Severity Of Acute Pain Research Articles

A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy.

BackgroundPerioperative neuropathic pain is under-recognized and often undertreated. Chronic pain may develop after any routine surgery, but it can have a far greater incidence after amputation, thoracotomy or mastectomy. The peak noxious barrage due to the neural trauma associated with these operations may be reduced in the perioperative period with the potential to reduce the risk of chronic pain.Databases and data treatmentA systematic review of the evidence for perioperative interventions reducing acute and chronic pain associated with amputation, mastectomy or thoracotomy.ResultsThirty-two randomized controlled trials met the inclusion criteria. Gabapentinoids reduced pain after mastectomy, but a single dose was ineffective for thoracotomy patients who had an epidural. Gabapentinoids were ineffective for vascular amputees with pre-existing chronic pain. Venlafaxine was associated with less chronic pain after mastectomy. Intravenous and topical lidocaine and perioperative EMLA (eutectic mixture of local anaesthetic) cream reduced the incidence of chronic pain after mastectomy, whereas local anaesthetic infiltration appeared ineffective. The majority of the trials investigating regional analgesia found it to be beneficial for chronic symptoms. Ketamine and intercostal cryoanalgesia offered no reduction in chronic pain. Total intravenous anaesthesia (TIVA) reduced the incidence of post-thoracotomy pain in one study, whereas high-dose remifentanil exacerbated chronic pain in another.ConclusionsAppropriate dose regimes of gabapentinoids, antidepressants, local anaesthetics and regional anaesthesia may potentially reduce the severity of both acute and chronic pain for patients. Ketamine was not effective at reducing chronic pain. Intercostal cryoanalgesia was not effective and has the potential to increase the risk of chronic pain. TIVA may be beneficial but the effects of opioids are unclear.

Comparison of Intravenous Ketamine with Morphine in Pain Relief of Long Bones Fractures: a Double Blind Randomized Clinical Trial.

The selective medication for pain control in many clinical situations is morphine but its complications prevent its widespread use. Ketamine has been introduced as an alternative for morphine in some studies. However, the efficacy of its solitary use has not yet been evaluated. Therefore, the present study was undertaken to evaluate the effect of ketamine alone in relieving pain in trauma patients referring to an emergency unit. In this double-blind clinical trial, patients with long bone fractures were randomly divided into two groups of treatment with intravenous (IV) morphine at a dose of 0.1 mg/kg and treatment with IV ketamine at a dose of 0.5 mg/kg. Pain severity of the patients was recorded before and 10 minutes after injection based on numeric rating scale. The means in the two groups were compared using independent t-test. Then the Kaplan-Meier curve and log rank analysis were used to evaluate the success of treatment. 126 patients were included in this study. The mean ages of the patients in the morphine and ketamine groups were 33.6±14.3 and 35.1±13.5 years, respectively (P=0.54). After therapeutic intervention, the pain severity significantly decreased in ketamine (2.7±1.8; P<0.0001) and morphine (2.4±1.5; P<0.0001) groups, with a similar effect of both medications on alleviating pain (P=0.28). The success rate of the treatment at 10-minute interval in groups receiving ketamine and morphine were 59 (93.65%) and 61 (96.8%) patients, respectively (P=0.62). The results of the present study showed that administration of ketamine at a low dose (0.5 mg/kg) results in a significant decrease in the severity of acute pain in patients with fractures of long bones. This palliative effect is very similar to that of morphine.

(272) The ADRA2A genetic variant rs3750635 influences extent and severity of acute pain after motor vehicle collision and may do so by regulating microRNA function

Adrenergic alpha 2A receptors (ADRA2A) are known to play an important role in descending pain pathways and in the generation of stress-induced analgesia. However, the influence of ADRA2A genetic variants on acute pain severity after motor vehicle collision (MVC) has not been assessed. In this study we hypothesized that a genetic variant in the 3’UTR of ADRA2A, rs3750625, would be associated with acute pain outcomes following MVC. In addition, based on bioinformatics analyses, we hypothesized that the allele at this location determines the efficiency of binding of miR-34a, a microRNA (miRNA) known to regulate pain and stress responses.

