Reduction In Mean Pain Score Research Articles

Comparison Between Intra-Articular Steroid Injection And Ultrasound Therapy in Management of Chronic Knee Osteoarthritis

Objective: To compare the mean pain score and range of motion in chronic knee osteoarthritis patients treated with intraarticular Steroid injection versus ultrasound therapy.
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Department of Rehabilitation Medicine, Combined Military Hospital, Pano Aqil Pakistan, from Oct 2020 to Apr 2021.
 Methodology: Patients were divided into two groups (50 patients in each group). One group received ultrasound therapy for six weeks, with three sessions per week. The second group received a single 80mg intraarticular Triamcinolone Acetonide. Patients in both the groups were monitored for six weeks to assess the pain score and range of motion.
 Results: A total of one hundred (100) patients with knee pain due to chronic osteoarthritis were included in the study. The mean age in the ultrasound group was 54 ± 4.8 years and in the intra-articular group, the mean age was 54 ± 4.7 years. The mean reduction in pain score and mean improvement in the range of motion were compared between two groups and statistically significant difference was observed (p-value <0.001).
 Conclusion: According to our findings, intra-articular Corticosteroid injection is more effective in comparison to ultrasound therapy. However, there were statistically significant reductions in pain scores and improvements in the range of motion in both groups.

COMPARISON OF LOCAL METHYLCOBALAMINE INJECTION VERSUS LOCAL BUPIVACAINE INJECTION FOR THE TREATMENT OF ACUTE HERPETIC NEURALGIA

Objective: To compare the reduction in mean pain score with local Methylcobalamin injection versus local Bupivacaine injection in patients with acute herpetic neuralgia.
 Study Design: Quasi experimental study.
 Place and Duration of Study: Dermatology Outpatient Department, Pak Emirates Military Hospital, Rawalpindi, from Jun to Dec 2019.
 Methodology: Total 100 patients, having pain score more than 3, fulfilling the selection criteria were divided into two groups. Group A was treated with daily subcutaneous injection Bupivacaine, whereas Group B was treated with daily subcutaneous injection Methycobalamin at the site of neuralgia. Patients were followed up for 4 weeks. The pain score was noted. All the data was entered and analyzed on SPSS version 21.
 Results: In this study mean age of patients in group A was 43.82 ± 15.76 years and in group B was 44.76 ± 16.92 years. The mean visual analogue pain score at 4th week in the group A patients was 1.14 ± 0.32 and in group B was 1.90 ± 0.97. Statistically significant difference was found in group A (local Bupivacaine) with visual analogue score (VAS) at 4th week (pvalue=0.002).
 Conclusion: The local Bupivacaine injection showed significant reduction in mean pain score than local Methylcobalamin injection in patients with acute herpetic neuralgia.

Effectiveness of Trigger Point Dry Needling on Lumbosacral Radiculopathy among Indian Homemakers: A Randomized Controlled Trial

Background and Aim Lumbosacral radiculopathy is a typical disorder among people belonging to diverse populations. Myofascial trigger points are commonly located on the lumbar and pelvic girdle areas, which are known for aggravating pain in lumbar radiculopathy. This study was conducted to know the effectiveness of trigger point dry needling on lumbosacral radiculopathy among Indian homemakers in pain. Methods One hundred subjects between the age group of 40 to 60 years clinically diagnosed with lumbosacral radiculopathy associated with myofascial trigger points were screened, and 40 subjects who matched the inclusion criteria were enrolled to study after ethical approval. Subjects were randomly allocated into group A (n = 20) (experimental/trigger point dry needling) and group B (n = 20 control/sham needle therapy) for five sessions in a week. Outcomes were measured using a numerical pain rating scale for pain. Results The level of significance was determined by p < 0.05 at 95% confidence interval. Statistically, significant improvements were seen between the mean pre- and postscores of both the groups (p < 0.05). However, the reduction in mean pain scores was statistically more significant in group A (decrease by 65.7%) than group B (decrease by 14.1%). Conclusion Trigger point dry needling on lumbosacral radiculopathy provided to group A was more effective than intervention provided to group B control study participants.

