Is early physical therapy associated with long-term opioid use by patients with musculoskeletal pain?In this cross-sectional analysis of 88 985 patients with shoulder, neck, knee, or low back pain, early physical therapy was associated with an approximately 10% statistically significant reduction in subsequent opioid use.By serving as an alternative or adjunct to short-term opioid use for patients with musculoskeletal pain, early physical therapy may play a role in reducing the risk of long-term opioid use. Nonpharmacologic methods of reducing the risk of new chronic opioid use among patients with musculoskeletal pain are important given the burden of the opioid epidemic in the United States.To determine the association between early physical therapy and subsequent opioid use in patients with new musculoskeletal pain diagnosis.International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes, Current Procedural Terminology codes, and date of service as well as pharmaceutical information . Early physical therapy was defined as at least 1 session received within 90 days of the index date, the earliest date a relevant diagnosis was provided. Data analysis was conducted from March 1, 2018, to May 18, 2018.This cross-sectional analysis of health care insurance claims data between January 1, 2007, and December 31, 2015, included privately insured patients who presented with musculoskeletal pain to an outpatient physician office or an emergency department at various US facilities from January 1, 2008, to December 31, 2014. The sample comprised 88 985 opioid-naive patients aged 18 to 64 years with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. The data set  included person-level Opioid use between 91 and 365 days after the index date.P = .003), neck pain , knee pain , and low back pain . For patients who did use opioids, early physical therapy was associated with an approximately 10% statistically significant reduction in the amount of opioid use, measured in oral morphine milligram equivalents, for shoulder pain , knee pain , and low back pain , but not for neck pain .Of the 88 985 patients included, 51 351 (57.7%) were male and 37 634 (42.3%) were female with a mean (SD) age of 46 (11.0) years. Among these patients, 26 096 (29.3%) received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder pain (odds ratio [OR], 0.85; 95% CI, 0.77-0.95; Early physical therapy appears to be associated with subsequent reductions in longer-term opioid use and lower-intensity opioid use for all of the musculoskeletal pain regions examined. This cross-sectional study examines the association between early physical therapy and subsequent opioid use among opioid-naive adults with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. In particular, by serving as an alternative or adjunct to short-term opioid use for episodes of acute musculoskeletal pain, early use of physical therapy may reduce total opioid exposure. In addition, by concurrently addressing physical impairments, physical therapy may present functional gains that decrease long-term opioid use. In the case of low back pain (LBP), previous work has found an equivocal association between the use of early physical therapy and patient-reported outcomes, health care costs, and opioid use.4 In particular, an important issue given recent guideline recommendations4 is whether early physical therapy is associated with reduced long-term opioid use for patients with musculoskeletal conditions.12 Using a large database of health care claims for privately insured patients, we examined whether early physical therapy was associated with reductions in long-term opioid use. Our analysis focused on patients with low back, neck, knee, or shoulder pain that was severe enough to require 2 visits to a physician within 30 days and at least 1 opioid prescription during the 90 days after the initial diagnosis.Given the recent convergence in national priorities, a broader investigation of nonpharmacologic pain management for LBP and other prevalent types of musculoskeletal pain, such as neck and knee pain, is warranted.International Classification of Diseases, Ninth Revision or Tenth Revision, (ICD-9 or ICD-10) diagnosis codes, Current Procedural Terminology (CPT) codes, and date of service. For pharmacy claims, the database provides details such as National Drug Code, generic name, dose, and the number of days supplied. These data are frequently used in analyses of health care use and spending.16 This study received approval from the Institutional Review Board at Stanford University, which also issued a waiver of consent. Patient consent was waived because the data used were deidentified. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies. Data analysis was conducted from March 1, 2018, to May 18, 2018.The study data consisted of insurance claims between January 1, 2007, and December 31, 2015, obtained from the IBM MarketScan Commercial database. The MarketScan database provides person-level data on health care use and expenditures for people enrolled in private insurance plans through a participating employer, health plan, or government organization. For inpatient and outpatient encounters, the database provides information such as CPT code for an outpatient visit and/or a CPT code for an emergency department visit  who presented to a physician office (outpatient visit) or an emergency department at various US facilities with musculoskeletal neck, knee, shoulder, or low back pain between January 1, 2008, and December 31, 2014. We identified these visits by identifying claims with (1) a For each patient, we defined the index date as the earliest date a relevant diagnosis was received and the study period as the time from the year before the index date to the year after the index date. We restricted our analysis to patients (1) who were continuously enrolled in a preferred provider organization or traditional indemnity plan with prescription drug coverage for the entire study period and (2) who were opioid naive, defined as having filled no prescription for an opioid in the 12 months prior to the index date. In addition, because musculoskeletal pain is a common diagnosis that can represent varying levels of severity, we restricted our analysis a priori to patients whose pain was severe enough to result in (1) a second outpatient visit or emergency department visit with a primary diagnosis of musculoskeletal pain within 30 days after the index date and (2) an opioid prescription within 90 days after the index date.ICD-9 diagnosis code for musculoskeletal pain or an inpatient admission with any ICD-9 diagnosis code corresponding to an accident or a trauma during the study period , to exclude potential trauma patients (n = 13 259); a cancer diagnosis during the study period (n = 5990); and musculoskeletal pain in more than 1 region during the study period . We imposed this latter restriction because individuals with pain in multiple sites may represent a distinct patient population and a different set of disease processes compared with individuals with single-site pain. We excluded individuals with LBP who had another diagnosis that could be mistaken for musculoskeletal pain (n = 19 799) ; an inpatient admission with a primary CPT code  and an accompanying ICD-9 diagnosis code that corresponded to the patient’s pain site.The exposure of interest was whether the patient received early physical therapy, defined as at least 1 physical therapy session within 90 days of the index date. Early physical therapy was measured by identifying claims with a relevant 17The primary outcome consisted of opioid use, measured as an opioid prescription or measured in oral MMEs between 91 and 365 days after the index date. We isolated prescriptions for an opioid  during the aforementioned study period, using pharmacy claims data. We converted each prescription to MMEs according to the reported drug dose and quantity supplied.18 to measure the presence of the medical comorbidities  that compose the Elixhauser index, an index that is frequently used for risk adjustment.19 Third, we measured opioid use (MMEs) during the first 90 days after the index date.We included additional variables to adjust for potential confounding. First, we adjusted for age and sex, which are directly provided in the claims data. Second, using claims submitted during the year prior to the index date (1-365 days before the index date), we used previously described methodst test for continuous variables  and a χ2 test for discrete variables . We used a 2-sided P ≤ .05 to assess the statistical significance of differences between the 2 groups. Because of the large sample, even trivially small differences may be statistically significant; thus, we used Hedge g to estimate the magnitude of the standardized difference between the 2 groups. Hedge g is the difference between the means of 2 groups divided by the population SD,20 with values of less than 0.2 typically representing small differences between the 2 groups, between 0.2 and 0.5 representing moderate differences, and greater than 0.5 representing large differences.21Descriptive statistics in the form of means and 95% CIs were used to describe the distribution of demographics and comorbidities across each group. To assess the differences in characteristics between patients who received early physical therapy and those who did not, we used an unpaired, 2-tailed 22 To address this issue, we performed a 2-step analysis. The first analysis consisted of a multivariable logistic regression in which the dependent variable