Pain is a leading symptom which influences patients to seek medical attention. The management of pain among patients attending in-patient care in southern African countries has been little described. Information regarding the prevalence of pain and the quality of its management may be useful in guiding clinical decisions, training of health workers and health care quality improvements.A hospital-based audit was conducted to estimate the prevalence of pain and examine the quality of its management among patients admitted to adult medical wards at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi in 2004. Data were abstracted from ward charts of consecutive patients' who had been either been discharged or had died within a specified period. Characteristics of interest included; socio-demographic data, presence or absence of pain at admission, characterization or description of pain when present, and drug treatment given. Data were analyzed to obtain frequencies and proportions of the characteristics and assess the prevalence of pain and quality of care.A total of 121 patients' case notes were reviewed and the prevalence of pain was recorded for 91 (75.2%) of the patients. Clinicians had recorded pertinent information regarding pain management with the following frequency: pain severity or intensity 5/91 (5.5%), alleviating factors 5 (5.5%), pain radiation 7 (7.7%), exacerbating factors in 9 (9.9%) and periodicity in 43 (47.3%) of the cases. Males with pain were more than 3 times more likely to receive analgesic as compared to females, p < 0.01. Paracetamol was the commonest analgesic prescribed.Inadequate management of pain among patients attending medical wards at QECH was found. There is need for prospective studies to further characterize pain management and identify pain management gaps in Malawi. Interviews of clinicians and documentation of observations within clinical practice are likely to be of value. Pain is a common medical symptom prompting patients to seek care. However adequate management of pain remains a global challenge. In 1982, the World Health Organization (WHO) recognized inadequate management of (cancer) pain as an international health problem [Pain may be acceptable to patients as an inevitable and natural aspect of illness; this may affect patients' tolerance of the symptom (pain) and request for analgesia . Health In a country where the adult HIV sero-prevalence is estimated at about 12% , the majPain syndromes are common among AIDS patients . In the We are unaware of any published studies on the prevalence of pain and the quality of its management among adult medical in-patients in Malawi. We therefore conducted this audit to contribute to literature on the prevalence of pain and its management through an assessment of patients' hospital charts at the QECH in Blantyre, Malawi. Such a report may raise awareness and garner attention towards the study of pain and its management in setting where such an interest is lacking.This was a retrospective, descriptive audit aimed to estimate the prevalence of recorded pain and the quality of its management among adult medical in-patients. The study was carried out at the Queen Elizabeth Central Hospital (QECH), the major referral hospital in Malawi and the main teaching hospital of the University of Malawi, College of Medicine. The hospital is also a teaching center for the Kamuzu College of Nursing (KCN), for training nursing students and the Malawi College of Health Sciences, for the training of clinical officers, medical assistants and enrolled nurses. Like other public referral (and district level) health facilities in Malawi, clinical officers and medical doctors work side by side both in the ambulatory services and within hospital wards.Consecutive case files for patients who had died or had been discharged within a period of two weeks were included. Data for patients still admitted within the medical wards were not reviewed as there was possibility that their symptoms and management could have changed during the course of the study, and no complete records would be possible as they were still under care. Data were abstracted by two research assistants and a sample verified by one of the investigators. For patients who had been discharged or had died, their reported record of pain or its management had "been sealed." Data were entered into Excel and analysis conduced using SPSS version 9.0  to obtain frequencies and correlations. A p value of less than 0.05 was considered statistically significant.The study was considered an audit and therefore full ethics review board was not done. Permission to conduct the study was provided by the Medical Director of the hospital. The study proposal was also reviewed by Hospice Africa Uganda research committee as it was part of the Diploma in Palliative Care, Makerere University program (Uganda), in which the first author was a student.The results are presented below under the following sub-headings: socio-demographic characteristics of patients; prevalence of pain; characterization of pain and recorded management plan.A total of 121 patients' case notes were reviewed and analyzed of which 60 (49.6%) and 61 (50.4%) were males and females respectively. Patient's weight was not indicated in any of the files; religion was indicated in only 27 (22.3%) of the files, while 94 (77.7%) had no record of religious affiliation. The majority of the patients, 111 (91.7%%) had their current marital status recorded. A fifth, 21 (17.4%) patients had died while 100 (82.6%) had been discharged alive.Of the 121 patients, 91 (75.2%) were recorded as having at least one pain while 30 patients (24.8%) had no record of pain (including no report of absence of pain). For those patients with recorded pain, the body chart/map was used in 38 (41.8%) cases showing the body site with pain; formal pain severity scores were never used at all. The number of pains was also assessed e.g. a patient with headache, stomachache and backache was labeled as having 3 pains while a patient with only one anatomical site of pain was categorized as having one pain site. The frequency of the different numbers of pain is presented in Table For patients with a record of pain, we aimed to determine the frequency of whether the pain had been characterized. Furthermore we also assessed the description of the pain by recorded by clinicians in the case notes based on severity, periodicity, radiation, alleviating and exacerbating factors. Table Of the 91 patients with history of pain recorded, 88 (96.7%) had recorded previous pain medications received before the current hospital admission. While in hospital for the current hospitalization however, analgesics were prescribed for 70/91 (76.9%), the commonest of which was paracetamol 62 (68.1%), aspirin 9 (9.9%), while other analgesics and opioids were prescribed less than 3%. The majority of patients (67.8%) were prescribed as thrice daily intake of analgesics. Drug adjuvant treatment was prescribed for only 2 patients. 31 (34.1%) patients were first seen by doctors while the rest had been first seen by other clinical staff such as clinical officers. Males with pain were 3.2 times more likely to receive analgesics as compared to female patients ((p < 0.01).We also aimed to determine whether clinicians were interested to follow up on pain among the patients. This was assessed by identifying whether any record on pain was made at second patient review following admission. At second clinician consultation, only 8 (8.8%) of the 91 patients had any information on pain while the rest 83 (91.2%%) had no record of the pain on a second ward consultation. The quality of sleep among patients was recorded in only one patient and in 19 (20.9%) of patients with pain on admission it was reported they had pain on discharge or the last consultation prior to death.The prevalence of reported pain among adult in-patients at QECH, Blantyre was 75.2%; this was much higher than the 54% pain prevalence reported by Dix et al  among meFurthermore, it appeared that clinicians did not care to ask about associated symptoms with the pain such as interference of sleep . In our In both pre-service and in-service training of clinical personnel, adequate history taking and physical examination are emphasized as important tools for adequate diagnosis and management of patient symptoms. The adequate documentation and management of pain symptom is clinical practice should therefore expected. Soyannwo and Amanor-Boadu,  however The WHO analgesic ladder when used properly is likely to lead the clinicians to provide analgesic(s) and adjuvant therapy based on the characterization and severity of the pain.For instance, noting about the periodicity of pain , severity and sleep disturbance, will enable the clinician determine the functional disturbance the pain may be causing the patient.It is a matter of concern that the majority of patients in our study did not have important socio-demographic data recorded, for instance, religion. To provide holistic care, there is need to have an indication of the religious or spiritual beliefs of the patient. Knowledge of spiritual beliefs for instance will enable the care team to facilitate linkages with spiritual leaders, especially as many of our patients are terminally ill. Similarly, upon death, it is important to be aware of any religious requirements for preparing the body for keeping or burial according to the patient's religious beliefs ,26.While the other socio-demographic characteristics were not adequately recorded, it is important to note that marital status was recorded 92.4% of the time. Knowledge about the patients' marital status will enable the care team to identify the 'significant' others in the patient's life. Decisions on the pattern of care when discharged may also have to be discussed with family member, if available.The reasons why males with pain were more likely to receive analgesics as compared to females with pain can not be deduced from the present study. It is possible that male patients were better able to communicate with clinicians . Paracetamol was the most commonly prescribed analgesic followed by aspirin. These are the commonest available analgesic at QECH and this may explain clinician's preferences to prescribing these drugs. On the other hand, lack of appreciation of the analgesic ladder and poor assessment and recording could lead clinicians to favour first level analgesics as prescribing the higher levels and adjuvants really means that one understands the characterization of the pain.Our study had a number of limitations. Firstly, we assumed that if any piece of information was not available in the case notes, we decided that the relevant questions were never asked and the health professional who took the patient's history did not have the information. In actual practice, this may not be the case. Secondly, our audit may not have collected data from a representative sample of patients attending medical wards. However, we decided to collect case files of patients who had "passed through" the wards over a two week period. If there had been changes in the patient profiles or clinical staff, the sample studied may not have been representative. Thirdly, we only studied patients in the medical wards. Our findings may therefore not be representative of the diversity of patients attending the hospital. Finally, the clinician case load and other work environment situations were not assessed so as to explain the observed quality of management.The present study was unable to determine why clinicians at QECH were unable to document pain adequately in patients' case notes. While this study is primarily of local focus, we believe that our findings can spur research and consideration of adequate of management of pain in similar setting where it has not received proper attention. We suggest that the factors that prevent clinicians from adequately manage pain be further studied in a prospective study. Possibilities for the current practice include; lack of adequate time to document pain as many of wards at QECH have few staff attending many patients, lack of appreciation by clinicians on proper management of pain, especially using the WHO's analgesic ladder when indicated. This is particularly worrying for QECH which is the teaching hospital for medical students and nurse trainees. Lack of models among trainees may impact negatively on proper pain management in generations to come. There is need to explore via operational research whether pain protocols as suggested by Beck  may evenThe authors declare that they have no competing interests.ASM designed the study, supervised research assistants in abstracting data from patients' case note and participated in the interpretation of the findings and drafting of the manuscript. HEM analysed the data and participated in the interpretation of the findings and drafting of the manuscript. All authors read and approved the final manuscript.


