Muscle Relaxant Medications Research Articles

Clinician contributions to central nervous system-active polypharmacy among older adults with dementia in the United States.

Exposure to central nervous system (CNS)-active polypharmacy-overlapping exposure to three or more CNS-active medications-is potentially harmful yet common among persons living with dementia (PLWD). The extent to which these medications are prescribed to community-dwelling PLWD by individual clinicians versus distributed across multiple prescribers is unclear. We identified community-dwelling Medicare beneficiaries with a dementia diagnosis and Medicare Parts A, B, and D coverage for at least one month in 2019. Using fill date and days' supply for prescriptions filled between January 1, 2019 and December 31, 2019, we identified beneficiaries exposed to CNS-active polypharmacy (i.e., >30 days of overlapping exposure to three or more antidepressant, antipsychotic, antiseizure, benzodiazepine, opioid, nonbenzodiazepine benzodiazepine receptor agonists, or skeletal muscle relaxant medications). We examined the number and type of clinicians who contributed to polypharmacy person-days among PLWD. The cohort included 955,074 PLWD who were primarily female (64.0%), were White (78.5%), and had a mean age of 83.4 years (standard deviation 8.0). Notably, 14.3% were exposed to CNS-active polypharmacy. At the person level, 24.6% of PLWD experienced polypharmacy prescribed by a single clinician. Considering total days of exposure, 45.3% of polypharmacy person-days were prescribed by a single clinician. Primary care physicians prescribed 63.0% of polypharmacy person-days and accounted for the plurality of days for all seven medication classes, followed by psychiatrists for antipsychotics and benzodiazepines and primary care advanced practice providers (APPs) for antidepressants and antiseizure medications. In this cross-sectional analysis of Medicare claims data, primary care clinicians (both physicians and APPs) prescribed the majority of medications that contributed to CNS-active polypharmacy for PLWD. Future research is needed to identify strategies to support primary care clinicians in appropriate prescribing of CNS-active medications to PLWD.

Long-Term Use of Muscle Relaxant Medications for Chronic Pain

Stricter opioid prescribing guidelines have increased prescriptions of skeletal muscle relaxants (SMRs) for chronic pain, but the efficacy of long-term use of SMRs for chronic pain is unknown. To systematically review the effectiveness or efficacy of long-term use of SMRs for chronic pain. Two reviewers systematically searched Ovid MEDLINE, Embase (Ovid), Web of Science, CINAHL, and Cochrane through December 4, 2023. They included articles published in English, Spanish, or Italian. Only randomized clinical trials (RCTs) and cohort studies with comparator groups evaluating at least 1-month duration of SMRs for chronic pain were included. The reviewers dually reviewed data abstraction, risk-of-bias, and quality. They characterized studies by chronic pain syndrome: low back pain, fibromyalgia, headaches, painful cramps or spasticity, and other syndromes. A total of 30 RCTs with 1314 participants and 14 cohort studies with 1168 participants assessed SMRs for chronic pain. Studies were primarily short-term (4-6 weeks). Nine unique SMRs were represented by the studies identified. Eleven studies (25%) examined baclofen, 8 (18%) examined tizanidine, and 7 (16%) examined cyclobenzaprine. Evidence for effectiveness was strongest for SMRs used for trigeminal neuralgia, neck pain, and painful cramps; evidence suggested SMRs for fibromyalgia, low back pain, and other syndromes were not more beneficial than placebo. The most common adverse effects were sedation and dry mouth. RCTs had a low to moderate risk of bias, and the quality of cohort studies was fair to good. In this systematic review of long-term use of SMRs for chronic pain, findings suggest that their long-term use may benefit patients with painful spasms or cramps and neck pain; their long-term use for low back pain, fibromyalgia, and headaches did not appear to be beneficial. Clinicians should be vigilant for adverse effects and consider deprescribing if pain-related goals are not met.