was whether the patient used any opioid at all and the independent variable of interest was whether the patient received early physical therapy. Therefore, the first analysis estimated the association between early physical therapy and the subsequent use of any opioid at all.Next, we estimated the association between early physical therapy and the primary outcome (opioid use between 91 and 365 days after the index date) by using multivariable regression models. Most patients (76%) in the sample did not use any opioid at all during this period. When there are many observations for which the dependent variable  is 0, a simple regression analysis tends to be downward biased .25The second analysis consisted of a multivariable linear regression in which the dependent variable was the actual MMEs used between 91 and 365 days and the independent variable of interest was whether the patient received early physical therapy. This second analysis was restricted to patients who used opioids between 91 and 365 days after the index date . The analysis estimated the association between early physical therapy and the intensity of opioid use among patients who used opioids. This 2-step approach has been used in other studies to obtain nonbiased estimates when a large proportion of observations assumed a value of 0.For both the logistic and linear regressions, we included adjustments for potential confounders, including age, sex, year of diagnosis, patient comorbidities shown in , and opi26We examined the robustness of the study results as applied to alternative specifications. First, to characterize the specific period when physical therapy may be advantageous, we performed a sensitivity analysis in which we divided patients who received early physical therapy into 2 groups: those who received physical therapy in the first 30 days after the index date, and those who received physical therapy between 31 and 90 days after the index date. We then estimated the association between these 2 groups and opioid use between 91 and 365 days after the index date, using the previously described statistical approach. Second, we performed an analysis in which we raised the threshold for early physical therapy to require 2 or more physical therapy visits within the first 90 days after the index date. Third, we conducted a sensitivity analysis in which we considered an alternative outcome: chronic opioid use, defined as having filled 10 or more prescriptions or filled the 120 or more days’ supply between 91 and 365 days after the index date.The final sample of 88 985 patients consisted of 51 351 (57.7%) men and 37 634 (42.3%) women with a mean (SD) age of 46 (11.0) years. Of this sample, 26 096 patients (29.3%) received early physical therapy, and the use of early physical therapy increased from 3318 of 12 262 patients (27.1%) in 2008 to 2706 of 8705 patients (31.1%) in 2014. The numbers of patients for each pain site are shown in P < .001; P < .001). For 15 of the 28 comorbidities that we examined, no statistically significant differences were found across the groups. For the remaining 13 comorbidities, 1 comorbidity (depression) was more prevalent among patients receiving early physical therapy, whereas the other 12 comorbidities  were more prevalent among the group of patients who did not receive early physical therapy. However, the magnitude of all of these differences was small, with a Hedge g of 0.05 or less for all characteristics.Patients who received early physical therapy, compared with patients who did not receive early physical therapy, were slightly younger  for shoulder pain, 0.94  for neck pain, 0.87  for knee pain, and 0.99  for LBP (P = .003), neck pain , knee pain , and LBP .The unadjusted odds ratio (OR) of receiving 1 or more opioid prescription between 91 and 365 days after the index date for patients with early physical therapy was 0.91 , neck pain , knee pain , and LBP  (P = .03), knee pain , and LBP . No statistically significant difference was found in the case of neck pain .Among patients who did use opioids between 91 and 365 days after the index date, our unadjusted analyses showed no difference in the case of shoulder pain  . After aThe sensitivity analysis characterizing the timing associated with the benefits of early physical therapy is presented in 26 Early physical therapy was associated with sharp reductions in chronic opioid use among patients with knee pain  and LBP , but no statistically significant association was found for shoulder pain  or neck pain .We also performed a sensitivity analysis in which we considered an alternative definition of early physical therapy requiring 2 or more physical therapy visits within 90 days of the initial diagnosis date; the results were qualitatively similar to the baseline results  was smaller in this cohort. In a previous study of patients with neck pain in a single health system, early physical therapy management was associated with larger improvements in functional outcomes and pain intensity ratings.27 In addition, another previous study at a single institution found a decrease in the odds of opioid use 12 months later among patients with neck pain whose first clinician was a nonpharmacologic health care practitioner .28 Similar protective effects for narcotic uses were reported in Medicare beneficiaries receiving early rehabilitation for atraumatic knee pain in ambulatory settings.29 We found no previous studies in shoulder pain for comparison.These results are largely in line with previous work for patients with LBP. In an analysis of the Military Health System Data Repository, early physical therapy was associated with reductions in opioid use,This analysis expands on these previous studies by examining simultaneously a much broader set of patients  and the association between early physical therapy and opioid use across the 4 most common types of musculoskeletal pain conditions . In this manner, this study may help inform the potential implications of the widespread application of the American College of Physicians and the Centers for Disease Control and Prevention guidelines for management of musculoskeletal pain. The magnitude of these findings suggest that early physical therapy may provide mild to moderate protection against the risk and intensity of long-term opioid use for patients with severe musculoskeletal pain. The sensitivity analyses provide an indication of clinical relevance or application by highlighting how receiving physical therapy within 30 days enhances protection against opioid use, and the largest protective effects were associated with limiting the number of prescriptions or supply days for knee pain or LBP. In addition, these findings suggest that early physical therapy may result in mild to moderate reductions in the intensity of opioid use by patients with shoulder and knee pain and possibly for LBP.31 Overall, our findings suggest that American College of Physicians and Centers for Disease Control and Prevention guidelines can be more confidently applied for patients with shoulder, knee, and low back pain if reducing the risk of long-term opioid use is a treatment goal.In contrast, early physical therapy may not reduce the intensity of opioid use for patients with neck pain. The lack of convergence between our findings and those of previous studies of neck pain could be explained by the differences in the patient populations, the resistance of many neck conditions such as whiplash to physical therapy, the underlying rate of opioid use, the timing and rate of patients receiving early physical therapy, or our decision to limit the analysis to patients with indicators of higher severity.11 The definition used for this study is later than the others reported in the literature. Third, we were not able to capture specific details about the physical therapy, such as the type of approach used. Fourth, we were not able to assess the association between physical therapy and measures of function or disability, as these data are typically not provided in administrative claims databases. Fifth, this study was limited to patients who had employer-sponsored private health insurance and who were continuously enrolled for the 2-year period before and after the date of their musculoskeletal pain diagnosis.These results should be viewed in light of the study limitations. First, as with all observational studies, we cannot rule out the possibility of residual confounding from unmeasured factors. However, the differences between patients who did and did not receive early physical therapy met statistical significance for most of the comorbidities we examined, and where differences existed, were small in magnitude. Second, this study captured early physical therapy, but no standard time definition exists in the literature.Using early physical therapy, consistent with recent clinical guidelines, could play an important role in reducing the risk of transitioning to chronic long-term opioid use for patients with shoulder, neck, knee, and low back pain. The same protective association was not identified for the intensity of opioid use in patients, particularly in patients with neck pain, suggesting that additional research is needed to determine what services mitigate long-term opioid use in neck pain. Understanding why early physical therapy appears to alleviate some types of musculoskeletal pain but not others is another high-priority area for further research. Such a study can provide insights into the implications of the widespread adoption of nonpharmacologic pain management strategies.


