was conducted in 406 patients scheduled to undergo elective, single-site orthopedic or abdominal surgery. All patients received morphine administered by patient-controlled analgesia pump, or by hospital staff at the request of the patient, after surgery and were randomly assigned in a 1:1:1 ratio to receive ibuprofen 400 mg IV, ibuprofen 800 mg IV, or inactive vehicle (placebo). The first dose of study drug was administered intraoperatively at the initiation of wound closure, then every 6 hours for a total of 8 doses over the first 48 hours of the study. After the initial 8 doses, the protocol allowed for continued administration of IV ibuprofen or placebo every 6 hours, at the discretion of the investigator, for control of postoperative pain for a total of up to 120 hours (5 days). The ibuprofen and placebo were administered while patients had access to morphine throughout the duration of the study. The primary outcome measure was morphine use in the first 24 hours after surgery. Secondary measures were patient self-reports of pain scores at rest and with movement. Pain intensity was measured before (baseline) and at 1, 2, 3, 6, 9, 12, 15, 18, 24, 27, 30, 33, 36, 39, 42, 45, and 48 hours after the first administration of study medication, and then once daily through day 5 if the patient continued to receive study medication. Patients were assessed by study personnel for treatment-emergent adverse events (AEs). Results: A total of 406 patients were enrolled (319 women, 87 men; mean [SD] age, 45 [12] years; weight, 83.8 [19.1] kg; ibuprofen 400 mg IV, 134 patients; ibuprofen 800 mg IV, 138; and placebo, 134). In the intent-to-treat population, median morphine use was significantly reduced during the first 24 hours after administration of the study drug in patients who received ibuprofen 800 mg IV q6h (by 22% vs placebo; P = 0.030). The use of ibuprofen 800 mg IV q6h was associated with significant reductions in pain at rest and with movement across 3 time periods (1-24, 6-24, 12- 24 hours) compared with placebo. Ibuprofen 400 mg IV q6h was associated with significant reductions in pain at rest and with movement during the 6- to 24-hour and 12- to 24-hour time periods compared with placebo. The prevalences of AEs and abnormalities in laboratory measurements were not significantly different between patients who received IV ibuprofen and those who received placebo. Treatment-emergent AEs were reported in 368 of 406 patients (91%). With respect to the number of patients who experienced serious AEs, the differences in the 400-mg IV ibuprofen group (118/134 [88%]) and the 800-mg IV ibuprofen group (124/138 [90%]) compared with the placebo group (126/134 [94%]) were not statistically significant. There were significant reductions in the proportions of patients who experienced gastrointestinal disorders in the 400- and 800-mg IV ibuprofen groups compared with the placebo group (99/134 [74%] and 98/138 [71%], respectively, vs 113/134 [84%]; P = 0.05 and P = 0.009). There were significant reductions in the numbers of patients experiencing pyrexia in the 400- and 800-mg IV ibuprofen groups compared with the placebo group (9/134 [7%] and 10/138 [7%] vs 23/134 [17%]; P = 0.013 and P = 0.015). Dizziness occurred in a significantly greater proportion of patients in the ibuprofen 800-mg q6h group compared with the placebo group (P = 0.011). Conclusions: In these patients undergoing postoperative pain management, ibuprofen 800 mg IV q6h was associated with significant reductions in morphine use and pain at rest and with movement compared with placebo. Ibuprofen IV was not associated with significant increases in AEs compared with placebo, with the exception of dizziness with the 800-mg dose. These findings suggest that ibuprofen 800 mg IV q6h was effective for postoperative pain management and was generally well tolerated. ClinicalTrials.gov identifier: NCT00225732.

Inpatient Geriatric Pain Management Discussion Cases

Abstract This module includes discussion cases designed to enhance small-group learning for multidisciplinary house-staff regarding inpatient geriatric pain management. The content is arranged into...

Pain assessment and management in surgical nursing: a literature review

Although postoperative pain assessment and management is an integral part of surgical nursing practice, it remains ad hoc despite numerous costly empirical research studies. Patients have a right to pain relief; however, the barriers to assessing and managing patient pain in practice have not as yet been overcome. A literature review to establish the main barriers to effective postoperative pain relief in clinical practice was carried out. The findings suggest that time management, and attitudes and beliefs of both patients and nurses are significant factors hampering practice. The authors conclude that future research in this area is futile, and suggest that nurses should focus on auditing their own practice to improve the effectiveness of pain management in practice and enhance standards of care.

Does Classification of Persons with Fibromyalgia into Multidimensional Pain Inventory Subgroups Detect Differences in Outcome after a Standard Chronic Pain Management Program?

The present study aimed to replicate and validate the empirically derived subgroup classification based on the Multidimensional Pain Inventory (MPI) in a sample of highly disabled fibromyalgia (FM) patients. Second, it examined how the identified subgroups differed in their response to an intensive, interdisciplinary inpatient pain management program. Participants were 118 persons with FM who experienced persistent pain and were disabled. Subgroup classification was conducted by cluster analysis using MPI subscale scores at entry to the program. At program entry and discharge, participants completed the MPI, Medical Outcomes Study Short Form-36, Hospital Anxiety and Depression Scale and Coping Strategies Questionnaire. Cluster analysis identified three subgroups in the highly disabled sample that were similar to those described by other studies using less disabled samples of FM. The dysfunctional subgroup (DYS; 36% of the sample) showed the highest level of depression, the interpersonally distressed subgroup (ID; 24%) showed a modest level of depression and the adaptive copers subgroup (AC; 38%) showed the lowest depression scores in the MPI (negative mood), Medical Outcomes Study Short Form-36 (mental health), Hospital Anxiety and Depression Scale (depression) and Coping Strategies Questionnaire (catastrophizing). Significant differences in treatment outcome were observed among the three subgroups in terms of reduction of pain severity (as assessed using the MPI). The effect sizes were 1.42 for DYS, 1.32 for AC and 0.62 for ID (P=0.004 for pairwise comparison of ID-AC and P=0.018 for ID-DYS). These findings underscore the importance of assessing individuals' differences in how they adjust to FM.