The effect of local anaesthetic wound infiltration on chronic pain after total hip replacement: a randomised controlled trial

The effect of local anaesthetic wound infiltration on chronic pain after total hip replacement: a randomised controlled trial

Genetic Polymorphisms in the Dopamine Receptor 2 Predict Acute Pain Severity after Motor Vehicle Collision

Genetic Polymorphisms in the Dopamine Receptor 2 Predict Acute Pain Severity after Motor Vehicle Collision

Resolution of Pain After Childbirth

BACKGROUND: Chronic pain after surgery occurs in 10-40% of individuals, including 5-20% of women after cesarean delivery in previous reports. Pain and depression 2 months after childbirth are independently associated with more severe acute post-delivery pain. Here we examine other predictors of pain at 2 months and determine the incidence of pain at 6 and 12 months after childbirth. METHODS: Following Institutional Review Board approval, 1228 women were interviewed within 36 h of delivery. Of these, 937 (76%) were successfully contacted by telephone at 2 months, and, if they had pain, at 6 and 12 months after delivery. The primary outcome measure was presence of pain which began at the time of delivery. We also generated a model of severity of acute post-delivery pain and 2 month pain and depression. RESULTS: Pain which began at the time of delivery was remarkably rare 6 and 12 months later (1.8% and 0.3% [upper 95% confidence limit, 1.2%], respectively). Past history of pain and degree of tissue damage at delivery accounted for 7.0% and 16.7%, respectively, of one aspect in the variability in acute post-delivery pain. Neither of these factors was associated with incidence of pain 2 months later. CONCLUSIONS: Using a definition of new onset pain from delivery, we show a remarkably low incidence of pain 1 yr after childbirth, including those with surgical delivery. Additionally, degree of tissue trauma and history of chronic pain, risk factors for pain 2 months after other surgery, were unimportant to pain 2 months after cesarean or vaginal delivery.

Pain after knee arthroplasty: an unresolved issue

Despite the recent advances in the understanding of pain mechanisms and the introduction of new drugs and new techniques in the postoperative management, pain after total knee arthroplasty (TKA) is still an unresolved issue. It affects the quality of life and rehabilitation of an important percentage of patients undergoing TKA. The aim of this narrative review was to give an overview on pain mechanisms and multimodal pain management. A review of all peer-reviewed articles on pain after knee arthroplasty was performed by two reviewers. Recent articles on incisional pain mechanisms were included because of their importance in the understanding of postsurgical pain. Search was performed in Pubmed, Cochrane and Google Scholar data bases. Postsurgical pain mechanisms are based on both local and systemic inflammatory reactions. Peri-operative pain management starts with the anaesthetic technique and resides on a multimodal analgesia regimen. New concepts, drugs and techniques have shown their efficacy in reducing the severity of acute postoperative pain and the risk of developing chronic pain after TKA. This narrative review offers a clear overview of pain mechanism after knee arthroplasty and an understanding on how multimodal pain management can reduce the intensity and duration of pain after knee arthroplasty.

Clinical study of acute and chronic pain after temporal craniotomy

Objective To investigate the correlation of chronic pain after surgery and acute pain within 48 h after temporal craniotomy. Methods One hundred and seventy-six patients who underwent surgery through temporal approach were divided into 3 groups and treated with morphine 30 mg (Group M, N = 57), tramadol 1000 mg (Group T, N = 60) and morphine 20 mg + flurbiprofen 200 mg (Group F, N = 59) by patient-controlled intravenous analgesia (PCIA). Postoperative acute pain (resting and movement) was evaluated by Visual Analogue Scale (VAS) at 4, 16, 24 and 48 h respectively. Chronic pain was measured by Short-Form McGill Pain Questionnaire (SF-MPQ) 3 months after surgery. The characteristics of acute and chronic pain, the relationship between them and analgesic effect of 3 kinds of analgesic drugs were analyzed. Results The differences of observed indicators including gender, age, weight and operating time, which might affect the degree of postoperative pain between before and after surgery were not statistically significant (P > 0.05). VAS scores at different time points within 48 h after surgery in each group decreased gradually. The VAS scores in group T (2.91 ± 1.64) was significantly higher than group M (2.19 ± 1.68) and group F (1.71 ± 1.17, P 0.05). The overall incidence rate of chronic pain was 71.02% (125/176), with moderate and severe pain in 15.91% (28/176). Chronic pain and acute postoperative pain severity were positively correlated (resting: rs = 0.171, P = 0.012; movement: rs = 0.190, P = 0.006). The difference of the acute pain (VAS) corresponding to SF-MPQ Ⅱ score > 0 and SF-MPQ Ⅱ score = 0 was statistically significant (P < 0.05). Conclusion The postoperative chronic pain following temporal craniotomy is related to acute pain within 48 h after operation. Effective treatment of early postoperative acute pain may reduce the incidence of chronic pain.

