Over 500,000 spinal surgeries are performed annually in the United States. Although pain relief and improved health-related quality of life (HRQOL) are expectations following lumbar spinal surgery, there is limited research regarding this experience from the individual's perspective. In addition, no studies have examined the HRQOL of persons who have had this surgery using a comprehensive approach. The intent of this study was to address this deficiency by an assessment of both the individual and environmental factors that impact perceived HRQOL using the Wilson and Cleary Model for Health-Related Quality of Life in persons who have undergone lumbar spinal surgery.This was a pilot study of 57 adult patients undergoing elective lumbar spinal surgery for either herniated disk and/or degenerative changes. Individuals completed questionnaires measuring perceived pain, mood, functional status, general health perceptions, social support and HRQOL preoperatively and three months following surgery. Descriptive statistics, dependent t-tests, and MANOVAs were used to describe and compare the differences of the study variables over time.Preliminary results indicate overall perceived physical HRQOL was significantly improved postoperatively , however, it was lower than the published norms for patients with low back pain. Both functional disability  and pain  were significantly improved after surgery. Although levels of fatigue and vigor were also significantly improved after surgery, both were less than the published norms. There was no change in the level of social support over time; however, level of support was consistent with that reported by patients with chronic illness.Although perceived physical HRQOL was significantly improved three months postoperatively, fatigue and lack of vigor were issues for subjects postoperatively. Excessive fatigue and low vigor may have implications for successful rehabilitation and return to work for patients following lumbar spinal surgery. Further research is needed with a larger sample size and subgroup analyses to confirm these results. Lumbar spinal surgery is one of the most common types of surgeries performed in the United States with over 500,000 surgeries performed for lumbar herniated disks and lumbar spinal stenosis in 2004 . NumerouJAMA in 1995 [Using a framework in quality of life research is important because it promotes the selection of appropriate measurement variables and identifies potential links between variables within the complex construct of quality of life. Wilson and Cleary published their conceptual model of quality of life in  in 1995  and it w in 1995   in patients undergoing lumbar spinal surgery was much less robust than the pain literature. Although there is literature to suggest that back pain is often associated with mood disorders , no studWilson and Cleary  defined According to Wilson and Cleary , generalA number of studies were conducted measuring the HRQOL in patients undergoing spinal surgery . The mosThis longitudinal one-group pretest-posttest study was part of a larger study that examined the relationships between changes in social support, pain, mood, functional status, perceived health status, patient expectations, optimism, and perceived QOL of subjects undergoing lumbar spinal surgery for either herniated disk and/or degenerative changes ,23. ThisUsing a consecutive convenience sample, the study was conducted at five Midwestern hospitals in the United States. Surgical technique and procedures were considered similar among these sites. The inclusion criteria were patients undergoing elective lumbar spinal surgery for the first time for degenerative changes and/or herniated disks, age 18 years or older, with the ability to read and write English. Patients undergoing lumbar spinal surgery for degenerative changes and/or herniated disks were chosen because they were expected to make at least some symptom and functional improvements by 3 months postoperatively. Patients with cancer, spinal cord injury, cauda equina syndrome, and more than two levels of fusion were excluded from the study in order to control for significantly different recovery trajectories. Both genders as well as different ethnic groups were included in the study based upon meeting the inclusion criteria.Ninety-four patients were approached for participation in the study. Of these, 73 (77.6%) completed the preoperative questionnaire. Postoperatively, 57 (78%) subjects completed the follow up questionnaire resulting in a total sample size of 57 for analysis.The study was approved by the university and hospital institutional review boards. A one-page information sheet inviting patients who met the inclusion criteria to participate in the study was made available in waiting rooms and exam rooms. In addition, potential subjects were identified by the surgeons and clinic nurses.Potential subjects were informed of the purpose, risk/benefits of the study, and were invited to participate in the study. After obtaining informed consent, subjects completed a preoperative questionnaire booklet 2–14 days prior to surgery and then a postoperative questionnaire booklet approximately 3 months after surgery.The revised Wilson and Cleary Model for Health-Related Quality of Life  providedThe investigator developed a demographic form to collect subject demographic information such as patient age, gender, marital status, race, work status, and educational level.The Medical Outcomes Study (MOS) Social Support Survey  was usedA medical chart review form was developed by the investigator to collect biological and physiological variables pertinent to this study including comorbidities, presence of obesity as measured by body mass index over 30, and type of surgery.The Numeric Pain Rating Scale (NPRS) was used to assess degree of back pain. The NPRS is a 0 to 10 point scale in which 0 is considered no pain and 10 is the worst pain possible. The instrument has been used extensively in a wide variety of settings and has been validated with low back pain patients . Level oThe Profile of Mood States-Brief Form (POMS-Brief)  was usedDisease-specific functional status was measured using the Oswestry Disability Index for Low Back Pain (ODI) Version 2.0 . The ODITest-retest scores with an interval of 4 days was found to be high (r = 0.91) . InternaGeneral health perceptions were evaluated at each time point with a single item that asked the respondent to rate their overall health as "excellent", "very good", "fair" or "poor". Studies have supported the reliability and validity of using a single-item indicator to measure such variables as well-being and health perceptions .Health-related quality of life was measured with the SF12v2 . The SF1Published reliability coefficients range from 0.73 to 0.87 across all eight subscales of the SF-12v2 . For theThe authors of the S12v2 recommend intraclass correlations for estimating test-retest reliability for the SF-12 PCS and MCS . For thiData was entered into the statistical analysis program, SPSS 14.0  for each instrument. Missing data per subject ranged from 0.5% to 11.3% with a mean of 2.9% (N = 57). Upon examination of each question, no patterns of missing data were noted. Missing data in key variables were replaced with values using a multiple imputation procedure based upon a regression model.Descriptive statistics, dependent t-tests, and analysis of variance (ANOVA) were used to describe and compare differences between the preoperative and postoperative variables. Multivariate analysis of variance (MANOVA) was used to detect changes over time in subscales.M = 48.81, SD = 12.93). As expected, the mean age for patients undergoing surgery for spinal stenosis and degenerative changes  was higher . Patients undergoing lumbar fusion  had a mean age of 56.53 (SD = 11.30). There were slightly more women  than men  who participated in the study. Most subjects were married . The majority were white  and had at least some college education. Only 19.3% (N = 11) of participants were working full-time without any restrictions prior to surgery. Preoperatively, 36.8% (N = 21) of subjects indicated that they had decreased their work hours or were not able to work because of their back problem.Subjects (N = 57) averaged 53.4 years of age with age ranging from 21 to 84 years old. For patients undergoing surgery for primarily herniated disk(s), , the mean age was lower  and postoperatively  , osteoarthritis , and diabetes  being the most common. Most subjects were either overweight or obese , which is a common risk factor in the development of back pain. The type of surgical procedures performed included lumbar microdiscectomy , lumbar fusion  and lumbar laminectomy . Most participants  had only one spinal segment operated on and the majority  did not require instrumentation.The variables of pain and mood corresponded to symptom status in this study. The Numeric Pain Rating Scale (NPRS) was used to measure degree of pain on a scale of 0 to 10 with 0 being no pain and 10 being extreme pain. Pain decreased from a mean of 7.0 preoperatively to a mean of 3.19 postoperatively Table . The decThe POMS-Brief Form was administered both preoperatively and postoperatively to measure mood. The overall total mood disturbance score was calculated as well as six subscales measuring tension-anxiety, anger-hostility, vigor-activity, fatigue-inertia, confusion-bewilderment, and depression-dejection Table . A pairePreoperatively, the ODI mean was 51.3 indicating severe disability in functional status Table . PostopeGeneral health perception did not change significantly between the preoperative and postoperative periods Table   and Mental Component Summary (MCS-12). In addition, eight subscale scores  were calculated for both the preoperatively and postoperative data. Means for the summary scores as well as all eight subscales improved from the preoperative to postoperative period  were similar to other studies of patients undergoing lumbar spinal surgery in terms of reported prevalence of obesity  and mostRace was uncommonly reported in the spinal surgery literature. However, in the published studies where race was reported, racial disparity existed with most samples being predominately white . The samIn terms of environment, to the authors' best knowledge, this study is the first to use the Medical Outcomes Study (MOS) Social Support Survey to measure level of social support in patients undergoing lumbar spinal surgery. Only one study was found that examined social support as a predictor of surgical outcome of lumbar discectomy and found that subjects who had severe psychological strain and lack of social support had poor surgical outcomes . Level oAlthough functional status was significantly improved after surgery, subjects remained moderately disabled three months after surgery. This finding is consistent with the literature regarding spinal surgery . Yukawa In terms of symptom status, subjects experienced significant improvement in pain relief following surgery. This is also supported by other studies of spine surgery patients that examined pain relief . Jang & Despite overall mood being significantly improved after surgery, subjects still reported lower levels of vigor and higher levels of fatigue as compared to published norms . This maIn the current study, the postoperative total mood disturbance score was slightly higher than a sample of patients who had undergone coronary artery bypass surgery one month previously  and patiOverall perceived health was unchanged after surgery when compare to preoperative level. This finding may be related to comorbidities. No other studies were found that reported overall perceived health in the back surgery population. Including a comorbidity measure in future studies may help clarify the role of comorbidities in perceived health.Health-related quality of life as measured by the SF-12v2 was significantly improved after surgery in terms of the perceived physical component summary (PCS) but not the perceived mental health summary (MCS). The improvement in the physical component can be attributed to decreased level of pain and better functional status. However, despite reporting an improved health-related quality of life three months after surgery, perceived physical health in this sample was lower than published norms for patient with low back pain  declare that they have no competing interests.KLS: Participated in the conception and design of study, coordinated the study and drafted manuscript.SMP: Participated in the conception and design of study, edited manuscriptIA: Participated in the conception and design of study, edited manuscriptFBB: Participated in the conception and design of study, edited manuscript