Orofacial pain may have a variety of causes and offers a significant clinical challenge for its diagnosis and management.To assess the headache disorders presenting in a tertiary multidisciplinary orofacial pain clinic, after dental causes have been excluded.Clinic letters from the initial consultation and subsequent follow up reviews of the 142 patients, who were seen in the tertiary Multidisciplinary Orofacial Pain clinic between January 2015 until January 2018 were reviewed as a clinical audit.n = 62, 44%), migraine  and painful post-traumatic trigeminal neuropathy . The most common trigeminal autonomic cephalalgia diagnosis was hemicrania continua , which is higher than the reported prevalence in neurology and headache clinics.The most common diagnoses were possible trigeminal autonomic cephalalgia (This study demonstrates the importance of a multidisciplinary approach to diagnosing complex orofacial pain patients and the importance of awareness of primary headache disorders, in particular trigeminal autonomic cephalalgias, thereby reducing unnecessary diagnostic delays or procedures. Trigeminal autonomic cephalalgias (TACs) are characterized by unilateral intense pain involving predominantly the orbito-temporal region and associated with presence of ipsilateral cranial autonomic symptoms . At leasThe distinction between the four different TAC conditions is based on headache duration, frequency and treatment response. Namely, cluster headache (CH) attacks last 15–180 min when untreated, with a frequency of up to 8 attacks a day. Paroxysmal hemicrania (PH) attacks are shorter in duration 2–30 min) and usually more frequent reaching a maximum of 40 attacks per day. Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT), and Short-lasting Unilateral Neuralgiform headache Attacks with cranial autonomic features (SUNA) are the shortest type of TAC (1 s-10 min) [–30 min aThe incidence of TACs is low, with CH being the most common with a prevalence of approximately 0.1% of the population .The pathophysiology of these entities is thought to involve the hypothalamus in its posterior, lateral and paraventricular nucleus, the trigeminovascular complex and the parasympathetic fibres with a crucial role of the sphenopalatine ganglion via the trigeminal autonomic reflex .From neuroimaging studies, the acute phase of pain involves the ipsilateral hypothalamus in CH , the conThe pain CH patients experience can be easily and often misdiagnosed as dental pulp pain. Interestingly, Peñarrocha and colleagues explored the possible relationship between oral surgery, endodontic procedures and CH. The authors described a series of 54 patients who underwent oral surgery and endodontic procedures . Among tWith regards to patients with CH, Bahra and Goadsby documented that dentists and ear, nose and throat (ENT) surgeons were most commonly consulted prior to neurologists (45% of 511 subjects) and that 52% had an invasive procedure performed for pain . The autThe application of the ICHD-II criteria to 502 patients who presented with Temporo-Mandibular Dysfunction (TMD) and orofacial pain in a Temporo-Mandibular Joint and Orofacial Pain Clinic found, surprisingly, one single case of CH with no other TACs reported, and being tension-type headache the most frequent entity, diagnosed in 246 patients .From a neurologist’s perspective, a prospective study of all surgical referrals to one consultant neurologist in the UK over a 42-month period found 12 patients from oral and maxillofacial surgery clinics being 5 diagnosed of trigeminal neuralgia and 3 of atypical facial pain . Most reThis study aims to evaluate the headache disorder diagnoses seen at a tertiary Multidisciplinary Orofacial Pain (OFP) clinic and more specifically the diagnoses and management of TACs. The work has been presented in preliminary form at the Congress of the International Headache Society  .Clinic letters from the initial consultation and subsequent follow up reviews of the 142 patients, who were seen in the tertiary Multidisciplinary Orofacial Pain clinic between January 2015 until January 2018 were reviewed as a clinical audit. In this clinic, all patients are first reviewed by an experienced Orofacial Surgeon (TR) to exclude a dental cause for their facial pain. The Multidisciplinary Orofacial Pain clinic has approximately 300 new patients a year, approximately 12% of patients present with a dental cause for primary complaint, of which the most common is painful post-traumatic trigeminal neuropathic (48%) and TMD is second most common (23%). Patients are then seen by Headache fellows under the supervision of a Headache Specialist (PJG). For these patients, their demographics, the presence of dental work, time until diagnosis and diagnosis were recorded. Of the patients with a possible TAC diagnosis, the pain localisation, cranial autonomic symptoms and result of the indomethacin test (if applicable) were recorded. The diagnoses were made according to ICHD-III beta [Indomethacin response was determined either by intramuscular indomethacin placebo-controlled testing with 150 mg indomethacin or by course of oral indomethacin, with a titrating regime starting at 25 mg three times a day in the first week, increased to 50 mg three times a day for a week and finally 75 mg three times a day. A positive test was deemed to be at least a 50% reduction in pain intensity and/or 50% in frequency or duration of the worsenings present with the indomethacin and not with the placebo.Data were collected in Excel, where quantitative analysis was performed, and STATA (SE 15.1 for Mac) was used for chi square and Fischer’s exact testing..Of the one hundred and forty-two patients reviewed; there were 100 women (70%) and 42 men (30%). The mean age was 51 ± 3 . Among all consultations, 109 (77%) were new patients and 33 (23%) were follow ups. A TAC was suspected in 62 patients (44%) based on the history of unilateral pain in the trigeminal distribution and the presence of ipsilateral cranial autonomic symptoms, as per ICHD-III beta criteria. Of the remaining patients, the most common diagnoses were chronic and episodic migraine, painful post-traumatic trigeminal neuropathy and trigeminal neuralgia , migraine (n = 8), SUNCT (n = 1) and painful trigeminal neuropathy (n = 2). However, only 7 had a correct previous diagnosis and, interestingly, trigeminal neuralgia was the most commonly misdiagnosed (5/6 patients). As a previous comorbidity, temporo-mandibular dysfunction, was present in 10 (7%) patients. Neuroimaging (either MRI or CT) had been performed in 72 patients (51%) by the time they attended the consultation.A previous suspected diagnosis was only reported in 17 patients, including trigeminal neuralgia (n = 6) the average delay was 5 years.Time to diagnosis for the whole cohort was 5.6 years, in patients with a confirmed TAC  was 7 years. Time to diagnosis in patients with HC, the most common diagnosis among TACs, was 8.7 years. In the two CH patients the delay was 6 and 17 years, in the one case with chronic PH the delay was 12 years and in SUNCT/SUNA patients (TAC was suspected in 62 patients. This group included 40 women (65%) and 22 men (31%). The mean age was 53 ± 4 years .This group comprised of 13 confirmed HC, 1 confirmed PH, 6 SUNCT/SUNA, 2 CH, 17 negative indomethacin (chronic migraine), 21 possible HC and 2 possible PH (not confirmed) patients , being only two cases of strictly V1 pain. Pain located in V2 (18/62) as well as V2 and V3 (17/62) were the most commonly reported followed by pain in V1 and V2 (9/62), hemifacial pain involving all three branches (13/62) and pain exclusively on V3 (3/62).p − 0.001) but not with a negative indomethacin test . Pain was also described as pressure-like, stabbing, sharp, shooting, dull, burning or shooting/electrical, with no noteworthy differences among patients. Pain was rated as moderate to severe in all cases.Description of the pain varied widely among patients. However, the pain was described, at least at times, as throbbing by 25 out of 62 patients. This type of pain, was present in migraineurs and non-migraineurs, although it was significantly associated with a migrainous background (Chi square: n = 22) reported on average 2.5 cranial autonomic symptoms per patient. The most common cranial autonomic symptom, within the whole group with possible TAC, was lacrimation (n = 35), followed by nasal congestion (n = 27) and conjunctival injection (n = 23).Of the patients with a possible TAC diagnosis, the average number of cranial autonomic symptoms per patient was 3. Patients with a confirmed TAC diagnosis , different dental procedures were recorded. Overall, dental extraction was the most common 15/62; 24%), followed by root canal treatment  and dental filling . Dental implant, minor trauma in the gum, mucosal biopsy and parotid surgery were performed in single cases  was found between the variables “previous oral work” (25/62) and the variable “pain within 1 week after the procedure” (16/62), however this test does not show causation and there is a potential selection bias as all the patients have been referred from dentists and oral surgeons. Additionally, 10 patients underwent dental work afterwards to treat their pain, with only one patient getting some pain relief. A single patient underwent 3 procedures (tooth extractions) with no benefit. Only one procedure to treat the pain was performed in the remaining patients.A significant association (χTwenty-six out of 62 patients (42%) had a previous pain background, migraine being the most common. Namely, 16 patients had been previously diagnosed with episodic migraine without aura, 5 with episodic migraine with aura and 2 with chronic migraine. Two patients had fibromyalgia and one patient had temporomandibular joint dysfunction and bruxism.An indomethacin test was performed in 31 patients .After the administration of the drug, pain relief was observed in 14 (positive) patients, with no benefit in the remaining 17 subjects (negative).TACs often present to other specialities given the distribution and location of the pain. Patients often see dentists and orofacial specialists to find the root of the pain. Therefore, a multi-disciplinary team approach involving dental, oral surgery team and headache specialists is important to optimise patient outcomes. The patients presenting to our Multidisciplinary Orofacial Pain clinic are often complex and have had dental causes excluded as the reason for the pain. Within our cohort, the most common initial diagnosis was possible TAC, this was more common than migraine. Most patients with possible TAC, localised their pain to the second and/or third trigeminal nerve distribution, this should be considered with some care and can be explained by selection bias as most patients presented to a dentist for the pain initially.The delay to diagnosis for patients with a TAC  was 7 years, in particular the delay until diagnosis for CH was 6 years for an episodic CH patient and 17 years for a chronic CH patient; this is higher than the average delays reported in a systemic review  and caseTraditionally, HC has been considered a rare condition and a recent study by Hryvenko and colleagues reviewed 1617 new patients seen in their TMD and Orofacial Pain Clinic, and only found 6 (0.4%) patients with HC, with 5 patients with nearly complete response with oral indomethacin 150-225 mg/day) and one patient had to remain on 75 mg/day due to intolerable side effects, and therefore had partial pain relief . In a po5 mg/day This is a retrospective study of clinic letters to identify patients who attended the Multidisciplinary Orofacial Pain clinic, therefore we cannot assess any predictive or causative factors. The clinical documentation is, however, structured and systematic since a priori we have seen patients referred from such services before our new service was initiated. A strength of the study is the certainty of the diagnosis, as we followed the patients carefully through the years. Importantly, the patients with HC were confirmed with placebo-controlled intramuscular indomethacin testing.TACs are an important group of primary headache disorders dentists and oral surgeons should be aware of as many patients with unilateral side-locked primary headaches present to the dental services. Neurologists should be cognisant of this presentation pattern when seeing patients from these pathways. HC is underdiagnosed and this may be due to the presentation to other specialities rather than to neurology and headache services. We have found the most effective way to ensure patients are diagnosed correctly and managed optimally is a multidisciplinary service with dentists, oral surgeons and headache specialists.