Psychological, surgical, and sociodemographic predictors of pain outcomes after breast cancer surgery: A population-based cohort study

Chronic postsurgical pain (CPSP) is a common postoperative adverse event affecting up to half of women undergoing breast cancer surgery, yet few epidemiological studies have prospectively investigated the role of preoperative, intraoperative, and postoperative risk factors for pain onset and chronicity. We prospectively investigated preoperative sociodemographic and psychological factors, intraoperative clinical factors, and acute postoperative pain in a prospective cohort of 362 women undergoing surgery for primary breast cancer. Intraoperative nerve handling (division or preservation) of the intercostobrachial nerve was recorded. At 4 and 9months after surgery, incidence of chronic painful symptoms not present preoperatively was 68% and 63%, respectively. Univariate analysis revealed that multiple psychological factors and nerve division was associated with chronic pain at 4 and 9months. In a multivariate model, independent predictors of CPSP at 4months included younger age and acute postoperative pain (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.12 to 1.60), whereas preoperative psychological robustness (OR 0.70, 95% CI 0.49 to 0.99), a composite variable comprising high dispositional optimism, high positive affect, and low emotional distress, was protective. At 9months, younger age, axillary node clearance (OR 2.97, 95% CI 1.09 to 8.06), and severity of acute postoperative pain (OR 1.17, 95% CI 1.00 to 1.37) were predictive of pain persistence. Of those with CPSP, 25% experienced moderate to severe pain and 40% were positive on Douleur Neuropathique 4 and Self-Complete Leeds Assessment of Neuropathic Symptoms and Signs pain scales. Overall, a high proportion of women report painful symptoms, altered sensations, and numbness in the upper body within the first 9months after resectional breast surgery and cancer treatment.

Resolution of Pain After Childbirth

Eisenach, James C.*; Pan, Peter*; Smiley, Richard M.†; Lavand’homme, Patricia‡; Landau, Ruth§; Houle, Timothy T.* Author Information

Association of Pain Catastrophizing with the Incidence and Severity of Acute and Persistent Perineal Pain after Natural Childbirth: Longitudinal Cohort Study

Background and objectives Vaginal birth delivery may result in acute and persistent perineal pain postpartum. This study evaluated the association between catastrophizing, a phenomenon of poor psychological adjustment to pain leading the individual to magnify the painful experience making it more intense, and the incidence and severity of perineal pain and its relationship to perineal trauma.Method Cohort study conducted with pregnant women in labor. We used the pain catastrophizing scale during hospitalization and assessed the degree of perineal lesion and pain severity in the first 24hours and after 8 weeks of delivery using a numerical pain scale.Results We evaluated 55 women, with acute pain reported by 69.1%, moderate/severe pain by 36.3%, and persistent pain by 14.5%. Catastrophizing mean score was 2.15 ± 1.24. Catastrophizing patients showed a 2.90 relative risk (RR) for perineal pain (95% CI: 1.08-7.75) and RR: 1.31 for developing persistent perineal pain (95% CI: 1.05-1.64). They also showed a RR: 2.2 for developing acute and severe perineal pain (95% CI: 1.11-4.33).Conclusions The incidence of acute and persistent perineal pain after vaginal delivery is high. Catastrophizing pregnant women are at increased risk for developing acute and persistent perineal pain, as well as severe pain. Perineal trauma increased the risk of persistent perineal pain.

