Benefits of the ais include less frequent gynecologic, cerebrovascular, and thromboembolic adverse events; greater disease-free survival; and lower tumour recurrence. Although approximately 25% of postmenopausal women with early breast cancer report experiencing symptoms of arthralgia with ai therapy, 68-month data from the Arimidex, Tamoxifen, Alone or in Combination trial showed that, compared with tamoxifen, anastrozole treatment was associated with only a modest increase in the incidence of joint symptoms. The events, which were mostly mild-to-moderate in intensity, led to treatment withdrawal in 2% of patients on anastrozole as compared with 1% in the tamoxifen arm. The symptoms and changes correlate with clinical, biochemical, and radiologic findings in symptomatic women. To determine appropriate intervention, it is therefore essential to perform a comprehensive evaluation of musculoskeletal complaints to distinguish natural menopause-related degenerative disease from ai-related effects. The present review explores the advantages of differential diagnosis with an emphasis on history and physical and musculoskeletal examination; laboratory investigations are used to corroborate or rule out clinical impressions. The transient symptoms associated with the ais are manageable with an appropriate combination of lifestyle changes, including exercise and joint protection in conjunction with pharmacologic approaches.For the upfront adjuvant therapy of postmenopausal estrogen receptor–positive breast cancer, the third-generation aromatase inhibitors ( In atac, after 68 months’ median follow-up, the incidence of arthralgia was significantly higher in the anastrozole group than in the tamoxifen group [1100 of 3092 (35.6%) vs. 911 of 3094 (29.4%) patients] ai therapy , with a peak incidence at 6 months . However, half of the patients who recovered were symptom-free within 6 months of onset, and in 75% of patients, symptoms resolved within 18 months. Most events were mild to moderate in intensity, and only a small fraction of patients (2% with anastrozole and 1% with tamoxifen) discontinued treatment because of bone symptoms The Intergroup Exemestane Study, which enrolled 4742 postmenopausal women with hormone receptor–positive or unknown breast cancer, has also shown a link between arthralgia and the The prevalence of joint pain in the knees, hands, feet, and other joints increases with age in women, reaching a maximum in the group 50 to 59 years of age, implicating hormonal changes ai therapy of postmenopausal early and advanced breast cancer results in enhanced nociception and higher rates of arthralgia than are seen with tamoxifen The physiologic underpinnings of joint pain involve activation, by inflammatory mediators such as prostaglandins and bradykinin, of the nociceptive fibres innervating the articular structures. Activated nociceptors increase sensitivity to pain caused by a stimulus, including a mechanical stimulus. Inflammation leading to expansion of the nociceptor’s receptor field enhances neural transmission and the overall pain perception Unfortunately, coexisting conditions such as degenerative joint disease, fibromyalgia, osteoporosis, and degenerative disc disease contribute to worsening of the arthralgia or bone pain syndrome ai therapy from bone disease and inflammatory and degenerative arthropathies, and from pain secondary to other diseases. The complex challenge facing the physician is therefore to accurately distinguish arthralgia associated with ai therapy. This discomfort is usually symmetrical, and may be associated with mild soft-tissue thickening In the preliminary assessment of musculoskeletal complaints, the emphasis is on patient history and physical examination The next step entails determining whether the condition is articular  or non-articular; inflammatory or non-inflammatory; and acute (less than 6 weeks’ duration) or chronic (6 weeks’ duration or longer). Complaints of “joint pain” may originate from the joint itself or from periarticular loci such as adjacent bone, ligaments, tendons, bursae, or soft tissues  25,28.ibd), psoriasis, reactive arthritis, hemochromatosis, and hypothyroidism. All medications should be reviewed as completely as possible, including diuretics, antihypertensives, anticonvulsants, cholesterol-lowering agents, and others. Social history should be examined for work, sexuality, living, travel, and familial patterns of connective tissue disease, psoriasis, ibd, and gout. A systems review should also be undertaken to note any other symptoms or infections of the gastrointestinal, genitourinary, ocular, and skin systems Appropriate medical history should include investigation of the co-morbidities linked with musculoskeletal complaints: inflammatory bowel disease , or the presence of renal, pulmonary, neurologic, or ocular signs or symptoms. Any joint effusion may be clinically significant and should be observed expectantly, except when septic arthritis, osteomyelitis, fracture, mechanical derangement, or tumour is suspected. Lyme arthritis should be considered in patients with new persistent inflammatory features—including effusions—in regions where Lyme disease is endemic, or in patients with a history of travel to an endemic area. Synovitis is usually indicated by the presence of “stress pain” or an effusion.Mal-alignment and bony enlargement may suggest advanced osteoarthritis. On the other hand, joint tenderness with full and painless passive range of motion may indicate a peri-arthritis, including bursitis, tendonitis, tenosynovitis, or enthesitis, but no inflammation of the synovial lining of the joint space , Table  The pattern and number of inflamed joints should be observed: acute monoarthritis may represent septic arthritis or crystal arthritis , psoriatic arthritis, or arthropathy of ibd involve peripheral joints, enthuses, and whole digits (dactylitis).Psoriasis and osteoarthritis should be suspected if the distal interphalangeal and proximal interphalangeal joints are involved. Gonococcal arthritis, Myalgias and stiffness of the shoulder and pelvic girdle that occur in patients more than 50 years of age may be suggestive of polymyalgia rheumatica. Infection, metastatic malignancy, or neurologic causes must be ruled out when evaluating new low back pain in this group of patients.esr) and C-reactive protein (crp) test are non-specific and may be elevated with other conditions, including malignancy and infection. Rheumatoid factor is also non-specific and increases with