Many studies on transcutaneous electrical nerve stimulation (TENS) had been undertaken to explore its pain relieving efficiency on several medicals/surgical conditions but none, specifically, had been carried out to determine the effect it has on post-injection sciatic pain (PISP) which comes about from wrong administration of intramuscular pain. This study aims to assess the effects of TENS in the management of PISP.P < 0.05.A total of 72 PISP subjects comprising 40 test subjects and 32 control subjects participated in a non-randomized controlled clinical trial in the current study. Participants were recruited from Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi and Landmark Physiotherapy Services, Nnewi. The participants were however blinded to the intervention method they will receive before being allotted conveniently to test/experimental group (TG) or control group (CG). A written informed consent was obtained from participants before enrollments in the study. TENS and sham TENS (STENS) was applied to 40 test and 32 subjects respectively, 3 times a week, and 1 hour per session for the 10 weeks the study lasted. The Visual Analogue Scale was used to collect baseline data as well as those of 2nd, 4th, 6th, 8th and 10th weeks after TENS and STENS interventions. The data analysis was performed with the Descriptive statistic of Mean ± SD, mean comparison test, repeated analysis of variance and paired wise t-test. Statistical level of significance was set at p = 0.01); with the intervention accounting for the 19% of the variance. The effect size  = 0.19.Results of repeated measure ANOVA showed that the pain level among participants in the treatment group at the end (after 10 weeks) of the intervention was significantly lower than that of their counterparts in the control group . The study was registered retrospectively on the 29th May, 2018.Pan Africa Clinical Trial Registry ( Nerve injection injury (NII) is a common complication following intramuscular injection; the sciatic nerve is the most frequently affected nerve , 2. SciaSignificantly, when giving gluteal injections, it is safe to use the upper outer quadrant. The choice of site for injection must be based on good clinical judgment, using the best evidence available and individualized client assessment. There is wide agreement on the literature that the ventrogluteal site is preferable . Review For years, clinicians have been using TENS in an attempt to manage pain. It has been widely used in the treatment of various types of pain. It has also been shown that TENS is highly effective alleviating pain and reducing analgesic use following cesarean section, orthopedic and thoracic operations as well as mixed surgical procedures . TENS isPain is a subjective sensation and therefore difficult to quantify. It is, however, important to quantify it for several reasons; one of the most compelling reasons is that assigning a measurement of pain gives patients a sense of control over their condition and has positive effects on their cop abilities. Pain measurements also provide a means of assessing the efficacy of response to treatment and prognosis. The Visual Analogue Scale (VAS) is a well-studied method of measuring both acute and chronic pain; its usefulness has been validated by several investigators –16.Individuals who have PISP are often driven to seek relief from conventional medical treatment, alternative therapies, to miracle centers. One of the long-term effects being that many of the patients with PISP that were later referred for physiotherapy are in chronic stages of the problem. This study, therefore, examines the possibility of the use of TENS to bridge this gap. There were no previous empirical studies on the effect of TENS in managing PISP. The nearest were several case reports and a small number of controlled trials which reported improvements in pain symptoms in people with peripheral neuropathy or nerve damage , 18. How. Participants were blinded to the intervention they would receive by the investigator; two plain sheet papers had inscriptions T or C and folded. As participants came they were asked to pick either of the papers. Those that pick T will go to the TG while those that pick C will go to the CG. Ethical approval was sought from Nnamdi Azikiwe University Teaching Hospital Ethics Committee (NAUTHEC), Nnewi. A written informed consent was obtained from the participants in the study. The Visual Analogue Scale (VAS) was presented and described to participating subjects who were instructed to describe their level of pain by signifying a number on the VAS scale; 10 cm is the highest level of pain and 0 cm shows no pain. The baseline VAS scores were recorded for all the participants; it will constitute the basis of comparison of subsequent VAS scores. By this procedure, the mean pre and post VAS scores were obtained for the TG and CG at 2nd, 4th, 6th, 8th, and 10th weeks. The data analysis was performed with student t-test and independent t-test. Statistical level of significance was set at P < 0.05. The current study adheres to CONSORT guidelines.The current study was a non-randomized controlled clinical trial involving seventy-two subjects − 40 test and 32 control participants. Participants were recruited from patients referred to Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi and Landmark Physiotherapy Services, Nnewi. The purposive sampling technique was applied; all the subjects were required to meet certain selection criteria before participation in the studyThe sample size determination was based on the 17% prevalence of injection palsy yearly as reported by Fatunde and Famulusi in Nigeria  and 22]22].\docuit is recommended by various authors that a precision of 5% is appropriate for prevalence rates between 10 and 90% –24.\docuthe age range of 20 to 50 yearspost injection sciatic pain of not more than 1 yearparticipants that stopped the medication for 2 weeks before interventionparticipants without foot dropparticipants without significant wasting of the musclesSpondylosisosteoarthritis of the kneemetallic implantmentally unbalanced participantsparticipants that refused to stop the medicationvery elderly peopleOnly TENS application was used on the 42 subjects that participated in the test group. Each patient was then made to lie on the available treatment plinth in a position (prone lying) that was comfortable and suitable for TENS application.The adhesive electrodes were four in number in the dual channel type of TENS. They were securely placed along the route or course of the presenting sciatic pain Figs. , 2 and 3us) with an intensity greater than that of the traditional TENS was chosen because of its “carryover effect”. With all settings on zero, the TENS machine was switched on and the output increased until the patient perceives a fairly strong buzzing or pulsating sensation. The parameters of pulse frequency, pulse width, and pulse amplitude were varied from minimum to maximum rates of the chosen TENS mode to demonstrate the range to the subjects. The rate was varied (because each patient/subject felt and experienced each of these parameters differently) until the level that was most comfortable to the subject and which did not produce motor contraction was found. When the subject ceased to feel the stimulus after a few minutes probably because of nervous accommodation the output intensity was turned up until some strong sensation was felt again.TENS which uses lower frequency stimulation (2-5 Hz) and a wider (longer) pulse width of  with a variable pulse frequency of 2-250 Hz, the variable pulse width of 50–250 microseconds and variable pulse intensity (amplitude) of 0-80 mA produced by Avionix Medical Devices, Texas, USA (Appendix 4) was used for both the test group and the control group. But that of the control was not activated to deliver electrical impulses to the control subjects.Stethoscope - Littman’s modelMercury Sphygmomanometer (Accusson model)Cotton and pin for skin sensation test.Measuring tape for muscle bulk measurement.Toilet soap, distilled water, and hand towel for skin cleansing.Visual analog scale by Price et al. . Used foA Seca model weighing scale calibrated in a kilogram.A Seca model stadiometer calibrated in centimeter and inches.P < 0.05.The SPSS software package version 23 was applied for data analysis. Descriptive statistic of Mean ± SD and mean comparison test was used to analyze baseline characteristics of subjects. Repeated analysis of variance was (ANOVA) was used to compare mean VAS scores between the TG and CG. A paired t-test was used for pair-wise comparison of pain level in each group across 10 weeks the Statistical level of significance was set at In Table In Table p = 0.01); with the intervention accounting for the 19% of the variance (Table Table ce Table .Table 3Mp < 0.05) except between pain levels at sixth and eightieth, and between those at eightieth and tenth weeks. In the control group, the baseline pain level was significantly lower than that at second, eightieth and tenth weeks (p < 0.05)  in the management of sciatic pain following intramuscular injection. In carrying out the current study the authors noted that no similar studies had been done in the past regarding the effect of TENS in the management of PISP; however, the effect of TENS in managements other medical and surgical conditions were well documented. Interestingly, these studies used TENS device as adjunctive therapy, but most of the outcomes had not equivocally established combination therapy as producing lasting pain relief on the patients, This notwithstanding, the use of TENS in combination with other therapies were suggested by most previous studies in contrast to using it in monotherapy form as applied in this current study , 27. TheThe result in Table p = 0.01); with the intervention accounting for the 19% of the variance. The effect size  was 0.19 (large) (Table p > 0.05) between the TG and the CG after 10 weeks of TENS and STENS applications.Results of repeated measure ANOVA showed that the pain level among participants in the treatment group at the end (after 10 weeks) of the intervention was significantly lower than that of their counterparts in the control group  Table . The cliIt has to be emphasized that TENS achieves its pain relief: pain gate mechanism or the endogenous opioid system. The variations in stimulation parameter used to activate these two systems will be briefly considered. Pain relief by means of the pain gate mechanism involves activation (excitation) of the beta sensory fibers, and by so doing reduce the transmission of the noxious stimulus from the ‘c’ fibers, through the spinal cord and on to the higher center. The Aβ fibers respond better when stimulated at a relatively high