Role of regulatory T cells in patients with acute herpes zoster and relationship to postherpetic neuralgia

This study is to analyze distribution of peripheral T cell subsets including regulatory T cells in patients with acute herpes zoster (AHZ) and investigate its relationship to the development of postherpetic neuralgia (PHN). T lymphocyte subsets in peripheral blood from 76 patients with AHZ and 38 normal controls were analyzed using flow cytometry. According to the visual analogue scales in the acuter phase and followed up by PHN for 3months, patients with herpes zoster (HZ) were divided into different patient groups. The results demonstrated a significant decrease in the percentage of CD4 lymphocytes and CD4/CD8 ratios in each patient group as compared with normal controls, and the CD4+ subsets in the severe group were significantly decreased as compared with mild group and moderate group (p<0.01). Moreover, there seemed a relationship between severity of acute pain during zoster and PHN. The proportions of regulatory T cells (Treg; CD4+CD25+FoxP3+ T cells) were significantly elevated from AHZ patients as compared with normal controls, and CD4+ T cells were inversely correlated with Treg cells (p<0.01). Furthermore, FoxP3 expression was significantly increased by CD4+CD25(high) T cells in the severe group as compared with mild group, moderate group and normal controls. These results indicated that T cellular immunity in AHZ patients was impaired and suggested increased activation of Treg cells may suppress anti-viral CD4+ T cells immune responses, especially in the severe HZ patients. Treg cells may play an important role in the pathogenesis of AHZ and progression toward PHN.

Resolution of pain after childbirth.

Chronic pain after surgery occurs in 10-40% of individuals, including 5-20% of women after cesarean delivery in previous reports. Pain and depression 2 months after childbirth are independently associated with more severe acute post-delivery pain. Here we examine other predictors of pain at 2 months and determine the incidence of pain at 6 and 12 months after childbirth. Following Institutional Review Board approval, 1228 women were interviewed within 36 h of delivery. Of these, 937 (76%) were successfully contacted by telephone at 2 months, and, if they had pain, at 6 and 12 months after delivery. The primary outcome measure was presence of pain which began at the time of delivery. We also generated a model of severity of acute post-delivery pain and 2 month pain and depression. Pain which began at the time of delivery was remarkably rare 6 and 12 months later (1.8% and 0.3% [upper 95% confidence limit, 1.2%], respectively). Past history of pain and degree of tissue damage at delivery accounted for 7.0% and 16.7%, respectively, of one aspect in the variability in acute post-delivery pain. Neither of these factors was associated with incidence of pain 2 months later. Using a definition of new onset pain from delivery, we show a remarkably low incidence of pain 1 yr after childbirth, including those with surgical delivery. Additionally, degree of tissue trauma and history of chronic pain, risk factors for pain 2 months after other surgery, were unimportant to pain 2 months after cesarean or vaginal delivery.

Chronic Pain after Lower Abdominal Surgery: Do Catechol-O-Methyl Transferase/Opioid Receptor μ−1 Polymorphisms Contribute?

BackgroundPreoperative pain, type of operation and anesthesia, severity of acute postoperative pain, and psychosocial factors have been identified as risk factors for chronic postsurgical pain (CPP). Recently, it has been suggested that genetic factors also contribute to CPP. In this study, we aimed to determine whether the catechol-O-methyl transferase (COMT) and opioid receptor μ-1 (OPRM1) common functional polymorphisms rs4680 and rs1799971 were associated with the incidence, intensity, or duration of CPP in patients after lower abdominal surgery.MethodsOne hundred and two patients with American Society of Anesthesiologists (ASA) physical status I/II underwent either abdominal radical prostatectomy (n = 45) or hysterectomy (n = 57). The incidences of CPP in the pelvic and scar areas were evaluated in all patients three months after surgery.ResultsThirty-five (34.3%) patients experienced CPP after lower abdominal surgery. Within this group, six (17.1%) patients demonstrated symptoms of neuropathic pain. For COMT rs4680, 22 (21.6%) patients had Met158Met, 55 (53.9%) patients had Val158Met, and 25 (24.5%) patients had Val158Val. No association was found between CPP phenotypes (incidence, intensity, and duration) and different rs4680 genotypes. For OPRM1 rs1799971, only CPP patients carrying at least one copy of the G allele had higher pain intensity than A118A carriers (p=0.02). No associations with other phenotypes were found. No combined effect of COMT/OPRM1 polymorphisms on CPP phenotypes was observed.ConclusionsOPRM1 genotype influences CPP following lower abdominal surgery. COMT didn’t affect CPP, suggesting its potential modality-specific effects on human pain.