The role of mivacurium in contemporary anesthesiology: a narrative review

Background: Mivacurium is the shortest-acting non-depolarizing neuromuscular blocking agent (NMBA) with a rapid onset of action that is mainly used for short procedures. Despite the fact that mivacurium has a very favorable average 6-minute recovery index after its infusion in comparison to the approximately 15–30 minutes for atracurium, mivacurium is still not really popular among practicing anesthesiologists. Many new studies showing the potential further benefits of implementing mivacurium into daily practice are still being published. Aim of the Study: This study aimed to focus on spreading the common knowledge about the detailed pharmacokinetic and pharmacodynamic properties of mivacurium as a medication that has yet to be used widely by practicing anesthesiologists. Material and methods: The literature review was conducted using the common sources of original articles such as PubMed and Google Scholar from 1975 to September 2022. Results: Based on the literature review, we observed that Mivacurium at a dosage of 6μg produces a lower impact on hemodynamics, shorter intubation and extubation times, faster postoperative recovery, absence of the accumulation of neuromuscular blockade, higher safety, and no significant increase in allergic related adverse events in comparison with other NMBAs.Conclusions: Mivacurium is a muscle relaxant medication that is particularly suited for short-lasting surgical procedures. However, it is important to remember that existing mutations in the butyrylcholinesterase enzyme (BChE) may prolong the effect of the neuromuscular blockade due to significantly reducing plasma cholinesterase activity. Therefore, it is advised to stay cautious during its use as more research needs to be done to be able to thoroughly assess the potential advantages and disadvantages of mivacurium introduction in particular patients

Safety Culture of Physicians’ Medication in Saudi Arabia

Objective: The study aims to demonstrate the Physicians’ Medication Safety Culture in Saudi Arabia.Methods: It examines a cross-sectional survey of physicians' medication safety practices in Saudi Arabia. It self-reported an electronic survey of physicians in Saudi Arabia, ranging from intern to consultant level, and physician specialties. The survey included respondents' demographic information about physicians who reported medication safety items in medical care, as well as medications who executed medication safety. With closed-ended questions, the 5-point Likert response scale system was used. The survey monkey system was used to analyze data on the Physicians’ Medication Safety Culture. In this study, the statistical package for social sciences (SPSS), Jeffery's Amazing Statistics Program (JASP), and Microsoft Excel sheet version 16 were used.Results: The total number of responding physicians was 253, with the majority 73 (54.07 %) coming from the central region, which was statistically significant among the areas (p<0.01). The majority of those who responded were from private hospitals 48(18.97%), MOH hospitals 41(16.21%), and University hospitals 40 (15.81%). Furthermore, 72 (60.50%) were female, while 47 (39.50%) were male, with a statistically significant difference (p<0.01). The average frequency of medications safety items reported monthly in medical care was (5.97), with the highest score element being Medication’s wastage services system (6.42), followed by Medications labelling before use (6.31), Medical drug information resources (6.15) and Medication’s safety committee for medical care (6.11). Anticoagulants 33 (33.33 %) and NSAIDs 32 (32.32 %) were the medications used in medication error reporting. Sedation medications 38(38.78%) and muscle relaxant medications 36 (36.73%) were the drugs used in ADR reporting. Antineoplastic 40 (40.00%) and Anti-seizure drug 39 (39.39%) were the most commonly used medicines in the looks like sound-alike system (38.24 %). Anti-arrhythmic 43 (43.88 %) and anti-psychotic medication 40 (40.40%) were the drugs used in the high alert medication system.Conclusion: The Physicians’ Medication Safety Cultures were inadequate and contradictory. Consequently, the physicians instituted non-serious aspects of medication safety culture. Hence, reviewing aspect medications safety cultures in medical practice with a focus on education and training is strongly advised in Saudi Arabia.

Opioid Use Among Orthopaedic Patients and Comparison of Opioid Prescribing Patterns Among Spine Surgeons and Other Orthopaedic Subspecialists in the United States