rate (in the order of 90–30 Hz or pps) but it is difficult to find support for the concept that there is a single frequency that works best for every patient, this range appears to cover the majority of individuals. An alternative approach is to stimulate the Aβ fibers which respond preferentially to a mode stimulation, which will activate the opioid mechanisms, and provide pain relief by causing the release of an endogenous opiate  in the spinal cord. A third possibility is to stimulate both nerve types at the same time by employing burst mode stimulation. In this instance, the higher frequency stimulation output  is interrupted (or burst) at the rate of 2 --3 bursts per second. When the machine is ‘on’, it will deliver pulses of the 100 Hz rate, thereby activating the Aβ and the pain gate mechanism, but by virtue of the rate of the burst, each burst will produce excitation in the A-delta fibers, therefore stimulating the opioid mechanisms. For some patients, this is by far the most effective approach to pain relief, though as a sensation, numerous patients find it less acceptable than other forms of TENS .As applied to current study, 60-min cumulative treatment time was applied on PISP patients per session of treatment as against the recommended 20 or 30 min by previous TENS related studies, especially where TENS was used as addictive therapy modality. Consequent upon this, in carrying out this study, the authors were aware of likely depreciating effect of TENS overtimes probably due to adaptation to particular treatment mode and took measures to vary the parameters to minimize or avert it as it can negatively impact its efficiency in pain relief. This agrees with the scientific finding that the benefit of TENS tends to fall with time –46. Alsop < 0.05) between the test and control groups for age and duration of symptom at baseline, this difference in baseline the authors noted could possibly have influenced the outcome of the study but no literature to back it up. Table p > 0.05) in the subjects’ baseline mean values of height, weight, and VAS between the test and control groups, this the authors assumed did not influence the outcome of this study.In the current study, from Table Moreover, deductions from the subjects’ recruitment flowchart Fig.  showed mThe strength of the study lies in the use of VAS which is still generally accepted as a good tool for measuring variations in pain perception, the cost-effective nature of the measuring tool, the cooperation of the authors and the seemingly novel nature of the study which highlighted the application of TENS as a monotherapy treatment tool and one-hour application TENS for management of PISP.. Furthermore, the significant differences in baseline VAS scores between age and duration of symptom could have influenced the outcome of the study.The current study was however weakened by non-randomization of the samples, low sample size relative to the calculated sample size; the possibility that subjects in the groups still ingested one form of analgesic medication or the other; the subjective nature of pain assessment tool used, and the fact that the treatment modes of intensity, frequency and pulse width which varied amongst participants, and time did not provide for equal treatment of participants using a uniformed parameterThe outcome of the study showed significant improvement in PISP after 10 weeks TENS application. It also shows that STENS also achieved varied pain relief to control subjects but not significant enough to compare the effect of TENS on the test group. This has shown the usefulness of TENS in managing PISP of sub-acute and chronic nature. The implication for management and rehabilitation is that TENS alone is beneficial in the management of injection-related nerve pain as demonstrated from the outcome of the current study. A future line of study is consideration of comparative effects of TENS and TENS in combination in the management of PISP. Also, future studies that should factor the limitations highlighted above are advocated by the authors as it will help to strengthen quality, acceptability, and generalizability of the study outcome.


Reassuring information is recommended in clinical guidelines for the treatment of low back pain (LBP), but has not been clearly defined. The Consultation-based Reassurance Questionnaire (CRQ) was developed as a tool for measuring to what extent reassurance is present in back pain consultations and may provide important information about the clinical encounter. Until now the CRQ has only been tested in general practice patients in the UK although many patients with LBP are seen outside of this setting. The objectives of this study were to translate the CRQ into Danish, test its feasibility in chiropractic practice, and determine if CRQ scores were associated with satisfaction with care and perceived pain control.On the day of the first visit for a LBP episode, patients received an electronic survey including the CRQ. Distributions and completeness of responses on the four subscales of the CRQ  were assessed, and internal consistency for each subscale calculated as Cronbach’s alpha. Outcomes at 2 weeks were; satisfaction with care  and ability to control pain (0–10). Associations of the CRQ with patient characteristics and outcomes were determined in mixed models to account for dependency of observations within clinics.From 964 patients visiting between November 2016 and October 2017 with new episodes of LBP, 717 completed the CRQ with no more than 1% missing values on any single item. The internal consistency was acceptable for all subscales (0.67–0.86). Scores were generally high, and more so in patients visiting a chiropractor for the first time. All four subscales were positively associated with satisfaction (Odds ratios 1.08–1.23) and generic reassurance was weakly associated with pain control (β = 0.07 [95% CI 0.03–0.11]).The CRQ was feasible for use in a Danish chiropractic setting and scores on all four reassurance subscales related positively to patients’ satisfaction. Patients who had visited a chiropractor previously reported slightly lower levels of reassuring information, and it should be explored if this is in accordance with the patients’ needs. The potential impact on patient outcomes needs investigation. Back pain is the most frequent cause for care seeking in parts of the world and globally the leading cause of disability , 2. In mBecause the support of positive health beliefs and self-efficacy seem central to people with back pain, clinical guidelines generally agree that people seeking care for back pain should have reassuring information as part of the consultation to help people understand the nature of back pain . Still, The Consultation-based Reassurance Questionnaire (CRQ), published in 2016, was developed as a tool for measuring to what extent back pain consultations include aspects of affective and cognitive reassurance and how patients perceive the way information is gathered during the consultation . The CRQThe CRQ provides a tool for quantitative investigations of reassurance, an option for gaining insights in the impact of reassuring information on patient outcomes, and potentially for evaluating ways of educating clinicians in providing reassurance. Thus, there are important potential benefits of the CRQ, but till now it has only been tested in general practice patients in the UK. The objective of this study was to translate the CRQ into Danish and test its feasibility in chiropractic patients. We specifically aimed at determining the completeness and distribution of scores and the construct validity of the subscales. Further, to explore if age, gender, educational level, symptom duration, or previous chiropractic care were associated with reassurance scores. Lastly, we investigated if CRQ scores were associated with satisfaction with care and with the patients’ self-perceived control of pain after 2 weeks, and whether this association differed between patients who had previously consulted a chiropractor and those who had not.The CRQ was translated from English to Danish and incorporated in the Danish Chiropractic back pain Cohort (ChiCo). This study uses data from ChiCo from the period November 1 2016 to October 31 2017. Patients completed surveys including the CRQ on the day they consulted the chiropractor for low back pain (LBP) and reported satisfaction with care and perceived ability to control pain at a follow up 2 weeks later. Data were collected using the electronic data capture software REDCap licensed by Odense Patient data Explorative Network (OPEN).The translation of the CRQ was conducted as recommended by forward and back translation . The forFour private chiropractic clinics with a total of 18 chiropractors recruited study participants. The clinics that were asked to take part in the ChiCo were in the Central Denmark Region and chosen among clinics that had a digital radiography system, which was required for subprojects related to imaging. In Denmark, chiropractors are self-employed and have a contract with the Board of Wages and Fees that regulates costs for care. Approximately 20% of payment for chiropractic services is reimbursed by national health insurance. Patients seek care from chiropractors without requirement of a referral.Patients initiating care (not visiting for a follow up consultation) for non-specific LBP or LBP with radiculopathy were eligible for inclusion if above 18 years, Danish speaking, and having access to an email account. Patients were not included if immediate referral for surgery was required or if LBP was suspected to be caused by systemic pathology. This would also mean exclusion if occurring after study participation had started.On the day of the initial visit to the chiropractor the patients completed the first part of the baseline questionnaire in the reception area before seeing the chiropractor and a second part of the baseline questionnaire was received electronically directly after the consultation via a link to their email address. Within a few days after inclusion a research assistant called the participants to welcome them to the study, answer questions about participation, and remind them to complete the second part of the baseline questionnaire if that had not been done.Consultation reassurance was measured in the second part of the baseline on the CRQ , relationship-building , generic reassurance , and cognitive reassurance ) ). There were no statistically significant interactions between previous chiropractic care and reassurance scores for any of the subscales.This is the first study to test the feasibility of the newly developed CRQ questionnaire outside of the development setting. In a cohort of chiropractic patients with LBP, very