Pain is said to be one of the most feared and distressing symptoms of cancer and one that disrupts all aspects of life. The purposes of this study were: 1) to compare depression and quality of life among Iranian cancer patients with and without pain; and 2) to determine the relationships between pain beliefs and depression and quality of life.A consecutive sample of gastrointestinal cancer patients attending to Tehran Cancer Institute were entered into the study. Three standard instruments were used to measure quality of life (the EORTC QLQ-C30), depression (the HADS) and pain beliefs (the PBPI).A total of 142 hospitalized gastrointestinal cancer patients, 98 with pain and 44 without pain were studied. The main findings of this study were that cancer patients with pain reported significantly lower levels of role functioning, emotional functioning and global quality of life. They also showed higher levels of depression than cancer patients who did not experience pain. Among patients with pain, higher scores on pain permanence and pain consistency were positively and significantly associated with higher depression. Also, higher scores on pain consistency were negatively and significantly associated with global quality of life.This study has demonstrated the effect of cancer pain on patients' quality of life and emotional status and has supported the multidimensional notion of the cancer pain experience in cancer patients. Although these data are correlational, they provide additional support for a biopsychosocial model of chronic pain. Pain is said to be one of the most feared and distressing symptoms of cancer ,2 and onCancer pain has a significant impact on the overall quality of a cancer patient's life by influencing physical, psychological, and spiritual aspects . Pain isDuring the past two decades, a small body of research has accumulated that suggests a relationship between pain and mood disturbance in patients with cancer. Gerbershagen et a1.  studied Pain is a multidimensional experience, far beyond a nociceptive signal. It is rooted in our socio-cultural context and belief system . BeliefsAlthough certain cognitions and beliefs may be adaptive and help patients to cope with the experience of pain, others may actually contribute to increased pain and affective distress. Identification of adaptive and maladaptive pain-related beliefs and cognitions might improve our understanding of individual responses to chronic pain and contribute to more effective treatment interventions . CognitiIn chronic non-cancer pain, it is generally agreed that the meaning assigned to pain can play an important role in the experience of pain and in the response to treatment. Several studies have demonstrated the impact of pain cognition on patients' pain experience, disability, distress, non-adherence, and outcome of treatment ,17,18. FThis study was conducted at a large teaching hospital  in Tehran, Iran from November 2005 to April 2006. The intention was to interview all gastrointestinal cancer inpatients attending the hospital for their treatments. To be included in the study patients had to be a) over the age of 18 years, b) diagnosed within the last 12 months, and c) conscious and able to communicate. Patients were classified into two groups: pain group and pain-free group based on the presence or absence of cancer related pain. A psychologist in a face-to-face interview administrated the questionnaires. In the first part of the investigation, depression and health-related quality of life was compared between cancer patients with and without pain. The second part of the study addressed the association between pain belief and depression and quality of life. Verbal consents obtained from all patients prior to interview. The Ethics Committee of the Tehran University of Medical Sciences approved the study.Depression was evaluated by the Hospital Anxiety and Depression Scale (HADS). It is a 14-item questionnaire consisting of two subscales: anxiety and depression. Each item is rated on a four-point scale giving maximum scores of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered to be a significant "case" of psychological morbidity, while scores of 8–10 represents "borderline", and 0–7 "normal" . The psyQuality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). This is a core cancer-specific questionnaire containing 30 items measuring functioning, global quality of life, and disease- and treatment related symptoms . The valPain beliefs was measured using the Pain Beliefs and Perceptions Inventory (PBPI). This is a 16-item scale that measures the extent of agreement or disagreement with certain beliefs about pain . The insDescriptive statistics were used to describe the sample characteristics in terms of demographic and disease-related variables. The t-test was employed to determine if scores are differed in response to patients' experiences of pain. Among patients experiencing cancer-related pain, Pearson's correlation (r) was used to explore the relationship among pain-related beliefs, depression and global quality of life. A p value < 0.05 was regarded to be statistically significant.A total of 98 cancer patients with pain and 44 cancer patients without pain n = 142) participated in the study. Patients in the pain and pain-free groups were similar in their demographics and clinical characteristics. The detailed demographic and clinical data are summarized in Table 42 particFunctioning, global quality of life and depression scores for cancer patients with and without pain are presented in Table Comparison of functioning and global quality of life scores between cancer patients with and without pain indicated that those who experienced pain showed a significant lower degree of global quality of life (P < 0.0001), physical (P = 0.001), emotional (P = 0.014) and role functioning (P < 0.0001). In addition, the analysis showed that patients in the pain group had significantly higher levels of depressive symptoms than patients in the pain-free group (P < 0.0001).For patients with pain (n = 98), the mean (SD) pain beliefs scores on the PBPI were: pain permanence: -4.45(2.5); self-blame: -1.33(4.6); pain consistency: -2.71(3.6); mysteriousness: 1.92(3.4).P = 0.003), but not with global quality of life. In addition, there were no significant relationships between depression, quality of life and self-blame and mysteriousness  and global quality of life . Pain permanence was significantly correlated with depression (r = 0.3, The results of this study provide several important implications for understanding the impact of cancer pain on patients' quality of life and depression. The findings of this study support the multidimensional notion of the cancer pain experience  and demoDepressive symptoms are significantly more frequent in pain patients than in patient without pain. These results from the current study conducted in Iran is consistent with prior studies conducted in other countries ,25,26 whThe cognitive dimension of pain refers to the way patients think about their pain and what the pain means for them, in terms of thoughts, beliefs, attitudes, and self-efficacy expectations. The meaning patients ascribe to their pain may differ among different individuals . BeliefsThe results of the present study replicate and extend previous findings about relationship between pain beliefs and emotional functioning. In this study higher score on some pain beliefs and perceptions including pain permanence and pain consistency were positively and significantly associated with higher depression. Also, higher scores on pain consistency were negatively and significantly associated with global quality of life. These are similar to findings from previous studies where it was found that pain beliefs and cognitions were related to pain adjustment ,24,35. AAlthough our findings should not be interpreted as indicating that negative beliefs cause mood disturbance, they do indicate the need for further research examining this relationship. It is likely that there might be a mutual relation among these variables. Greater use of longitudinal designs should help in understanding the ability of beliefs and cognitions to predict quality of life in patients who suffer from cancer related pain. However, the results of this study should be read with caution. This was a descriptive design and it would be useful to replicate this study using measures obtained by other methods, especially behavioral observations.The findings demonstrated that Iranian cancer patients, similar to cancer patients in other countries, are affected by cancer pain in many dimensions of their lives. The similarity in these patients' responses indicates that the negative impact of cancer pain is not culture specific. It is important for clinicians to make every effort to prevent cancer pain and to relieve pain effectively and promptly. Based on experiences from Western countries, pain therapy that addresses only one component of the pain experience might be destined to fail . InterveThe authors declare that they have no competing interests.AT was the main investigator and wrote the first draft of the manuscript. AM supervised the study, analyzed the data and wrote the final draft of the manuscript. RR supervised the study. ZT contributed to the study design. MM contributed to the data collection. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Acute pain caused by musculoskeletal disorders is very common and has a significant negative impact on quality-of-life and societal costs. Many types of acute pain have been managed with traditional oral non-steroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase-2 inhibitors (coxibs). Data from prospective, randomised controlled clinical trials and postmarketing surveillance indicate that use of oral traditional NSAIDs and coxibs is associated with an elevated risk of developing gastrointestinal, renovascular and/or cardiovascular adverse events (AEs). Increasing awareness of the AEs associated with NSAID therapy, including coxibs, has led many physicians and patients to reconsider use of these drugs and look for alternative treatment options. Treatment with NSAIDs via the topical route of administration has been shown to provide clinically effective analgesia at the site of application while minimising systemic absorption. The anti-inflammatory and analgesic potency of the traditional oral NSAID diclofenac, along with its physicochemical properties, makes it well suited for topical delivery. Several topical formulations of diclofenac have been developed. A topical patch containing diclofenac epolamine 1.3% , approved for use in Europe in 1993, has recently been approved for use in the United States and is indicated for the treatment of acute pain caused by minor strains, sprains and contusions. In this article, we review the available clinical trial data for this product in the treatment of pain caused by soft tissue injury. Information was gathered through a search of MEDLINE, Derwent Drug File, BIOSIS and EMBASE databases on diclofenac epolamine topical patch and diclofenac hydroxyethylpyrrolidine patch, for publications from 1985 to present, in any language. Additional sources used in the development of this article include product prescribing information and relevant conference poster presentations.Interest in topical NSAIDs that provide analgesia while minimising systemic absorption has increased as a result of growing awareness of adverse events associated with systemic therapy. The diclofenac epolamine topical patch 1.3% (DETP), available in Europe since 1993, was recently approved in the United States for topical treatment of acute pain caused by minor strains, sprains and contusions. Newly available postmarketing surveillance data covering approximately 14 years strengthen available safety data. DETP continues to offer a viable treatment option in patients with acute pain caused by minor strains, sprains and contusions.In the United States, between 2004 and 2005, soft tissue injuries such as strains, sprains and contusions each accounted for approximately 18% of initial visits to the emergency department for injuries , for whiUse of an analgesic medication, in particular the judicious use of oral traditional non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 inhibitors (coxibs), has been shown to be beneficial in reducing pain and swelling in acute soft tissue injuries ,7. NSAIDThe consequences associated with pain include negative effects on quality-of-life and societal costs . MusculoUse of oral NSAIDs has been associated with a significantly increased risk of GI complications ; among pThe GI tolerability and favourable systemic toxicity profile observed with topical NSAIDs may be a result of low systemic blood concentrations ,24. HeynTopical agents that are now available include NSAIDs, counter-irritants (e.g. capsaicin) and local anaesthetics, such as the lidocaine patch 5% ,26. A clThe goal of topical agents is to achieve similar efficacy to oral formulations with potentially lower systemic side effects . PenetraN = 433) that compared topical vs. oral NSAIDs showed similar efficacy , DETP provides a defined dose to a defined area of skin for 12 h, requiring twice per day application . DETP haN-(2-hydroxyethyl)-pyrrolidine (DHEP) , developed and patented by IBSA Institut Biochimique SA   is the fe (DHEP) ,43. The e (DHEP) . High coe (DHEP) .DETP is a ready-to-use adhesive patch composed of two layers: an outer layer of non-woven polyester felt backing and an adhesive inner layer containing 1.3% of diclofenac epolamine in a polymeric hydrogel  10). Th. Th10). The anti-inflammatory, analgesic and antipyretic actions of diclofenac are well established ,46. It iLow systemic absorption of diclofenac following DETP application has been shown in a study by Rusca et al. . Over 12N = 8). Synovial fluid concentrations of diclofenac were 36% of concentrations found in plasma. These concentrations indicate direct transport of diclofenac across the skin to reach the synovial fluid compartment. The mean plasma concentration was 3.62 ng/ml at 4 h after the last application (N = 24). The maximum peak plasma concentrations were 1.55 ng/ml (0–12 h) and 1.57 ng/ml (0–24 h)  were noted between 10 and 20 h after application  assessedlication . Steady lication . During lication . Gschwenlication  assessed(0–24 h) . In a st(0–24 h) . In anotDiclofenac is highly bound to serum proteins  and has The plasma elimination half-life of diclofenac after application of DETP is approximately 12 h . DiclofeN = 140) demonstrated the effectiveness and tolerability of DETP vs. placebo in reducing the acute pain of ankle sprain (N = 134) who sustained an ankle sprain < 48 h before study entry and with spontaneous pain of at least 50 mm on a 1- to 100-mm VAS were treated with DETP, applied every morning for the 7-day study period . DETP achieved statistically significant pain relief vs. placebo as measured by summed pain intensity difference at days 3 (p = 0.036) and 14 (p = 0.048)  with localised inflammatory diseases. In this controlled, randomised, 2-week study both treatments decreased pain; however, significantly more patients and investigators reported superior efficacy with DETP than with DDA (p < 0.001). The authors theorised that better results were because of the constant release of active substance by DETP vs. the DDA emulgel, as the latter required four applications daily. Both treatments were well tolerated , as opposed to topical NSAID gels or creams that are applied up to four times daily ,12. ApplTopical NSAID formulations may be important for patients who are at risk for GI AEs that may result from the use of oral NSAIDs, because topical NSAIDs expose patients to lower systemic levels of diclofenac. Risk factors for serious GI events include older age, prednisone use, previous NSAID GI side effects and prior GI hospitalisation . Some paMany clinicians and patients are familiar with patch formulations. For example, the lidocaine patch has demonstrated efficacy in the treatment of neuropathic pain types, mainly by stabilising neuronal activity, without significant side effects . TopicalOver the next few years, we will likely witness an effort dedicated towards optimising delivery of NSAIDs while minimising associated risks, along with an increased acceptance of topical formulations. It is likely that additional topical analgesic formulations will be introduced, and more clinical studies will be performed both in support of these applications and in light of the new evidence about the risks of oral NSAIDs.Placebo-controlled studies included in the present report found that patients treated with DETP experienced a significantly faster and greater improvement in pain compared with patients treated with placebo. Taking into consideration the safety profile of topical diclofenac formulations in general, and diclofenac epolamine in particular, as well as the low incidence of local adverse reactions and lack of systemic side effects, DETP offers a viable treatment option in patients presenting with acute pain caused by minor strains, sprains and contusions.


Most cutaneous surgeries are performed under local anaesthesia. It is important the process of administration of local anaesthetics is pain free. This article suggests simple tips to make local anaestesia less painful. Dermatologists have always been at the forefront of office-based surgery. Office-based surgery cannot be accomplished without the help of local anaesthesia. Local anaesthetic administration with intradermal or subcutaneous lignocaine infiltration is associated with discomfort. The level of pain felt during surgery is of utmost importance and has a significant impact on the patient. It is gratifying to hear at the end of a surgery, “Did you start yet?”Number of injections, size of the needle, amount and type of anaesthetic, level of anxiety of the patient are all important factors which contribute to pain during local anaesthesia. Besides these factors, individual variations in reactions to pain do exist.We have adopted the following techniques to reduce pain during local anaesthesia:Sodium bicarbonate was added to the local anaesthetic solution. This reduces the stinging sensation caused by acidic pH . The formulation used was as follows:2% Lignocaine, 19 mlAdrenaline 1: 1000, 0.1 mlNormal saline, 20 mlSodium bicarbonate (8.3%), 4 mlEighty percent patients reported much reduced pain as compared to experience on the control site.Bupivacaine was used when prolonged local anaesthesia (LA) was desired. Bupivacaine has more prolonged action and hence repeated pricks are not necessary.® or xylocaine viscus for mucosa, use of small bore needle 27G, 30G.Other measures to reduce the needle prick pain, include, pre-cooling with ice packs, use of eutectic mixture of local anaesthetic (EMLA) cream, 4% xylocaine ointment, 10% xylocaine spray, ethyl chloride spray, MucopainAnxiety alleviation: Apprehensive patients were given premedication with anxiolytic like diazepam or alprazolam. For very anxious patients conscious sedation was induced using midazolam, pentazocine or propofol. Both the approaches made it easier to give needle pricks in majority of patients.A useful modification is to give the first prick intradermally, at right angles to the surface and a small quantity infiltrated to raise a wheal. After waiting for 2 min subsequent prick were given through the anaesthetized area. Repetitive rapid rubbing and shaking of the skin proximal to the site of injection during lignocaine infiltration also reduced the level of pain and discomfort.Reasons for pain during administration of local anaesthesia include needle prick, acidic medium of the medication and improper technique. Addition of sodium bicarbonate reduced the stinging sensation related to the acidic nature of adrenaline containing LA. Similarly various topical applications prior to prick also helped patients to tolerate the prick pain better. Apprehension is always a big problem in any surgical procedure. Conscious sedation utilizes a combination of sedatives, analgesics and tranquilizers to induce a state of amnesia, anxiolysis and analgesia. This places the patient in a quiescent state so that LA and nerve blocks may be comfortably administered.gated” at the spinal level by afferent signals carried by thick fast fibres emanating from the same dermatome. When the low-threshold fibres are activated by pressure and/or vibration, this stimulus transmission gates or diminishes the pain stimulus, reducing the perception of pain.Reduction in the level of pain and discomfort by repetitive rapid pinching and shaking of the skin proximal to the site of injection during lignocaine infiltration works on the ‘gate control hypothesis’: the ascending transmission of pain by thin slow fibres could be modified or “Finally, it is important to make the patient comfortable during any office surgery. If the patient is uncomfortable, he/she is more likely to move during surgery, which can make the surgeon uncomfortable, leading to detrimental outcome.