A behaviour-based pain scale for horses with acute colic: Scale construction

A validated tool for assessing the severity of acute abdominal pain is needed for the effective management of colic in horses. Two behaviour-based colic pain scales were constructed by combining together mathematical and judgemental approaches. The mathematical approach identified easily-recognised pain behaviours to select as items. The judgemental approach further modified the items and weighted them based on expert-opinion. Thirty equine practitioners assessed the level of pain demonstrated in 23 film clips of clinical cases exhibiting signs of acute abdominal pain prospectively using a 10cm visual analogue scale (VAS). The practitioners also identified behaviours noted in each clip from a checklist of 23 behaviours identified from the literature. Nine behaviours had insignificant bias and moderate-to-excellent inter-observer agreement (multirater kappas: 0.5–0.95).Six experienced veterinarians then completed questionnaires in an iterative Delphi process to independently judge 15 items that best reflected severity of pain out of 42 items generated from the literature. Two behaviours were generated by the process. Subsequently, an advisory panel of three equine practitioners constructed two clinimetric-type scales based on the results of both approaches. The two resulting equine acute abdominal pain scales (EAAPS) included 12 behaviours. One weight was assigned to each behaviour in the EAAPS-1. In the EAAPS-2, gradations of weights were assigned, based on the frequency of the behaviour being demonstrated. The EAAPS scales are the first pain severity scales designed specifically for clinical use in cases of acute colic utilising the clinimetric approach to scale construction. Further studies are underway to validate the scales.

An inverse correlation of VZV skin-test reaction, but not antibody, with severity of herpes zoster skin symptoms and zoster-associated pain

BackgroundCell-mediated immunity (CMI) has been considered to be related to the development of herpes zoster (HZ). However, there have been no large-scale prospective studies on the relationship between VZV-specific CMI and severity of HZ. ObjectiveWe carried out a large-scale prospective cohort study to clarify the relationship between immunological factors for varicella-zoster virus (VZV) and the clinical severity of HZ. MethodsWe carried out a cohort study on VZV immunity in a population living on an island cluster, Shozu County in Japan, and examined the people who developed HZ during a median follow-up period of 2 years, with a focus on the relationship between cell-mediated and humoral immunity and the severity of skin lesions and zoster-associated pain. A total of 12,522 people over the age of 50 were enrolled in this study, and 258 registrants were diagnosed as HZ. CMI was measured by VZV skin test, and humoral immunity was assessed with serological tests (neutralization test, immunoadherence hemagglutination test, and gpELISA test) for VZV-specific antibodies. ResultsCMI to VZV assessed by VZV skin test showed a significant inverse relationship to the severity of HZ skin lesions, and also to the severity of acute and subacute pain. Furthermore, weak response to the VZV skin test was associated with a high risk of post-herpetic neuralgia. In contrast, VZV-specific antibody titer was not associated with the severity of skin lesions and zoster-associated pain. ConclusionVZV-specific CMI, but not humoral immunity, may play a key role in controlling the severity of HZ skin lesions and zoster-associated pain.

Acute to Chronic Postoperative Pain in Children: Does it Exist?

The transition from acute to chronic pain after surgery is a well-studied clinical syndrome that was first described approximately 10 years ago. Since then, a substantial body of literature has evolved exploring this phenomenon in significant detail [1–7]. Known as chronic postoperative surgical pain (CPSP), this clinical entity is highly prevalent, reportedly affecting anywhere from 5 to 50% of adults recovering from surgery. According to the International Association for the Study of Pain, CPSP is a pain syndrome of at least 2 months’ duration, occurs postoperatively, and does not result from other causes such as chronic infection or pre-existing disease. Several predictive patient factors for developing CPSP in adults have been recognized, including the severity of acute postoperative pain, female gender, young age, obesity, preoperative anxiety, pain catastrophizing and a history of pre-existing pain. Acute postoperative pain has emerged as one of the strongest predictors of CPSP [8]. Furthermore, a number of surgical procedures associated with an increased risk of CPSP have been identified such as inguinal herniorrhaphy, thoracotomy, breast surgery and limb amputation. Unfortunately, treatment of CPSP can be a challenging task for the healthcare provider and a difficult burden for the patient to bear. Not only may the patient suffer from significant negative functional and social impact, but there are substantially increased healthcare and economic costs incurred as well. Despite the breadth of evidence examining CPSP in adults, this is a relatively unstudied topic in the pediatric population. Little is known about CPSP in children: whether it even exists, the number of children affected, possible predisposing risk factors and the long-term impact of the disease. Because over 5 million children undergo surgery in the USA each year, the risk of developing CPSP in children is a very real and significant threat. It is reported that the majority of children suffer from clinically significant acute postoperative pain and that this pain is overwhelmingly undertreated, particularly in the home setting [9–15]. A review of the literature found two retrospective questionnaire studies examining the occurrence of CPSP in children [16,17]. These two studies enrolled adult patients who had surgery as children