The Analgesic Effects of Oral Acetaminophen vs. Ibuprofen in Children with Supracondylar Fractures: A Triple-blind Randomized Clinical Trial

Introduction: A supracondylar fracture are common in children with the average age of is 5-8 years. It is especially important to pay attention to pain control in these children because of lots of pain. This study was design to compare the analgesic effect of oral ibuprofen vs acetaminophen in children with supracondylar fractures who undergoing non-surgical treatment.Material & Methods: This triple-blind clinical trial was conducted on children with supracondylar fracture referred to the Emergency Department of Emam Reza and Hosheminejad Hospital. Children’s pain were assessed 2, 4 and 12 hours after taking the drug by VAS (Visual Analog Scale) criteria, which was explained by researcher to their parents. Results: In this study, 64 children with a mean age of 5.7±1.7 years were studied. 31 children in the acetaminophen group and 33 children in the ibuprofen group were evaluated. The mean pain score reduction within 12 hours of drug administration showed no difference between the two groups (P = 0.710). After 12 hours of drug administration, 5 and 7 children being painless in the acetaminophen and ibuprofen, respectively, with no difference between the two groups.Conclusion: During the 12 hours after ibuprofen and acetaminophen, children had similar analgesia and there was no significant difference between the two drugs in terms of pain relief and side effects, and both drugs are safe and effective for pain-control in children.

Outcome of Transforaminal Epidural Injections in Patients with Lumbar Radicular Pain

Background: Backache is quite a common problem in adults.one of the common reasons for this is compression on nerve roots due to disc bulge. The pain may start from back and radiate to legs. Objective: The study aimed to evaluate the efficacy of corticosteroids when injected by transforaminal route. Study design: This descriptive study was conducted at Orthopedic Unit 2 Mayo Hospital Lahore. The duration of the study was six months from January 2018 to June 2018. Material and Methods: The study was conducted on the 127 patients attended the orthopedic department of our institute hospital. The ethical and review board committee of the hospital approved the study. Every participant was informed about the study and they willingly signed the written consent. According to the inclusion criteria the patients of age above than 18 diagnosed with the lumber pain. The 127 patients of both genders that were included in the study were given transforaminal epidural injections (TEI). The results were studied after 4 weeks. The pain reduction was scored using Oswesrty Disability Index (ODI). The age range of the patients included in the study was from 20 to 80 years. SPSS 5 was used for statistics analysis of the data collected. Results: The calculated mean ODI of patients at the start was 73.90+ and after four weeks it was reduced to 27.62-+8.66. The mean ODI score at baseline of the patients was 73.90±7.64 with lowest and highest value of 46 & 94 respectively. The average ODI score at 4th week of the patients was 27.62±8.66 with lowest and highest values of 10 & 60. The study results showed that the average reduction of ODI from baseline to 4th week of the patients was 46.29± 10.98 with lowest and highest reduction of 20 & 68. Conclusion: This study concluded that a significant reduction in mean pain score was noted with transforaminal Injections in patients with lumbar radical pain. It can be recommended to be used in patients with lumbar radical pain. The pain reduction was statistical significant after TEI. Keywords: Transforaminal epidural injection, Oswesrty score, lumbar radicular pain.

Gabapentin enhances the antinociceptive effect of intrathecal morphine in refractory cancer pain patients.

