Unpredictable Pain Research Articles

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) results in a poor quality of life and absenteeism due to unpredictable abdominal pain, diarrhea, and bloating. IBS has prevalence rates of approximately 6% to 22% in various countries, and more women than men are diagnosed with this disorder. This study explored how Taiwanese women with IBS gain knowledge about the disorder and studied their experiences in using alternative remedies. An ethnographic study design involving interviews and Internet online discussions was used. Women (18-45 years) either diagnosed with IBS or with self-reported symptoms that met the Rome II criteria were included. All interviews were transcribed verbatim and analyzed by the constant comparison method. Results showed that symptom pattern recognition was used most often by participants to interpret symptoms. The bodily practices of the IBS women followed Taiwanese gender norms, with bodily experiences being represented as a dialogue between the disordered body and the social body. Linking diarrhea with social norms of female slenderness, IBS women applied cultural strategies to manage symptoms. The findings facilitate a partnership between healthcare professionals and IBS women, which can facilitate the development of an appropriate self-management manual, self-help groups, and Internet discussion groups to facilitate symptom management. It is hoped that this study will enhance nurse understanding of the traditional Chinese view of the body and the corresponding dietary practices used to harmonize the body's yin and yang. Although Asian women may resist Western medications due to their side effects, study results provide nurses with information on alternative therapies that may be more acceptable in the Asian context. In conclusion, the bodily experiences and practices of women with IBS are developed from personal cultural views of the body and gender norms.

Sickle Cell Hospital Unit: A Disease-Specific Model

American urban hospitals often serve large populations of sickle cell disease (SCD) patients. Those hospitals that choose to implement an adult SCD-specific inpatient unit have the opportunity to acquire multiple operational benefits. Such units may ultimately reduce patient morbidity and mortality; improve timely access to quality medical care in a cost-effective manner; reduce overcrowding in the emergency department; and increase patient, family, physician, and payer satisfaction. SCD is a serious, painful, genetic blood disorder that affects a growing population of adults in the United States. A single mistake in the gene that codes for hemoglobin causes crescent-shaped red blood cells that are sticky, are stiff, and have a short life span. These cells cause blockages, tremendous pain brought on by lack of oxygen in the muscles, organ damage, stroke, and problems with infections. The cells' short life span often results in anemia. The unpredictable pain event-sickle cell disease with crisis-is the most common reason for presentation to the emergency department and for hospital admission. For many SCD patients, the emergency department process and the general, overly conservative approach to pain relief lead to a delay in treatment and prolong needless suffering. Regional Medical Center at Memphis (Tennessee) established an SCD unit and developed an inpatient care delivery model that decreases the burden of caring for SCD patients on its busy emergency department, improves SCD patients' satisfaction and access to timely quality care, and reduces the needless pain and suffering of SCD patients. This SCD model may be replicated in large urban hospitals with a daily SCD patient census of five or more.

Patient‐Controlled Analgesia in Chronic Pain Patients: Experience with a New Device Designed to be Used with Implanted Programable Pumps

Intrathecal drug delivery using implantable pumps is an effective method to control stable chronic pain. However, the appropriate alleviation of unpredictable pain fluctuations remains challenging. A possible solution is the use of patient-controlled analgesia (PCA) by means of a specific device--the personal therapy manager (PTM)--designed to be used with implanted programmable pumps. A multicenter (n = 17), open-label registry recording 168 patients suffering from chronic pain with unsatisfactory control of pain episodes was initiated. While 79 patients (47%) (group A) already carried an implanted pump at enrollment, all other patients were implanted after being registered in the study (group B). Parameters assessed included pain relief (visual analog score, VAS), quality of life (EQ-5D), patient and physician satisfaction, medication use, PTM programming parameters and adverse events. Final follow-up was at 12 months. At 12 months, there was a significant reduction (29%) of the overall average VAS compared with baseline (P < 0.01) in patients with newly implanted devices (group B). All patients tended to decrease the concomitant pain medication and the quality of life tended to improve (10% on the EQ-5D scale). In total, 85% of patients were satisfied with the PTM. No serious adverse events related to the use of the PTM device were observed. Patient-controlled analgesia using a PTM with a programmable, implantable pump system is an effective therapy for the treatment of chronic pain and allows patients to feel that they have more control over unpredictable pain fluctuations.

Understanding the pain experience in hip and knee osteoarthritis – an OARSI/OMERACT initiative

To examine the pain experience of people with hip or knee osteoarthritis (OA), particularly changes over time and most distressing features. Focus groups in individuals aged 40+ years with painful hip or knee OA obtained detailed descriptions of OA pain from early to late disease. A modified Patient Generated Index (PGI) was used to assess the features of OA pain that participants found most distressing. Content analysis was performed to examine response patterns; descriptive statistics were used to summarize PGI responses. Mean age of the 143 participants (52 hip OA; 91 knee OA) was 69.5 years (47-92 years); 60.8% were female and 93.7% Caucasian. Participants described two distinct types of pain - a dull, aching pain, which became more constant over time, punctuated increasingly with short episodes of a more intense, often unpredictable, emotionally draining pain. The latter, but not the former, resulted in significant avoidance of social and recreational activities. From PGI responses, distressing pain features were: the pain itself (particularly intense and unpredictable pain) and the pain's impact on mobility, mood and sleep. Two distinct pain types were identified. Intermittent intense pain, particularly when unpredictable, had the greatest impact on quality of life.