To assess the efficacy of facet joint infiltrations for pain relief in 44 selected patients with chronic nonradicular low back pain (LBP).Forty-four patients with chronic LBP of more than 3 months' duration were selected for facet joint infiltration. The majority (n = 24) had facetal pain with no evidence of significant facetal arthropathy on imaging. Fifteen patients had radiological evidence of facetal arthropathy, one had a facet joint synovial cyst, three were post–lumbar surgery patients, and two patients had spondylolysis. Facet joint injections were carried out under fluoroscopic guidance in 39 patients and under CT guidance in 5 cases. Pain relief was assessed using the visual analog scale at 1 h post-procedure and, thereafter, at 1, 4, 12, and 24 weeks.A total of 141 facet joints were infiltrated in 44 patients over a 2-year period. There was significant pain relief in 81.8% patients 1 h after the procedure, in 86.3% after 1 week, in 93.3% after 4 weeks, in 85.7% after 12 weeks, and in 62.5% after 24 weeks. No major complications were encountered.Facet nerve block was found to be a simple, minimally invasive, and safe procedure. With meticulous patient selection, we achieved long-term success rates of over 60%. We conclude that this method represents an important alternative treatment for nonradicular back pain. Chronic low back pain (LBP) has assumed endemic proportions, with an annual prevalence of 5–20% in the industrialized world. It is no2Chronic LBP of more than 3 months' duration, not responding to conventional drugs, exercise, and physiotherapySymptoms suggestive of facetal pain; i.e., LBP with or without radiation to the buttocks, thigh, or groin; pain increasing on hyperextension; and pain when initiating movementFocal tenderness over the facet joint elicited by digital pressurePost–lumbar disc surgery patients with persistent pain and no MRI evidence of arachnoiditis or recurrent disc diseaseAll patients were initially assessed by a neurosurgeon before referral to the anesthesiologist-run pain clinic. A total of 44 patients were included in the study on the basis of the following criteria:All the patients had a preprocedure MRI for categorical exclusion of a discogenic cause for the LBP. Evidence of facetal arthropathy on MRI was noted but was not considered an inclusion criterion by itself.A neurological deficit in the lower limb or a positive sciatic nerve stretch sign Evidence of nerve root compression at the expected level on MRIClinical or imaging evidence of infection or neoplastic diseasePossible pregnancy, bleeding diathesis, or anticoagulant therapyHistory of sensitivity to local anestheticsThe exclusion criteria were:4–5 and L3–4 levels, respectively.There were 23 men and 21 women included in the study; the ages ranged from 20–74 years. The duration of symptoms varied from 3 months to 2.5 years (mean duration: 11 months). In our patient population, the largest subgroup (23/44) had clinical signs and symptoms of facetal pain but no evidence of significant facetal arthropathy on imaging (radiography / CT / MRI). Fifteen patients had clinical as well as radiological evidence of facetal arthropathy , one patThe procedure was explained to the patient in detail and written consent was obtained. Injections were performed under fluoroscopic guidance in most (39/44) patients. CT guidance was used in five cases. The levels and side(s) to be injected were selected by the treating pain physician on the basis of the tenderness elicited over the joint, correlated with imaging findings, if any.Fluoroscopic procedure: The patient was placed in the prone position with a pillow under the abdomen to correct the lumbar lordosis. The joint to be injected was located and marked. The x-ray tube was then slowly rotated till the joint appeared in profile as two parallel lines. After cleaning and draping, and administration of local anesthesia, a 22-G spinal needle was inserted in line with the x-ray beam till it contacted bone at the lip of the facet joint. With fine movements the needle tip could be made to enter the joint with a distinct ‘give.’ In the early cases, we confirmed the intra-articular position of the needle by injecting 0.5 ml iohexol  under fluoroscopy. Later, with increasing experience, we found that confirmation of correct needle placement could be made by feel and by viewing the joint in the lateral oblique projection [ojection . Once thCT-guided procedure: The patient was placed in the prone position and 5-mm axial sections were obtained at the level of interest to determine the entry site and the angle of approach. The entry site was marked on the skin and a 22-G needle was advanced into the joint [he joint . The druPain relief was assessed using a visual analog scale (VAS), with a score of 0 denoting ‘no pain’ and a score of 10 the ‘worst pain possible’ . The VAS4–5 (31.9%) followed by L3–4 (26.5%) [A total of 141 facet joints  were infiltrated in 44 patients, over a period of 2 years. The maximum number of infiltrations were at L (26.5%) . Only a The number of patients with significant postprocedure pain relief on day 1 and at 1, 4, 12, and 24 weeks is detailed in At 4 weeks, the three patients who did not respond were re-injected at the affected levels. Of these, one responded to the reinjection; the other two remained non-responders throughout the period of follow-up. Four of the patients who had responded well at 4 and 12 weeks required repeat injections between 16 and 20 weeks to maintain the pain relief. Another four patients who had good relief till 12 weeks received repeat injections at 24 weeks as the effect waned.A further analysis of the pain relief in the different subgroups of patients is shown in We saw no major complications. Five patients had minor undesired effects in the form of soreness or local skin bruising; these symptoms lasted 2–3 days and subsided without treatment.Facet joints are true synovial joints which are innervated by the medial branches of the dorsal rami. The presence of nociceptive nerve fibers in the synovium and fibrous capsule of the facet joints suggests that these joints may be a cause for LBP when they are stressed due to segmental instability, inflammatory synovitis, degenerative arthritis, or a combination of all of these.6 Based o2Unfortunately, there are no clinical or imaging findings to definitively diagnose facetal pain and very often the term ‘facet syndrome’ is used as a ‘dustbin diagnosis’ when nothing else fits. However, there are some features that are characteristic of facetal arthropathy. These include diffuse referred pain over the buttock and posterolateral thigh, exacerbation of pain with hyperextension or lateral bending, tenderness localized over one or more facet joints on deep pressure, and absence of root pain or neurological deficits.Imaging is not reliable for the diagnosis of facetal osteoarthritis since the changes seen on x-ray, CT, and MRI are equally common in patients with and without LBP, and most studies have failed to show a correlation between radiologic imaging findings and facet joint pain.–10Facet joint injection with local anesthetic and steroid is the simplest and most common procedure for facet joint–mediated pain. These infiltrations are diagnostic as well as therapeutic and the choice of guidance—whether CT or fluoroscopic—is largely a matter of personal preference and experience, as both are equally effective.910 The i9Accurate assessment of pain is a prerequisite for the effective management of patients with LBP. Of the numerous tools available to assess pain, we adopted the numerical visual analog scale (VAS) since it is an objective measure and can be used to track serial changes. Many rec12Literature describing the effectiveness of facet joint infiltrations is as abundant as it is controversial. Early studies of facetal infiltrations showed poor results and led to the conclusion that this is a nonspecific and ineffective method of treatment.15 It is 1012171012Injections for spondylolysis are a modification of facetal injections, providing good response in most patients. Some workers feel that it is the fracture site which is painful and, accordingly, infiltrate the break in the pars interarticularis. Others h1014The major complications of facet joint infiltrations are related to improper needle placement, bleeding, or infection. Complications include dural puncture, hematoma formation, spinal cord or neural trauma, spinal anesthesia, septic arthritis / spondylitis, and chemical men-ingitis. Despite We acknowledge the following limitations of our study. Firstly, we did not have a control group receiving placebo injections. Secondly, we did not carry out a preliminary diagnostic block for patient selection prior to giving the therapeutic injection. This was because we found it difficult to justify a preliminary diagnostic block followed by a subsequent therapeutic injection; such a protocol would have delayed treatment and exposed the patient repeatedly to the risk of complications and radiation exposure. Therefore we selected our patients on the basis of a good clinical examination.Recent evidence-based guidelines, published in 2007, with respect to lumbar facet joint injections have convincingly demonstrated moderate evidence for short- and medium-term (up to 6 months) relief and limited evidence for long-term relief. Facetal


Osteoarthritis trials usually report average changes in visual analogue scale (VAS) pain, and examine the difference between treatment and placebo. We investigated whether dichotomous responder analysis provides a more informative interpretation of drug efficacy.Merck supplied the number of patients who, by 6 weeks, had achieved pain relief compared with a baseline of 0% or more, 10% or more, 20% or more, and so on at equal intervals up to 90% or more. These different levels of pain relief were used to distinguish different definitions of responders, for example at least 50% pain relief from baseline. Numbers and percentages of patients achieving each level were identified. Information was sought from a dose–response trial over 6 weeks in osteoarthritis using placebo and using etoricoxib at 5, 10, 30 and 60 mg daily.With placebo, the proportions of patients achieving at least 20%, 50% and 70% pain relief over baseline at 6 weeks were 30%, 11% and 2%. With 60 mg etoricoxib the equivalent percentages were 74%, 49% and 29%. The numbers needed to treat for 30 mg and 60 mg etoricoxib to produce at least 50% pain relief at 6 weeks compared with placebo were 4.2  and 2.6 (2.0 to 3.9), respectively. Levels of pain relief of 50% and above discriminated best between different doses of etoricoxib.Responder analysis seemed to be more sensitive than examination of average changes in VAS pain scores. Validation would require calculations to be performed on a set of trials using individual patient data not available in publications. In recent years, meta-analyses of randomised trials in osteoarthritis have suggested that the benefits of some well-established therapies – oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs, intra-articular steroid injections, and opioids – are small and limited to the first 2 to 3 weeks after the start of treatment . The argThis and previous papers  