Morphine infusion through Intrathecal Drug Delivery System (IDDS) is widely used to relieve refractory cancer pain. However, continuous escalation of morphine dose caused by opioid tolerance and/or progress of cancer was commonly observed. Combining morphine with medications of different analgesic mechanisms is applied to blunt the rate of morphine increase. The purpose of this study was to determine the analgesic efficacy and safety of combining gabapentin with morphine after IDDS implantation. This study compared patients that received IDDS implantation from January 1, 2017 to November 10, 2018 in our institute. Key outcomes included change in mean pain score, dose of morphine used in patients, percentage of patients with 30% and 50% reduction in mean pain score, Patient Global Impression of Change scores, breakthrough pain characters and side effects. 34 patients in the combination group (morphine + gabapentin) and 40 patients in the monotherapy group(morphine)were analyzed. The results showed that both therapy groups achieved similar analgesic efficacy, demonstrated by Numerical rating scale (2.42 ± 0.88 vs 2.57 ± 0.85; Combination vs Monotherapy), PGIC and responder status. Mean daily dose of morphine was significantly lower in combination group compared to monotherapy group (3.54 ± 1.29mg vs 4.64 ± 1.28mg, P = 0.007). More patients experienced dizziness and somnolence after receiving combination therapy compared to morphine-alone treatment although no statistical significance was found (P = 0.49). Addition of gabapentin achieved similar analgesic efficacy with lower dose of morphine compared to morphine alone accompanying with higher incidence of dizziness and somnolence.

Comparison of postoperative pain in photorefractive keratectomy using topical versus oral nonsteroidal anti–inflammatory drugs

Objective: Most of the ophthalmic surgery is done under topical anesthesia or nerve blocks. Local anesthetic agents are usually used for both analgesic techniques. We hypothesized that nonsteroidal anti–inflammatory drugs (NSAIDs) could be used preoperatively for postoperative pain, either topically or by oral route. Present study aimed to compare mean reduction in pain scores with oral versus topical NSAIDs following photorefractive keratectomy. Methodology: This prospective study was conducted at Department of Ophthalmology, Eye Donors Organization (EDO) Hospital, Wah Cantt, for 6 months (March 2019–August 2019). A sample size of 40 patients was calculated using World Health Organization calculator. We selected patients through convenient (non–probability) sampling. We took IRB approval, and written consent form the patients. All patients underwent photorefractive keratectomy. Patients were randomly divided (lottery method) into two groups; Group A was treated with topical NSAIDs while group B was treated with oral NSAIDs. Patients were followed for 3 days. We measured pain scores using visual analogue pain scale (VAS). Data analysis was done using SPSS version 24. T–test and fissure exact test were applied. A p ≤ 0.05 was considered significant. Results: A total of 40 patients were included in study. Mean age of patients was 28.1 ± 2.9 y. There were 21(52.5%) males and 19(46.3%) females. Topical NSAIDs showed significant reduction in pain scores as compared to oral NSAIDs at day 1 (5.25 ± 0.6 vs. 7.20 ± 0.69, p = 0.000), day 2 (4.15 ± 0.5 vs. 6.65 ± 0.48, p = 0.000) day 3 (2.25 ± 0.63 vs. 6.15 ± 0.74, p = 0.000). Conclusion: Topical nonsteroidal anti–inflammatory drugs are safe and effective for reducing postoperative pain management following photorefractive keratectomy as compared to oral nonsteroidal anti– inflammatory drugs. Key words: Nonsteroidal anti–inflammatory drugs; Pain; Photorefractive keratectomy Citation: Javaid S, Shafi M, Lodhi Y. Comparison of postoperative pain in photorefractive keratectomy using topical versus oral nonsteroidal anti–inflammatory drugs. Anaesth. pain intensive care 2021;25(3):324–328. DOI: doi.org/10.35975/apic.v25i3.1527 Received: January 29, 2021, Reviewed: February 27, March 13, 2021, Accepted: March 31, 2021

A prospective study to compare serial changes in pain scores for patients with and without a history of frequent ED utilization