Is There a Role for Resurfacing Hemiarthroplasty?

The treatment of Ficat stage III osteonecrosis is a challenge in young patients. Various treatment methods to preserve the native femoral head have been used with varying success. Limited femoral head resurfacing has been used traditionally with mixed results. It is an extremely conservative arthroplasty for the young patient with osteonecrosis. The unpredictable and incomplete pain relief afforded by this procedure however, may negate the benefit of bone conservation. The present paper discusses the history, current indications, results, and future of this procedure.

Femoral head resurfacing for the treatment of osteonecrosis in the young patient.

We reviewed the clinical and radiographic results of 29 consecutive femoral head resurfacing procedures in 28 patients with avascular necrosis done from February 1997 until April 2000. There were 18 males and 10 females with an average age of 31.6 years (range, 12-48 years). The average Harris hip score significantly improved from 48.1 points preoperatively to 79.3 points at last followup. At final followup, 17 patients (18 hips [62%]) reported feeling much better or better than they did before hemiresurfacing. The overall survivorship was 75.9% at 3 years. Eight hips (27.6%) were converted to a total hip arthroplasty (THA) at an average 18 months (range, 8-43 months) after resurfacing. The results of this study suggest that femoral head resurfacing in a young patient with ON can greatly improve symptoms. The majority of patients were satisfied with the procedure but outcomes are unpredictable with only 62.5% of patients reporting satisfaction and good pain relief at last followup. We continue to offer this procedure in young patients with large necrotic lesions with the understanding that this procedure provides somewhat unpredictable pain relief; however, hemiresurfacing avoids the negatives associated with a bearing surface.

The threat of predictable and unpredictable pain: Differential effects on central nervous system processing?

Central nervous system performance is disrupted by pain and by the threat of pain. It is not known whether disruption caused by the threat of pain is dependent on the likelihood of pain occurring. We hypothesised that when a painful stimulus is possible but unpredictable central nervous system performance is reduced, but when the pain is predictable and unavoidable it is not. Sixteen healthy subjects performed a reaction time task during predictable and unpredictable conditions (100% and 50% probability of pain, respectively). Group data showed increased reaction time with the threat of pain by 50 ms (95% CI 16 to 83 ms) for the predictable condition and 46 ms (95% CI 12 to 80 ms) for the unpredictable condition (p lt 0.01 for both), but there was no difference between predictable and unpredictable conditions (p = 0.41). However, individual data showed that there was a differential effect in 75% of subjects (p lt 0.05 for all) and that there was a greater effect of predictable pain for some subjects and a greater effect of unpredictable pain for others. Reaction time was related to reported anxiety (r = 0.49, p = 0.02 for both conditions). The predictability of a painful stimulus may have a differential effect on central nervous system performance within individuals, but anxiety about the impending pain appears to be important in determining this effect.

Anatomy and blood supply of the lower four cranial and cervical nerves: relevance to surgical neck dissection.

This study is a continuation of previous work searching for possible anatomic reasons to explain variable and usually unpredictable postoperative pain and dysfunction after the same nerve losses with similar neck dissection operations. The study consisted of dissections of 19 deceased unpreserved elderly subjects arterially injected with dyed latex. Of the 19 subjects, 14 had brain stem and cervical spinal cord dissections, and all had neck dissections. The findings suggested two possible anatomic reasons for the pain and dysfunction: (i) The intracranial anatomy of the lower four cranial nerves, the glossopharyngeal (IX), the vagus (X), the spinal accessory (XI), and the hypoglossal (XII), was just as variable as the previously reported peripheral spinal accessory nerve plexus; and (ii) Both the intracranial and neck dissections indicated that the blood supply to the lower four cranial and cervical nerves, particularly to the brachial plexus, could be impaired by atherosclerosis and/or neuroforaminal impingement or operative loss. This loss of blood supply theoretically could result in ischemia as another possible cause of postoperative pain and dysfunction. It is concluded that because of the potential importance of each nerve and vessel, often unknown at operation, it is very important to spare as many of them as possible to avoid subsequent painful impairment.

Irritable Bowel Syndrome.