have beeWhatever the eventual success of these methods, science is informing us that there are very large differences between individuals, and that small changes in genetic makeup can greatly influence response to drugs. We know, for instance, that there is variation in plasma concentration and pharmacological response , and thiWe therefore sought to use data from a single clinical trial in osteoarthritis to explore whether a more informative interpretation of osteoarthritis trials might be obtained by using dichotomous responder analysis, as has been done previously for acute ,15 and cTo obtain a range of responses, we asked Merck Research Laboratories  for responder information from clinical trial 007 . They prPatients discontinued their pre-study NSAID for a period ranging from 3 to 8 days (for instance diclofenac) to 10 to 15 days (piroxicam). For inclusion, pain on a 100 mm scale had to be a minimum 40 mm walking on a flat surface at the flare visit, plus at least 15 mm increase and worsening in investigator global assessment since baseline visit. This was designated the flare, and if patients fulfilled these and other criteria they were randomised to treatment with placebo (n = 60) or with etoricoxib at single daily doses of 5 mg (n = 117), 10 mg (n = 114), 30 mg (n = 102), 60 mg (n = 112) or 90 mg (n = 112) for 6 weeks.We asked Merck to supply the number of patients in each group who, by 6 weeks, had achieved pain relief compared with baseline of at least 0%, at least 10%, at least 20%, and so on at equal points to at least 90%. The numbers and percentages of patients achieving, say, at least 50% pain relief from baseline, might be defined as a responder, and presentation of data in this way allowed different definitions of responder to be applied.The number needed to treat (NNT) to produce each level of response for each etoricoxib dose compared with placebo was calculated, with 95% confidence interval (CI) . RelativPatients in the trial were predominantly female (72%) and white (89%), were aged between 40 and 87 years, had a median duration of arthritis of 6 years, and were mostly diagnosed as American Rheumatism Association class II/III (85%). Most patients completed 6 weeks of therapy, with all-cause discontinuation rates of 8 to 17% in different groups.There was a very wide individual range of responses to the various treatments. With each, some patients achieved only small amounts of pain relief, whereas others had close to complete relief. Table Using at least 50% pain relief as an arbitrary level of success to define response, the absolute differences between placebo and 30 and 60 mg etoricoxib daily at 6 weeks were 24% and 38% of patients, respectively. The NNTs for 30 and 60 mg etoricoxib to produce at least 50% pain relief at 6 weeks compared with placebo were 4.2 (95% CI 3.8 to 8.6) and 2.6 (2.0 to 3.9), respectively.The absolute differences between etoricoxib and placebo were used to calculate NNTs at each level of pain relief Figure . At loweThe trial  originalThis is not a surprise. Although fewer than half of the patients achieved at least 50% pain relief with 60 mg etoricoxib, this level of response is not uncommon. For instance, in migraine it is common for oral drugs to yield 50 to 60% response rates with the low hurdle of no pain or mild pain at 2 hours after an attack, but this falls to 20 to 40% for pain-free at 2 hours . In neurThe differences between active drug and placebo were large. For instance, the NNTs for at least 50% pain relief of 4.2 (95% CI 3.8 to 8.6) and 2.6 (2.0 to 3.9) for 30 and 60 mg etoricoxib in osteoarthritis compare well with those found for at least 50% pain relief in postoperative pain (range 2 to more than 6 ), migraiGreater discrimination between pain therapies at higher levels of pain relief has been shown previously for acute pain . That beOther workers have attempted to calculate numbers needed to treat for osteoarthritis trials. For example, NNTs of 3 to 4 were calculated for pain reduction and patient global assessment after intra-articular corticosteroid, on the basis of fewer than 200 patients . The NNTThis exploratory study is limited by size, and by examining only one trial. Validation would require calculations to be performed on a larger set of trials using individual patient data not available in publications, and expanded to scales other than pain while walking on a flat surface. Outcomes other than pain might be considered, particularly the OMERACT-OARSI  definition of responder .It would also be possible to test the discriminating power of various outcomes in larger, better-conducted trials. It is maintained that dichotomous outcomes have less statistical power than continuous outcomes . This haThe question is: What makes a good definition of improvement for a patient in a clinical trial? Any definition should embody truth, discrimination and feasibility, and so it should be readily translatable for use in a clinical trial, make clinical sense, be specific to the clinical situation, have good statistical power, and be easy to calculate and interpret . It is nAverage differences in visual analogue pain scales between active drugs and placebo in arthritis trials seem to understate the efficacy of active medicines. Dichotomous responder analysis using higher levels of pain relief of at least 50% over baseline demonstrated an efficacy equivalent to that measured in other pain states, contradicting the idea that that it is time to reconsider the place of drug therapies in arthritis .Reporting of a responder analysis, called a cumulative proportion of responders analysis, as well as the actual proportions achieving certain levels of pain relief  may be an important addition to clinical trial reporting. It helps to show potential benefits of higher and lower than average doses for individual patients, and possibly highlights different criteria for determining effective or licensed doses. This is much more informative than average differences in VAS pain between treatment and placebo.CI = confidence interval; NNT = number needed to treat; NSAID = non-steroidal anti-inflammatory drug; VAS = visual analogue scale.RAM and HJM have received research grants, consulting fees or lecture fees from pharmaceutical companies, including Pfizer, MSD, GSK, AstraZeneca, Grunenthal, Menarini and Futura. RAM, HJM and SD have also received research support from charities and government sources at various times. RAM is the guarantor. No author has any direct stock holding in any pharmaceutical company.RAM was involved with the original concept, planning the study, searching, writing it, analysis, and preparing the manuscript; OAM and RAM performed calculations and analysis; OAM, SD and HJM were involved with planning and writing. All authors read and approved the final manuscript.


Patients with fibromyalgia often feel disabled in the performance of daily activities. Psychological factors seem to play a pronounced disabling role in fibromyalgia.The objectives of the study are: Firstly, to investigate contributing factors for disability in fibromyalgia. Secondly, to study psychological distress in patients with fibromyalgia as compared to other nonspecific pain syndromes. And finally, to explore the impact of fibromyalgia on a patient's quality of life.In this cross sectional study, explaining factors for disability were studied based on a regression analysis with gender, mental health, physical and social functioning as independent variables. For the assessment of disability in fibromyalgia the FIQ was used. The levels of psychological distress in patients with fibromyalgia, Complex Regional Pain Syndrome (CRPS) and chronic low back pain (CLBP) were compared based on scores on the Symptom Checklist (SCL90). Quality of life of patients with fibromyalgia was compared with scores (SF36) of both patients with fibromyalgia and other health conditions as derived from the literature.Disability in fibromyalgia seemed best explained by a patients mental health condition (β = -0.360 p = 0.02). The level of psychological distress was higher in patients with fibromyalgia as compared to patients with CRPS or CLBP (p < 0.01). The impact of fibromyalgia on quality of life appeared to be high as compared to the impact of other health conditions.Patients with fibromyalgia report a considerable impact on their quality of life and their perceived disability level seems influenced by their mental health condition. In comparison with patients with other pain conditions psychological distress is higher. Musculoskeletal diseases are a major public health problem in western society with a high impact on both health care and total societal costs . 41% of In the last decennia the focus of research on pain related disability has been shifted from a biomedical view to a holistic perspective in which in addition to biomedical also psychological and social factors have their influence . A promiIn addition to the fear avoidance model, alternative models have been proposed to explain disability in chronic pain. Hasenbring hypothesized that, in addition to patients using avoidance strategies as a coping mechanism, other patients with pain will have the tendency to cope with pain using persistent strategies . These pIt seems that several explanatory models for activity related behaviour in musculoskeletal pain might be applicable. McCracken et al confirmed this supposition by the finding that different activity related patterns can be present in patients with chronic pain disability . Based oThe aim of the current study was threefold:Firstly, the aim of this study was to investigate contributing factors  to the level of disability in patients with fibromyalgia. Secondly, to study psychological distress in patients with fibromyalgia as compared to patients with other nonspecific pain syndromes. And finally, to explore the impact of the fibromyalgia syndrome on a patient's quality of life as compared to patients with other chronic pain conditions and the general population.Patients with fibromyalgia were referred to the study by a consultant in rehabilitation medicine of the department of rehabilitation medicine in one of the five participating hospitals in the South of the Netherlands. They were referred to the department by a medical specialist or general practitioner. Their pain syndrome was labelled as fibromyalgia by a rheumatologist (94.6%) or a general practitioner (5.4%). In order to be able to contrast the impact of fibromyalgia on a patient's daily life situation, patients with two other non-specific pain syndromes were included. Firstly, patients with Complex Regional Pain Syndrome (CRPS) were included in the study; they were referred to the rehabilitation department by one of the anaesthesiologists of the pain clinic in the Laurentius hospital in Roermond. And secondly, patients with chronic low back pain (CLBP) were included who visited a physiatrist in a tertiary care rehabilitation centre after referral by a physiatrist of one of the five before mentioned hospitals. Inclusion criteria were: (1) one of the pain syndromes: fibromyalgia, CRPS or CLBP. (2) no other somatic disease, that could be responsible for the reported pain complaints. (3) sufficient knowledge of the Dutch language in order to be able to read and interpret the questionnaire.The information and informed consent procedure was approved by the Medical Ethics Committee of the Rehabilitation Foundation Limburg, the Netherlands.For all participating patients:The Dutch Version of the Symptom Checklist (SCL-90) was used to assess psychological distress. The SCL-90 is a multidimensional state measure of psychopathology and consists of eight dimensions: anxiety, agoraphobia, depression, somatic symptoms, distrust and interpersonal sensitivity, anger hostility as well as sleeping disorders. The total SCL-90 score reflects general psychoneurotiscism or psychological distress. Reliability and validity of the Dutch version of the SCL-90 have been reported