age, regardless of the presence or absence of joint disease. Patients with connective tissue diseases, diffuse musculoskeletal symptoms, or drug-induced diseases may have positive antinuclear antibodies.The laboratory test that is most useful for evaluating patients with inflammatory arthritis and an effusion is synovial fluid analysis . The eryai-induced arthralgia have not been clearly delineated, but the musculoskeletal symptoms and changes have been investigated at the clinical, biochemical, and radiologic levels in symptomatic women. For instance, after an average of 8 weeks’ treatment, the symptoms most commonly reported with ais such as letrozole or exemestane have been severe early morning stiffness and hand–wrist pain. Clinical signs included severely limited mobility in the affected part of the hand or wrist. “Trigger finger” and carpal tunnel syndrome were the most frequently reported clinical signs, but inflammatory disease was ruled out in the absence of elevation in crp or esr, although those tests have not been assessed for sensitivity or specificity in this population. However, ultrasound examination showed fluid in the tendon sheath surrounding the digital flexor tendons. Magnetic resonance imaging (mri) in various patients showed fluid in the tendon sheaths of the digital flexor muscles, intra-articular fluid accumulation in the metacarpal joints, and synovitis of the radiocarpal joint mri of the spine and computed tomography The pathogenic and anatomic features of ai-related joint symptoms being 7 for pain and 6 for stiffness on a scale of 0–10. However, more than half of patients with ai-associated joint symptoms reported relief with medications or supplements. Of those taking an analgesic, 41% took acetaminophen, 59% took a nonsteroidal anti-inflammatory drug (nsaid), and 12% took other medications. The median score for relief achieved with oral medications was 7. In addition, 55% of patients used non-pharmacologic interventions, mainly exercise, to alleviate joint symptoms Studies reveal that the three most common sites of arthralgia, in descending order, are knees, hands and wrists, and shoulders, with the median severity scores of nsaid alone or in combination with mild analgesics Compared with patients receiving tamoxifen, patients receiving anastrozole had only a modest increase in joint symptoms, and most reported symptoms that were mild to moderate in intensity, eliminating the need for treatment withdrawal. Indeed, more than 90% of patients treated for anastrozole-induced joint aches and pains were managed with an ai-associated arthralgia may be a combination of lifestyle changes, such as introducing weight-bearing exercise, abstaining from smoking, being moderate in alcohol consumption, and taking dietary calcium supplements and vitamin D for bone protection in conjunction with pharmacologic approaches. aiThe most appropriate intervention for pain management in Chronic pain may be relieved either with heat, in the form of warm showers or hot massage, or with acupuncture and acupressure techniques or transcutaneous electrical nerve stimulation Pain associated with arthralgia of the knees may also be managed through patellar taping and appropriate footwear with lateral wedged insoles . Furthermore, regular stretching, joint mobility exercises and physiotherapy to regain strength, increase flexibility, relieve tension, and reduce fatigue are recommended. In addition, psychotherapy including relaxation training, biofeedback, visual imagery, distraction methods, and psychiatric intervention could effectively alleviate pain-related emotional stress and depression nsaids such as naproxen, mild opiates, strong opiates, and glucosamine cox2 may be a good choice when nsaids are contraindicated. As well, topical medications such as capsaicin and methylsalicylate may provide pain relief. Antidepressants may help in the event of comorbid depression associated with chronic pain ai-associated arthralgia with a low body mass index is still not clearly established, although several possible mechanisms associate the phenomenon with an incidence of microfractures and local activation of inflammatory mediators.Bisphosphonates have been associated with modest adjunctive analgesic benefits, but little clinical evidence is available to support their use in early-stage breast cancer nsaids, and those who present with new joint pain symptoms require a rheumatologic evaluation to rule out inflammatory conditions.Patients with severe pain that is refractory to simple analgesics or ai therapy than with tamoxifen. However, they are predictable and may be easily managed with appropriate lifestyle changes and non-pharmacologic interventions, or with pain medications after accurate musculoskeletal evaluation and differential diagnosis. Although a few studies suggest the use of bisphosphonates to manage bone-related side effects ais are discontinued at the end of therapy.Adverse events such as arthralgia and myalgia are more frequent with adjuvant


Pharmacological therapy of back pain with analgesics and anti-inflammatory drugs is frequently associated with adverse effects, particularly in the elderly. Aim of this study was to compare mesotherapic versus conventional systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids in patients with acute low back pain. Eighty-four patients were randomized to receive anti-inflammatory therapy according to the following protocols: (a) mesotherapy group received the 1st and 4th day 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + methylprednisolone 40 mg (1 mL), then on 7th, 10th, and 13th day, 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + methylprednisolone 20 mg (1 mL) (b) conventional therapy group received ketoprofen 80 mg × 2/die and esomeprazole 20 mg/die orally for 12 days, methylprednisolone 40 mg/die intramuscularly for 4 days, followed by methylprednisolone 20 mg/die for 3 days, and thereafter, methylprednisolone 20 mg/die at alternate days. Pain intensity and functional disability were assessed at baseline (T0), at the end of treatment (T1), and 6 months thereafter (T2) by using visual analogic scale (VAS) and Roland-Morris disability questionnaire (RMDQ). In both groups, VAS and RMDQ values were significantly reduced at the end of drug treatment and after 6 months, in comparison with baseline. No significant differences were found between the two groups. This suggests that mesotherapy may be a valid alternative to conventional therapy in the treatment of acute low back