BackgroundIn the face of the opiate addiction epidemic, there is a paucity of research that evaluates limitations for our current pain rating methodologies for patient populations at risk for drug seeking behavior. ObjectiveWe hypothesized that VAS scores would be higher and show less serial improvement for patients with a history of frequent ED use. MethodsThis was a prospective, observational cohort study of a convenience sample of adult ED patients with chief complaint of pain. Initial VAS scores were recorded. Pain scores were subsequently updated 30–45 min after pain medication administration. ED frequenter defined as having >4 ED visits over a 1-year time period. Categorical data analyzed by chi-square; continuous data analyzed by t-tests. A multiple linear regression performed to control for confounding. Results125 patients were enrolled; 51% ED frequenters. ED frequenters were similar to non-ED frequenters with respect to gender, mean age, Hispanic race, educational level, chief complaint type, and initial pain medication narcotic. ED frequenters more likely to have higher initial VAS score (9.17+/-1.25 vs. 8.51+/-1.68; p = 0.01) and higher second VAS scores (7.48+/-2.56 vs. 5.00+/-3.28; p <0.001) and significantly lower mean change in first to second VAS scores (1.69+/-2.17 vs. 3.51+/-3.25; p <0.001). Within our multiple linear regression model, only ED frequenter group (p < 0.001) and private insurance status (0.04) were associated with differences in mean reduction in pain scores. ConclusionWe found that ED frequenters had significantly less improvement between first and second VAS measurements.

Comparison of opioid rotation on pain, symptoms, and daily opioid dose in a supportive care clinic.

Opioid rotation (OR) is used to decrease patients' cancer-related pain and mitigate opioid-induced adverse effects. There is limited evidence regarding its effect on symptoms and morphine equivalent daily dose (MEDD). The objective of this study was to investigate the effects of OR on pain scores, Edmonton Symptom Assessment Score (ESAS), and MEDD in patients with cancer. Retrospective observational study in an outpatient supportive care clinic using a within-subject design to analyze data collected over 34 months. Study included 676 patients with 217 rotations identified in 128 patients at supportive care clinic at a National Cancer Institute (NCI) Cancer Center. OR were identified and analysis compared the pre-visit data with the subsequent post-visit data following OR using paired t-tests. Primary endpoints included pain scores, total ESAS, and MEDD for OR and these endpoints were compared amongst rotations to specific opioid analgesics. Following OR, there was a statistically significant reduction in mean pain scores from 6.25 at the pre-visit to 5.75 following OR. Of the 194 ORs, 29.90% were successful in reducing patients' pain by either 30% or by 2-points. Only rotations to morphine, oxycodone, and methadone correlated with significant decreases in pain scores. Overall, OR did not correlate with significant changes in ESAS or MEDD. Only rotations to methadone correlated with a significant reduction in MEDD. These findings suggest OR is associated with decreased pain scores without increasing MEDD. Of the agents compared, only rotations to methadone correlated with both a significant reduction in pain scores and in MEDD.

Analgesic, anti-inflammatory and antipyretic studies on the residual aqueous fraction of Uapaca togoensis (Pax) stem bark in rodents

Uapaca togoensis Pax. (Euphorbiaceae) is used in traditional medicine to treat several diseases including pain, inflammation and fever. This study investigated analgesic, anti-inflammatory and anti-pyretic effects of the residual aqueous fraction of the plant. Preliminary phytochemical screening and acute toxicity studies were conducted. Analgesic activity was evaluated using acetic acid-induced writhing, hot plate and formalin-induced pain tests at doses of 250, 500 and 1000 mg/kg, p.o. Anti-inflammatory and antipyretic activities were investigated using carrageenaninduced paw edema and Brewer’s yeast-induced pyrexia model respectively in rats. Oral median lethal dose of the fraction was found to be greater than 5000 mg/kg. The fraction significantly (p&lt;0.05) reduced the number of acetic acid-induced writhes and increased the reaction time of mice to thermal stimuli. In the formalin test, a significant (p&lt;0.05) reduction in mean pain score was observed at the second phase. A significant (p&lt;0.05) decrease in paw edema at the 4th and 5th hours and a reduction in temperature was also observed at the 22nd hour. Phytochemical screening revealed the presence of saponins, tannins, steroids, cardiac glycosides, flavonoids, alkaloids and triterpenes. The result of the study revealed that the fraction possesses analgesic, anti-inflammatory and antipyretic activities, validating the folkloric use of the plant.&#x0D; Keywords: Analgesic, Anti-inflammatory, Anti-pyretic, Uapaca togoensis, Residual Aqueous Fraction