to be adequate ,12.The Dutch version of the Tampa scale for kinesiophobia (TSK) measures fear of movement. This questionnaire contains 17 items and is aimed to assess fear of (re)injury due to movement. The Dutch version of the TSK has been reported to be reliable and valid ,13,14.In addition, for the patients with fibromyalgia the following instruments were assessed:The Dutch version of the Fibromyalgia Impact Questionnaire (FIQ) was used to score disability due to fibromyalgia. The FIQ consists of 10 items. The scores of each item are standardized on a scale ranging from 0–10 with higher scores indicating a higher level of impairment. The FIQ is validated for the Dutch language and its reliability, construct validity and responsiveness appeared to be sufficient .The SF36 is a generic instrument measuring health related quality of life . It compTo answer the first research question, contributing factors for the explanation of disability in fibromyalgia were explored based on a linear regression analysis. The dependent variable in the regression model was disability as measured with the total FIQ score. Independent variables were selected based on a holistic view on pain related disability in which biomedical, psychological as well as social factors have their influence. From a biomedical perspective gender and physical functioning  were included as independent variables. To reflect psychological functioning both fear of injury and mental health  were included. A patient's social situation was represented by social functioning, which is assessed based on the score on this subscale of the SF36. Collinearity control included checking variable inflation factors (VIF), which had to be below 10. Extreme values, more than 3 box lengths from the upper or lower edge of the box, and outliers, with Cook's distance above 1, were discarded.2 analysis for dichotomous variables; (2) a one-way analysis of variance (ANOVA) including a post hoc range test according Tukey for normal distributed continuous variables; (3) a Kruskal-Wallis one-way analysis of variance for non-normal distributed continuous variables (two tailed-test with significance level of p < 0.05).To answer the second research-question three groups of patients with different pain syndromes were compared using the following tests: (1) a χTo interpret the impact of the fibromyalgia syndrome on the quality of life, the total score of the SF36 of patients with fibromyalgia in this study was studied in comparison with scores of patients with fibromyalgia from other studies, quality of life scores of patients with other chronic pain conditions and scores of persons out of the general population.Analyses were performed using SPSS software .111 patients participated in this study: 54 patients with fibromyalgia, 22 patients with CRPS and 35 patients with CLBP. Of the patients with fibromyalgia, 33.3% was referred by their general practitioner, 58.3% by their rheumatologist and 8.3% by another medical specialist. Main patient characteristics are presented in Table In view of answering the first research question in Table In order to test the impact of the pain syndrome on mental health as a prominent disabling factor, psychological profiles of patients within the three groups of pain syndromes were further analysed. The psychological profiles of patients with fibromyalgia and other pain syndromes (CRPS and CLBP) are presented in Table The health related quality of life of patients with fibromyalgia as related to the quality of life of patients in other chronic conditions is presented in Table Based on the results of this study, the level of perceived disability in patients with fibromyalgia seemed best explained by their mental health condition and less by their physical condition. Furthermore, it appeared that the level of psychological distress was higher in patients with fibromyalgia as compared to patients with CRPS or CLBP. The impact of fibromyalgia on the quality of life appeared to be considerable.This study is performed based on data of patients entering rehabilitation departments in a chronological order. Although patients with fibromyalgia entered the study after referral by consultants in rehabilitation medicine of one of five rehabilitation departments, patients with CRPS and CLBP were included out of only one department. As a result, the number of patients in both other pain conditions (22 with CRPS and 33 with CLBP) is rather low, and group sizes are unequal. For this reason non-parametrical testing was used when population based scores were compared. The group size of patients with fibromyalgia also had implications for the regression analysis performed. Due to the number of 54 participants, the number of independent variables that could be introduced in the regression analysis was rather limited. As a result of this, only the most prominent factors out of the explanatory models for pain related disability were chosen and introduced in the current regression model. A second drawback within this study is the fact that the composition of the three groups of patients appeared to be unequal regarding the male/female ratio. In addition, although all patients had a chronic pain condition, patients with fibromyalgia and CLBP had pain for a longer period in comparison with CRPS patients. However, differences in pain duration will presumably not have influenced the results of this study. Although median pain duration of 1.5 years for patients with CRPS was significantly shorter, this time period seems however extensive enough to elicit psychological distress. On the other hand, an interfering influence of gender could be hypothesized. For this reason, in the regression analysis the model is corrected for gender. Based on the results of the regression analysis, it appeared that gender did not significantly influence the explanation of the level of disability. In the analysis for psychological distress no correction for gender was performed, merely because of the low number of participants. As a result of this, in interpreting the result of this analysis, gender related differences have to be considered. Thirdly, the inclusion of the three groups of patients with chronic pain was based on their referral to secondary or third care rehabilitation care. Patients who entered the study visited the department of a rehabilitation specialist referred by different medical specialists or general practitioners. For the patients with fibromyalgia, at the moment of inclusion in the study, no additional check, such as a check of the American College of Rheumatology guideline, was performed by the researcher or consultant in rehabilitation medicine. However, before entering the rehabilitation department, for 94.6% of the patients fibromyalgia was diagnosed by a rheumatologist, according to their professional reumatological guidelines, which includes a check of the criteria of the American college of Rheumatology. In case the analyses were repeated with patients included referred by the rheumatologist (N = 51), results didn't differ from the results found on the total population of patients with fibromyalgia. The study population represents a population of patients with fibromyalgia and CRPS normally being referred to secondary care rehabilitation services in The Netherlands. The CLBP patients however, were referred to a tertiary rehabilitation centre, which might indicate that their level of distress and fear of injury might be higher than the ones normally seen in secondary care.In this study, it appeared that the level of psychological distress of patients with fibromyalgia exceeds the scores for patients with CRPS and CLBP. The median score of 159 and 152 for consecutively patients with CRPS and CLBP are in agreement with published mean score of 146 (SD 49) for male and 150 (SD 44) for female patients with chronic pain who visited Dutch pain clinics N = 2458 . In contThe fact that depression and anxiety appeared to be high in patients with fibromyalgia could support the hypothesis of van den Houdenhoven that in patients being deprived of "overactivity" as their favourite coping strategy, anxiety and depression can occur and can have a substantial influence on the level of disability. The fact that in the regression-analysis, mental health contributed significantly in the explanation of a patient's disability level confirms the influence of psychological wellbeing on the functioning of patients with fibromyalgia. It is of great importance to identify factors that are associated with disability in patients who persist in performing activities, as this group may be distinguished from patients who use avoidance strategies to cope. The idea of van Houdenhoven regarding disability in chronic pain patients with a premorbid overactive lifestyle matches the ideas explained in the self-discrepancy model of Higgins . In viewIt seems that patients with fibromyalgia experience a lower quality of life as compared to the general population. In comparison with patients with rheumatoid arthritis, especially mental health and social functioning of patients with fibromyalgia seem to be more affected. Quality of life of patients with fibromyalgia was associated with their fibromyalgia related disability level. The total impact on quality of life of fibromyalgia, as in CLBP, seem considerable. However, in comparing data of the different studies, it is important to consider that: Firstly, no statistical testing has been performed to confirm differences in scores on quality of life of the different patients groups and secondly data within Table If it can be confirmed that in a population of patients with fibromyalgia, especially patients with persistent behaviour seem to be present, these patients will not benefit from the current approach in rehabilitation medicine focusing on enhancing the level of physical activity. It may be speculated that patients who show persistent behaviour might benefit from learning how they can reduce for example their self discrepancies and associated negative emotions and fine tune their activities during the day. Distinguishing groups of activity related behaviour seems therefore an important research topic. This could lead to selecting specific treatments in the future for different patients with chronic pain, and especially in patients with fibromyalgia.This study is based on a cross sectional design and hypotheses on disabling factors for fibromyalgia are given. To study contributing factors in chronification of the pain related syndromes and their impact on daily life a prospective cohort study seems more appropriate as compared to the current cross sectional design. However, we believe that the preliminary results of the current study are of value for further research. As a result of this, further research is warranted.Based on the results of this study, it can be concluded that patients with fibromyalgia report a high impact on their quality of life. The level of perceived disability in patients with fibromyalgia seemed best explained by their mental health condition. It appeared that the level of psychological distress was higher in patients with fibromyalgia as compared to patients with other pain syndromes.ANOVA: One-way Analysis of Variance; CLBP: Chronic Low Back Pain; CRPS: Chronic Regional Pain Syndrome; FIQ: Fibromyalgia Impact Questionnaire; SCL90: Symptom Checklist; SD: Standard Deviation; SF36: 36 Items Short Form Health Survey; SPSS: Statistical Package for the Social Sciences; TSK: Tampa Scale of Kinesiophobia; VIF: Variable inflation factor.The author(s) declare that they have no competing interests.JAV was the first author of this study and had an initiating role in all phases of the study. DHP had an important role in the acquisition of the data and had a substantial contribution in drafting the manuscript. RJS has been involved in the analysis and interpretation of the data in combination with drafting the manuscript. All authors read and approved the final manuscript.