pain with corticosteroids and NSAIDs. Low back pain affects a high proportion of adult population in the developed countries and has a major impact on health care system and society , 2. ConvAmong the various attempts to reduce drug toxicity, the use of local therapy  has gained popularity among physicians , 11, desDuring the last decades, researchers and patients have become increasingly interested in complementary and alternative medicine (CAM) as a possible mean to ensure efficacy, while improving therapeutic safety –15. BackMesotherapy was introduced 50 years ago by Michel Pistor, a French physician who utilized this technique as a novel analgesic therapy for a variety of rheumatologic disorders . Mesothe Based on these premises, the following study was designed to evaluate the effectiveness of anti-inflammatory drugs (NSAIDs and corticosteroids) administered via mesotherapy in comparison with conventional systemic therapy by oral and intramuscular route, for the treatment of acute low back pain.The study was carried out at the Department of Physical Medicine and Rehabilitation of the University of Parma following the guidelines for experimental investigation with human subjects required by the local University. Informed written consent was obtained from each patient.Patients were recruited for the study from the Emergency Department between January and May 2007 and checked for eligibility by the clinical investigator. Patients were enrolled into the study, provided that they had been suffering from back pain since no more than 2 weeks and reported a current pain intensity >65 on a 100 mm visual analogic scale (VAS). Exclusion criteria were represented by diabetes, anticoagulant therapy, or pregnancy. Patients were also excluded if they had evidence of cardiovascular, renal, hepatic, gastrointestinal, or psychiatric diseases. Eighty-four patients  aged 24–77 years and suffering from acute low back pain, with cruralgia or sciatalgia were included into the study. Patients could leave the study at any time for any reason.Patients who met the eligibility criteria were randomly allocated to receive anti-inflammatory therapy with NSAIDs (ketoprofen) and corticosteroids , administered either by mesotherapic technique or by oral/intramuscular route, according to the study plan described in Drug regimen employed in group A  was as follows: 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + MP 40 mg (1 mL) at day 1 and 4, then 2% lidocaine (1 mL) + ketoprofen 160 mg (1 mL) + MP 20 mg (1 mL) at day 7, 10, and 13. Five repeated injections (3 mL for each injection) were administered at inter and paravertebral level along the running of sciatic nerve, through specific needles (30 G × 4 mm), which were inserted deeply for the whole lenght . LidocaiGroup B  received drug therapy according to the following protocol: ketoprofen 80 mg X2/die orally for 12 days; MP intramuscularly 40 mg/die for the first 4 days, then 20 mg/die for 3 days, then 20 mg/die at alternate days. Patients of this group received esomeprazole 20 mg/die for 12 days, as gastroprotective therapy.Self-rated pain intensity was assessed by using the VAS scale , a horizontal, unmarked 100 mm scale widely validated to assess pain . FunctioF test was employed for variance analysis and T test for independent data. A P  value < .05 was considered statistically significant.All quantitative data were entered into a specifically designed database (SPSS V 17.01). Chi-Square Mann-Whitney and Kolmogorov-Smirnov test were employed to evaluate the omogeneity of the groups, as for sex or age, respectively. Wilcoxon signed rank test was utilized to analyze the variations among values obtained at baseline (T0), end of treatment (T1), followup (T2), and T0-T1, T1-T2; Krusall-Wallis test was used to analyze differences among T0-T1-T2. A total of 84 patients were enrolled into the study. All treated groups were balanced with respect to demographic and baseline characteristics . In partP  <  .0001) whereas after 6 months only VAS score was still significantly different from baseline (P  =  .04)  and both scores were still significantly different from baseline after 6 months  (In group A (mesotherapy), VAS and RMDQ scores were significantly reduced at the end of the pharmacological treatment ( =  .04) . In groutration) . MesotheThe aim of this study was to evaluate the effectiveness of anti-inflammatory drugs administered via mesotherapy in patients with acute low back pain. Present results showed for the first time that the administration of NSAIDs and corticosteroids via mesotherapic technique can provide the same therapeutic benefit as that induced by conventional  drug administration. Indeed, both treatments significantly reduced pain intensity and disability in daily life activity, and the effect was maintained up to 6 months. These results are in accordance with previous studies showing that naproxen and diclofenac, administered via mesotherapy, were more effective than after oral administration , 32, 33.The major finding of this study is the comparable effectiveness of mesotherapy and conventional systemic therapy, despite the lower amount of drugs administered to patients undergoing mesotherapy  . The comAlthough no measurement was made in our study of drug plasma levels after the two routes of administration, it is presumable to hypothesize that mesotherapic treatment resulted in a lower systemic bioavailability of drugs, with consequent lower incidence of adverse reactions. This could offer a great therapeutic advantage, when considering the high rates of adverse effects, associated with NSAID or corticosteroid use in the elderly population , 4, 7. WAlthough mesotherapic techniques used in dermatologic surgery have been associated with a number of adverse effects at sites of injection, including atypical mycobacterial infections , urticarIn conclusion, results of the study indicate that combined administration of conventional NSAIDs and corticosteroids by mesotherapy is an effective and well-tolerated method for managing low back pain in the short-term, compared with drug therapy administered by oral and intramuscular route. Possible weaknesses of our study are the small number of patients, the short followup period, and the lack of drug plasma level measurements. However, if confirmed in a large trial, these observations could be of potential interest in the pharmacological treatment of low back pain to reduce the adverse effects associated with high plasma levels of antiinflammatory drugs.