Evaluation of a Pharmacist Managed Telephone Pain Clinic for Neuropathy Treatment

Pain is prevalent in our society, affecting more than a quarter-million U.S. adults and leading to poor patient outcomes. At the Veteran’s Affairs San Diego Healthcare System (VASDHS), a Telephone Pain Clinic (TPC) was developed to improve these outcomes. The purpose of this study was to evaluate the effectiveness of TPC in improving neuropathic pain. A retrospective cohort study was conducted at the VASDHS comparing pre- and post- self-rated Numeric Rating Scale (NRS-11), an 11-point scale from 0 to 10 with 0 equaling no pain and 10 equaling most severe pain. Patients were included if they were referred and enrolled to the TPC for neuropathic pain. They were excluded if they were co-managed by another pain provider or were referred for any other pain conditions. A total of 830 TPC patients were screened between January 2008 to December 2009 and 52 patients met criteria. Patients who participated in the clinic were found to have a significant 0.83 (p = 0.014) reduction in mean pain score from baseline (6.62, SD 1.96) to discharge (5.79, SD 2.49). At discharge, pain medications that were increased were use of serotonin and norepinephrine reuptake inhibitors (SNRIs), pregabalin, and capsaicin. Management by the TPC showed promise and trends toward reducing pain experienced by patients with diabetic neuropathy, fibromyalgia, or postherpetic neuralgia. The TPC also may be more effective in maximizing evidenced-based pharmacotherapy for neuropathic pain, suggesting expertise by pharmacist clinical specialists.

Treatment of headache in aneurysmal subarachnoid hemorrhage: Multimodal approach

Sudden severe headache is a cardinal symptom and the most common complaint amongst patients presenting with aneurysmal subarachnoid hemorrhage. The multifactorial etiology of these headaches makes pharmacotherapy problematic. Current aneurysmal subarachnoid hemorrhage guidelines have limited or no recommendations for headache treatment. Our institution utilizes a multimodal pharmacotherapy protocol in the management of aneurysmal subarachnoid hemorrhage headache. The purpose of this study was to evaluate the efficacy of the current aneurysmal subarachnoid hemorrhage headache treatment approach at our institution. This was a retrospective cohort study of patients presenting with aneurysmal subarachnoid hemorrhage. A multimodal aneurysmal subarachnoid hemorrhage headache treatment protocol was implemented in February 2014. After an eight-month washout period, patients treated between September 2014 and November 2017 represented the study cohort. Data collected included severity of aneurysmal subarachnoid hemorrhage and headache, interventions to secure the aneurysm, pain score response related to specific analgesic administered, and discharge status. Multivariate analysis and linear regression were used to identify predictors of treatment efficacy. A total of 249 patients were identified in the study cohort. The majority of patients were female (61.4%) with a median age of 54 years (±12.5), median Hunt and Hess score of 2 (interquartile range 2–3), and mean length of hospitalization of 15.2 days. Magnesium infusion had the largest reduction in mean pain score compared to baseline pain score (−0.75; p = 0.0002). In this retrospective cohort study involving patients presenting with headache secondary to aneurysmal subarachnoid hemorrhage, no agent resulted in a clinically significant improvement on headache pain scores.

Intravenous versus oral paracetamol in a UK ambulance service: a case control study.

Objectives:To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting.Methods:We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant.Results:80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups.Conclusion:Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.

The Effectiveness of Lavender (Lavendula Augustfolia) and Neroli (Citrus Aurantium) Aromatherapy Inhalation to Decrease Pain Labor