Objective: The purpose of this article is to describe the early clinical experience with AWBAT. Methods: Burn patients requiring (1) donor sites or (2) treatment of a superficial burn wound injury were treated. A total of 45 patients with 69 distinct wounds were included. AWBATTM-D was evaluated in donor sites and AWBATTM-S was evaluated in superficial partial-thickness burns. Days to healing, pain, hematoma/seroma formation, and infection were noted. Ease of application, adherence, transparency, and physical adaptability details were collected. Results: Average period to healing of donor sites treated with AWBAT-D (n=22 patients with n=26 wounds) was 11.2 days, σ =1.95, with a range of 8–15 days and a median of 11 days. Pain rating at 24 hours was 1.2, σ =0.43 (n=18) and at 48 hours mean was 1.2, σ =0.46 (n=15). Average period to healing of superficial burns treated with AWBAT-S (n=15 patients with n=18 wounds) was 8.1 days, σ =2.48, with a range of 5–13 days and a median of 7 days. Pain rating at 24 hours was 1.5, σ =0.85 (n=10) and at 48 hours mean was 1.75, σ =0.89 (n=8). There was zero incidence of hematoma/seroma. No infections were seen. Results indicate that AWBAT was easily applied with good initial adherence. It was noted to be transparent, conformant, and pliable. Discussion: Early experience demonstrates that AWBAT performs well on donor sites and superficial partial-thickness burns and delivers the desired attributes of a temporary skin substitute including good adherence, infection control, transparency, adapatability, and pain control. AWBATTM is a newly designed advanced wound care product intended to satisfy the desired attributes of a temporary skin substitute. AWBAT consists of a thin silicone-nylon membrane with porcine type 1 collagen peptides embedded in the nylon. AWBAT is manufactured in such a way that the continuity of the 3-dimensional nylon structure over the entire surface of the dressing is unharmed. AWBAT was cleared by the Food and Drug Administration in February 2009 and is available in 3 configurations: AWBAT-D, intended for donor sites after hemostasis has been established; AWBAT-S, intended for clean, superficial burn wounds; and AWBAT-M for use as a protective covering for meshed autografts. AWBAT was evaluated in an early clinical experience program between May and July 2009. Thirteen surgeons at 8 burn centers across the United States participated in this program.AWBAT-D was evaluated for use on donor sites, and AWBAT-S was evaluated on clean, superficial burns.AWBATTM are reported in this article. Both AWBAT-D and AWBAT-S consist of a thin silicone-nylone membrane with porcine type 1 collagen peptides embedded in the nylon. The primary difference in the 2 configurations is the porosity. AWBAT-D is approximately 9% porous, whereas AWBAT-S is approximately 5.5% porous.Two configurations of AWBAT-D was evaluated in patients requiring the harvest of donor sites for skin grafting of full-thickness burns, and AWBAT-S was evaluated in patients requiring treatment of clean, superficial burns. Each group will be described in detail.AWBAT-D was then placed on the hemostatic wound with the nylon/collagen (dull) side down and silicone (shiny) side up. Anchoring one edge, the product was smoothed over the wound to minimize wrinkling. Various anchoring methods including steri-strips, surgical staples, sutures, and liquid adhesives were used. An outer absorptive dressing was then placed over the secured AWBAT-D. Various products were used including an Exu-DryTM pad or an ABD pad. The outer dressings were held in place with a KerlixTM roll followed by an ace wrap. Patients were examined at 24 to 48 hours and evaluated for hematoma/seroma formation, level of pain, and signs of infection. In addition to these clinical parameters, the product was evaluated for physical characteristics including ease of application, adherence, and transparency. Patients were then followed until the donor sites were healed to document the number of days it took to heal the wound.Following surgical preparation and draping, donor sites were harvested using a dermatome. Depth of grafts ranged from 0.008 in to 0.015 in. Both tumescent and nontumescent techniques were used. Once harvested, hemostasis was achieved using a variety of techniques including epinephrine soaks and fibrin sealants. AWBAT-S. First, blisters, loose skin, and debris were removed from the burn wound. AWBAT-S was placed onto the wound with the nylon/collagen (dull) side down and silicone (shiny) side up. It was gently stretched and smoothed over the open wound to minimize wrinkling. Various anchoring methods were used including steri-strips, surgical staples, sutures, and liquid adhesives. An outer absorptive dressing was then placed over the secured AWBAT-S. Various products were used including an Exu-DryTM pad or an ABD pad. The outer dressings were held in place with a KerlixTM roll followed by an ace wrap. Patients were examined at 24 to 48 hours and evaluated for hematoma/seroma formation, level of pain, and signs of infection. In addition to these clinical parameters, the product was evaluated for physical characteristics including ease of application, adherence, and transparency. Patients were then followed until the donor sites were healed in order to document the number of days it took to heal the wound.Superficial partial-thickness burns were treated with At the time of application, the product was evaluated for a number of physical characteristics and qualities including transparency, adherence, and ease of application. In the following days, the wounds were evaluated for hematoma or seroma formation, as well as signs of infection. The primary end point was days to healing of the wound. Inpatients were evaluated for healing daily. Outpatients were evaluated at routine clinic visits. All patients were asked to evaluate their pain on a scale of 1 to 10, with 1 defined as no pain and 10 defined as being the worst pain ever experienced.AWBAT-D was used in 26 patients on a total of 34 wounds. AWBAT-S was used in 19 patients on a total of 35 wounds.The initial clinical experience in donor sites and superficial partial-thickness burns consisted of 45 patients with a total of 69 wounds. AWBAT-D for donor site wounds resulted in a total of 22 evaluable patients with 26 wounds. Data from 4 patients are not included as 2 patients had the AWBAT-D removed at day 6 per burn center donor site protocol, 1 patient expired, and 1 patient was lost to follow-up after surgery. Results are summarized in Table The experience using n = 18), and at 48 hours, the mean was 1.2 (SD = 0.46) (n = 15). No hematomas or seromas were noted. Importantly, there were no infections reported. The physical properties of AWBAT-D were also evaluated. Characteristics evaluated included the ease of application and the initial adherence of the product. In the 34 wounds covered with AWBAT-D, the ease of application was excellent (n = 27) and good (n = 7) in 100% of the patients treated. The initial adherence was excellent (n = 17) and good (n = 17) in 100% of the patients treated. In addition, AWBAT-D was consistently noted to be transparent, conformant to the wound, and pliable , and median was 11.0 days. Pain was evaluated at 24 and 48 hours. At 24 hours, the mean pain rating was 1.2 (SD = 0.43) , 1 patient expired, 1 patient was lost to follow-up after surgery, and 1 patient had AWBAT-S removed by the surgeon due to nonadherence on a deep wound. Results are summarized in Table The experience with n = 10) and at 48 hours, the mean was 1.75 (SD = 0.89) (n = 8). No hematomas or seromas were noted. Importantly, there were no infections reported.The range of days to healing was 5 to 13, the mean days to healing was 8.1 (SD = 2.48), and the median was 7.0 days. Pain was evaluated at 24 and 48 hours using a pain scale of 1 to 10. At 24 hours, the mean pain rating was 1.5 (SD = 0.85)  or good (n = 15) on 86% of the patients treated and fair (n = 5) in 13% of patients treated. The initial adherence was excellent (n = 9) or good (n = 26) in 100% of patients. In addition, AWBAT-S was consistently noted to be transparent, conformant to the wound, and pliable  the search has continued. The ideal properties of a synthetic wound dressing or biologic skin substitute have been outlined by numerous authors.1AWBAT were collected from 8 burn centers across the United States. The product evaluation process addressed the desired qualities of an advanced wound care product for use in burn centers.Early clinical experience data with AWBAT was noted to have excellent to good initial adherence in 92.8% of applications. Complications such as hematoma/seroma formation under biological dressings can complicate the postoperative course, leading to the need for evacuation of the fluid or removal of the dressing. Fluid collection can inhibit adherence and may also lead to infection. AWBAT is highly porous and features nylon that provides a contiguous 3-dimensional structure. It allows fluid to pass through the pores thereby minimizing fluid accumulation once placed on the wound. Fluid passes through the AWBAT into an outer absorptive dressing as noted in Figure AWBAT were also evaluated. This included transparency, conformance of the product to the wound, and pliability. AWBAT was consistently noted to be transparent, conformable to the wound, and pliable.The physical characteristics of AWBAT-D from a wound that appeared to be healed, application of a petrolatum-based product or soaking was effective. In addition, because of the rapid healing, it should be noted that the range of days to healing might be overstated in the program statistics.Among the numerous clinical observations made during the program, perhaps the most clinically significant was the rapid healing of donor site wounds. Healing was observed in 8 to 15 days. On some wounds, particularly outpatients, it was observed that the material could have been removed sooner because of this rapid healing process (Fig AWBAT was used as a primary, single application dressing. In all cases, it remained on the wound until healing was complete. Single application dressings typically reduce the need for multiple dressing changes and thereby the associated costs and patient discomfort. Cost data were not specifically tracked in this program; therefore, no specific conclusions can be drawn regarding cost savings.Another important clinical observation was that without exception AWBAT had very low postoperative pain scores. In addition, there were many anecdotal comments from the burn care teams regarding the minimal level of pain in patients treated with AWBAT.Data were collected on the patient's perception of pain from those patients who were able to verbalize. The data clearly indicate that patients treated with AWBAT is continuing in multicenter, comparative trials.Evaluation of AWBAT performs well as a donor site dressing and as a treatment of superficial partial-thickness burns. Early evaluation indicates that AWBAT delivers the desired attributes of an advanced wound burn dressing, including good adherence, moisture control, transparency, and physical adaptability. Importantly, AWBAT performed strongly in the areas of infection control and pain management.