Background/Introduction: The US opioid epidemic has received particular attention with 33091 reported deaths from narcotic overdose in 2015. A recent survey comparing US and Japanese opioid prescribing patterns from the AOA-JOA traveling fellows included 76 US orthopedic surgeons representing 8 subspecialties. We used this data to compare opioid prescribing patterns among US spine surgeons to other orthopaedic subspecialties. Materials/Methods: The survey included data based on surgeon demographics (gender, age, years in practice), patient baseline opioid use (pre/post-operative opioid use, types of opioid agents, duration of opioid use), perioperative pain management (procedure/institution factors, multimodal analgesic therapy), and responses to questions regarding opioid use attitudes. Survey responses were recorded as either categorical or semi-continuous variables. Statistical analysis was performed using chi-squared analysis for categorical responses and Kolmogorov-Smirnov testing to a statistical significance level of p < 0.05. Parameters that trended toward significance to p < 0.10 were also recorded. Statistical analysis was performed using Stata statistical analysis software [StataCorp, College Station, Texas]. Results: Spine patients were more likely using opioid medications prior to evaluation by spine surgeons compared to non-spine patients(p=0.029). Patients with spine pathologies treated non-operatively were also more likely to be prescribed opioids(p=0.006). Post-operatively, spine patients were less likely to stop opioid prescriptions on the intended time (p=0.046). Peri-operatively, spine patients were more likely to be given muscle relaxant medications, and less likely to receive local/regional anesthesia(p=0.0025). Additionally, spine patients showed a trend toward association for requesting additional opioids beyond their initial prescription(p=0.057). Spine surgeons showed a trend toward association for choice of opioid agent prescribed–spine patients were less likely to receive codeine/tramadol analogs(p=0.062). When surveyed on opinions regarding opioid use, US spine surgeons did not show significantly different opinions regarding opioid use compared to surgeons in other subspecialties. Discussion/Conclusion: Spine patients did demonstrate statistically significant patterns of opioid use, particularly regarding opioid use prior to evaluation by orthopedic surgeon and use of opioids for nonoperative pathologies. They were also less likely to stop opioid prescriptions on time. Surgeon prescription patterns and perceptions of opioid use were not significantly different for spine surgeons compared to other subspecialties.

The impact of data quality defects on clinical decision-making in the intensive care unit

ObjectivePoor clinical data quality might affect clinical decision making and patient treatment. This study identifies quality defects in clinical data collected automatically by bedside monitoring devices in the Intensive Care Unit (ICU) and examines their effect on clinical decisions. MethodsReal-world data collected from 7688 patients admitted to the general ICU in a tertiary referral hospital over seven years was retrospectively analyzed. Data quality defect detection methods that use time-series analysis techniques identified two types of data quality defects: (a) completeness: the extent of non-missing values, and (b) validity: the extent of non-extreme values within the continuous range of values. Data quality defects were compared to five scenarios of medication and procedure prescriptions that are common in ICU settings: Blood-pressure reduction, blood-pressure elevation, anesthesia medications, intubation procedures, and muscle relaxant medications. ResultsResults from a logistic regression revealed a strong connection between data quality and the clinical interventions examined: lower validity level increased the likelihood of prescription decisions for all five scenarios, and lower completeness level increased the likelihood of prescription decisions for some scenarios. DiscussionThe results highlight the possible effect of data quality defects on physicians' decisions. Lower validity of certain key clinical parameters, and in some scenarios lower completeness, correlated with stronger tendency to prescribe medications or perform invasive procedures. ConclusionsData quality defects in clinical data affect decision making even without practitioners’ awareness. Thus, it is important to emphasize these effects to ICU staff, as well as to medical device manufacturers.

Attitudes, beliefs, and practices among Swiss chiropractors regarding medication prescribing for musculoskeletal conditions: a national Q-methodology study

BackgroundSwiss chiropractors have been licensed since 1995 to prescribe from a limited formulary of medications for treating musculoskeletal (MSK) conditions. In January 2018, this formulary was expanded to include additional muscle relaxant, analgesic, and anti-inflammatory medications. Internationally, controversy remains over whether or not medication prescribing should be pursued within the chiropractic profession.ObjectiveThe purpose of this study was to assess Swiss chiropractors’ attitudes, beliefs, and practices regarding their existing medication prescription privileges. This information will provide new insights on the topic and help inform research and policy discussions about expanding chiropractic prescription rights in other jurisdictions.MethodsA 13-item questionnaire and Q-methodology approach were used to conduct the assessment. Recruitment was conducted by e-mail between December 2019 and February 2020, and all members of the Swiss Chiropractic Association were eligible to participate. Data were analyzed using by-person factor analysis and descriptive statistics.ResultsIn total, 187 Swiss chiropractors participated in this study (65.4% response rate). Respondents reported prescribing analgesics, anti-inflammatories, and muscle relaxants to a median of 5, 5, and 0% of patients, respectively. Forty-two percent of respondents expressed interest in further expanding the range of current medications available to Swiss chiropractors for treating MSK conditions. Only 15% expressed interest in expanding this range to include medications for treating non-MSK conditions. In the Q-methodology analysis, four salient viewpoints/groups regarding medication prescribing emerged: prescribers, non-prescribers, collaborators, and integrators. All except non-prescribers thought medication prescription privileges were advantageous for the chiropractic profession in Switzerland. There was also strong consensus among all four groups that medication prescribing should not replace manual therapy in chiropractic practice.ConclusionThis was the first national survey on attitudes toward prescribing medications among Swiss chiropractors since the year 2000, and the first using Q-methodology. With this approach, four unique groups of chiropractic prescribers were identified. Even with diversity among clinicians, the findings of this study showed general support for, along with conservative use of, prescribing privileges within the Swiss chiropractic profession. Studies in jurisdictions outside of Switzerland are needed to assess whether chiropractors are interested in expanding their scopes of practice to include similar prescribing privileges.