Maternal labor will experience almost all body pain, such as painful ribs, stitches, abdominal pain due to uterine contractions, and discomfort in the back due to epidural needles, and this discomfort will last several days and can be overcome by prescription for painkillers. In this study aimed at carrying out non-famacological pain relief therapy, namely by using aromatherapy which is believed to reduce pain, this study tried to compare the effectiveness of lavender and neroli aromatherapy inhalation to decrease post-labor pain. The research method used quasi-experimental that is given aromatherapy lavender (Lavendula Augustfolia) and neroli (Citrus Aurantium) inhalation treatments. The number of respondents was 60 with 1-2 days of normal and postpartum criteria, each group consisted of 30 respondents. Group 1 was held at the Pearl Delta Clinic RB and group 2 in the Karunia RB Clinic. Data were analyzed by univariable by using mean and standard deviation, bivariable with statistical test independent sample T test. The results of this study showed a mean reduction in pain scores on lavender aromatherapy inhalation of 2.36 ± 0.15, whereas in the aromatherapy neroli inhalation group the mean reduction in pain score was 3.03 ± 0.067 with a P value &lt;0.002 indicating a significant relationship. The conclusion of this study is the inhalation of lavender aromatherapy (LavendulaAugustfolia) and neroli (Citrus Aurantium) can reduce the intensity of postpartum pain, but in the aromatherapy neroli inhalation group has a greater pain reduction score than the lavender group.

Can addition of low level laser therapy to conventional physical therapy be beneficial for management of pain and cervical range of motion in patients with trigger point of upper trapezius?

Objective: Trigger points commonly develop in upper trapezius muscle. These might be associated with neck pain arising from trigger points of trapezius. This study was conducted to compare the effectiveness of conventional physical therapy (CPT) with and without low level laser therapy (LLLT) on pain and cervical range of motion (ROM) in patients with trigger point of upper trapezius muscle.&#x0D; Methodology: An RCT was conducted with a sample size of 62 patients. The study was completed within 9 months after approval of synopsis. Data were collected from Health Care Physiotherapy, Sports, Spine &amp; Rehabilitation Center, Faisalabad (Pakistan). Patients were randomly allocated into two equal groups; 31 patients of Group-1 received low-level laser therapy with CPT, while Group-2 (n=31) patients received CPT as the only treatment protocol. Patients pain level was assessed using Numeric Pain Rating Scale (NPRS) and cervical ROM was measured by goniometry at baseline and subsequently at 2nd and 4th week follow-ups.&#x0D; Results: Results of the study obtained by applying repeated measures ANOVA showed that there was mean reduction in pain scores from day 1 to week 4 in within group analysis of LLLT + CPT Group (Group=1) and within group analysis of CPT Group (Group=2) (p &lt; 0.05). Statistically significant improvement was observed in all mean cervical ROMs especially for lateral flexion ROM for both groups in within group analysis (p &lt; 0.05). Statistically significant improvement was seen in NPRS score at week four between Group-1 and 2, measured by independent sample t-test with p &lt; 0.05. Whereas, independent sample t-test results showed no significant improvement in cervical ROMs at week four between Group-1 and 2 (p ˃ 0.05).&#x0D; Conclusion: Conventional physical therapy and low level laser therapy used in combination are more effective than conventional physical therapy alone in patients of trigger points of upper trapezius.&#x0D; Citation: Waseem I, Tanveer F, Fatima A. Can addition of low level laser therapy to conventional physical therapy be beneficial for management of pain and cervical range of motion in patients with trigger point of upper trapezius? Anaesth pain &amp; intensiv care 2019;23(2):__&#x0D; DOI: https://doi.org/10.35975/apic.v24i1.&#x0D; Received – 4 September 2019,&#x0D; Reviewed – 31 December 2019, 26 January 2020,&#x0D; Revised – 18 March 2020,&#x0D; Accepted – 9 May 2019

Analgesic Effects of Cannabinoids for Chronic Non-cancer Pain: a Systematic Review and Meta-Analysis with Meta-Regression.