In this paper we explored thalamocortical functional connectivity in a group of eight patients suffering from peripheral neuropathic pain (diabetic pain), and compared it with that of a group of healthy subjects. We hypothesized that functional interconnections between the thalamus and cortex can be altered after years of ongoing chronic neuropathic pain.Functional connectivity was studied through a resting state functional magnetic resonance imaging (fMRI) paradigm: temporal correlations between predefined regions of interest  and the rest of the brain were systematically investigated. The patient group showed decreased resting state functional connectivity between the thalamus and the cortex.This supports the idea that chronic pain can alter thalamocortical connections causing a disruption of thalamic feedback, and the view of chronic pain as a thalamocortical dysrhythmia. It is already known  that cerSome recent findings posed the possibility that pain can be related to the emergence of large-scale synchrony, occurring at two different frequency bands; a synchrony that can be enhanced or destroyed by attention and distraction . These rThe recent discovery of low-frequency band fluctuations (LFBF) in the blood oxygenation level dependent (BOLD) signal (for a review see ), identiUnfortunately, despite its central role in the functioning of the cerebral cortex ,41, littEight right-handed consecutive patients suffering from peripheral NP (diabetic pain)  were enrolled from our multidisciplinary pain unit (tab. s2). All patients underwent a complete neurological and psychological examination as well as standard MR brain scanning by an experienced neuroradiologist (SD) to exclude structural/white-matter abnormalities on anatomical MR-images. Patients suffering from significant psychiatric disorders were excluded. All patients were assessed using standardized pain scales . The spontaneous component of their pain syndrome was evaluated on the MPQ checklist. VAS readings were obtained from their clinical records both the day before and on the day of the study to check the stability of the level of pain . In all cases pain was restricted to the bilateral lower limbs. Duration of pain was >2 years in all cases. Patients were washed out of their medications at least one month before imaging (opioids or cannabinoids were never administered). At the time of scanning, pain intensity had reached pre-treatment levels. Maximum care was taken to avoid situations that could actually trigger evoked pain during the imaging sessions. Eight age- and gender-matched right-handed healthy volunteers  acted as controls. None suffered from any neurological or psychiatric disorders, including chronic pain of any kind, nor had a history of drug or alcohol abuse. None were on medications known to alter brain activity. All females participating in the study were menopausal. All subjects gave their informed written consent, in line with the Declaration of Helsinki, and the study was approved by the local ethics committee.All subjects were instructed simply to keep their eyes closed, think of nothing in particular, and not to fall asleep. After the scanning session, participants were asked if they had fallen asleep during the scan; subjects who provided a positive or dubious answer were excluded from the study.T1-weighted structural images was acquired for each participant. This data-set was acquired using a Fast Field Echo (FFE) sequence, with a TR of 25 ms, ultra-short TE and a 30° flip angle. The acquisition matrix was 256 × 256, the field of view (FoV) 256 mm. The set consisted of 160 contiguous sagittal images covering the whole brain. In-plane resolution was 1 × 1 mm2 and slice thickness 1 mm (voxel of 1 × 1 × 1 mm3).Data acquisition was performed on a 1.5 Tesla INTERA™ scanner  with a SENSE high-field, high resolution (MRIDC) head coil optimized for functional imaging. Resting state functional BOLD imaging data were analyzed using the BrainVoyager QX software . Functional images were preprocessed to reduce artifacts  followinAfter pre-processing, a series of steps were followed in order to allow for the precise anatomical location of brain activity to facilitate inter-subject averaging. First, each subject's slice-based functional scan was co-registered on his/her 3D high-resolution structural scan. Second, the 3D structural data-set of each subject was transformed into Talairach space : the cer3 . The localizer study . In addition, since in the S1 rsFC a relevant area within the medial dorsal thalamic nucleus (MDN) was found to be less connected, we also computed a seed region in the bilateral MDN as determined using an anatomic atlas: we calculated the center of gravity of all voxels comprised in the MDN as mapped in the Talairach Daemon database [3 seed ROIs were drawn over these two points . All ROIs are listed in tab. s3.To obtain the S1 ROI we extracted the location of the peak voxel from a localizer study conducted on eight healthy subjects  and come et al. ) was a be et al. . Left andatabase . Left anAdditional analyses were conducted using alternative ROIs, i.e. ROIs which were moved from the original location in the rostral, lateral, ventral, medial and caudal directions (3 mm), reduced (3 × 3 × 3 voxels) and increased (8 × 8 × 8 voxels) in dimensions. We found high similarity between the resulting maps and those obtained using the original ROIs: probabilistic maps showed high overlapping between the original and the alternative connectivity maps  analyses was to extract BOLD time courses from each ROI by averaging over voxels within each region. Several nuisance covariates were included in the analyses to control for the effects of physiological processes (such as fluctuations related to cardiac and respiratory cycles) ,61 and mRandom effect group-level analyses and group comparisons controlling for age and gender effects were conducted using the ANCOVA analysis tool implemented in BrainVoyager QX. Corrections for multiple comparisons were carried out using the FDR   to assess the potential effect of this variable on the spatially specific activations revealed in the preceding analyses. To test for significant group-related differences, direct voxelwise group comparisons were performed using group-level contrasts. These contrasts computed the voxelwise statistical significance of mean group differences in FC, and produced FDR thresholded maps of those voxels that showed significant differences between the two groups. For MDN and VPL connectivity the resulting maps were then projected on a 3D representation of the brain using the BrainVoyager QX 3D cortical tool.To evaluate the spatial consistency of functional connectivity patterns across subjects we computed probabilistic maps, that were calculated separately for each ROI-generated network.For each subject and each ROI, we extracted the time course at each voxel. Using a home-made SPSS script, we computed the mean time course for each ROI. For each subject we performed pairwise correlations between the ROIs' mean time courses, in order to assess rsFC. In particular, within each hemisphere, we assessed the rsFC between the thalamus (VPL) and S1; we also assessed the rsFC between each area and its homologous area in the opposite hemisphere . Parametric analyses (t-tests for independent samples) were used at the group level to determine the statistical significance of the difference between patients and controls on each paired correlation.In connectivity comparison between the pain group and the control group we calculated the lateralization  of the portion of functionally connected Brodmann areas .px, py, pz) and Q =  was computed using the formula We calculated the Euclidean distance between the center of gravity of the three pairs of ROI  and every other voxel that reached significance in the thresholded Z-score map of positive FC (cluster significance: p < 0.05). The Euclidian distance between two voxels P =  in the thalamus and in the primary somatosensory cortex between normal and pain subjects.Although we used age as a covariate we further inspected possible age effects on the rsFC maps performing a correlational analysis between each subject-specific ROI-generated map and the relative age using the ANCOVA analysis tool implemented in BrainVoyager QX. We found no significant correlation between them (q<0.05 FDR corrected). Movement was assessed by summing the deviations (three translations plus three rotations at a radius of 50 mm) used to compensate for head motion within fMRI. The quantity reported here is head movement root mean square averaged over subjects. This quantity was 0.30 ± 0.09 mm (mean ± standard deviation) for patients and 0.28 ± 0.10 mm (mean ± standard deviation) for age-matched controls. Patients vs. controls comparisons were not significantly different (p = 0.84). Hence, it is unlikely that movement can account for the observed differences in connectivity between the two samples.Comparing the pain and healthy groups , and a reduced connectivity of areas related to modulation of emotional response to stimuli . Although this study did not include any formal evaluation of mood, patients with diabetic painful polyneuropathy frequently suffer from depression as well as sleep disturbances , which iAnother interesting observation on connectivity of cortical areas pertains to the increased connectivity of the primary sensory cortex with the posterior as well as the inferior parietal cortex. The latter result may be interpreted on the basis of the known role of the posterior parietal cortex in sequential motor performance, the so-called "internal controller" function matching efferent copy of motor command with sensory feedback . In the Focusing more closely on the reduced connectivity of the VPL and MDN nuclei of the thalamus observed in the present study, this is consistent with the observation reported above and with a recent study in which subjects with diabetic neuropathic pain had significant reduction in brain metabolites (NAA) in the thalamus compared with the no-pain group . A PET sModulation of thalamic activity in pain patients should also be interpreted in the light of electrophysiological studies.Pain, in healthy controls, has the unique capability of disrupting the idling electroencephalogram (EEG) rhythm on a large-scale spatial dimension . On theThe relative role of pain vs. deafferentation in the induction of the alteration of thalamus and cortex connectivity in our patients remains unresolved. However, some evidence points toward a crucial role of neuropathic pain. Firstly, the selective reduction of activity in the medial dorsal thalamus and ventrolateral nucleus is consistent with a specific pain-related phenomenon since both nuclei are part of the respectively medial and lateral spinothalamic tract. Secondly, even if these patients were affected by polyneuropathy with electrophysiological evidence of involvement of A beta fibers (data not shown), the influence of these alterations on brain function may be hypothesized to be more evident during tasks and may be reflected by a disruption of the so-called optimal feedback control circuit which is made by the primary