Is abdominal wall hemorrhage an avoidable complication of robotic radical prostatectomy?

Aim: We presented the diagnosis and treatment of patients with abdominal wall hemorrhage after robot-assisted laparoscopic radical prostatectomy (RALRP) in a high volume center. Materials and Methods: We retrospectively screened the data of 1950 patient RALRP series performed between June 2010 and December 2019 in our clinic. Patients who developed postoperative abdominal wall hemorrhage were included in the current study. The diagnosis of abdominal wall hemorrhage was established by ultrasonographic and physical examination findings. Results: In our 1950 patient RALRP series, 15 (0.7%) patients developed abdominal wall hemorrhage. The mean decrease in hemoglobin values was 3.9 (2.8-4.7) g/dl at postoperative 6th hour. On the postoperative 2nd day, areas of ecchymosis were observed on the abdominal wall skin. On the postoperative 4th day, hemoglobin level was stabilized. Blood transfusion was required for 8 of 15 patients. None of the patients required surgical exploration. At the postoperative 1st month control visits, we observed that the ecchymosis was completely disappeared. Conclusion: RALRP is a surgical technique that has been increasingly preferred in the treatment of localized prostate cancer. Abdominal wall hemorrhage is a rarely seen complication of RALRP that may be avoided by paying attention to some anatomical landmarks and optimizing the blood level of muscle relaxant medications at an effective dose. As a rerely seen complication of RALRP, abdominal wall hemorrhage can be successfully managed without the need for explorative surgery.

Test-retest reliability of the Dyskinesia Impairment Scale: measuring dystonia and choreoathetosis in dyskinetic cerebral palsy.

To assess test-retest reliability of the Dyskinesia Impairment Scale (DIS) in children and young adults with dyskinetic cerebral palsy (CP). Dystonia and choreoathetosis were assessed in 15 participants with dyskinetic CP (13 males, 2 females; age range 5-22y, mean 14y, SD 4y) using the DIS in two separate sessions over 7 days. Exclusion criteria were changes in muscle relaxant medication within the previous 3 months, orthopaedic or neurosurgical interventions within the previous year, and spinal fusion. Intraclass correlation coefficient, confidence intervals (CI), standard error of measurement, and the minimal detectable difference (MDD) were determined for test-retest reliability. Intraclass correlation coefficients of the DIS, the dystonia subscale of the DIS, and the choreoathetosis subscale of the DIS were 0.98 (95% CI 0.94-0.99), 0.97 (95% CI 0.92-0.99), and 0.96 (95% CI 0.90-0.99). The standard error of measurement and MDD were 2.6% and 7.2%. The DIS is a reliable tool to assess dystonia and choreoathetosis; it remains stable over time in children and young adults with dyskinetic CP. These results add to the current evidence for good clinimetric properties of the DIS. The Dyskinesia Impairment Scale (DIS) shows stability in scoring dystonia and choreoathetosis. The total DIS score and dystonia and choreoathetosis subscales are clinically useful.

Nonsurgical integrative inpatient treatments for symptomatic lumbar spinal stenosis: a multi-arm randomized controlled pilot trial.