There is growing interest in using cannabinoids for chronic pain. We performed a systematic review and meta-analysis of randomized controlled trials to evaluate the analgesic efficacy and adverse effects of cannabinoids for chronic non-cancer pain. PubMed, EMBASE, Web of Science, Cochrane CENTRAL and clinicaltrials.gov were searched up to December 2018. Information on the type, dosage, route of administration, pain conditions, pain scores, and adverse events were extracted for qualitative analysis. Meta-analysis of analgesic efficacy was performed. Meta-regression was performed to compare the analgesic efficacy for different pain conditions (neuropathic versus non-neuropathic pain). Risk of bias was assessed by The Cochrane Risk of Bias tool, and the strength of the evidence was assessed using the Grade of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Forty-three randomized controlled trials were included. Meta-analysis was performed for 33 studies that compared cannabinoids to placebo, and showed a mean pain score (scale 0-10) reduction of -0.70 (p < 0.001, random effect). Meta-regression showed that analgesic efficacy was similar for neuropathic and non-neuropathic pain (Difference = -0.14, p = 0.262). Inhaled, oral, and oromucosal administration all provided statistically significant, but small reduction in mean pain score (-0.97, -0.85, -0.45, all p < 0.001). Incidence of serious adverse events was rare, and non-serious adverse events were usually mild to moderate. Heterogeneity was moderate. The GRADE level of evidence was low to moderate. Pain intensity of chronic non-cancer patients was reduced by cannabinoids consumption, but effect sizes were small. Efficacy for neuropathic and non-neuropathic pain was similar.

Intranasal Ketamine for Abortive Migraine Therapy in Pediatric Patients: A Single-Center Review

BackgroundKetamine has recently emerged as a promising therapeutic alternative for abortive migraine therapy, likely secondary to N-methyl-d-aspartate antagonism. Most reports examine adults and the intravenous route. Fewer utilize intranasal administration or pediatric populations. Given the limited evidence for intranasal ketamine in pediatric migraine populations, we retrospectively reviewed our experience to further characterize safety and efficacy of intranasal ketamine in this population. MethodsA retrospective review in a free-standing, pediatric medical center was performed examining the utilization of intranasal ketamine at 0.1 to 0.2 mg/kg/dose up to five doses in pediatric migraineurs. Pain scores (scale = 0 to 10) were recorded at baseline and after each dose. Response was characterized as pain score reduction to 0 to −3 and/or reduction of at least 50%. ResultsTwenty-five encounters (25 of 34; 73.5%) were responders (mean pain score reduction of −7.2 from admission to treatment completion). Overall pain reduction from admission to discharge in the entire study population was 66.1%. Side effects were mild and transient. ConclusionsOur experience with intranasal ketamine has promising outcomes in both pain relief and side effect minimization. When other therapeutic options are unavailable, practitioners should consider intranasal ketamine.

Buprenorphine for Cancer Pain in Patients With Nonmedical Opioid Use: A Retrospective Study at a Comprehensive Cancer Center.

Outpatients with cancer commonly have nonmedical opioid use (NMOU) behaviors and use opioids to dull emotional and existential suffering. Buprenorphine is often used for cancer pain due to less reported euphoria when compared to other opioids. A retrospective review was done in patients who were prescribed buprenorphine for cancer pain. Pain scores were reported on a Likert pain scale of 1 to 10. Nonmedical opioid use was defined as patients taking opioids for emotional pain at or above the maximum prescribed amount. For 16 patients, the mean pain score prior to buprenorphine (pain pre) was 8.3 (Standard deviation (Std) 1.6), and the mean pain score on follow-up post-buprenorphine (pain post) was 6.1 (Std 2.3) with a reduction in mean pain score (pain change) of -2.0 (Std 2.9, P = .059). Those patients without NMOU had a pain prescore of 9.5 (Std 1.0) and pain post of 4.3 (Std 2.5) with a mean pain change of -5.0 (Std 1.7, P = .20). The mean pain change in those with chemical coping (-1.3/Std 2.7), illicit drug use (-2.8/Std 1.0), or psychiatric comorbidity (-2.4/Std 2.7) were reduced after buprenorphine, however, not statistically significant. Outpatient rotation to buprenorphine was well tolerated. The pain score in those patients without NMOU was significantly lower after rotation to buprenorphine than those with NMOU. We deduce that in those with NMOU, it is more challenging to achieve pain relief with buprenorphine. Overall, for all patients, rotation to buprenorphine resulted in a marginally significantly reduced pain score.