Chemotherapy-induced peripheral neuropathy (CIPN) is a frequently encountered complication. It can result from a host of agents. Various modalities of treatment have been advocated, of which a novel method is radio frequency ablation. A 63-year-old male, a case of carcinoma prostrate with bone metastases, presented with tingling and numbness in right upper limb. He was given morphine, gabapentin and later switched to pregabalin, but medications provided only minor relief. Initially he was given stellate ganglion block, then radiofrequency ablation of dorsal root ganglion was done, but it failed to provide complete relief. Pulsed radiofrequency ablation (PRF) was then done for 90 seconds; two cycles each in both ulnar and median nerve. After the procedure the patient showed improvement in symptoms within four to five hours and 80% relief in symptoms. We conclude that PRF can be used for the treatment of drug resistant CIPN. Chemotherapy-induced peripheral neuropathy (CIPN) is a common side effect observed following exposure of patients to the vinca-alkaloids, the taxanes, the platinum derived compounds, suramin, thalidomide and most recently also associated with bortezomib therapy. The onset of chemo-neuropathy is generally early in treatment, between the first and third cycle, with the peak in severity occurring approximately three months into therapy.2 PatientThe time course for resolution of CIPN is highly variable. Several pharmacological agents have been used in the prevention and treatment of established CIPN. They are tricyclic antidepressant, gabapentin, pregabalin, lamotrigine, topical combination of baclofen, amitrypline and ketamine and Acetyl-L-Carnitine. The RF lesioning technique involves placement of an insulated needle with an active tip in the vicinity of a nerve or ganglion. Two typeWe present the case of a 63-year-old male of carcinoma prostrate with multiple bone metastases who had received chemotherapy with docitaxel.A 63-year-old male with carcinoma prostrate was being treated in our hospital. The patient had developed multiple bony metastases in acetabulam, left ischium, femur head, spine, ribs, pelvis and skull. Patient had undergone bilateral orchidectomy and was on biclutamide, an antiandrogen.Patient was given chemotherapy with docitaxel and prednisolone after surgery along with palliative radiotherapy to hemipelvis. Three months after the surgery and completion of chemotherapy, the patient started complaining of pain in the right palm and tingling sensation in right hand. There was also numbness present in the distribution of right arm, forearm and hand. The patient was investigated and a cervical X-ray showed C5-C6 block vertebrae and C2-C3 fusion . Stellate ganglion block was performed but no significant relief was noted. The patient was put on morphine and gabapentin.The patient initially had some relief with oral medications. But soon higher doses of morphine were needed for pain control and radiofrequency ablation of dorsal root ganglion  was planned. The patient had good relief of arm and forearm pain with mild pain persisting in right palm. The pain gradually increased in severity after eight months, though earlier the patient was stable on a dose of morphine and pregabalin. Cervical epidural steroid was tried, but it gave only transient relief. Pain and numbness in the right hand increased, with patient needing increased morphine doses.A differential diagnosis of carpal tunnel syndrome was considered. Nerve conduction velocity study was done. Motor nerve conduction was normal in all tested nerves. Sensory nerve conduction study revealed latency difference of 0.6 milliseconds on the right side and 0.3 milliseconds on the left side, between the median and ulnar nerve. Nerve conduction studies were conclusive of Grade 1 carpal tunnel syndrome on right side. Nerve conduction study showed that carpal tunnel syndrome was unlikely to be the causative agent.Pulsed radiofrequency of the median and ulnar nerve was considered. Informed consent was obtained. Intravenous access was secured. The patient was made supine and right wrist was extended. Under full aseptic precautions, using landmark technique and nerve stimulator guidance, the pulse radiofrequency ablation was done for 90 seconds two cycles in both ulnar and median nerve. The patient started showing relief in the symptoms within two to four hours. On the next day, the patient reported 40% relief in pain. Within two days patient reported relief of 90% in pain. The dose of morphine was stopped and patient was discharged with no pain medications.Cancer patients suffer from numerous symptoms including fatigue, depression, sleep disturbance and pain that often co-occur and interact to magnify their respective impact. Disease and treatment related pain is a major cause of treatment failure. Pain is not only associated with active disease, but is also a common symptom that persists in cancer survivors. Cancer related pain has multiple mechanisms. The direct invasion by tumors into bone, soft tissues and viscera produces nociceptive, somatic and visceral pain, whereas tumor invasion and compression of the spinal cord and nerves causes neuropathic pain. Brachial and lumbosacral plexopathies are relatively common in patients with lung, breast and abdominal malignancies.CIPN is a common side effect observed post exposure to vinca-alkaloids, taxanes, platinum derived compounds, suramin, thalidomide and most recently with bortezomib therapy. It appears that onset and severity depends on a variety of factors including concomitant medical conditions such as diabetes, alcoholism and paraneoplastic sensory neuropathy.2 paclitaxel or higher developed paraesthesias on average 3.3 days after treatment and severity of symptoms peaked at 10 days after the infusion.[2The onset of chemo-neuropathy is generally early in treatment, between the first and third cycle, with the peak in severity occurring approximately three months into therapy.2 Onset iinfusion.–5 The clnfusion.2 SymptomsClinical examination of chemo neuropathy patients reveals an early loss of distal deep tendon reflexes followed by involvement of more proximal reflexes in a dose dependent manner. Ankle reflexes are decreased or absent in more than 95% of patients receiving paclitaxel and vincristine. Quantative sensory testing in subjects with chronic vincristine, paclitaxel, cisplatin or bortezomib induced peripheral neuropathy reveals many shared features as well as subtle disturbances. Patients with each type of neuropathy show increased touch sensation in areas directly affected by sensory disturbances, including the fingertips, palms, toes and soles of the feet, but also in volar skin outside the area of patient’s complaint. These changes likely underlie the impairment of daily activities noted in chemo neuropathy patients such as writing, buttoning clothes and handling objects. Nerve biCompared to other neuropathies or neuropathic pain syndromes, CIPN resembles diabetic neuropathy with similar glove and stocking distribution and other characteristics, such as pain, paraesthesias, and dysaesthesias. However, treatments for diabetic neuropathies are not necessarily helpful for preventing or treating neuropathies associated with chemotherapy. The agents used in the prevention of CIPN are calcium and magnesium infusion, vitamin E, glutamine, glutathione, N-acetyl cysteine and anti-epileptic drugs like carbamazeipne. There are several pharmacological treatments available for established CIPN like tricyclic antidepressant, gabapentin, pregabalin, lamotrigine, topical combination of baclofen, amitryplineand ketamine and acetyl-L-carnitine.et al. demonstrated that the pain relief produced by CRF of a dorsal root ganglion long outlasted the clinical evidence of denervation.[et al. demonstrated equal efficacy of CRF and PRF treatments.[The use of CRF treatment has been well-accepted in the realm of pain management practices, yet there remains a diverse body of conflicting literature that calls into question, not only its mode of action, but also its effectiveness.–8 Severaervation. Slappendeatments. It has beatments. As thereeatments.It is important to note the divergent techniques used in the two types of application. With CRF, electrode placement is directed parallel to the nerve, while with PRF, as most of the current is discharged through the electrode tip, the electrode is positioned perpendicular to the targeted structure. Also, as surrounding tissue fluids are felt to represent a “heat sink”, high tissue impedance is desired with CRF treatment. As a low tissue resistance allows more PRF current to be administered, efforts are made to maintain low tissue impedance during these applications. Moreover, when comparing RF studies, there is wide variability in the methodology used. For example, the proximity of the electrode to the targeted structure, as reflected by sensory stimulation parameters, is often accepted to be of any value less than 1 Volt.The RF lesioning technique involves placement of an insulated needle with an active tip in the vicinity of a nerve or ganglion. A groundNumerous case reports and case series of PRF of numerous peripheral nerves and ganglions for treatment of chronic pain can be found in the literature.–18 BenefPRF is minimally invasive, well tolerated, and lacks potential adverse effects associated with high temperatures and thus holds promise in patients with chronic neuralgic pain that is refractory to conservative therapies.