BackgroundLumbar spinal stenosis (LSS) is a chronic condition that causes low back pain and neurogenic claudication, often resulting in significant limitation of daily activities. In this open-label randomized controlled pilot study, we assessed the safety and feasibility of 4-week novel integrative inpatient treatments for LSS.MethodsThirty-six symptomatic LSS patients were randomly and equally allocated to one of the three groups: Mokhuri Chuna treatment 1 (MT1) group, Mokhuri Chuna treatment 2 (MT2) group, or conventional management treatment (CMT) group. MT1 patients were treated with herbal medication, Mokhuri Chuna, and acupuncture, and received daily physician consultation; MT2 patients were treated with Mokhuri Chuna and acupuncture without any herbal medication, and received daily physician consultation; and CMT patients received conventional pain management therapy that included epidural steroid injection, oral NSAID, and muscle relaxant medication, along with daily physiotherapy. The primary outcome of this pilot study was safety as measured by the type and incidence of adverse events (AEs). The secondary outcome measures included VAS score for low back pain and leg pain, Oswestry Disability Index, Oxford Claudication Score (OCS), walking capacity on a 50 m flat track and treadmill, and EuroQol-5D score. Magnetic resonance imaging was also performed up to 6 months after treatment cessation.ResultsThirty-four treated patients were included in the analysis, based on the modified intention-to-treat principle. No serious AEs were observed or reported. Compared to the CMT group, the MT1 and MT2 groups did show significant improvement at 3 and 6 months in various domains, including pain (VAS score for leg and back pain) and function (OCS and treadmill walking).ConclusionThese novel multimodal integrative treatments for LSS are both clinically safe and logistically feasible. Larger, adequately powered randomized controlled trials will be necessary to assess comparative efficacy and thoroughly analyze the cost-effectiveness of each treatment approach.Clinical trial registration number (CRIS)KCT0001218.

Opioid Analgesic Use in Patients with Ankylosing Spondylitis: An Analysis of the Prospective Study of Outcomes in an Ankylosing Spondylitis Cohort.

Opioid analgesics may be prescribed to ankylosing spondylitis (AS) patients with pain that is unresponsive to antirheumatic treatment. Our study assessed factors associated with opioid usage in AS. A prospective cohort of 706 patients with AS meeting modified New York criteria followed at least 2 years underwent comprehensive clinical evaluation of disease activity and functional impairment. These were assessed by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI). Radiographic severity was assessed by the Bath Ankylosing Spondylitis Radiology Index and modified Stokes Ankylosing Spondylitis Scoring System. Medications taken concurrently with opioids, as well as C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR), were determined at each study visit, performed every 6 months. Analyses were carried out at baseline, and longitudinal multivariable models were developed to identify factors independently associated with chronic and intermittent opioid usage over time. Factors significantly associated with opioid usage, especially chronic opioid use, included longer disease duration, smoking, lack of exercise, higher disease activity (BASDAI) and functional impairment (BASFI), depression, radiographic severity, and cardiovascular disease. Patients taking opioids were more likely to be using anxiolytic, hypnotic, antidepressant, and muscle relaxant medications. Multivariable analysis underscored the association with smoking, older age, antitumor necrosis factor agent use, and psychoactive drugs, as well as with subjective but not objective determinants of disease activity. Opioid usage was more likely to be associated with subjective measures (depression, BASDAI, BASFI) than objective measures (CRP, ESR), suggesting that pain in AS may derive from sources other than spinal inflammation alone.

Severity of ineffective esophageal motility is associated with utilization of skeletal muscle relaxant medications.

Ineffective esophageal motility (IEM) is the most common finding on high-resolution esophageal manometry (HREM). The underlying mechanisms for IEM remain to be fully elucidated. The aim of this study was to determine if utilization of skeletal muscle relaxants is associated with IEM, and with more severe subtypes of the disorder. Patients with diagnosis of IEM were gender and age matched to patients with normal HREM. Demographic information, symptoms, endoscopic findings, medication usage and medical comorbidities were recorded. Patients with a diagnosis of IEM were divided into subgroups based on mean distal contractile integral (DCI) and percentage of ineffective swallows, and assessed for clinically significant differences among patients with varying severity of underlying IEM. A total of 118 patients were included in each group. There were no significant clinical differences between the group of patients with IEM and the group of patients with normal manometry. Within the group of IEM patients, those with mean DCI<250mmHg/s/cm were more likely to be prescribed skeletal muscle relaxants (27.8% vs 11.0%, P=.044), and those using skeletal muscle relaxants had a larger mean percentage of ineffective swallows (81.1% vs 71.5%, P=.029). There were no significant differences across mean DCI subgroups in usage of any other medication, or in any of the demographic variables or disease comorbidities examined in this study. Use of skeletal muscle relaxants is associated with more severe IEM, which may suggest a causal association between this class of medications and weaker esophageal peristalsis.