sensorimotor, posterior parietal and premotor cortices , Wolpert recentlyTaking this view the left lateralization of the S1-thalamic connectivity reduction seems difficult to explain, however as shown by the pairwise correlation see fig.  the righFrom this perspective the distinction between brain function modulation induced by pain and by deafferentation may be less meaningful.In summary, exploring thalamocortical functional connectivity in a group of eight patients suffering from peripheral neuropathic pain (diabetic pain), and compared it with that of a group of healthy subjects we found a reduced synchrony between S1 and some of the thalamic nuclei involved in pain processing. Studying specifically the VPL and MDN connectivity we demonstrated that VPL has a reduced synchrony with sensorymotor, frontal, cingulated and parietal areas while MDN more with sensory and emotional processing areas. This supports the idea that chronic pain can alter thalamocortical connections causing a disruption of thalamic feedback, and the view of chronic pain as a thalamocortical dysrhythmia.This study enrolled only a limited number of patients so the inference on a general population may be partly impaired. However, as mentioned earlier, our results are consistent with previous results.The distinction between modulation induced by pain or by deafferentation, although less meaningful in the light of the theory of the introceptive system, should be analyzed in further studies comparing patients with diabetic neuropathy with and without pain.A major point remains unresolved: is the reduced connectivity of the medial dorsal thalamus an adaptive or misadaptive plastic change? Although it continues to be a matter of debate, the medial dorsal thalamus together with other limbic structures (fornix) seems to play an important role both in retaining and in re-learning encoded information ,91. TherBOLD: blood oxygenation level dependent; CSF: cerebrospinal fluid; GS: global signal; LFBF: low-frequency band fluctuations; MDN: medial dorsal nucleus; NP: neuropathic pain; ROI: region of interest; FC: functional connectivity; rsFC: resting state functional connectivity; S1: primary somatosensory area; VPL: ventral posterior lateral nucleus; WM: white matter.Experiments conceived and designed by: CF SK DS CD. Experiments performed by: CF SK DS CD. Data analyzed by: CF SK DF FM. Reagents/materials/analysis tools contributed by: CF SK DS CD FM DF GG. Paper written by: CF GI SK DF. All authors read and approved the final manuscript.Supplementary online material. additional methods, results, figures and tables.Click here for file


Guasha is a therapeutic method for pain management using tools to scrape or rub the surface of the body to relieve blood stagnation. This study aims to systematically review the controlled clinical trials on the effectiveness of using Guasha to treat musculoskeletal pain.Guasha (OR scraping) AND pain. Risk of bias was assessed with the Cochrane criteria .We searched 11 databases (without language restrictions): MEDLINE, Allied and Complementary Medicine (AMED), EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Korean Studies Information (KSI), DBPIA, Korea Institute of Science and Technology Information (KISTI), KoreaMed, Research Information Service System (RISS), China National Knowledge Infrastructure (CNKI) and the Cochrane Library. The search strategy was Guasha with acupuncture in terms of effectiveness, while the other trials compared Guasha with no treatment , acupuncture , herbal injection  and massage or electric current therapy . While two RCTs suggested favorable effects of Guasha on pain reduction and response rate, the quality of these RCTs was poor. One CCT reported beneficial effects of Guasha on musculoskeletal pain but had low methodological quality.Five randomized controlled trials (RCTs) and two controlled clinical trials (CCTs) were included in the present study. Two RCTs compared Guasha is effective in pain management. Further RCTs are warranted and methodological quality should be improved.Current evidence is insufficient to show that  Guasha was defined as a therapeutic modality that uses several tools to scrape or rub the surface of the body to relieve blood (Xue) stagnation. Guasha is used for pain relief in Chinese medicine. Tools for Guasha including a Chinese soup spoon, an edge-worn coin, a slice of water-buffalo horn, a cow rib, honed jade and a simple metal cap with a smooth round lip with oil or water are used in Guasha to scrape or rub the skin to relieve blood stagnation at the body surface [Guasha is also used to treat common cold, flu, respiratory problems and musculoskeletal (MS) pain [ surface . Guasha MS) pain .Guasha to relieve MS pain: (1) Guasha increases local microcirculation thereby decreasing distal myalgia [Guasha minimizes the direct effects of pain at nociceptors, their surroundings and the interconnections within the spinal cord [Guasha is demonstrated.There are three possible mechanisms of using MS pain:  Guasha inal cord . HoweverGuasha to treat MS pain. The present systematic review aims to critically evaluate the results of controlled clinical trials on the effectiveness of using Guasha to treat MS pain.To date, no systematic review is available to evaluate the effectiveness of using Guasha (OR scraping) AND pain. Korean and Chinese terms for Guasha AND pain were used when searching the Korean and Chinese databases. We also searched in the journals Focus on Alternative and Complementary Therapies (FACT) and Research in Complementary Medicine (Forschende Komplementarmedizin) electronically published between 1994 and July 2009. In addition, the references in all retrieved articles as well as our department files were searched.The following databases were searched between their inception and July 2009: MEDLINE (1969), Allied and Complementary Medicine (AMED) (1995), EMBASE (1966), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1981), Korean Studies Information (KSI) (1966), DBPIA (1966), Korea Institute of Science and Technology Information (KISTI) (1959), KoreaMed (1959), Research Information Service System (RISS) (1959), China National Knowledge Infrastructure (CNKI) (1974) and the Cochrane Library . The search strategy was Guasha to treat patients (regardless gender or age) diagnosed with MS pain. Trials published as journal articles, dissertations and abstracts were eligible. We excluded the trials that compared one type of Guasha with another. Trials with Guasha as a part of a complex intervention were also excluded. No language restrictions were imposed.We included all controlled clinical trials on using Hard copies of all articles included in the study were read in full independently by two authors . Data from the articles were validated and extracted according to pre-defined criteria Table .Guasha therapists, we assessed the blinding of patient and assessor separately. A point was given for assessor blinding if pain was assessed by another person (who was unaware of the group assignment). Disagreements were resolved between the two authors  through discussion and, if necessary, consulting another author (MSL).The Cochrane classification with four criteria  was used to assess the risk of bias . As it iChi-square test was used to compare the response rates. The relative risk (RR), mean difference and 95% confidence intervals (95%CIs) from each study were estimated with Review Manager (RevMan) Version 5.0 for Windows .n = 44) or they were part of a complex treatment or concomitant use of other therapies (n = 89). Five randomized controlled trials (RCTs) [The literature search found 224 articles, of which 217 were excluded after the full texts were retrieved  -9 and tws (RCTs) ,11 fulfis (RCTs) , neck sts (RCTs) , cervicapies n = 9. Five rs (RCTs) , scapuloAll of the included studies (five RCTs and two CCTs) had risks of performance bias, attrition bias and detection bias. None of these studies reported randomization methods or allocation concealment or the blinding of the outcome assessors. Dropouts and withdrawals were not mentioned in these studies.Guasha with acupuncture reported significantly favorable effects of Guasha on pain and the number of pain points in fibromyalgia patients [Guasha with massage and electric current therapy did not show beneficial effects of Guasha in patients with neck stiffness [Guasha with herbal injection in patients with cervical spondylosis [Guasha [Guasha with acupuncture in patients with scapulohumeral periarthritis reported that Guasha was superior in recovery rate [One RCT comparing patients . Anothertiffness . Two othndylosis  or no tr [Guasha . The lasery rate .Guasha in patients with cervical spondylosis with acupuncture found favorable effects of Guasha on the recovery rate in patients [Guasha in patients with lumbar disc herniation with acupuncture plus moxibustion did not find favorable effects of Guasha [One CCT comparing effects of patients . Anotherf Guasha .In all seven studies, no adverse events were reported.Guasha, few rigorous trials have tested the effects of Guasha on MS pain and evidence from the included studiesis limited. In terms of sequence generation, blinding, incomplete outcome measures and allocation concealment, all of the included studies had a high risk of biases. None of the studies reported allocation concealment.Low-quality trials are more likely to overestimate effect sizes . In the Guasha was compared with massage or electric current therapy [Guasha compared to acupuncture were found in two trials [Guasha with another unproved treatment are not informative. One RCT failed to show that Guasha is better than massage or electric current therapy. The other RCT failed to show favorable effects of Guasha when compared to no treatment in patients with cervical spondylosis [Guasha are non-specific. Controlled trials indicated that Guasha reduced MS pain in cervical spondylosis patients but not in patients with lumbar disc herniation [Guasha [ therapy , herbal  therapy , no trea therapy  or acupu therapy ,9-11. Who trials ,9, such ndylosis . This marniation ,11. All  [Guasha ,10,11, oOur review has a number of important limitations. Although strong efforts were made to retrieve all controlled clinical trials on the subject, we are not absolutely certain that we succeeded in doing so. Biases in publishing and reporting are possible ,14. It iGuasha on pain management should adhere to accepted standards of trial methodology and consider combined use of Guasha and other therapies. Sufficient sample sizes, validated outcome measures and an adequate placebo procedure for Guasha are necessary in further research.Future RCTs of Guasha is effective in pain management. Further RCTs are warranted and methodological quality should be improved.Current evidence is insufficient to show that The authors declare that they have no competing interests.MSL and JIK conceived the study design. MSL, TYC and JIK searched and selected the trials, extracted, analyzed and interpreted the data. MSL and TYC drafted the manuscript. SMC helped with the study design and critically reviewed the manuscript. All authors read and approved the final version of the manuscript.