I believe there are four essential elements in the management of patients with irritable bowel syndrome (IBS): to establish a good physician-patient relationship; to educate patients about their condition; to emphasize the excellent prognosis and benign nature of the illness; and to employ therapeutic interventions centering on dietary modifications, pharmacotherapy, and behavioral strategies tailored to the individual. Initially, I establish the diagnosis, exclude organic causes, educate patients about the disease, establish realistic expectations and consistent limits, and involve patients in disease management. I find it critical to determine why the patient is seeking assistance (eg, cancer phobia, disability, interpersonal distress, or exacerbation of symptoms). Most patients can be treated by their primary care physician. However, specialty consultations may be needed to reinforce management strategies, perform additional diagnostic tests, or institute specialized treatment. Psychological co-morbidities do not cause symptoms but do affect how patients respond to them and influence health care-seeking behavior. I find that these issues are best explored over a series of visits when the physician-patient relationship has been established. It can be helpful to have patients fill out a self-administered test to identify psychological co-morbidities. I often use these tests as a basis for extended inquiries into this area, resulting in the initiation of appropriate therapies. I encourage patients to keep a 2-week diary of food intake and gastrointestinal symptoms. In this way, patients become actively involved in management of their disease, and I may be able to obtain information from the diary that will be valuable in making treatment decisions. I do not believe that diagnostic studies for food intolerances are cost-effective or particularly helpful; however, exclusion diets may be beneficial. I introduce fiber supplements gradually and monitor them for tolerance and palatability. Synthetic fiber is often better-tolerated than natural fiber, but must be individualized. In my experience, excessive fiber supplementation often is counterproductive, as abdominal cramps and bloating may worsen. Antidiarrheal agents are very effective when used correctly, preferably in divided doses. I use them in patients in anticipation of diarrhea and especially in those who fear symptoms when engaged in activities outside the home. I encourage patients to make decisions as to when and how much to use. However, almost always, a morning dose before breakfast is used (loperamide, 2 to 6 mg) and, perhaps again later in the day when symptoms of diarrhea are prominent. I prefer antispasmodics to be used intermittently in response to periods of increased abdominal pain, cramps, and urgency. For patients with daily symptoms, especially after meals, agents such as dicyclomine before meals are useful. For patients with infrequent but severe episodes of unpredictable pain, sublingual hyoscyamine often produces rapid relief and instills confidence. In general, I recommend that oral antispasmodics be used for a limited period of time rather than indefinitely, and generally for periods of time when symptoms are prominent. For chronic visceral pain syndromes, I recommend small doses of tricyclic antidepressants. These agents are especially effective in diarrhea-predominant patients with disturbed sleep patterns but may be unacceptable to patients with constipation. I educate patients that side effects occur early and benefits may not be apparent for 3 to 4 weeks. I consider using SSRIs in low doses in patients with constipation-predominant IBS; cisapride, 10 to 20 mg three times per day, also may be beneficial. When taken with drugs that inhibit cytochrome P450, cisapride has been associated with serious cardiac arrhythmias caused by QT prolongation, including ventricular arrhythmias and torsades de pointes. These drugs include the azole fungicides; erythromycin, clarithromycin, and troleandomycin; some antidepressants; HIV protease inhibitors; and others. In patients with IBS with mild to moderate co-morbid depression, I have found that the use of SSRIs such as paroxetine, fluoxetine, or sertraline may be beneficial. It is important to tell patients that anxiety and disturbed sleep may occur during the first 10 days and benefits may not occur for 3 to 4 weeks. I prescribe a small amount of a short-acting benzodiazepine such as alprazolam, 0.5 mg two times per day, to control these symptoms. For generalized anxiety without depression, buspirone or clonazepam may be useful. I have found that patients who also have associated panic disorder may benefit from a benzodiazepine, tricyclic antidepressant, or an SSRI. However, these patients are best managed in conjunction with a psychiatrist or psychologist. I consider the use of alternative therapies in patients who fail to respond to conventional measures and who are receptive to alternative strategies. These include general relaxation techniques such as biofeedback and hypnosis therapies.

Impact of children's sickle cell history on nurse and physician ratings of pain and medication decisions.

The process of assessing and treating recurrent and unpredictable pain in children with sickle cell disease (SCD) is complex. A conceptual model is presented to aid in understanding the influence of mediating factors such as professional knowledge, attitudes and beliefs about pain, and learning history on the interpretation of objective data and resulting treatment decision. One aspect of this model, the effect of disease history on pain assessment and treatment decisions, is tested in an experimental study of SCD pain in children. Results suggest that nurses, but not pediatric residents, provide lower doses of narcotic analgesics to children with histories of frequent, as opposed to occasional, hospitalization for pain, although they do not differ in their ratings of the pain of children with these histories. Neither professional experience and training nor reported attitudes and beliefs about pain in children are related to this pattern of decision making. Results are discussed in terms of the aversive impact of repeated exposure to a noxious stimulus (pain behaviors) on caregiver interpretation of pain cues.

Erfahrungen erwachsener Patienten mit ihrer kieferorthopädischen Behandlung

Own experience with an orthodontic treatment stimulated us to interview patients out of retention about four topics concerning their opinion and experience: 1. Reasons for treatment, 2. doubts about treatment, 3. troubles during treatment, 4. attitude to the result of treatment. 50 adults, former patients of the Department of Orthodontics at the Erlangen-Nürnberg University, responded our questionnaire. Aesthetics range first in the patient's desires for treatment. Severe doubts about treatment rarely occurred before treatment. The occurrence of particular complaints cannot be predicted and does not show a characteristic distribution. Pain, induced by treatment generally was underrated. For unpredictable severe pain may occur, one might consider to review the treatment goals critically after the patient's own experience with orthodontic treatment.