Ameliorative Effects Of N-Acetylcysteine As Adjunct Therapy On Symptoms Of Painful Diabetic Neuropathy.

PurposePainful diabetic neuropathy (PDN) is a variant of diabetic peripheral neuropathy which is highly prevalent and distressing in diabetic patients. Despite its high burden, the optimal treatment of PDN has remained a clinical challenge. To explain the emergence and maintenance of PDN, increasing attention has been focused on dimensions of inflammation and oxidative toxic stress (OTS). Accordingly, the aim of this study was to investigate the effects of oral N-acetylcysteine (NAC), an agent with known anti-oxidant and anti-inflammatory effects, as an adjunct therapy in patients suffering from PDN.Patients and methods113 eligible patients with type 2 diabetes suffering from PDN were randomly assigned to either the pregabalin + placebo or pregabalin + NAC group for 8 weeks (pregabalin at a dose of 150 mg per day, NAC and matched placebo at doses of 600 mg twice a day). Mean pain score was evaluated at baseline, week 1, 2, 4, 6, and 8 of the study based on the mean 24 hr average pain score, using an 11-point numeric rating scale (NRS). As secondary efficacy measures, mean sleep interference score (SIS) resulting from PDN, responder rates, Patient Global Impression of Change (PGIC), Clinical Global Impression of Change (CGIC), and safety were also assessed. Additionally, serum levels of total antioxidant capacity (TAC), total thiol groups (TTG), catalase activity (CAT), glutathione peroxidase (GPx), superoxide dismutase (SOD), nitric oxide (NO), and malondialdehyde (MDA) were assessed at baseline and at the end of the study.ResultsNinety patients completed the eight-week course of the study. The decrease in mean pain scores and mean sleep interference score in pregabalin + NAC group was greater in comparison with pregabalin + placebo group (p value<0.001 in both conditions). Moreover, more responders (defined as ≥50% reduction in mean pain score from baseline to end-point) were observed in the pregabalin + NAC group, in comparison with pregabalin + placebo group (72.1% vs 46.8%). More improvement in PGIC and CGIC from baseline to the end of the study was reported in pregabalin + NAC group. Oral NAC had minimal adverse effects and was well tolerated in almost all patients. Furthermore, in respect to OTS biomarkers, adjuvant NAC significantly decreased serum level of MDA and significantly increased serum levels of SOD, GPx, TAC, and TTG.ConclusionThe pattern of results suggests that compared to placebo and over a time period of 8 weeks, adjuvant NAC is more efficacious in improving neuropathic pain associated with diabetic neuropathy than placebo. Ameliorative effects of NAC on OTS biomarkers demonstrated that NAC may alleviate painful symptoms of diabetic neuropathy, at least in part by its antioxidant effects.

Safety and efficacy of percutaneous sacroplasty for treatment of sacral insufficiency fractures: a systematic review.

Sacral insufficiency fractures are a common source of back pain in the elderly and are associated with significant morbidity due to poor recognition and delays in diagnosis. Previous treatment modalities have centered primarily on bed rest, oral analgesia, early mobilization and physical therapy. However, in recent years sacroplasty has emerged as a viable treatment option for sacral insufficiency fractures. Earlier recovery with sacroplasty, reduced incidence of deep venous thrombosis, and earlier return to activities of daily living are some of the features that made this treatment modality more appealing than traditional conservative management. We undertook a systematic review of the literature to examine the efficacy of sacroplasty for treatment of sacral insufficiency fractures in the elderly population. Thirty-one articles were included in this study for final analysis. Cement extravasation was the most commonly reported complication; however, it was not found to have clinical significance in the majority of studies that reported this outcome. Two studies reported S1 radicular pain after the procedure while only one study reported a patient with persistent pain requiring reoperation (1/8 incidence, 12.5%). The mean reduction in pain score from pre-procedure to latest follow-up post-procedure [reported as visual analog scale (VAS)] was 5.8+1.3 for those studies that reported this figure. Overall, sacroplasty is a safe and effective procedure associated with low complication rate and consistent pain relief in patients with sacral insufficiency fractures.