The West-Haven Multidimensional Pain Inventory (MPI) can be used to describe behavioural and psychosocial consequences of long-term pain but little is known about how MPI items and MPI subgroups relate to goals that patients find important in rehabilitation. Life satisfaction measured by the LiSat-11 checklist can be defined as an individual's perception of the difference between his reality and his needs or wants. This difference can be considered a "goal achievement gap". This study investigates the relation of MPI to LiSat-11 with the aim to explore the possibility that LiSat-11 can be used to measure pain rehabilitation outcomes that are important from the patients' view.Participators were patients (n = 294) referred to the Pain and Rehabilitation Clinic in Uppsala, Sweden. Measures used were LiSat-11, MPI and its Swedish version MPI-S. LiSat-11 domains were correlated to MPI scales. Cluster analysis was used to demonstrate MPI-S subgroups. Analysis of variance followed by post-hoc analysis was used to investigate life satisfaction in the three MPI-S subgroups.The strongest positive correlation were found for the LiSat-11 domains/MPI scales: psychological health/life control and contacts/social activities, and the strongest negative correlation for: psychological health/affective distress, partner relationship/punishing responses, somatic health/interference and leisure/interference. None or only little correlation was found between MPI scale pain severity and most LiSat-11 domains and satisfaction with life as a whole. Among the MPI-S subgroups, adaptive copers generally had better life satisfaction than the dysfunctional and the interpersonally distressed.Pain severity alone is a rather poor predictor of low life satisfaction. MPI and LiSat-11 partly supplement each other as tools to describe how functional impairments relate to life satisfaction domains, which may be relevant for identifying domains which the patients find important to improve. Furthermore, differences in life satisfaction between the MPI-S subgroups may help to identify functional domains that may be of particular importance in specialised rehabilitation programs. The prevalence of long term non malignant pain, defined as VAS > 5/10, has recently been reported to be 18% in the Swedish population), but thThe concept of life satisfaction (LiSat) focus on the individual's perception of the difference between the subjective reality and needs or wants regarding several important domains of functioning and activity/participation. This difference can be considered a "goal achievement gap" -6. The LIn addition to low life satisfaction and physical impairments, long-term pain is in general linked to a number of psychosocial and behavioural consequences. These can be demonstrated by using a questionnaire such as the West Haven Yale Multidimensional Pain Inventory (MPI). This instrument has been shown to have good psychometric properties. MPI is MPI is used to describe the behavioural and psychosocial functioning of the patient but so far it appears to be poorly known to what extent MPI scores are important for the individual patient in a rehabilitation program. One way of describing the importance of MPI scores would be to relate them to scores of LiSat-11 domains. Furthermore, if LiSat-11 can be correlated to MPI, then it might be possible to use LiSat-11 and MPI together as outcome measures in pain rehabilitation.The aim of the present study has been to explore the relation of behaviour/psychosocial functioning to life satisfaction. We first study the relation of individual LiSat-11 domains to individual MPI scales, and second LiSat-11 domains in patients belonging to the above mentioned MPI-S subgroups . We had the following hypotheses: impairments shown by MPI scales are associated with low values on related LiSat-11 domains, intense pain is strongly associated with low life satisfaction, AC patients have higher life satisfaction than ID and DYS patients, and finally that ID patients are comparatively less satisfied with family life and partner relationship.Participating subjects were 294 consecutive patients (collected from 2002–2005) diagnosed with long-term non-malignant pain (> 6 months) and fulfilling the inclusion criteria (see below). Demographic data for patients are shown in table Inclusion criteria were: age 18–64 years, ability to communicate in Swedish and to fill in medical questionnaires, and considered by the rehabilitation specialist to be in need of a multi-professional rehabilitation team  for their medical investigation. Patients with either depression or ongoing substance abuse so severe that they were judged to be unable to participate in the medical investigation by the rehabilitation team were excluded . We do not know how many these were. Furthermore, among the excluded patients were ten patients who did not fill in the questionnaires at all. The remaining 294 subjects filled in personal demographic data, and a life satisfaction checklist (LiSat-11) and Multidimensional Pain Inventory (MPI), see below. The frequencies of internal dropouts  were 9–25% for LiSat-11, and 8–18% for MPI. The final number of subjects that contributed full data to the analyses in the study was at least 75% for LiSat-11 and 82% for MPI.The Life Satisfaction checklist (LiSat-11),13 consiThe MPI is a self-report questionnaire on psychological, social and behavioural aspects of chronic pain, divided in 3 sections . The English original version was shown to have strong psychometric properties. The 13 Data analyses were made by using SPSS 11.5 software. As life satisfaction followed an approximate normal distribution we used parametric statistics in the calculations. Unpaired T-test was used to test the hypothesis of equal life satisfaction among those who estimated an average pain above median, and those who scored below median on pain severity (part of the MPI). The statistical significance level was set to 0.05. Correction of the significance level when having multiple tests was made by using Bonferroni's method.Internal reliability of MPI and LiSat-11 were calculated by using Cronbach's alpha. Pearson's product-moment correlations were calculated to evaluate the covariance between domain specific life-satisfaction and MPI items , including estimation of how pain severity affects different aspects of life satisfaction.Scores from the 34 items MPI-S were z-transformed to reach a standard with mean = 0 and standard deviation = 1. A non-hierarchical clustering procedure  was performed on the z-transformed scores using all patients in the sample. Since it has been shown that a solution of three clusters of MPI-S items was appropriate among pain patients,10, thisA Swedish ethical committee has previously confirmed that the national use of the questionnaires in the NRS-register is in accordance with applicable legislation, and the local ethical committee found that the design of the present study did not require further formal ethical consideration (Dnr 2004: M-381).The internal consistency of the LiSat-11 checklist was good (Cronbach's α = 0.82). The internal consistency of the MPI-Scales in this study were good in section 1  and in section 2 , but lower in section 3 . The subscales "activity away from home"  and "social activities"  did not show an acceptable internal reliability.Pearson product-moment correlations between LiSat-11 domains and MPI scales  are shown in table Patients who scored pain severity below the median value  on the MPI scale also scored higher on the following LiSat-11 domains compared to those who scored above the median value: leisure , contacts , sexual life , somatic health  and psychological health, . There was no statistically significant association, however, between pain severity and satisfaction with life as whole. After decreasing the level of significance due to multiple comparisons by using the method of Bonferroni, satisfaction in the domains somatic health and psychological health were still significantly better among the patients who scored pain severity below the median value.The cluster analysis divided 272 of the 294 patients into the 3 subgroups. The remaining 22 patients could not be placed in a cluster, mainly due to missing data. The hypothesis of equal centroids from the 8 MPI-S scales , referring to the MPI subgroups , was tested by Multivariate Analysis of Variance (MANOVA). Wilks' lambda was 0.014 (p < 0.001), showing significant differences between the scale centroids. Follow-up univariate F-tests of the 8 MPI-S scales showed that significant differences existed between the 3 subgroups on all scales (table Pair-wise comparisons between subgroups using Scheffé's method showed that the means corresponding to the AC patients (n = 40) were significantly lower on Pain Severity than both ID patients  and DYS patients . AC patients also scored significantly lower on Interference and Affective Distress than both ID and DYS patients  and higher on Life Control (both p < 0.001). This confirms the construct validity of AC patients.The DYS patients and ID patients scored similarly on Pain Severity, Interference and Affective Distress, and scored significantly higher on these scales than the AC patients . The score for the DYS patients on Life Control was significantly lower than for AC patients p < 0.001) but similarly to ID patients. However, DYS patients scored significantly higher than the other subgroups on Social Support, Solicitous Responses and on Distracting Responses . The result supports the construct validity of DYS patients.The ID patients scored similarly to DYS patients but significantly higher than AC patients on Pain Severity, Interference, and Affective Distress . They scored significantly lower on Life Control and on Social Support than AC patients (both p < 0.001). They also scored significantly lower on Solicitous and Distracting Responses than the other two subgroups (p < 0.030), and higher on Punishing Responses (both p < 0.001). This confirms the construct validity of ID patients.Significant differences in life satisfaction were found when the three MPI subgroups were compared, both for Life as a whole and for each domain of LiSat-11 . The strongest positive correlations were found for LiSat-11 domain/MPI scale: psychological health/life control and contacts/social activities, and the strongest negative correlations for: psychological health/affective distress, partner relationship/punishing responses, somatic health/interference and leisure/interference. Patients reporting pain severity below the median level reported higher life satisfaction on LiSat-11 somatic health and psychological health, but not on satisfaction with life as a whole. The internal consistency was confirmed for all three MPI-S subgroups: AC, ID, DYS. Finally, patients belonging to the MPI-S subgroup "active coopers" had higher satisfaction than "interpersonally distressed" and "dysfunctional" on most LiSat-11 domains.More than 20% among the LiSat-11 dropouts did not respond to questions about family life and partner relationship. One possibility is that respondents who were single did not know how to respond to these questions. The other dropouts were comparatively fewer.Regarding MPI, patients in this study responded inconsistently  on two of the scales, "activities away from home" (0.50) and "social activities" (0.57). For this reason, and in accordance with the conclusion of Bergström and collaborators who usedThere are several different questionnaires available to measure HRQL; generic instruments such as Short-form 36 (SF-36), Euro-QoLife satisfaction as measured by the LiSat-11 is separate from the medical observer-treatment tradition used in most quality of life instruments. It reflects the need/want perception of the patient. The "need/want" in LiSat-11 is a transformation from perceptions of dissatisfaction or suboptimal satisfaction with several important aspects of the human life situation, some of which are related to functioning. Helping the patient to become more satisfied with those domains may require not only medical, but also psychological and social interventions.Both LiSat-11 and MPI are multidimensional constructs that refer to a person's perceived quality of her/his