A comparison of conservative and invasive dental approaches in the treatment of tension-type headache.

To investigate the efficacy of conservative dental treatment (occlusal splint and pharmacologic therapy) and invasive therapy (prosthetic restorations) in the treatment of tension-type headache (TTH). The study sample was composed of 70 patients who presented with symptomatic TTH and were assigned to three treatment groups according to their treatment needs. Group A (30 patients): a conservative treatment protocol with a combination of an occlusal splint and analgesic and muscle relaxant medication. Group B (10 patients): invasive prosthodontic procedures. Group C (30 patients): patients who refused any type of treatment but consented to the study served as a control group. Pain quality was measured with the Headache Impact Test (HIT-6). The statistical analysis was performed with the Wilcoxon rank test (P≤.05). Conservative treatment with splints and analgesic medication and invasive treatment by prosthetic rehabilitation relieved the TTH symptoms. The patients who received treatment experienced a significant reduction in their discomfort after 6 months (P≤.01), whereas the patients who refused therapy remained, on average, at the same pain level (P≤.117). In group A, the HIT-6 score was reduced for 26 patients, and in group B for 8 patients. In group C a reduction of HIT-6 scores was observed in 10 patients. Conservative or invasive occlusal adjustments may serve as a useful tool in the treatment of TTH.

Das Fibromyalgiesyndrom – aktualisierte S3-Leitlinie

Patients with chronic widespread pain often present with musculo-skeletal pain and therefore often initially contact an orthopaedist. For these patients fibromyalgia syndrome is an important differential diagnosis. Recommendations for the diagnosis of and therapy for fibromyalgia syndrome based on the recent German S3 guidelines for fibromyalgia syndrome (AWMF registration number 041/004) are outlined in this paper. These guidelines were developed under the coordination of the German interdisciplinary association for pain management DIVS and two patient support groups. The history of a typical symptom complex and the exclusion of relevant somatic causes for the pain are epecially relevant for the diagnosis of fibromyalgia syndrome. Besides the exclusion of relevant orthopaedic causes for the pain, psycho-social aspects should always be evaluated. According to the modified ACR criteria 2010, chronic widespread pain and accompanying sleep disturbances and a physical as well as mental state of exhaustion lead to the diagnosis of fibromyalgia syndrome. It is not mandatory to check tender points (ACR 1990 criteria). A graduated treatment approach depending on the severity level of the fibromyalgia syndrome in the individual patient is recommended. Active treatment options (aerobic training, meditative movement therapies, strength training) should be preferred to any drug therapy in the long-term treatment of fibromyalgia. If indicated, amitryptiline or duloxetine may be used to treat accompanying depressive or generalised anxiety disorder. Muscle relaxant medication, non-steroidal anti-inflammatory drugs and strong opioids should be avoided. The multimodal pain therapy considering all psycho-social aspects is a promising treatment option for fibromyalgia syndrome of moderate to high severity.

The Dyskinesia Impairment Scale: a new instrument to measure dystonia and choreoathetosis in dyskinetic cerebral palsy