few missing values were recorded and the internal consistency of the subscales supported the four domains of the questionnaire. The scores were distributed across the scale with some skewness towards the higher scores on all four subscales. The rather high frequency of the highest possible scores, known as ceiling effect, might be problematic if the scale is considered for use as an outcome measure for educating clinicians in delivering reassuring information. However, for all scales, except relationship-building, the ceiling did not exceed 15% which is considered acceptable [The results suggest that patients generally perceive high levels of reassurance when consulting a chiropractor for LBP with median scores that resembled what has been observed in UK general practice . Low scoAll subscales of reassurance were positively associated with satisfaction with care reported after two weeks. This implies that the CRQ captures elements of care that are of importance to patients, but this study did not investigate if there is a causal relationship between reassurance in the consultation and the higher levels of satisfaction observed. This relationship should be explored in more depth. The CRQ was not associated with pain control at follow up except for a weak positive association with generic reassurance. It may be that other aspects of reassurance actually affect perceived pain control too, but this could not be demonstrated in this sample because of very few low scores on other subscales. Alternatively, the CRQ might not cover aspects of reassurance of importance for perceived pain control, or reassuring information is not sufficient to obtain the skills required to obtain a sense of control.This study was based on a sample that was adequately sized for exploring the potential relationships between CRQ scores and patient characteristics, and for obtaining sufficiently certain estimates of associations with outcomes. Also, it is clearly a strength of the study that patients received the CRQ on the same day as they had consulted for LBP which reduced the risk of recall bias. Patients were recruited by 18 chiropractors in four clinics and it is unknown if these are representative of Danish chiropractors and to what extent patients’ perceptions of reassurance would be similar in chiropractic practice generally. Approximately 25% of patients consenting to the study did not complete the full baseline questionnaire. These non-responders did differ from the rest of the sample on some parameters, but we find no reason to believe that the relationships between CRQ and other investigated factors and outcomes would be different in those than in the study sample. We included patients with different LBP durations to be able to investigate the potential relationship between duration and perceived reassurance. However, 70% of the study sample reported LBP of less than 4 weeks duration which fits with the population of people with acute LBP that participated in the development of the CRQ.The CRQ was feasible for use in a Danish chiropractic setting and scores on all four reassurance subscales related positively to patients’ satisfaction. Generic reassurance was related to perceived pain control after two weeks, and it should be explored further if generic reassurance supports patients in developing a sense of pain control. Since we did not observe very low scores on other aspects of reassurance this study cannot tell to what extent other subscales might influence sense of pain control. Patients who had visited a chiropractor previously reported slightly lower levels of reassuring information, and it should be explored if this is in accordance with patients’ needs. In summary, the CRQ is relevant for studying reassurance in chiropractic settings and there is a need for investigating the impact of reassurance on additional patient outcomes and at later follow up time points.


Background: Dental procedures often elicit pain and fear in pediatric dental patients.Aim: To evaluate the feasibility and effectiveness of immersive virtual reality as an attention distraction analgesia technique for pain management in children and adolescents undergoing painful dental procedures.Design: Using a within-subjects design, five patients  participated. Patients received tethered immersive interactive virtual reality distraction in an Oculus Rift VR helmet  during one dental procedure . On a different visit to the same dentist , each patient also received a comparable dental procedure during the control condition “treatment as usual” (treatment order randomized). After each procedure, children self-rated their “worst pain,” “pain unpleasantness,” “time spent thinking about pain,” “presence in VR,” “fun,” and “nausea” levels during the dental procedures, using graphic rating scales.Results: Patients reported significantly lower “worst pain” and “pain unpleasantness,” and had significantly more fun during VR, compared to a comparable dental procedure with No VR. Using Oculus Rift VR goggles, patients reported a “strong sense of going inside the computer-generated world,” without side effects. The dentist preferred having the patients in VR.Conclusion: Results of this pilot study provide preliminary evidence of the feasibility of using immersive, interactive VR to distract pediatric dental patients and increase fun of children during dental procedures. Pain during dental procedures is common, especially during invasive dental treatments such as tooth extractions or dental cavity fillings . AlthougIronically, when patients avoid going to the dentist, what could have been treated early as a tooth filling (preventative medicine), left untreated, may lead to advanced tooth decay such that patients require tooth extraction and/or root canal. Inflammation of the gums surrounding the infected tooth makes the dental care more painful, and healing after surgery takes longer with more advanced tooth decay. In some cases, unpleasant dental experiences can generalize to avoidance of healthcare in general.Several techniques, both pharmacological and psychological, can be used to reduce patients’ pain and anxiety during dental procedures. Local anesthesia is the most frequent pharmacological technique to reduce dental pain. Ideally, local anesthesia results in complete absence of pain in the anesthetized area during dental procedures. However, local anesthesia requires an injection into the jaw with a long needle, and patients often refuse it because they consider the injection painful and or because patients fear/avoid needles . Among tVirtual Reality (VR) analgesia is showing promise as an effective pain distraction technique for helping reduce the suffering and increasing the amount of fun children experience during painful medical procedures .The essence of immersive virtual reality is the user’s illusion of going inside the 3D computer generated world, as if the virtual world is a place the patient is visiting. Researchers propose the following explanation for why VR reduces pain , 2011. “The current pilot study is the first to explore the feasibility, acceptability and the effectiveness of immersive VR to reduce pain during dental procedures such as dental fillings, and to explore the dentist’s thoughts and opinions on the feasibility/applicability of this technique during dental procedures.For 6 months, patients aged 7–17 years, who needed dental fillings or a tooth extraction during two visits were recruited. Patients were selected in a Private Dental Practice in the city of Prato (ITALY) with the help of the staff assistant who schedules patients, according to the following criteria based on the existent literature . To be iFive patients, three males , and two females (aged 12 and 17 years) met the inclusion criteria and underwent tooth extraction or dental fillings on two dental visits separated by at least 1 week between visits.The protocol used in the current study was approved by the IRB ethics committee at the University of Florence Italy. The study was undertaken with the understanding, approval and written consent of each subject and their parent/guardian. The protocol was conducted under internationally accepted ethical standards and was approved by the dentists of the Dental Private Practice. Children and adolescents meeting the inclusion and exclusion criteria were referred to the psychologist researcher. Selected patients and their parents were approached in the waiting room of the Dental Practice to determine if they had any interest in participating. Interested families accompanied the psychologist researcher into a private room where they were informed about what would be involved, and if they were interested, they signed written informed assent/consent forms. Each patient received VR during one dental procedure, and received no VR during a second comparable procedure on a different day . Using a within-subjects crossover design, with treatment order randomized, each patient received Yes VR on 1 day, and No VR on the second visit . No reward was given to patients for participating.Pain levels, the quality of the VR experience, nausea and fun were measured using the Italian translation of the 0–10 graphic rating scale GRS,  questionPatients were asked to respond to the following questions with a score between 0 and 10: While experiencing the virtual world, to what extent did you feel like you WENT INSIDE the virtual world? . How REAL did the virtual objects seem to you during virtual reality? 