Recent evidences show that education and rehabilitation while waiting for knee replacement have positive effects on the patients' health status. Identification of factors associated with worse pain, function and health-related quality of life (HRQoL) while waiting for surgery could help develop pre-surgery rehabilitation interventions that target specifically these factors and prioritize patients that may benefit the most from them. The objectives of this study were to measure pain, stiffness, function and HRQoL in patients at enrolment on waiting lists for knee replacement and to identify demographic, clinical, socioeconomic and psychosocial characteristics associated with these outcomes.This study is part of a broader study measuring the effects of pre-surgery wait in patients scheduled for knee replacement. From 02/2006 to 09/2007, 197 patients newly scheduled for total knee replacement were recruited from the waiting lists of three university hospitals in Quebec City, Canada. Pain, stiffness and function were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the SF-36 Health Survey. Stepwise multiple regression analysis was used to assess the strength of the associations between the independent variables and the WOMAC and SF-36 scores.The scores of all eight HRQoL physical and mental domains of the SF-36 were significantly lower than aged matched Canadian normative data (p < 0.05). Contralateral knee pain, higher psychological distress, higher body mass index (BMI) and the use of a walking aid were significantly associated with worse function (p < 0.05) and contributed to 22% of the variance of the WOMAC function score (multiple r = 0.47). A higher BMI, the use of a walking aid, contralateral knee pain and advanced age were significantly associated with worse physical function (p < 0.05) and contributed to 17% of the variance of the SF-36 HRQoL physical functioning score (multiple r = 0.41).Patients waiting for knee replacement have poor function and HRQoL. Characteristics that were found to be associated with these outcomes could help develop pre-surgery rehabilitation program and prioritize patients that may benefit the most from them. Such programs could include interventions to reduce psychological distress, therapeutic exercises targeting both knees and weight loss management. Knee replacement surgery is a common surgical procedure that allows for an effective reduction of pain and adequate restoration of function for the vast majority of patients suffering from advanced knee osteoarthritis or other forms of arthritis.  In the lprehabilitation) have positive effects on the patients' health status and could lead to better outcomes postoperatively. [Waiting for knee replacement surgery represents a significant burden for patients as they experience great pain, suffer functional limitations and loss of health-related quality of life (HRQoL) for many months. Some authors have suggested that long delays for surgery could result in patient's deterioration in terms of pain, functional limitations and HRQoL and may have negative impacts on post-surgery outcomes. -9 To ligatively. ,12 Untilatively.  but thesatively.  Other statively. -19The objectives of the current study were to measure pain, stiffness, function and HRQoL in patients at enrolment on waiting lists for total knee replacement surgery and to identify demographic, clinical, socioeconomic and psychosocial characteristics associated with these outcomes.This study is part of a broader study measuring the effects of pre-surgery wait in patients scheduled for total knee replacement. From 02/2006 to 09/2007, patients were recruited from the waiting lists of the departments of orthopaedic surgery of three university hospitals in Quebec City, Canada .Every week, patients newly enrolled on the waiting lists were contacted over the phone by a research nurse. To be eligible for the study, patients had to meet the following criteria: 1-Aged = 40 years; 2-Newly enrolled on the orthopaedic waiting lists for primary unilateral total knee replacement; 3- Residents of the province of Quebec and beneficiaries of the provincial universal health insurance coverage ; 4- Understand and speak French. Patients were excluded if they presented severe cardiac condition, degenerative disease or mental disorder. Patients with a previous contralateral knee or a hip replacement were also excluded. Those who suffered a major trauma to the knee in the previous year or were operated urgently within 30 days of being put on the waiting list were also excluded.Data were collected through the review of the subjects' medical files and structured telephone interviews conducted within three weeks of the enrolment on waiting lists. The interviews lasted about 45 minutes. Daily attempts were made during weekdays and week-ends to contact new patients.The first dependent variable was the Western Ontario and McMaster Osteoarthritis Index (WOMAC), which measures pain, stiffness and functional limitations related to the knee.  The 5-poThe second dependent variable addressed HRQoL, measured with the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), a generic questionnaire on health status and HRQoL related to eight dimensions of health.  It allow2). Data were typically taken from the pre-operative consultation about 6 weeks before surgery. Patients were also asked about their weight and height at the time of enrolment on the waiting list during the interview. The intraclass correlation coefficient between both measurements was very high .Anthropometric data were collected through the review of the subjects' medical files after enrolment on the orthopaedic waiting lists and allowed the calculation of the BMI . Using the medical files, comorbidities were documented with, the Cumulative Illness Rating Scale (CIRS).  This indDescriptive statistics were used to summarize the subjects' characteristics, WOMAC and SF-36 scores. Ninety-five percent confidence intervals (95% CI) were built around the mean WOMAC pain, stiffness and function score. Means and 95% CI of the SF-36 eight domain scores and the physical (PCS) and mental (MCS) component summary scores were compared to Canadian age-matched normative data using student t-tests.Stepwise multiple regression analysis was used to assess the strength of the associations of the independent variables considered with the WOMAC and SF-36 scores. All three sub-scales of the WOMAC were used as dependent variables in separate models. For the SF-36, separate models were built with the physical and mental summary scores as dependent variables, as well as with the three more responsive health domain scores related to physical health: physical functioning, role-physical and bodily pain.  Age and The information and consent forms were read over the phone and verbal consent was sought. The information and consent forms were then mailed to the patient and all participants signed and returned the consent form. This procedure allowed for timely data collection right at the enrolment on the orthopaedic waiting list. The study was approved annually by the Research Ethics Boards of all three hospitals.Figure 2, indicating a high frequency of obesity defined at ≥30 kg/m2). [Table  kg/m2).  Psycholo kg/m2). Participants presented important pain, stiffness and loss of physical function as measured by the WOMAC: the mean pain score was 47.5 (95% CI: 44.9 – 50.1), the stiffness score was 42.8 (95% CI: 39.8 – 45.8) and the function score was 47.1 (95% CI: 45.1 – 49.2).Summary measures of the SF-36 are presented in Table Because no important differences were found in the selection of independent variables between the initial models and the models in which the dependent variables were transformed into ranks, the final models were built with untransformed scores. Age and sex were forced into all models and no other adjustments of confounding variables were necessary.Results of multivariate analyses on the WOMAC scores are presented in Table Results of multivariate analyses on the SF-36 scores are presented in Table For the physical component scale, use of a walking aid and higher BMI were significantly associated with worse physical HRQoL and explained 8% of the variance of this score (multiple r = 0.28). Higher psychological distress, low social support and contralateral knee pain were significantly associated with worse mental HRQoL and explained 42% of the variance of the mental component score (multiple r = 0.65).In this cross-sectional study, 197 patients were recruited at the time of enrolment on waiting lists for total knee replacement to measure pain, stiffness, function and HRQoL and to identify demographic, clinical, socioeconomic and psychosocial characteristics associated with these outcomes. We found that subjects reported important pain, stiffness and loss of function. HRQoL was also significantly impaired in these subjects, compared to the Canadian norms, for all the domains and components measured. These findings likely reflect the surgical indication of the subjects' condition. Interestingly however, mental aspects of HRQoL were also impaired. This finding may have implication regarding prehabilitation interventions for these patients, since it suggests that it might be beneficial to include mental health interventions to better help these patients. It is coherent with previous evidence that show that good mental health is a protective factor of functional decline in subjects suffering from knee osteoarthritis. We believe that one very interesting finding of our study is that contralateral knee pain is associated with worse pain, stiffness, function and HRQoL related to the knee scheduled for replacement surgery. Although no studies have formally identified this kind of association, from a clinical point of view, it seems logical that patients suffering from both knees have a worse condition. Only one study by Merle-Vincent (2007) has looked at that specific factor but the authors did not find a significant association.  Clearly,Psychological distress was low in this cohort of patients waiting for knee replacement surgery. Nonetheless, it was significantly associated with worse pain, stiffness, function and HRQoL. Other studies have outlined the important role of psychological distress on the health status of patients suffering from knee pain or undergoing knee replacement surgery. ,17 High Low social support was significantly associated with worse mental HRQoL in our study. This finding is compatible with the results published by Ethgen et al. (2004), who found a significant association between social support and mental and physical aspects of HRQoL in subjects suffering from knee osteoarthritis. These authors recommended that physical health interventions should also add a social support component to improve health outcomes in these patients.  In our sContrary to what other studies found, sociodemographic factors were not related to pain, stiffness, function or HRQoL in our study. This may results from the fact that in this cohort of Canadian patients, access to surgery is equitable as it is not diminished in subjects of lower socioeconomic backgrounds nor that workers are fast tracked to see the surgeon. ,16,55Although the association between longer duration of symptoms and knee stiffness found in our study was small, it is unclear why subjects with longer duration would show less stiffness. Maybe it results from a response shift and possible adaptation to the chronic condition of knee osteoarthritis or arthritis.  