In the last decade the sub grouping of low back pain (LBP) patients according to their likely response to treatment has been identified as a research priority. As with other patient groups, researchers have found few if any factors from the case history or physical examination that are helpful in predicting the outcome of chiropractic care. However, in the wider LBP population psychosocial factors have been identified that are significantly prognostic. This study investigated changes in the components of the LBP fear-avoidance beliefs model in patients pre- and post- their initial visit with a chiropractor to determine if there was a relationship with outcomes at 1 month.Seventy one new patients with lower back pain as their primary complaint presenting for chiropractic care to one of five clinics (nine chiropractors) completed questionnaires before their initial visit (pre-visit) and again just before their second appointment (post-visit). One month after the initial consultation, patient global impression of change (PGIC) scores were collected. Pre visit and post visit psychological domain scores were analysed for any association with outcomes at 1 month.Group mean scores for Fear Avoidance Beliefs (FAB), catastrophisation and self-efficacy were all improved significantly within a few days of a patient's initial chiropractic consultation. Pre-visit catastrophisation as well as post-visit scores for catastrophisation, back beliefs (inevitability) and self-efficacy were weakly correlated with patient's global impression of change (PGIC) at 1 month. However when the four assessed psychological variables were dichotomised about pre-visit group medians those individuals with 2 or more high variables post-visit had a substantially increased risk (OR 36.4 (95% CI 6.2-213.0) of poor recovery at 1 month. Seven percent of patients with 1 or fewer adverse psychological variables described poor benefit compared to 73% of those with 2 or more.The results presented suggest that catastrophisation, FAB and low self-efficacy could be potential barriers to early improvement during chiropractic care. In most patients presenting with higher psychological scores these were reduced within a few days of an initial chiropractic visit. Those patients who exhibited higher adverse psychology post-initial visit appear to have an increased risk of poor outcome at 1 month. Trials comparing physical therapies, including chiropractic, to other types of care have generally found them to provide superior benefits for lower back pain patients, but often only marginally ,2. It haIn a series of prospective trials looking for predictors of outcome in chiropractic patients the 'Nordic Back Pain Sub-population Program' examined 70 potential baseline factors. Five were found to negatively influence prognosis; total duration of LBP in the preceding year (> 30 days), gender , leg pain, concomitant painful musculoskeletal complaints and receipt of social benefit -10. StudStudies using the general back pain population have similarly identified few physical factors capable of explaining why back pain in some individuals settles quickly whilst in others develops into more chronic conditions, often despite treatment. Psychological and social influences however have been found to have significant impact on response to treatment and the development of chronicity. A range of cognitive and affective domains have been linked to enduring back pain including beliefs that back pain is inevitably negative, depression, anxiety, catastrophisation  and fear-avoidance beliefs -14. ThisDespite the significant predictive value of psychosocial factors found in other patient groups, investigation of these factors in chiropractic patients indicate they are of less importance ,21. It hWhilst few pre-treatment measures have yet been found which influences outcome, Axen et al.,  have indSeveral models exist to explain the influence of non-physical factors on the development of chronicity and treatment resistance. Amongst the more widely investigated is the fear-avoidance beliefs model introduced by Lethem et al ,23 and dSome back pain patients hold the belief that there is something inevitably negative about back pain, and in a secondary analysis of the data from the BEAM UK  study  refers to aberrant or excessive concerns individuals may hold regarding the likelihood of their causing (re)injury by performing activities. These beliefs are significant when they cause people to change their activities (fear-avoidance behaviour). FAB's are seen to be predictive of outcomes of care where these are measured by disability, but not by severity of pain, -39. LoweSelf-efficacy is the belief in one's capabilities to organise and execute the actions required to manage prospective situations . It has Although considerable evidence exists that supports the impact of psychological variables on recovery in LBP patients generally, limited investigation of these domains in chiropractic patients suggests they may be of less importance ,21. ThisThe aim of this study therefore, was to further investigate the components of the fear-avoidance beliefs model within a chiropractic LBP patient population. In particular we aimed to ascertain to what extent fear-avoidance belief components pre and post an initial visit are associated with outcome at 1 month follow up.During 2009, consenting new patients with lower back pain as their primary complaint presenting for chiropractic care to one of five clinics (nine chiropractors) were asked to complete questionnaires before their initial visit (pre-visit) and again just before their second appointment (post-visit).Follow up patient global impression of change (PGIC) scores were ascertained 1 month after the initial consultation concerning patients perceived improvementAll patients fulfilled inclusion criteria, which consisted of presenting as a new patient to a chiropractor with lower back pain as the main complaint (with or without leg symptoms), and being accepted for care.The Fear-avoidance beliefs questionnaire developed by Waddell et al.  has beenThe work sub-scale has been shown to relate predominately to work related outcome measures. Because our outcome determinant did not directly include return to work, as an earlier study has found few patients from samples similar to ours taking sickness absence, and to reduce the overall size of our test instrument, we chose to use just the physical activity sub-scale .2 0.46, p < 0.001) [As further support for use of this sub scale it was shown to predict low back disability in patients attending an orthopaedic outpatient clinic (adjusted R< 0.001) . As usedThe catastrophising sub-scale of the Coping Strategies Questionnaire developed by Rosenstiel and Keefe  asks patThe CSQ consists of six items with a score range of 0-36 with higher scores indicating more catastrophic thinking. It is scored on a seven point Likert scale with zero being anchored by 'Never' and 6 as 'Always'.The Back Belief Questionnaire was developed to assess the beliefs a patient may hold about back pain, particularly that it is an inevitably negative process. It has reliable psychometric properties  .The BBQ consists of nine items with a score range from 9-45. It uses a Likert scale anchored at 1 by 'completely agree' and 5 by 'completely disagree' to rate statements such as 'Back trouble must be rested' and 'Once you have back trouble there is always a weakness'. Lower scores indicate more negative beliefs regarding back pain.The functional sub-scale of the Pain Self-efficacy Scale was developed by Anderson et al. . It enquHaving adapted it to a nine point Likert scale with 0 anchored to 'very uncertain' and 8, 'very certain', Woby et al  found itAn eleven point numerical rating scale (NRS) with 0 = No pain and 10 = Worst pain possible was used to assess patients perceived pain intensity. It has been described