0 = completely fake, 1–4 somewhat real, 5 = moderately real, 6–9 = very real, 10 = indistinguishable from a real object. To what extent  did you feel nausea (sick to your stomach) as a result of experiencing the virtual world during the most recent VR session? .The dentist’s experience during the procedure while the patients were using VR distraction, was investigated with a semi-structured interview of 30 min conducted by a psychologist at the end of data collecting (July 2016). The dentist answered the following questions: (1) How did you feel when you performed the procedure and the patient was interacting with VR, compared to the standard routine? (2) What do you think about patients’ experience during VR? (3) Did you find any impediment for the use of VR during dental procedures? and (4) Do you have any suggestion to improve VR distraction?1, with two miniature computer screens, one screen per eye. The goggles received video and audio input from an MSI GT Series GT72 Dominator Pro G-1252 Gaming Laptop 6th Generation Intel Core i7 6700HQ (2.60 GHz) 16 GB Memory 1 TB HDD 512 GB SSD NVIDIA GeForce GTX 980M 4 GB GDDR5 17.3” with Windows 10 Home 64-Bit. Patients interacted with SnowWorld2, a virtual environment specifically designed for pain management of immobilized patients with severe burn injuries during painful procedures such as wound cleaning and range of motion exercises , and dropped to 0.60 (SD = 0.55) during virtual reality, t(4) = 3.67, p < 0.05, SD = 1.10. The mean “worst pain” was 3.80 (SD = 2.59) during No VR, and this dropped to were 2.20 (SD = 1.79) during virtual reality, t(4) = 3.14, p < 0.05, SD = 1.14. One patient showed no reduction in pain during VR, the other four patients all reported reductions in pain during VR. Although the difference in “time spent thinking about pain” was not statistically significant for this measure, responses showed the predicted pattern of results. Patients spent more time thinking about their pain during No VR  vs. during Yes VR , t(4) = 2.36, p = 0.08 NS, SD = 1.52.Mean pain ratings were significantly lower during VR compared to the control condition for affective, and sensory components of pain. The mean “pain unpleasantness” during No VR was 2.40 (SD = 2.70) corresponding to “a strong sense of going inside the computer generated world,” and a mean of 7.40 (SD = 1.82) for the realism of VR objects, corresponding to “very real.” Mean nausea ratings were considered negligible in both conditions . When interacting with VR, patients reported significantly higher levels of fun during the painful procedure, compared to the control condition. Fun during No VR  was “mildly fun” vs. “pretty fun” during Yes VR , t(4) = 2.80, p < 0.05, SD = 4.00.While undergoing the painful dental procedure while interacting with VR, patients reported mean presence ratings of 7.40  was also one of the authors of the current manuscript.During a semi-structured interview after the study, the dentist made the following observations and comments. (1) The dentist felt more relaxed and was able to be more concentrated on his job when he performed the dental procedures while the patient was interacting with VR, compared to the routine standard care.(2) The dentist considered patients less stressed during the interaction with VR and thought that they felt less pain than during the standard care. In the dentist’s opinion, the VR system was suitable both for children and adolescents, because all patients reported fun during the interaction with the virtual world and many of them wanted to continue playing after the end of the procedure. The dentist considered VR to be an effective distraction technique especially for patients with high levels of anxiety.(3) No impediment or contraindication emerged. In the dentist’s opinion, the VR goggles/VR system didn’t impede the dentist’s ability to perform the dental procedures, and the dentist was able to easily communicate with the patient. The dentist found SnowWorld suitable for all patients.(4) The dentist highlighted the need of a new VR software with a “hot” scenario in the future, because, he was concerned that the illusion of cold sensations could evoke pain during dental procedures in some patients . Moreover, he expressed the desire to extend the use of VR pain management to also include adult patients.The current pilot study was conducted as a proof of concept, to explore the feasibility of using a new generation of mass produced commercially available Virtual Reality to distract children during painful/fear inducing dental procedures. The current study tested the effects of immersive, interactive Oculus Rift virtual reality distraction as a psychological technique to control pain during tooth extraction and dental fillings/cavities in children and adolescents. Based on the Interruption of Attention Pain Model by Eccleston and Crombez, we predicted that patients focusing their attentional resources on the virtual environment, would experience less pain, including the cognitive, affective and sensory components of pain, and we predicted patients would report having more fun during their dental procedure, on the day they received VR compared to the day they received standard of care with No VR. During VR, patients reported a significant 42% reduction in their “worst pain ratings, a significant 75% reduction in patients ratings of “pain unpleasantness” and patients reported a significant 61% increase in their ratings of how much fun they experienced during the dental procedure. Despite having to keep their heads still, and using a computer mouse to look around and shoot snowballs at objects in the virtual world, patients reported a “strong sense of going inside the computer-generated world” during VR, without side effects.Although promising, the current pilot study has several limitations. First of all, the dentist who declared the “Dentist’s experience” is one of the authors, raising a high risk of confirmation bias. The small sample size is another limitation. Studies with small samples sizes are vulnerable to the possibility that results may be biased if one single patient reports an extreme value overshadowing other patients’ response. Fortunately, this was not a problem in the current study. One patient showed no reduction in pain during VR, the other four patients all reported reductions in pain during VR, with no outliers. However, small sample size is always an important concern. Because it is not possible to make broad scientific conclusions based on the results of studies that use small sample sizes , the cur3,4). The current results also provide preliminary evidence that VR can also be an effective technique to promote good emotions and help patients cope with painful procedures in a non-stressful manner. Indeed, patients that interacted with VR during tooth extraction and dental fillings reported significantly higher levels of fun, compared to No VR, treatment as usual. During an interview after completing the study the dentist who performed the procedures suggested that VR distraction could be especially effective for anxious patients. Future studies should evaluate VR effectiveness for pain management comparing dental fears patients vs. patients do who do not have dental fears. For many children, experiences at the dentist give the young pediatric patients their first impressions about visiting healthcare givers.The current study showed no problems with VR induced nausea. Having patients keep their heads still  greatly reduces the computational demands on the high performance gamers VR computer, reducing lag that can lead to VR simulator sickness/motion sickness in some people  and by the Dentists of the Dental Practice.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To determine the ideal method for postoperative pain management after circumcision by comparing the most frequently used different methods like; dorsal penile block, caudal epidural block, subcutaneous ring block, intravenous paracetamol and intravenous tramadol HCl.st 2015 to May 1st 2016, 500 children between 2-10 year old were circumcised at the department of pediatric surgery of Istanbul Medipol University Health Care Practice & Research Center Sefakoy Hospital. Five groups were formed according to postoperative analgesia methods which were planned to be compared; Group-I. penile block, Group-II. Caudal epidural block, Group-III. subcutaneous ring block, Group-IV as intravenous paracetamol and Group-V as intravenous tramadol HCl. In order to evaluate the postoperative pain levels of children, Children’s Hospital Eastern Ontario Pain Scale (CHEOPS) was filled at 30, 60, 120, 180 minutes after circumcision by a researcher who does not know which method was applied.Between May 1No significant difference is found between the groups (p>0.05). In the statistical analysis, no significant difference was found in the effect of analgesia methods on CHEOPS scores between 30, 60, 120 and 180 minutes (p>0.05). In parallel with this result, no significant difference was found in the effect of heart beat rates and respiration rate averages between 30, 60, 120 and 180 minutes (p>0.05).It has been shown that none of the five method has any superiority in reducing pain after circumcision and that all five methods can be used. However, we think that side effects of regional anesthesia and systemic analgesic applications should not be ignored. Circumcision is the oldest and most common surgical procedure in the world and managing such a common surgery basically requires patient safety, reliability, rapid recovery and adequate pain management.4In our daily medical practice, we frequently encounter circumcision demands for boys who are both newborn and older. One of the biggest concerns of the parents in this respect is the state of pain which is the main factor for determining the comfort of children after circumcision. Based on our clinical experience, we observe that the families of children who are suffering pain after being circumcised have panic and do not know what to do. However, unfortunately no standard pain relief method has been established to reduce pain after circumcision. Systemic NSAID’s, opioid analgesics or local anesthetic techniques are being used for postoperative pain management. On the other hand systemic analgesic agents like NSAID’s and opioid analgesics can cause gastrointestinal , genitourinary , dermatological  and pulmonary (asthma provacation) adverse side effects and other invasive techniques also can cause local , systemic and neurological  adverse side effects.In this study, we aimed to determine the ideal method for postoperative pain management after circumcision by comparing the most frequently used methods like; dorsal penile block, caudal epidural block, subcutaneous ring block, intravenous paracetamol and intravenous tramadol HCl.After obtaining the hospital ethical committee approval  we collected patients’ data retrospectively. Five groups were formed according to postoperative analgesia methods which were planned to be compared; Group-I. penile block , Group-II. Caudal epidural block , Group-III. Subcutaneous ring block , Group-IV as intravenous paracetamol (15 mg / kg during the operation) and Group-V. intravenous tramadol HCl (1 mg / kg during the operation). After the approval of the parents of the children are taken, between 01.05.2015 and 01.05.2016 one pediatric surgeon planned to perform circumcision operation at the department of pediatric surgery of Istanbul Medipol University Health Care Practice & Research Center Sefakoy Hospital under general anesthesia with the guillotine method, 500 children between 2-10-year-old were randomly assigned to the groups in equal numbers. Patients with any additional health problems identified during the history and physical examination are excluded from the study. Without premedication, after patients are taken to the operation room, IV cannulation is performed and anesthesia induction is made with Propofol 2-3 mg/kg and fentanyl 2µg/kg. After performing