physical, psychological, social and existential functioning and can, in a broad sense, therefore be considered to be associated with of the HRQL family of instruments. However, whereas MPI measures the impact of pain on different aspects of the patients' life, the intThe first approach was to search for individual MPI scales which were clearly linked to high or low life satisfaction. Most correlations between individual MPI scales and LiSat-11 items were weak, indicating that many of the functional impairments as measured by MPI are not necessarily linked to strong impact on life satisfaction. However, we found three correlations that were more pronounced than others. Firstly, MPI life control correlated well to LiSat-11 psychological health. This correlation is in good accordance with the basic general ideas of improving sense of control as a mean to improve the perception of health. Secondly, MPI scale punishing responses from near relatives was negatively correlated to LiSat-11 partner relationship. This finding was not unexpected either but nevertheless indicates the importance of involving relatives in the rehabilitation strategies. Third, also not unexpected, the MPI scale affective distress was negatively correlated to LiSat-11 psychological health.Interestingly, satisfaction with vocation, economy and activities of daily living was not correlated to any of the MPI scales. We do not know at this point whether they would have judged this domain differently without financial support from the National Insurance system.Special interest was focused on the relation of reported pain severity to the different LiSat-11 domains. We used the median value from the MPI scale "pain severity" to dichotomize the patients into those who reported more intense pain, and less intense pain. The result showed that lower pain severity tended to be associated only with higher satisfaction with somatic health and psychological health. The patients in the present study were probably more affected by pain than patients with long term pain in general, as they had been referred to a multidisciplinary team rehabilitation. For this reason, the results in this study may not represent patients with long-term pain in general.Like life satisfaction, it has repetitively been shown that HRQL is comparatively low among patients with long-term pain, and also that other factors than pain severity, such as catastrophizing,25 may pThe second approach was to study life satisfaction in the three MPI-S subgroups: AC, DYS, and ID patients. These subgroups relate to different categories of patient behaviour and therefore may be more meaningful for comparison with life satisfaction in a clinical setting than individual MPI scales.MPI and/or MPI-S has previously proved to be useful to describe impact of pain in patients with non-specified pain, temporoHere we used only the first two of the three MPI sections, as the third (activity) showed low internal validity. Multivariate analysis followed by univariate tests showed that differences existed between three similar subgroups in our material, and pair-wise comparisons confirmed the validity among the patients in the present study. Corresponding MPI subgroups have also been described by Graded Chronic Pain scale GCP, at least for patients with tempero-mandibular joint pain.In the present study AC patients reported higher life satisfaction than the DYS and ID patients in all LiSat-11 domains, except family life and partner relationship for which such difference between AC and DYS could not be established. This finding seems to be in correspondance with the findings of Bergström et al[It has previously been suggested that DYS patients benefit most from a combination of physical therapy and cognitive behaviour therapy whereas The results of this study may indicate less direct needs of intervention for AC patients. However, it is also possible that they are in need of interventions to help them to remain in that subgroup "have more to lose". Previous studies have shown that MPI subgroups may change with time. AC patients becomes fewer and the ID patients increase, perhapsThe predictive value of MPI subgroups vary in reports of outcome after treatment and rehabilitation for long-term pain. MPI subgroups did not predict differential outcome after a fibromyalgia program, a medicThe strongest positive correlation were found for the LiSat-11 domains/MPI scales: psychological health/life control and contacts/social activities, and the strongest negative correlation for: psychological health/affective distress, partner relationship/punishing responses, somatic health/interference and leisure/interference. The latter may indicate domains that need to particular attention in rehabilitation programs. Furthermore, none or only little correlation was found between MPI scale pain severity and most LiSat-11 domains and satisfaction with life as a whole. This finding raises the question of the value of partial pain relief alone for these patients. Patients belonging to the MPI-S subgroup "adaptive copers" had higher satisfaction than "interpersonally distressed" and "dysfunctional" on most LiSat-11 domains. This may indicate that individual rehabilitation programs designed to meet the need each of these MPI-S subgroups are required.The authors declare that they have no competing interests.AJS contributed to the final designing of the project, collected patient data and drafted the manuscript. HK contributed to the design of the project, performed statistical analysis, and contributed to the manuscript. KP was involved in the initiation of the project and contributed to the manuscript. CM contributed to the final designing of the project and to the drafting of the manuscript. All authors commented on the drafts of the manuscript and read and approved of the final version.


The Doloplus-2 is used for behavioural pain assessment in cognitively impaired patients. Little data exists on the psychometric properties of the Doloplus-2. Our objectives were to test the criterion validity and inter-rater reliability of the Doloplus-2, and to explore a design for validations of behavioural pain assessment tools.Fifty-one nursing home patients and 22 patients admitted to a geriatric hospital ward were included. All were cognitively impaired and unable to self-report pain. Each patient was examined by an expert in pain evaluation and treatment, who rated the pain on a numerical rating scale. The ratings were based on information from the medical record, reports from nurses and patients (if possible) about pain during the past 24 hours, and a clinical examination. These ratings were used as pain criterion. The Doloplus-2 was administered by the attending nurse. Regression analyses were used to estimate the ability of the Doloplus-2 to explain the expert's ratings. The inter-rater reliability of the Doloplus-2 was evaluated in 16 patients by comparing the ratings of two nurses administrating the Doloplus-2.2 = 0.02). There was an association (R2 = 0.54) between the expert's ratings and the Doloplus-2 scores in a subgroup of 16 patients assessed by a geriatric expert nurse (the most experienced Doloplus-2 administrator). The inter-rater reliability between the Doloplus-2 administrators assessed by the intra-class coefficient was 0.77. The pain expert's ratings were compared with ratings of two independent geriatricians in a sub sample of 15, and were found satisfactory (intra-class correlation 0.74).There was no association between the Doloplus-2 and the expert's pain ratings (RIt was challenging to conduct such a study in patients with cognitive impairment and the study has several limitations. The results do not support the validity of the Doloplus-2 in its present version and they indicate that it demands specific administration skills. Pain is common in elderly institutionalized patients, and prevalence rates ranging from 45% to 84% have been reported ,2. CogniProper pain assessment is a prerequisite for optimal pain treatment , but paiCognitive impairment can make self-report tools for pain assessment invalid and consequently limits their usefulness. Observational assessment of behaviour is an alternative. While self-report tools primarily assess communicative pain behaviours that are under the subject's control, observational tools assess behaviours that are more unconscious or automatic . BehavioThe Doloplus, launched by Bernard Wary in 1992/93, was originally a 15-item clinical tool for proxy rating of pain in elderly patients with cognitive failure ,23. It w2 = 62%). The results demonstrated satisfactory criterion validity in some domains. The Doloplus-2 item for facial expressions was the most informative, while the item for social life contributed least. All the three items forming the psychosocial domain  were reported as problematic to conceptualize and contributed marginally to explain the expert pain score [Despite a shortage of validation studies published in international journals and despite a call for thorough validation , includiin score . These rin score . This stin score .Based on the previous results and our experiences with the use of a pain expert as a criterion for pain, a new study was launched in order to further study the psychometric performance of the Doloplus-2. The objectives of the present study were to:1. Assess the criterion validity of the Doloplus-2 in patients who are unable to self-report pain due to cognitive failure.2. Test the inter-rater reliability of a pain expert's ratings (used as criterion).3. Evaluate the inter-rater reliability of the Doloplus-2 by comparing the results from different and independent administrators.The subjects were a convenience sample of 73 consecutively recruited patients from two nursing homes (N = 51) and from the Section of Geriatrics at St. Olav's University Hospital (N = 22) in Trondheim, Norway. As previous publications had demonstrated pain to be prevalent in regular nursing homes and in geriatric hospital units , these wCognitive function was assessed by the Mini Mental State Examination (MMSE) ,29 adminThe Doloplus-2 ,24 is coThe Doloplus-2 was administered by trained enrolled nurses, or registered nurses who were familiar with the patient. The attending daytime nurse completed the Doloplus-2 registration after consulting with the other personnel who had been involved with the patient during the past 24 hour period. Pain in the Doloplus-2 was registered according to the instructions for Doloplus-2 and recorded once for each patient, usually between noon and 3 p.m. .In line with psychiatric methods for observational assessment and diagnoses in cases where an objective measure is inaccessible a clinical expert statement was used as the criterion for pain -35. A paAs a validation of the evaluations performed by the pain expert, two geriatricians with expertise in pain presentation in demented patients observed the pain expert while he evaluated 15 consecutive patients. Without discussing the patients with the pain expert, the two geriatricians independently rated the patients' pain using NRS-11. Their ratings were later examined for degree of association with the expert's ratings.Inter-rater reliability of the Doloplus-2 was assessed in 16 patients consecutively included at the Section of Geriatrics at St Olav's University Hospital. A geriatric specialist nurse (GN) and an enrolled nurse evaluated each patient at the same day and blinded from each other. The GN assessed all patients, while a team of six different enrolled nurses made the second assessment.See Figure Univariate regression analyses were performed in order to analyse how well the Doloplus-2 predicted the expert pain score (R-squared), and to analyse the contributions of each of the ten items. Since the Doloplus-2 score maximizes pain by adding the scores of all items, we chose to compare with the highest of the pain expert's scores. The pain-in-movement score was higher than the pain-at-rest score in all patients and consequently used as the pain criterion.Association between the expert's pain ratings and the two geriatricians' ratings and the inter-rater reliability of the Doloplus-2 were evaluated with intra-class correlation coefficients. All analyses were performed by the SPSS statistical software