Estimating the clinical effectiveness of cognitive behavioural therapy in the clinic: Evaluation of a CBT informed pain management programme

Randomized controlled trials and meta-analyses provide evidence for the efficacy of cognitive-behaviourally informed treatment (CBT) programmes for chronic pain. The current study aims to provide practice-based evidence for the effectiveness of CBT in routine clinical settings. Over a 10-year period 1013 pain patients were accepted into a 4 week in-patient pain management programme. Data from more than 800 patients was available at pre-treatment and at one month post-treatment and for around 600 patients at pre-treatment and at 9 months follow-up. Measures reported in this analysis were pain experience and interference, psychological distress (depression and anxiety), self-efficacy, catastrophizing, and walking. Change from pre-treatment to post-treatment and follow-up was assessed with conventional statistical tests, the computation of effect sizes and by the reliable change index (RCI) and clinically significant change (CSC) methodology. These analyses provide evidence of statistical improvement at post-treatment and follow-up and the RCI/CSC methodology suggested that between 1 in 3 and 1 in 7 (depending on the outcome measure) achieved clinically significant gains. There was also evidence that a small percentage of patients (1–2%) reliably deteriorated during the period of treatment. The limitations in the inferences that can be drawn from this study and of the methodology are discussed. A case is made for the application of benchmarking methods using data from RCTs in order to more fully evaluate practice and to generate better quality practice based evidence.

What are the psychiatric sequelae of burn pain?

Burn injuries and their subsequent treatment cause one of the most excruciating forms of pain imaginable. Practitioners in the field have been concerned about the suboptimal management of acute pain in this population. Recent studies have shown that greater levels of acute pain are associated with negative long-term psychologic effects such as depression, suicidal ideation, and post-traumatic stress disorder for as long as 2 years after the initial burn injury. Research in other non-burn trauma populations has also pointed to the potential for unmanaged acute pain to delay wound healing and lead to other medical complications, such as infection and extended hospitalization period. The concept of allostatic load is presented as a potential explanation for the relationship between acute pain and subsequent psychologic and physiologic outcomes. A biopsychosocial model is also presented as a means of obtaining better inpatient pain management and helping to mediate this relationship.

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

Purpose. To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.Methods. Study design: exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8 – 21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.Results. Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.Conclusion. The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.

The quality of postoperative pain management from the perspectives of patients, nurses and patient records

To study the quality of postoperative pain management in a university hospital. Paired patient and nurse assessments of the patient's pain management were conducted in two departments, complemented with audit of patient records. The Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire was answered by 121 patients and 47 Registered Nurses. Of 14 items in the Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire, four items in general surgery and five items in thoracic surgery reached the threshold for high quality of care. No significant differences were found between the assessments in the two departments, but the patients in general surgery experienced more pain than the patients in thoracic surgery. In general surgery, the patients assessed their worst pain significantly higher than the nurse did. The patients who experienced more pain than expected were less satisfied with the quality of their care and experienced higher pain intensity levels. For 25 (41.0%) patients in general surgery and four (6.7%) patients in thoracic surgery, pain intensity was documented according to hospital quality goals. In both departments, areas for improvements could be found in all subscales of the Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire, i.e. communication, action, trust and environment. It is important to discuss what information the patient needs, as well as how and when it should be given. Furthermore, considering earlier pain experience and the goal of pain relief for the individual patient may facilitate an adequate assessment of the patient's pain. In future, electronic health records have the potential to support the use of clinical guidelines.

An Integrative Approach for Treating Postherpetic Neuralgia—A Case Report

This report describes the successful treatment of a patient with postherpetic neuralgia using traditional pharmacology in combination with acupuncture. A 13-year-old girl developed postherpetic neuralgia following a severe attack of varicella zoster. Despite a 1-week course of intravenous acyclovir initiated at the onset of symptoms, the patient developed persistent left facial pain and constant nausea after lesions were healed. A comprehensive pain treatment regimen, consisting of a stellate ganglia block, medications, transcutaneous electrical nerve stimulation and hypnosis, was administered, but the patient did not gain any incremental pain relief. The acupuncture service was consulted to provide assistance with this patient's pain management. A combination of body and auricular acupuncture as well as related techniques, including acupressure and transcutaneous acupoint electrical stimulation, was added to the pain treatment regimen. After 10 complementary acupuncture treatments over a 2-month period, the patient's nausea disappeared. Her left facial pain continued to decline from a maximum of 10 to 0 as assessed by a visual analog scale over a period of 4 months following self-administered treatments of acupressure and transcutaneous acupoint electrical stimulation. The patient was then gradually weaned off all her medications and the complementary acupuncture treatment. She was discharged from the pediatric pain clinic after 5 months of the combined therapy. Acupuncture and its related techniques may be an effective adjunctive treatment for symptoms associated with postherpetic neuralgia and deserve further study.