appropriate laryngeal mask for the patient, sevoflurane, oxygen and nitrogen is used for the maintenance of anesthesia. Children’s ages, weights and duration of operation were recorded. During or after the circumcision procedure, the appropriate planned analgesia method to the child’s group is applied  and in order to evaluate the postoperative pain levels of children, Children’s Hospital Eastern Ontario Pain Scale (CHEOPS)  was fillOther data analysis was performed using IBM SPSS Version 18.0 statistical package program. The significance level is determined as 0.05 in all analyzes. Since the homogenity  is considered among the studied groups, the assumption of the normality of distribution  is fulfilled and because of there are five groups at the study, the ANOVA test was used to analyze the data. As a result of this analysis, post-hoc test statistics were applied to determine the source of significant difference between groups.The mean age, weight and duration of operation of the cases are given in Circumcision is one of the most common surgical procedures of pediatric surgeons. Contrary to the past, a good pain control is aimed during and after circumcision nowadays to increase the comfort of the child and to reduce the psychological effects of this period. If postoperative analgesia can be successfully achieved, it may prevent the adverse effects of pain. In this way, patient anxiety, morbidity, length of hospitalization and cost are reduced.In daily pediatric medical practice, intravenous paracetamol administration is a frequently used method to provide analgesia, whether postoperatively or not. Rare side effects associated with the use of paracetamol includes anaphylaxis, liver disorders, hypotension, and tachycardia. Similarly, intravenous tramadol HCl is an analgesic tool with a practical use to reduce pain in postoperative periods. Side effects include sweating, nausea, anaphylaxis and liver disorders. In the light of recent developments in the field of anesthesia, regional anesthesia techniques are used safely and effectively in combination with general anesthesia in children.In many previous studies, the efficacy of various methods for postoperative analgesia after circumcision were compared with each other and different results were obtained. Unfortunately, there is no common point accepted by everyone. For example; Vater et al.6Fundamentally all circumcision methods can be grouped under four main headings. These are; dorsal slit, Sheldon method , special circumcision clamps and open surgical methods . In studies conducted to investigate the effects of analgesic agents after circumcision, it has been reported that surgical method also has an effect on postoperative analgesia. Therefore, in our study the same surgical method (guillotine method) was used in all cases. In the second step of our study, we aim to evaluate different anesthesia methods with different surgical procedures.As pediatric surgeons, we are frequently faced with the desire for circumcision in our country due to religious and social traditions. It is the physicians’ duty to take the necessary measures to help the child overcome this process with as little as possible physical and psychological damage. In this way, families can spend this stressful period more easily and comfortably. For the post-circumcision period, the main concern of the families is the pain of their children. Unfortunately, circumcision, a procedure that is so frequently performed, does not yet have a definitive analgesia procedure for postoperative pain, and many different methods are used in many clinics. Our study was designed to eliminate this complexity and compared the most commonly used methods to reduce postoperative pain after circumcision. In the literature search, we have not found any previous studies comparing these five methods with each other.This study has shown that none of the five method has any superiority in reducing pain after circumcision and that all 5 methods can be used with peace of mind. However, we think that side effects of regional anesthesia and systemic analgesic applications should not be ignored.


Nasogastric (NG) intubation is a common yet one of the most uncomfortable minor procedures done in children and adults alike. A variety of analgesics, such as ketamine, lidocaine, and nitrous oxide, have been shown to reduce pain in various minor pediatric procedures. This retrospective study explores how often various pain management practices are used, either alone or in combination. The study examines NG intubation in pediatrics in one pediatric academic health system. The comfort measures used include analgesics, distraction, child life, swaddling, nitrous oxide, and others. Pharmacological intervention  and distraction were most frequently used. Larger randomized studies should be conducted to determine the best practices for comfort measures for NG intubation in order to achieve maximal pain and anxiety reduction for children of various ages. Nasogastric (NG) intubation is a common procedure in children that involves inserting a thin, hollow (nasogastric) tube through the nose, the throat, and eventually into the stomach. Nasogastric tubes provide access to the stomach for therapeutic and diagnostic purposes. Common indications for nasogastric intubation include gastric decompression, gastrointestinal bleeding, enteral feeding, and administration of radiographic contrast medium or medication, among many others . HoweverAccording to a study in emergency medicine, patients and practitioners have rated NG intubation as the most painful procedure . In ordeDespite the availability of various agents for reducing pain for NG tube insertion, pain management is not consistently used in clinical practice in pediatrics . In thisIn this retrospective study, NG intubation data from 2015 from two pediatric hospitals were analyzed. The database contains methods of pain management used for each patient, if recorded. The database was stripped of all patient identifying information except for patient age and gender. The database contains the dates of tube insertion and removal. Health care professionals who intubated the patients are listed.Statistical analysisFrequencies and frequency percentages for each comfort measure at each hospital and both hospitals combined were presented as n (%). The frequencies for the treatment combinations that were used at each hospital were calculated and are presented as n. Since some patients received a combination of comfort measures, the frequencies and frequency percentages do not add up to the total number of patients and 100%, respectively. Comfort measures were not recorded for every patient with NG tube insertion. Only data entries with recorded comfort measures were included in the analysis. Statistical computations were conducted manually.The total number of patients between the two hospitals was 130 (Table Treatment combinationTreatment combinations were used in 8.7% (10/115) and 53.5% (8/15) of the patients at Alfred I. duPont Hospital for Children (AIDHC) and NCH, respectively. The most common combination included pharmacological treatment + distraction/distraction kit at AIDHC and distraction + relaxation + swaddling at NCH. Other combinations were also used, though much less frequent. Pharmacological treatment was used in most of the combinations at AIDHC. Distraction/distraction kit was used in all of the combinations at NCH.Pain and discomfort associated with NG intubation can be mitigated in many different ways, both pharmacological and non-pharmacological. Pharmacological measures, such as nebulized lidocaine, have been shown to greatly reduce discomfort associated with NG tube in adult patients . HoweverMultiple interventions may be combined to achieve more effective pain relief. Pharmacological treatment combined with distraction/distraction kit was the most frequently used combination at AIDHC. This specific combination can be compared with either pharmacological treatment or distraction/distraction kit alone in future research in terms of their pain relief effect. Children in particular are responsive to pain reducing techniques that involve their sense of play, therefore distraction kits containing various toys may be quite effective in reducing procedural pain . FurtherDespite some differences in the type of comfort measures used between the two hospitals, both pharmacological treatment and distraction were commonly used, likely due to familiarity with these tools/methods, easy accessibility, and/or their efficacy for pain management for other minor pediatric procedures. Some of the other less frequently used interventions in our study, such as nitrous oxide, swaddling, and child life intervention, may also warrant further research, either alone or in combination with other pharmacological and non-pharmacological interventions to test their efficacy for reducing pain associated with NG intubation in children.Our study has several limitations. As a retrospective chart review, it often provides an inferior level of evidence when compared to prospective studies, for multiple reasons. There were some missing variables that may have provided more insights into our data. Some of these missing variables include the type of analgesic agent used, the method of distraction, patients’ diagnoses, and patients’ level of pain and anxiety before and after the intervention. Furthermore, our sample sizes were skewed between AIDHC (n = 115) and NCH (n = 15), likely due to NCH being a new hospital and lack of data collection. A larger overall sample size that is equally distributed between the two hospitals may be more representative. Nonetheless, the point we want to illustrate is that while data for pain management in pediatric NG intubation is lacking, a variety of comfort measures are being used and further studies are needed to establish higher quality evidence and guidelines.For future research, we suggest a prospective, controlled trial to test the efficacy of various comfort measures, either alone or in combination. The Wong-Baker Faces Pain Rating Scale has been shown to be a reliable tool for assessing pain in children and would be a great tool for measuring the primary endpoint (pain level) for our purposes . In addiIn summary, this study reviewed the comfort measures offered in two hospitals in one pediatric health system. Our data demonstrate that there is a wide variability in the types of comfort measures used, with analgesics and distraction being the most commonly used. Larger randomized studies should be conducted to determine the best practices for comfort measures for NG intubation, either alone or in combination, in order to achieve maximal pain and anxiety reduction for children of various ages.