as having a Cronbach's α of 0.82 and intra-class correlation coefficient > 0.8 . In a chThe Patients Global Impression of Change (PGIC) is widely used as an outcome measure and has been described within a chiropractic patient population . This scThis has advantages over other outcome tools in asking about the impact of any improvement within the context of individual patient's lives. It therefore measures outcomes in terms of what individual patients feel is important. Despite concerns as to patients being biased as to their current status and recall of initial status these outcomes have been widely used and recommended for their relevance to meaningful change for the patient ,60.All data was tested for parametric distribution using a Kolmogrov-Smirnov test. For data not parametrically distributed (CSQ scores) non-parametric tests were used including correlation analysis. Logistic regression was used to calculate both univariate and adjusted odds ratios. The results were analysed using SPSS v18.0.Seventy-five patients were recruited to the study, and completed the baseline questionnaire. Of these, three were incomplete and one patient was found not to have back pain as their main complaint, resulting in a sample size of 71. The sample had a mean age of 42.3 (SD 14.4) years with a range 19 to 82, with 46.5% (n = 33) being male and 39.4% (n = 28) having had their pain for over 1 month. There was an average interval of 4.3 days (SD 2.7) between the first and second appointments with a range of 1 - 12 days. Four patients did not complete post visit questionnaires, two because they did not attend their next booked appointment and two for administrative reasons, resulting in 65 completed post visit questionnaires. Forty-eight correctly completed PGIC questionnaires at 1 month, which translated to a 67.6% follow up.Table Pre and post scores were investigated for any association with outcome (PGIC) at 1 month. The results for this analysis are presented in Table In order to ascertain any predictive utility of post visit psychological scores, logistic regression analysis were performed with dichotomised PGIC as the dependant variable (scores > 5 on the PGIC were taken as improvement). The first analysis included all raw post-visit psychological scores in the model. This first model significantly predicting 1 month outcome . This model accounted for between 33% and 47% of the variance in PGIC with a sensitivity of 91.4% and a specificity of 53.8%. Regression coefficients reveal that a decrease of one point on CSQ (decreased adverse psychology) is associated with a decrease in the odds of poor outcome (OR 0.85 (95% CI 0.73 0.94). In addition, a 1 point reduction in PSS score (increased adverse psychology) was associated with an increased risk of poor outcome, although only marginally (OR-1.05 (95% CI 1.00-1.09)).In a second and otherwise identical analysis, scores for PSS, CSQ, FABQ and BBQ were dichotomized about pre-visit group medians. Initially a univariate analysis revealed no significantly increased odds of poor outcome for high pre-visit scores for any variable. However, post-visit high scores were each associated with a raised risk of poor outcome Table . SubsequIn light of the above results, an assessment was made to ascertain the proportion of improved and not improved patients with 0, 1, 2 3 or 4 psychological variables  that were raised above the pre-visit group median when assessed post-visit (Table It is apparent from table In this study, adverse psychological indices in patients post the initial visit seems important to subsequent outcomes. However, in the group of practices from which the trial patients were recruited it is unusual for new patients to receive no hands-on care at their first session with a chiropractor. Indeed a review of the case files indicated that all but four of the patients in this study received treatment during their first visit and it is plausible therefore that treatment during this visit may have significantly reduced pain and that it is reduction in this parameter that successfully modifies psychological factors pre to post visit. In order to investigate the impact of early improvement in pain on changes pre to post visit correlation between change in pain and change in psychological scores were calculated. Table . The resThe results from this trial largely confirm previous studies involving chiropractic patients in finding that the assessment of a patients psychological profile before an initial consultation is not helpful in identifying those less likely to improve ,21. The st visit can be significantly predictive of outcome. It is possible that psychological factors are useful components that when used alongside others can mark early change and therefore indicate greater capacity for recovery in sub-groups of LBP patients. Treatment packages currently suggested for those at higher risk of persisting LBP are typically resource intensive [That assessment of psychological variables after a consultation is more predictive of outcome is a potentially important observation. The literature to date in this population indicates that few if any modifiable prognostic factors are identifiable at baseline ,21. One ntensive . HoweverThe relationship between changes in pain and improving self-efficacy was in contrast to other psychological metrics measured. Self-efficacy towards an activity is an appraisal of actual physical ability, the additional pain anticipated in performing the task and the individual's belief in their ability to tolerate this extra pain. Therefore with lower overall pain being related to lower anticipated pain for any specific task, it is not unexpected for reduced pain to be related to an increase in self-efficacy . On the In this study, given the lack of relationship between changes in catastrophising and FAB versus pain, it maybe suggested that something other than physical treatment may account for some of the improvement seen. It is possible that providing time for patients to talk about their problem and for them to be examined by someone who is perceived as interested and concerned may directly ease some of the affective aspects of worry and anxiety such as fear-beliefs and catastrophisation surrounding their pain . PatientWhen reviewing the role of reassurance in the management of patients in pain Linton et al concludes that reassurance is a complex process involving an interaction of patient experience, thoughts and beliefs, and emotions . FurtherClear limitations exist in this study. One is the fact only a restricted population from a group of linked clinics were investigated. Sampling bias and clustering effects strongly limit the generalisability of these results. In addition the absence of a control group precludes any causative relationships between improvement in symptoms and treatment. Further prospective matched studies are called for, with larger patient samples from a wider cohort of practitioners to investigate possible components of consultation that may modify psychological variables, reassure patients or reduce non-physical barriers to recovery.pre-visit catastrophisation was moderately associated with poor short-term outcome in patients presenting to chiropractors with lower back pain. In contrast, post-visit catastrophisation, pain related self-efficacy, fear-avoidance beliefs and negative back beliefs had a significant influence on outcomes.In this study higher The authors declare that they have no competing interests.JF conceived of the study, and was involved with its design, data collection, statistical analysis, interpretation and drafting the manuscript. DN performed the statistical analysis and was involved with its interpretation and in drafting the manuscript. PM participated in designing the study, interpreting the data and in drafting the manuscript. All authors read and approved the final manuscript.