version 13.0 .The Regional Committee for Medical Research Ethics approved the study. As recommended by the committee, written informed consent was not obtained from the patients due to their cognitive impairment. Instead, the patient's nearest relative was informed, both in writing and orally, and asked to give consent. Eligible patients were informed orally and asked if they would participate before the administration of the MMSE and the pain expert evaluation. Patients were not to be included if they or their relative declined participation, but no one did.The constructors of the Doloplus-2 have approved our use of the tool.Seventy-three patients were approached and all were included. The mean age of the sample was 84 years Table , and 74%The expert rated seven patients ≥ 4 for pain-in-movement (moderate-to-severe pain), 40 were rated 1–3, and 26 were rated as without pain. In all patients, the pain-in-movement score was equal to or higher than the pain-at-rest score. The association between the pain expert's ratings and the two geriatricians' ratings (N = 15) was estimated with an intra-class correlation of 0.74 with a 95% confidence interval from 0.5 to 0.89.The mean Doloplus-2 score was 7.47 (SD = 5.08) with a range from 0–22. Five patients received a Doloplus-2 score of zero. Among these, three were also rated with no pain by the expert, while the other two received a score of zero at rest and two in movement.2 of 0.023, implying poor criterion validity of the Doloplus-2 in this data set  who administered the Doloplus-2 in 16 patients in the Section of Geriatrics, with an Rprotective body postures at rest and the expert's pain-in-movement score  and for the Doloplus-2 item pain complaints and the expert's pain-at-rest score .Univariate regression analyses of the different Doloplus-2 items (full sample) showed small but significant relationships between the Doloplus-2 item for The intra-class correlation for inter-rater reliability of the Doloplus-2 administrators was 0.77, with a 95% confidence interval of 0.47 – 0.92.et al. (2004) called for extensive testing of the Doloplus-2 to provide sufficient details on which to base sound judgment of the tool, and a recent review questioned both the specificity of the Doloplus-2 and the nurses' competence for scoring and interpreting the results [Herr  results . The pre results , in whicWe acknowledge several limitations in the present study. The samples sizes were small as indicated by the confidence intervals for the inter-rater analyses and the majority of the subjects were female (74%). Use of analgesics was not recorded. Analgesic efficacy might fluctuate throughout the day and information on the use of analgesics could have provided valuable baseline information. However, since all patients were evaluated on the basis of the full 24-hour period any potential bias from analgesics should be equivalent in both the expert and in the Doloplus-2 assessments.The use of a pain expert's rating as a pain criterion is disputable as it may be questioned whether this represents a valid criterion. In line with psychiatric methodology for cases where no obvious gold standard exists, we used an expert-evaluation of the patients as the pain criterion. We tested the expert's performance in a sub-sample (N = 15) and found satisfactory inter-rater reliability between the expert and the two geriatricians. The low end of the confidence interval for the inter-rater reliability indicates that despite the small sample size of 15 evaluations the agreement is satisfactory.It is probably an advantage for an expert-rater to know the patients. In the pilot study, the physicians responsible for the patients' treatment acted as the expert . It is pFive patients were rated with a Doloplus-2 score of zero, as opposed to 26 in the expert's ratings. In order to discuss the discrepancy between Doloplus-2 and expert score, the pain expert, the GN and the Doloplus-2 administrators at one nursing home were consulted. It was impossible to know whether the pain expert identified false negative pain cases or whether the Doloplus-2 identified false positives. A general conclusion was that Doloplus-2 assessment in many of these patients was perceived as difficult. In patients who had high Doloplus-2 scores and low expert scores, clinical examinations revealed that the patients' discomfort seemed frequently related to grief, depression, anxiety and/or agitation rather than to somatic pain. This might suggest that the Doloplus-2 identifies patients with pain who may not have somatic pain , on the other side we can not out rule that this is a result from the pain expert underrating pain. The Doloplus-2 administrators were instructed to give positive scores on items only if changes in behaviour were suspected to be pain-related. In practice however, they were not able to evaluate this. As a result, they may have given positive scores on behavioural changes probably related to other causes than pain. This illustrates some well-known difficulties in pain assessment among patients with Behavioural and Psychological Symptoms of Dementia (BPSD) who are not able to describe their problems thoroughly and who may also have atypical symptom presentation ,36. The Analyses indicated that competence in geriatrics improved the validity of the Doloplus-2 assessment. The Doloplus-2 scores had higher correlations with the expert's pain ratings in a small sub-group in which the Doloplus-2 was administered by a specialist GN. This finding was in concordance with the pilot study, where the Doloplus-2 administrators had higher skills than the administrators in the present study, as all assessments were made jointly by an enrolled nurse/registered nurse in cooperation with a fully trained final-year medical student . Thus, iSome of the patients could provide limited information about pain at the moment and this was demonstrated during the expert's clinical examination and during the morning sessions, while the nurses wash and dress the patients, which caused some patients to express pain complaints, which then again lead to positive expert pain score and positive score on the Doloplus-2 item about pain complaints. The subjects' self-report was consequently taken into account when it was available. Future studies could try a simple verbal rating scale for self-report of pain intensity in some patients and use this in a combination with other criterions.Reports have shown that pain is frequent, under-recognised and under-treated in nursing homes. Therefore we approached patients at regular nursing home units and at a geriatric department in order to include patients with higher levels of pain than in the pilot study . As expeTo validate a tool is a long process and solid conclusions regarding the validity of the Doloplus-2 cannot be reached on the basis of our two studies. Through our studies we have established some experience in the design of studies for such validations. Future studies should include some patients with known painful diagnoses like patients with post operative hip-fractures. It will also be most valuable to have more than one pain criterion to test for agreement, in those where self-report is invalid. Pain experts could be used to establish a criterion. The use of more than one expert, blinded or unblinded, in each patient will strengthen the study. Test treatment with analgesics in patients with suspected pain and use of other behavioural tools and a verbal rating scale for present pain intensity may be valuable amendments.The lack of agreement between expert and Doloplus-2 might reflect a common challenge for pain measurement in cognitively impaired by the use of behavioural assessment tools. Other tools recommended for use in these patients Abbey Scale , PADE 1, PAINAD Based on the results from our two studies combined, we recommend the use of more than one pain criterion. Pain experts can be used as one of these, especially in patients that have no or limited ability to self-report. A combination of pain experts, other behavioral pain assessment tools, a verbal rating scale for self-report of present pain intensity and test-treatment with analgesics could constitute a promising pain criterion in future studies. The present study does not support the criterion validity of the Doloplus-2 as a clinical pain assessment tool in its present version. The results indicate that there seems to be a need for systematic training of the administrators before the instrument can be of clinical use.The author(s) declare that they have no competing interests.JCH, IS, PMF and SK contributed to the design of this study. JCH and IS organized and performed the data-collection. JCH, PMF and JHL performed the statistical analysis. All authors participated in interpretation of the data, drafting the manuscript and all read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Saudi Journal of Anaesthesia, Elmetwaly and coauthors have added two additional effective adjuvant drugs to our armamentarium for intravenous regional anesthesia.[Intravenous regional anesthesia is simple, low risk anesthetic for surgery of distal extremity. Drawbacks to its use include tourniquet pain, slow onset of action and rapid resolution of postoperative analgesia. Non-steroidal anti-inflammatory drugs and clonidine have previously been shown to improve postoperative analgesia and clonidine improves tourniquet pain. In this esthesia.In a randomized, double blind study of 75 patients having hand surgery, 25 received lidocaine supplemented with ketamine 0.1 mg/kg, another 25 received lidocaine supplemented with 200 g nitroglycerine and the other 25 received lidocaine alone. Both the adjuvant treatments were associated with more rapid onset of sensory and motor block after initiation of anesthesia and slower resolution. Less tourniquet pain was reported by patients who received adjuvant treatment with a larger effect size in the ketamine group. Both the treatments reduced postoperative pain.Metabolism of nitroglycerine to NO within the vasculature causes vasodilation within the blocked area which would be expected to speed the onset of the block. Intrathecal NO donors are thought to reduce central sensitization and treatment with systemic nitroglycerine has been shown to prolong the effect of intrathecal sufentanil and may act synergistically with intrathecal neostigmine. However, since nitroglycerine is evanescent in the vasculature, the mechanism by which it would reduce postoperative pain after 45 minutes of metabolism within the vasculature during surgery is less clear. There is no known peripheral affect.The effect of ketamine on postoperative pain is easier to understand. Ketamine is a well-known analgesic drug that acts at least in part as an N-methyl-D-aspartate acid (NMDA) antagonist. Ketamine may enhance intra-operative conditions including tourniquet pain by blocking NMDA receptors expressed on peripheral c-fibers in the forearm. It is metabolized in the liver by N-demethylation to nor-ketamine; so, it would be expected to be released from the arm unchanged after deflation of the tourniquet. A significant postoperative pain effect from ketamine 0.1 mg/kg is not surprising.Regardless of the mechanism of action, practitioners of intravenous regional anesthesia now have four reasonable adjuvant agents from which to choose. Individual patient characteristics should guide the choice of adjuvant drug. Patients with poor peripheral vasculature may particularly benefit from the vasodilatory action of nitroglycerine added to the local anesthetic for peripheral regional anesthesia. Patients with severe ongoing pain or opioid tolerance would be expected to have additional benefit from adjuvant clonidine or ketamine as these drugs are known to be efficacious in these conditions. Non-steroidal analgesics are efficacious as adjuvant analgesics in many postoperative settings but care should be taken when bone healing and renal perfusion are an issue.et al. have described two potentially useful adjuvant drugs for intravenous regional anesthesia. A clear delineation of which drug is best for which class of patient will have to wait for future clinical trials but the availability of additional options is undoubtedly better.In summary, Elmetwaly