The aim of this study was to examine the reliability and validity of the Dyskinesia Impairment Scale (DIS). The DIS consists of two subscales: dystonia and choreoathetosis. It measures both phenomena in dyskinetic cerebral palsy (CP). Twenty-five participants with dyskinetic CP (17 males; eight females; age range 5–22y; mean age 13y 6mo; SD 5y 4mo), recruited from special schools for children with motor disorders, were included. Exclusion criteria were changes in muscle relaxant medication within the previous 3 months, orthopaedic or neurosurgical interventions within the previous year, and spinal fusion. Interrater reliability was verified by two independent raters. For interrater reliability, intraclass correlation coefficients were assessed. Standard error of measurement, the minimal detectable difference, and Cronbach’s alpha for internal consistency were determined. For concurrent validity of the DIS dystonia subscale, the Barry–Albright Dystonia Scale was administered. The intraclass correlation coefficient for the total DIS score and the two subscales ranged between 0.91 and 0.98 for interrater reliability. The reliability of the choreoathetosis subscale was found to be higher than that of the dystonia subscale. The standard error of the measurement and minimal detectable difference values were adequate. Cronbach’s alpha values ranged from 0.89 to 0.93. Pearson’s correlation between the dystonia subscale and Barry–Albright Dystonia Scale was 0.84 (p<0.001). Good to excellent reliability and validity were found for the DIS. The DIS may be promising for increasing insights into the natural history of dyskinetic CP and evaluating interventions. Future research on the responsiveness of the DIS is warranted.

High-Frequency Pallidal Stimulation for Camptocormia in Parkinson Disease: Case Report

Camptocormia is characterized by abnormal flexion of the thoracolumbar spine that increases during upright posture and abates in the recumbent position and has been reported to occur in patients with Parkinson disease. Camptocormia causes significant spinal and abdominal pain, impairment of balance, and social stigma. A 57-year-old woman with Parkinson disease developed severe camptocormia, which did not improve with trials of antiparkinsonian and muscle relaxant medications. The patient was successfully treated with bilateral globus pallidus interna deep brain stimulation surgery under general anesthesia. High-frequency neuromodulation afforded relief of camptocormia and improvement in Parkinson disease symptoms. Camptocormia in Parkinson disease may represent a form of dystonia and can be treated effectively with chronic pallidal neuromodulation.

Manejo de la sedoanalgesia y de los relajantes musculares en las unidades de cuidados intensivos pediátricos españolas

Objective The aim of the study was to define the strategies for the use and monitoring of sedative, analgesic, and muscle relaxant medication in Spanish paediatric intensive care units (PICU). Material and methods A questionnaire with 102 questions was sent by e-mail to all Spanish PICUs. Results Replies were received from 36 of the 45 PICUs (80%). A written protocol for sedation and analgesia was used in 64%; this medication was adjusted according to the diagnosis and clinical status of the patient in 30% of the units. Midazolam was the most widely used drug for sedation, followed by ketamine and propofol. Fentanyl was the most widely used drug for analgesia, followed by paracetamol and metamizole. The combination of midazolam and fentanyl in continuous infusion was used most frequently in patients on mechanical ventilation (MV), followed by propofol. Scales to monitor sedation and analgesia were employed in 45% of PICUs, most used the Ramsay scale. The bispectral index (BIS) was used in 50% of PICUs. Muscle relaxants were administered to 26% of patients on MV; the most common indications for MV were head injury and severe respiratory disease. The principal methods for avoiding withdrawal syndrome were a progressive withdrawal of the drugs and morphine chloride. Conclusions Although there is insufficient scientific evidence to determine the ideal drugs for sedation and analgesia in the critically ill child and the methods for monitoring and control, the production of guidelines and written treatment and monitoring protocols could help to improve the management and control of sedation and analgesia.

Treatment patterns among physician specialties in the management of fibromyalgia: results of a cross-sectional study in the United States