Persistent whiplash associated disorders (WAD) have been associated with alterations in kinesthetic sense and motor control. The evidence is however inconclusive, particularly for differences between WAD patients and patients with chronic non-traumatic neck pain. The aim of this study was to investigate motor control deficits in WAD compared to chronic non-traumatic neck pain and healthy controls in relation to cervical range of motion (ROM), conjunct motion, joint position error and ROM-variability.Participants (n = 173) were recruited to three groups: 59 patients with persistent WAD, 57 patients with chronic non-traumatic neck pain and 57 asymptomatic volunteers. A 3D motion tracking system (Fastrak) was used to record maximal range of motion in the three cardinal planes of the cervical spine , and concurrent motion in the two associated cardinal planes relative to each primary plane were used to express conjunct motion. Joint position error was registered as the difference in head positions before and after cervical rotations.Reduced conjunct motion was found for WAD and chronic neck pain patients compared to asymptomatic subjects. This was most evident during cervical rotation. Reduced conjunct motion was not explained by current pain or by range of motion in the primary plane. Total conjunct motion during primary rotation was 13.9°  for the WAD group, 17.9°  for the chronic neck pain group and 25.9°  for the asymptomatic group. As expected, maximal cervical range of motion was significantly reduced among the WAD patients compared to both control groups. No group differences were found in maximal ROM-variability or joint position error.Altered movement patterns in the cervical spine were found for both pain groups, indicating changes in motor control strategies. The changes were not related to a history of neck trauma, nor to current pain, but more likely due to long-lasting pain. No group differences were found for kinaesthetic sense. Whiplash associated disorders (WAD) have been studied mainly in comparison to asymptomatic subjects and it remains controversial whether WAD represent a diagnostic entity different from chronic neck pain. WAD patients are separated from chronic neck pain merely on the history of trauma . The traThere is conflicting evidence for presence of kinaesthetic change in WAD patients, as measured by head repositioning or joint position error (JPE) in comparison to healthy controls -14, and There is consistent documentation for reduced standing balance and increased sway in WAD patients compared to healthy subjects -25. Smalend of primary range was investigated in a previous study which found small differences between WAD and healthy controls, but the study did not include non-traumatic neck pain patients [during execution of the primary motion which from a motor control perspective is more complicated.Pain has been shown to induce decreased variability in postural strategies in low back pain ,34, and patients . In addiIn order to explore motor function characteristics of WAD patients in particular, control groups of non-traumatic neck patients and asymptomatic subjects were included in this study. The main purpose was to investigate motor control deficits in WAD compared to the two control groups in relation to conjunct motion, JPE, ROM and ROM variability.A case-control study with a total of 173 participants was conducted in the period Jan 2004 – Oct 2006. The study group consisted of persons with persistent WAD for more than 6 months (WAD group). Two control groups were included; a group of chronic non-traumatic neck pain patients (chronic neck pain group) and a group of asymptomatic volunteers (asymptomatic control group). All subjects gave written informed consent and the study was conducted in accordance with the Helsinki Declaration and approved by the Regional Ethics Committee.Participants were recruited successively from WAD-patients referred to the National Center for Spinal Disorders, St Olav's Hospital, Trondheim, Norway. A total of 59 subjects with WAD injury classified as Québec Task Force grades I-II , were inA total of 57 subjects with chronic non-traumatic neck pain were recruited by local physiotherapists and general practitioners. Pain duration of at least 6 months and not more than 10 years was required for inclusion. Alternatively, the subjects could have repetitive episodes of pain of at least one week's duration every 3 months the last 2 years. Subjects were excluded if they had any history of neck trauma or any known systemic disease that could explain their symptoms.The asymptomatic control group included 57 subjects with no previous or current neck pain or history of neck trauma. Participants in this group were recruited from different workplaces and educational institutions.The study was part of a more comprehensive study also involving diagnostic imaging of the cervical spine. Pregnant women and persons with contra-indications to MR imaging  were therefore excluded.All cervical motion measurements were made using the 3 Space Fastrak  with a sampling rate of 120 Hz. The system has been found to reliably record head position and cervical range of motion among asymptomatic persons as well as persistent neck pain patients -38. The Maximal cervical ROM was recorded in the three primary motion planes. Conjunct motion in the two associated planes was recorded continuously throughout maximal primary range movements. The variability of maximal ROM has previously been used as a measure of sub-maximal effort in the testing situation due to fear of pain or movement. ROM-variability was in this study computed as the standard deviation (SD) of three repeated trials for each primary neck movement plane . JPE was recorded as the difference in head orientation at neutral position before and after cervical rotation. Neck pain and headache intensity at the time of testing was registered on numeric rating scales (NRS), where 0 denoted "no pain" and 10 "worst pain possible". Insurance compensation status in the WAD group was obtained from a self-reported questionnaire and used to explore differences within the group in pain intensity reports and ROM.The examiner was not blinded to the subjects' group allocation but all commands were standardized. Maximal cervical range of motion was measured with the subject seated on a wooden bench with a footrest and a backrest. Shoulders and thorax were fixed to the backrest with shoulder straps when measuring maximal cervical spine movements. The subjects were asked to move "as far as possible" in all three primary motion planes: axial rotation, side-bending and flexion/extension. In each trial the movement was carried out in both directions of the plane with a short pause in the neutral position. Each movement trial was repeated 3 times. Movements were performed at a self-determined pace.JPE was recorded with the subject comfortably seated with the head and neck in a neutral position with thorax/shoulders unfixed. A laser beam device was placed above the Fastrak sensor on the subject's head pointing to the middle of a target (bull's eye) approximately 1.5 meters in front of the subject's head to record neutral position. With the eyes closed, the subject was asked to rotate the head "as far as comfortable" towards the left, and then reposition the head to the starting position and give a verbal signal when he/she thought that the starting position was retrieved. The orientation (degrees) of the sensor at end-position was recorded. The subject was then asked to open his/her eyes and reorient the laser beam back to the middle of the target before the next trial. The procedure was repeated twice in each direction of cervical rotation.mean) of the three planes was used in the analyses. Mean ROM in each primary plane was summed to express total cervical ROM. Conjunct motion was calculated as the maximum deviation range (°) in each associated conjunct motion plane during execution of the primary movement, i.e., the maximal ROM trials  of three trials. The SD of three repetitions of maximal ROM was used to express ROM-variability for each cardinal plane, and the mean value  and post-hoc by the Tukey-Kramer multiple comparison test. Conjunct motion was analyzed both with and without introduction of covariates and adjusted for age, gender, neck pain intensity on day of