Poor sleep quality and exaggerated salivary cortisol reactivity to the cold pressor task predict greater acute pain severity in a non-clinical sample

Poor sleep is often independently associated with greater pain sensitivity and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis (e.g., greater basal cortisol and exaggerated stress-induced cortisol reactivity). However, the interactions among sleep, pain, and the HPA axis have not been adequately evaluated. In this study, 40 healthy adults provided self-report regarding perceived sleep quality over the past month prior to completion of an acute noxious physical stressor (i.e., cold pressor task; CPT). Following the CPT, they reported on the severity of pain experienced. Salivary cortisol was sampled before, immediately following, and during recovery from CPT. Using bootstrapped confidence intervals with a bias correction, results showed that poor sleep quality was significantly associated with greater reports of CPT-induced pain severity and greater cortisol reactivity (i.e., increase from baseline). Furthermore, greater cortisol reactivity to the CPT was found to significantly mediate the relationship between poor sleep and pain severity.

Herpes Zoster: Report of a Treated Case with Review of Literature

Herpes zoster is a localized, generally painful cutaneous eruption that occurs most frequently among older adults and immunocompromized persons. It is caused by reactivation of latent varicella zoster virus (VZV). Approximately one in three persons will develop zoster during their lifetime. A common complication of zoster is postherpetic neuralgia (PHN), a chronic, often debilitating pain condition that can last months or even years. The risk for PHN in patients with zoster is 10 to 18%. Approximately 3% of patients with zoster are hospitalized. Death attributable to zoster are common among immunocompromized persons. Prompt treatment with the oral antiviral agents, corticosteroids and analgesics decreases the severity and duration of acute pain from zoster. This article reviews herpes zoster and reports one such case, which was treated successfully without any complications.

Predictors of Patient Satisfaction With Pain Management and Improvement 3 Months After Burn Injury

Very little is known about what influences patient satisfaction with burn pain management. The aim of this prospective study was to examine predictors of patient satisfaction with pain management following burn injury. Participants were 97 adult burn patients admitted to Royal Perth Hospital, Western Australia between June 2007 and February 2009. Key patient satisfaction domains were: pain treatment in hospital, pain medication provided, and improvement since hospitalisation. Acute pain medication use, pain severity, psychological symptoms, and patient expectations were assessed as potential predictors of patient satisfaction. Patients reported moderate to high levels of satisfaction across all domains. Whether treatment matched patients' expectations was a significant predictor of satisfaction with pain treatment, pain medication and improvement (p < .001, p < .001, p < .05 respectively). Current pain at follow-up was a significant predictor of satisfaction with pain treatment and improvement (p < .01, p < .001 respectively). Acute pain medication use, depressive symptoms and reductions in average pain at three months were not significant independent predictors of patient satisfaction with pain management and improvement in this sample (p > .35). Yet, severity of posttrauma symptoms at three months was a significant predictor of satisfaction with pain medication and was moderately and positively associated with satisfaction with pain treatment (p < .05, p = .07, respectively). These findings suggest that acute medication use and reductions in perceived pain symptoms are less closely related to patient satisfaction compared with treatment expectations, current pain and posttrauma symptoms. Collectively, these findings indicate a need to proactively address treatment expectations about pain management, and manage current pain and psychological distress following burn injury in order to improve patient satisfaction with care received.