Background:Fibromyalgia (FM) is characterized by persistent and widespread pain and often associated with other symptoms and comorbidities. Thus, FM patients seek care from multiple physician specialties. This study compared prescribing patterns, patient-reported outcomes (PROs), healthcare resource use (HRU), and direct costs related to FM in routine clinical practice across physician specialties.Methods:This cross-sectional, observational study recruited 203 FM subjects from 20 community-based physician offices (eight primary care, six rheumatology, three neurology, three psychiatry). Subjects completed questions about pain, other symptoms, quality of life, productivity, treatment effectiveness and satisfaction, and out-of-pocket expenses related to FM; site staff recorded subjects’ treatment and HRU based on medical chart review. Results were compared across specialties. Statistical significance was evaluated at the 0.05 level. Annual direct costs associated with FM were calculated in 2009 US dollars.Results:Subject demographic and clinical characteristics were not significantly different across physician specialties, except psychiatry subjects had the highest mean number of co-morbid conditions; p < 0.001. PROs were similar across physician specialties except fatigue; neurology subjects reported the highest levels. There were no significant differences in subject-reported outcomes of medication effectiveness (p = 0.782) and medication satisfaction (p = 0.338) for FM. Psychiatry subjects had more FM-related physician visits compared to other specialties (p = 0.013) and a higher proportion received diagnostic tests related to FM (p = 0.013). The mean (SD) number of FM prescription medications prescribed per subject was highest in the primary care and lowest in the neurology group; p = 0.024. The proportion of hypnotic (p = 0.001), muscle relaxant (p = 0.005), anxiolytic (p = 0.005), anti-epileptic (p = 0.007), and other medications (p = 0.044) prescribed for FM were significantly different across specialties. Overall direct medical costs did not differ significantly (p = 0.284) across specialties.Conclusions:Patient characteristics were similar across specialties, except with regards to comorbidity burden. This study noted significant differences among physician specialties in HRU and treatment patterns among medications, diagnostics, and outpatient visits. Consistent with other studies, this study did not identify a dominant strategy for FM management across physician specialties as overall per patient medical costs and subject-reported treatment satisfaction were similar. Future research to better characterize differences among physician specialties in FM management, as well as the reasons for these differences, would be useful.

132 Management of Sedation, Analgesia, and Muscle Relaxation in Critically Ill Children: A Survey in Paediatric Intensive Care Units in Spain

Introduction: To define the strategies for the use and monitoring of sedative, analgesic, and muscle relaxant medication in Spanish paediatric intensive care units (PICU).Methods: A questionnaire with 102 questions was sent by e-mail to all Spanish PICUs.Results: Replies were received from 36 of the 45 PICUs (80%). A written protocol for sedation and analgesia was used in 64%; this medication was adjusted according to the diagnosis and clinical status of the patient in 30% of the units. Midazolam was the most widely used drug for sedation, followed by ketamine and propofol. Fentanyl was the most widely used drug for analgesia, followed by paracetamol and metamizole. The combination of midazolam and fentanyl in continuous infusion was used most frequently in patients on mechanical ventilation (MV), followed by propofol. Scales to monitor sedation and analgesia were employed in 45% of PICUs, most used the Ramsay scale. BIS was used in 50% of PICUs. Muscle relaxants were administered to 26% of patients on MV; the most common indications for MV were head injury and severe respiratory disease. The principal methods for avoiding withdrawal syndrome were a progressive withdrawal of the drugs and morphine chloride.Conclusions: Although there is insufficient scientific evidence to determine the ideal drugs for sedation and analgesia in the critically ill child and the methods for monitoring and control, the production of guidelines and written treatment and monitoring protocols could help to improve the management and control of sedation and analgesia.

Effect of Acupressure and Trigger Points in Treating Headache: A Randomized Controlled Trial

The efficacy of acupressure in relieving pain has been documented; however, its effectiveness for chronic headache compared to the muscle relaxant medication has not yet been elucidated. To address this, a randomized, controlled clinical trial was conducted in a medical center in Southern Taiwan in 2003. Twenty-eight patients suffering chronic headache were randomly assigned to the acupressure group (n = 14) or the muscle relaxant medication group (n = 14). Outcome measures regarding self-appraised pain scores (measured on a visual analogue scale; VAS) and ratings of how headaches affected life quality were recorded at baseline, 1 month after treatment, and at a 6-month follow-up. Pain areas were recorded in order to establish trigger points. Results showed that mean scores on the VAS at post-treatment assessment were significantly lower in the acupressure group (32.9+/-26.0) than in the muscle relaxant medication group (55.7+/-28.7) (p = 0.047). The superiority of acupressure over muscle relaxant medication remained at 6-month follow-up assessments (p = 0.002). The quality of life ratings related to headache showed similar differences between the two groups in the post treatment and at six-month assessments. Trigger points BL2, GV20, GB20, TH21, and GB5 were used most commonly for etiological assessment. In conclusion, our study suggests that 1 month of acupressure treatment is more effective in reducing chronic headache than 1 month of muscle relaxant treatment, and that the effect remains 6 months after treatment. Trigger points help demonstrate the treatment technique recommended if a larger-scale study is conducted in the future.