testing and range of motion in the primary plane. For some variables residual plots showed an increasing variance with increasing predicted values. Transformation of these variables using natural logarithms (Ln) gave acceptable residual plots and similar statistical results. Thus, the non-transformed values are reported. The Kruskall-Wallis test was used for evaluating group differences in JPE and ROM-variability. Differences in pain levels and ROM between subjects with and without ongoing compensation claims within the WAD group were evaluated by the two sample t-test. Group differences were considered significant at the p < 0.05 level. Analyses were performed using SPSS 14.0 and NCSS 2007 .Of the 173 subjects participating in the study, motion data from three persons in the WAD group were lost due to technical problems during data collection. In addition, one person in the WAD group did not report compensation status. Baseline characteristics of the three groups are given in Table There were no differences within the WAD group between subjects with (n = 35) and without ongoing insurance compensation claims, although small non-significant reduction in ROM and higher mean intensity levels of headache and neck pain were found in those with claims Table .Conjunct motion was largest during primary cervical rotation and smallest during primary flexion/extension for all study groups Fig . ReducedGroup differences in total conjunct motion were most clearly seen during primary rotation, and separated the three groups significantly (p < 0.01), Fig . Total cmean) or JPE.Maximal primary cervical motion ranges, total cervical ROM, ROM-variability and JPE for the three study groups are shown in Table The main finding in this study was that patients with chronic neck pain showed altered motor control in the cervical spine. We found no indications for differential effects between traumatic and non-traumatic chronic neck patients in terms of conjunct motion. No group differences were found in ROM-variability or joint position error. Maximal cervical range of motion in the primary planes was however significantly reduced among the WAD patients compared to both control groups.Conjunct motion was included in this study to get an impression of motor function or motion stiffness during execution of primary plane movements, believed to reflect central nervous motor control strategies ,41. ConjWhether reduced conjunct motion reflects altered motor control strategies needs further investigation. If confirmed, it remains to reveal if such changes are peripherally driven or merely confined to central processing mechanisms. Perceived position of the head is greatly influenced by proprioceptive signals from the neck . HypotheKinaesthetic sense deficits in patients with cervical pain have in previous studies been demonstrated as reduced accuracy, or increased cervical joint position error, when relocating the head to the initial position after a maximal or sub-maximal cervical movement ,49,52,53As expected, and in agreement with other studies ,30,55,56mean as measure of variability implies that the "size" of ROM did not influence the variability measure. An alternative that would normalize the variation to the mean ROM is the coefficient of variation (CV). However, the small variability of the nominator (SDmean) relative to the large variability in the denominator (mean ROM) would make the CV heavily depend on the latter and thus add little information beyond that of mean ROM. A correlation analysis was performed between mean ROM and SDmean to investigate whether SDmean was dependent on the "size" of mean ROM and thus needed to be normalized. No correlation was found in any of the study groups, and SDmean was considered the best variability measure. When direction-specific maximal ROM is repeatedly recorded from neutral position, variability in the neutral position starting point could hypothetically add to the variability in ROM. This factor was eliminated by recording total plane ROM in our study. Since increased ROM-variability was not found between any of the groups, sub-maximal effort due to simulation, pain or fear of pain was not confirmed in this study.ROM-variability from repeated recordings of maximal cervical range has been introduced as a measure that could distinguish between maximal and sub-maximal effort in the ROM testing situation ,58. HypoCompared to asymptomatic controls both whiplash and chronic neck pain patients showed reduced conjunct motion, particularly during primary cervical rotation. We found no indications for a difference between traumatic and non-traumatic neck pain patients. Reduced conjunct motion was not explained by variation in current neck pain or range of motion in the primary plane. Less flexible movement patterns in the two pain groups compared to the asymptomatic group may reflect motor control adaptations, possibly due to long lasting pain. JPE and maximal ROM-variability did not separate the study groups. The whiplash patients showed reduced maximal cervical ROM compared to both control groups, and the chronic neck pain group had less ROM compared to the asymptomatic controls. No significant differences in ROM and pain intensity were found between WAD-patients with ongoing insurance compensation claims and the rest of the WAD-group.The authors declare that they have no competing interests.The authors have contributed equally to the conduction of the study, the data analysis and the writing of the manuscript. The final manuscript has been read and approved by both authors.The pre-publication history for this paper can be accessed here:


Pain is a common primary symptom of advanced cancer and metastatic disease, occurring in 50-75% of all patients. Although palliative care and pain management are essential components in oncology practice, studies show that these areas are often inadequately addressed.We randomly selected 152 patients receiving palliative radiotherapy (PRT) from October 2006 to August 2008, excluding metastatic bone lesions. Patients' records were studied retrospectively.A median follow-up of 21 weeks was available for 119 males and 33 females with a median age of 55 years. Maximum (60%) patients were of head and neck cancers followed by esophagus (14%), lung (10%) and others. Dysphagia, growth/ulcer and pain were the chief indications for PRT. Pain was present in 93 (61%) cases out of which, 56 (60%) were referred to pain clinic. All except one consulted pain clinic with a median pain score of 8 . Fifty-three of these 56 patients (96%) received opioid-based treatment with adequate pain relief in 33% cases and loss of follow-up in 40% cases. Only five (3%) cases were referred to a hospice. Twenty-two (14%) cases were considered for radical treatment following excellent response to PRT.In this selective sample, the standard of analgesic treatment was found to be satisfactory. However, there is a lot of scope for improvement regarding referral to pain clinic and later to the hospice. Patients' follow-up needs to be improved along with future studies evaluating those patients who were considered for further RT till radical dose. Programs to change the patients' attitude towards palliative care, physicians' (residents') training to improve communication skills, and institutional policies may be promising strategies. Up to 70% of patients with cancer are expected to experience pain during the cancer illness and it is more likely as the disease progresses. Severe pDespite the introduction of the World Health Organisation WHO ladder for pain management more than two decades back, cancer pain is still a major problem in clinical practice. InvestigSeveral studies have documented under-reporting of symptoms and under-treatment of pain in cancer patients and the most frequently identified barriers in adequate pain management are found to be physician's underestimation and patient's reluctance to report pain. PatientsMeasurement of pain has remained a burning issue for decades and there is still no gold standard method for evaluating pain. Commonly used methods to measure pain include Visual Analogue Scale (VAS), 101-point Numerical Rating Scale (NRS-101), 11-point Box Scale (BS-11), 6-point Behavioral Rating Scale (BRS-6), 4-Point Verbal Rating Scale (VRS-6) etc. The Edmonton Classification system for Cancer Pain (ECS-CP) recently attempted to classify cancer pain on the basis of seven characteristics having clinical prognostic value. The characteristics included mechanism of pain, incidental pain, daily opioid use, cognitive function, psychological distress, tolerance, and a past history of addiction or alcoholism. Depending on the combinations of these features, patients were defined as having good, intermittent or poor prognosis for pain control.