However Several factors were significantly associated with increased pain, stiffness, loss of function and loss of HRQoL in the study subjects. One of the strengths of our study is that many of these independent factors have a consistent effect across the scales of the WOMAC or the SF-36, which further supports the validity of our results. Other strengths include a high participation proportion (81.7%), thorough and relevant independent variables selection and no indication of selection bias (there were no significant differences between participants and eligible non participants on age and gender (data not shown). The regression models were adjusted for age and gender and further adjustments with other potential confounding factors only marginally changed the strength of the associations and were therefore not kept in the final models.This study used a cross-sectional design and therefore caution is warranted when interpreting our results. Hypothesis related to the causality of the different independent variables on patients' health status need to be validated prospectively. Nonetheless, we believe our results provide valuable information regarding the patients' condition right at their enrollment on pre-surgery waiting list for knee replacement.Another limitation was that the main outcome measures were self-reported and we did not include performance-based measures. The WOMAC and the SF-36 have been found to be valid instruments; still, it has been reported that performance-based measures provide distinct impressions of pain and function that complement self-reported measures.  ThereforAs seen in this cohort or elsewhere in other Canadian provinces or countries, patients will be waiting for many months, often for more than six months with severe pain, loss of function and poor HRQoL.  We acknoThe authors declare that they have no competing interests.This paper reports part of the doctoral dissertation in Epidemiology of FD, realized under the supervision of CED and the co-supervision of RB. FD participated in the design, coordination and collection of data. He performed the statistical analyses, led the interpretation of results and drafted the manuscript. CED participated in the design, coordination, interpretation of results and writing of the manuscript. EB participated in the design, coordination and writing of the manuscript. RB participated in the design and writing of the manuscript. PF participated in the collection of data and the writing of the manuscript. All authors read and approved the final version of the paper.The pre-publication history for this paper can be accessed here:


Pain is the most common reason due to which patients come to the emergency department (ED).The purpose of this study was to measure the correlation, if any, between pain reduction and the level of satisfaction in patients who presented to the ED with pain as their chief complaint.This study used a randomly selected group of patients who presented to the ED with pain of 4 or more on the Visual Analogue Pain Scale (VAS) as their chief complaint to a level one adult and pediatric trauma center. Instruments that were used in this study were the VAS, Brief Pain Inventory (BPI), and the Medical Interview Satisfaction Scale (MISS). They were administered to patients by research fellows in the treatment rooms. Statistical analysis included frequencies, descriptive, and linear regression. This study was approved by the Internal Review Board.A total of 159 patients were enrolled in the study. All patients were given some type of treatment for their pain upon arrival to the ED. A logistic regression showed a significant relationship to reduction in pain by 40% or more and customer service questions.A reduction in perceived pain levels does directly relate to several indicators of customer service. Patients who experienced pain relief during their stay in the ED had significant increases in distress relief, rapport with their doctor, and intent to comply with given instructions. Pain is the most common reason due to which patients come to the emergency department (ED). At leastSeveral studies have shown that patients rate their satisfaction as very good with the treatment they received in the ED despite receiving minimal pain relief.–4 HoweveThe focus on patient satisfaction with the ED encounter has been shown to predict compliance with the treatment. The highSurvey tools with a range of variables, including questions about facilities to measure customer service indicators, have been used in studies. Patient The purpose of this study was to measure the correlation, if any, between pain reduction and the level of satisfaction in patients who presented to the ED with pain as their chief complaint.This study was conducted for a 10-month period, enrolling patients who presented to an urban level one trauma center with 60,000 annual visits, with a chief complaint of pain of 4 or more on the visual analogue scale . Using EXCEL, a random number lists was generated each day in order to randomly select patients who were eligible to take part in the study. Those under 18 years of age, unable to give consent and not presenting with a chief complaint of pain of 4 or more were excluded from the study. This study was Internal Review Board (IRB) approved.Three instruments were used in this study. All these instruments were administered by research fellows in the treatment rooms. For the measurement of initial and 1-hour follow up after treatment was administered, the VAS was given to record pain levels. In additThe MISS, the third instrument administered after treatment and prior to the patient’s discharge, was used to measure the patient’s satisfaction with the individual consultation within the ED. It is a survey that consists of 21 questions that break down the patient’s satisfaction with the ED visit into four categories: distress relief, communication comfort, rapport, and compliance intent. The use of this survey to measure customer service allows for a more cohesive understanding of the components that go toward a positive patient doctor encounter versus previous studies which have measured customer service based on a series of wide variables such as throughput times, facilities, and all staff input. It has been shown to demonstrate evidence for concurrent validity and for internal consistency  on MISS.A total of 200 patients were approached, with 159 patients enrolling in the study. The chief reason given by those not consenting to take part in the study was that they were in too much pain to participate. The sample consisted of 57% females and 43% males. The top four locations of pain were 36% abdominal, 23% chest, 16% extremities, and 5% other. The vast majority (82%) reported having pain on a scale of 7 or more when they presented to the ED for treatment. All the patients were given some type of treatment for the pain upon arrival to the ED. These treatments did bring about relief for 60% of the patients, with 40% reporting no relief .P = 0.03), “The doctor told me all I wanted to know about my illness” (P = 0.01), “The doctor seemed warm and friendly to me” (P = 0.00), “This is a doctor I would trust with my life” (P = 0.01), “The doctor seems to know what he/she is doing” (P = 0.03). Patients who did not experience relief of their pain reported having had a relationship with the doctor “not allowing me to talk about my problem” (P = 0.01), “not certain why I came in” (P = 0.01), and were “not sure the treatment is worth the trouble” (P = 0.01).The overall results of the MISS survey were positive with the majority (60%) stating that the doctor was interested in them as a person, seemed warm and friendly (65%), took their problems seriously (68%), and they felt free to talk to the doctor about private matters (55%), and the doctor gave advice that was easy to follow (73%). It did capture a few negatives about the patient’s ED experience in that they did not feel that the physician let them say everything they wanted to about their problems (58%) and did not fully understand them (75%). One limitation, however, is that for 8 of the 21 questions, 15–20% of patients were uncertain of the answers. However, when looking at pain reduction and survey results, the logistical regression model did show a significant relationship between relief of pain by 40% or more and interaction with the physician. The selection of 40% or more pain reduction was used to comply with the guidelines for pain reduction put forth by JCAHO (4). The significant questions were as follows: “After talking to doctor I know how serious my illness is” , seemed warm and friendly (65%), took their problems seriously (68%), they felt free to talk to the doctor about private matters (55%), and the doctor gave advice that was easy to follow (73%). They did not, however, feel that the physician let them say everything they wanted to about their problems (58%) or fully understood them (75%). For 8 of the 21 questions, there were 15–20% of patients who were uncertain of the answers, suggesting that a large portion of patients might not have fully understood either the questions or the information given to them by their physician during their ED encounter. These questions were within each of the domain areas which negatively impacted the ability and usefulness of a score within each domain area.We observed from this study that a positive impact on customer service questions in the MISS survey was in important areas of distress relief, rapport, and compliance intent. The patients’ knowledge was increased with regard to what was occurring by making them understand the seriousness of their illnesses and providing them everything they wanted to know about those illnesses. It also increased their positive regard for the physicians involved in that the patients felt the physicians to be warmer and friendlier, understanding, and the patients could trust the physicians with their lives, and believed that the physicians knew what they were doing. As a result, the patients stated that they were more likely to follow the advice given. These findings confirm previous studies which showed a relationship between increased customer service and patients’ intent on following medical advice.As seen in other studies, there were a number of patients (40%) who either did not have relief or experienced less than a 40% reduction in pain during their ED visits.–10 This This study was conducted at one site, an inner city ED with a skewed population. A convenience trial of patients is always a limitation. A study comparing customer service, pain, and other interventions would be more useful if it could be done over several diverse sites. Further studies should also examine why a large number of patients did not receive significant pain relief, as this study was not able to determine the reasons for this outcome. This study was unable to perform subset analysis due to low numbers in some categories such as the difference between patients with low and high levels of pain, diversity in treatment and cause of pain. It was also skewed toward patients with severe pain since the majority of patients presented with pain scale rating of 7 or above. All these factors could have biased results toward a specific type of patient presenting in the ED.The MISS survey did give a more comprehensive view of customer service; however, 20% of respondents answering “not sure” for 8 out of 21 questions strongly suggest some confusion or misunderstanding of the questions and limited the ability to use the questions to generate a score for each domain area. A study using another customer service survey and the MISS might be useful to determine if it is the survey tool or other issues such as the educational levels of subjects that impacted the uncertain responses.Patients who had a reduction in pain during their ED visit did change how they felt about their patient encounter. It appeared to positively impact the perceived level of doctor patient communication about the pain, increase the patient rapport with the physician and whether or not the patient would comply with the medical advice given during the encounter .The use of the MISS survey gave a more direct understanding of what areas of customer service the pain reduction impacted. It also showed that there are other areas that are not impacted by a positive physical outcome, such as communication comfort levels between physicians and patients. This gives an indication, as other studies have shown, that simply solving or addressing the patients’ presenting condition will not uniformly increase their customer service indicators. This was seen in this study in those patients who did not experience pain relief during their encounter. Their response to the survey with the exception of the noted questions was similar to patients who did get pain relief. The fact that such a large percentage had little to no pain relief is an indicator that more needs to be done to address the JHACO concerns apart from its impact on customer service indicators.