[Management of pain involves efforts from all the healthcare providers engaged in the curative and palliative phase of treatment but maintaining this continuity while the patient shifts from one phase to another is the biggest challenge. The transition from the curative to the palliative phase represents a critical juncture at which continuity of care is often compromised. Therefore, it is necessary that this transition should take place gradually. The chalPalliative radiotherapy (PRT) is indicated in 30-50% of all cancer patients and patients receiving PRT should be adequately attended for pain and symptom relief. Issues related to pain, difficult physical symptoms and psychosocial aspects can coexist during PRT, which needs to be addressed by a palliative care unit (PCU).The term palliative care has often been misused; many people still refer to palliative medicine as being entirely focused on terminal illness. PalliatiIn addition, there are other PCU-related issues which include poor access to PCUs , environment of PCUs , poor communication between staff of PCU and general ward, economic problems , doctrine beliefs of PCU  etc.The aim of the present study was to assess the pain management and referral trend from the radiotherapy department to the pain clinic, PCU or the hospice in a tertiary multidisciplinary academic centre. The study also evaluated the characteristics of pain assessment, management and follow-up in the pain clinic of those patients who actually were seen in the in-house pain clinic and PCU. The objective was to assess the shortcomings and difficulties that prevail in such a scenario so that adequate steps can be taken in the future to improve the overall pattern of referral, assessment, treatment and follow-up of cancer patients who are having pain and need palliative care.The present study is a retrospective analysis done in the Radiation Oncology department of Dr. B R Ambedkar Institute Rotary Cancer Hospital (IRCH), All India Institute of Medical Sciences (AIIMS), New Delhi, India. AIIMS is a multidisciplinary biomedical institution and IRCH is the dedicated cancer facility within this center. This hospital is a regional cancer center under the National Cancer Control Program of the Government of India for patient care, academics and cancer research. The cancer facility has an in-house pain clinic (running Out Patient Department OPfour days a week) and a PCU with six beds. A freestanding hospice, Shanti Avedna Sadan, exists within a distance of 1.5 kilometers from the AIIMS campus, which provides free care to deserving patients.Overall, 152 consecutive patients, whose files with reasonable treatment details were available, were studied irrespective of the age, sex, primary and consultant in charge of the case. All these patients received PRT in our department between October 2006 and August 2008. The following information was retrieved from their IRCH file in each case: Age at diagnosis, gender, main symptom and its duration, location of primary, disease extent, pain assessment, treatment outcome, referrals and compliance to it, status at last follow- up, and follow-up duration. The referral trend was analyzed in the form of total number of patients who presented with pain and those who were referred to the pain clinic of IRCH, number of patients who reached pain clinic and the number of patients who defaulted.Patients of all types of advanced malignancies irrespective of their primaries were included in the study except those with bone metastases. Patients with bone metastases were excluded as it formed a major proportion of the patients with advanced cancer and their inclusion could have introduced a sampling bias in the study.The need for referral was assessed according to the status of the patient on the last day of PRT. The pain clinic details were obtained from the pain chart attached in the file where the pain assessment was done on an 11-point scale (0-10) with 0 representing “no pain at all” and 10 representing the “most severe pain that can be imagined”. Duration of follow-up (DOFU) was defined as the date of last follow-up or death minus date of diagnosis and it was used as a surrogate parameter to estimate overall survival of the patient since data regarding patient's death was not available in most cases.In the group of 152 patients evaluated in our study, there were 119 (78%) males and 33 (22%) females with a median age of 55 years (range 1-86 years). Most of the primaries were of head and neck region (60%) followed by gastrointestinal malignancies in 14% and lung cancer in 11% cases. As expected, most of the cases, i.e. 72% belonged to Stage IV at presentation, followed by 27% cases in Stage III. In two cases, stage was not mentioned in the record. Overall, metastases were present in 24 (16%) cases with lung as the commonest site of metastases (37% cases) followed by brain (29% cases) and liver .Out of total 152 cases, only 46 (30%) cases had received cancer-directed therapy in the past with chemotherapy being the commonest used modality. All other cases were considered for PRT upfront, either in view of advanced disease at presentation or due to the poor performance status of the patient. The commonest indication for PRT was cytostatic PRT (39% cases) in the presence of progressive visible growth or ulceration. The intention in those cases was either relieving the pressure symptoms due to tumor mass or to control the bleeding, discharge or pain due to ulceration The second commonest symptom for which palliation was considered was dysphagia in 52 (34%) patients. Dyspnea was seen in 19 (12.5%) patients and pain as the primary symptom for palliation was present only in 13 (08%) patients . The PRTOut of total 152 cases, 93 cases (61%) were having some degree of pain at the assessment done during the period of PRT or on the day of RT completion. In three patients no details were found regarding pain while in the remaining 56 (37%) cases, no pain was reported by the patient. The severity of pain according to any assessment scale was not mentioned by the radiation oncologist in most of the files.Out of the 93 patients with pain, 33 patients (35%) were not referred to the pain clinic. Referral details of four patients were not found in the file, while the remaining 56 (61%) patients were referred to the pain clinic at IRCH. All except one patient, who were referred to the pain clinic actually followed the instructions and were later seen in the pain clinic. Only five patients out of the total 152 cases were referred to hospice care .In the pain clinic, patient's pain was assessed on the 11-point pain assessment scale. In the 55 patients assessed in the pain clinic, the median pain score was found to be 8, with a range of 3-10. Thirty-one (20%) of patients had a score of 8 or more and were categorized to have severe pain.When patient's pain treatment was analyzed with respect to the WHO ladder of pain management, it was seen that 62% patients were treated up to Step 3 of the ladder i.e. strong opioids were ultimately used in them. About 35% patients were managed with Step 2 and less than 4% were treated with Step 1 of the WHO ladder . Most ofOut of the 55 patients treated at the pain clinic, 18 patients (33%) achieved adequate pain relief and 14 patients (25%) had partial relief while one patient had progressive pain in spite of using the strong opioids in increasing doses. In a large number of patients i.e. 40% of cases, the result of analgesic treatment could not be retrieved due to incomplete details in the patients' records .At the last follow-up in the hospital, six (04%) patients had complete relief of their overall symptoms following PRT and supportive management, while 26 (40%) patients had partial relief. Progression of symptoms in spite of PRT, analgesics and supportive treatment was seen in 25% cases while in others the symptom score remained constant. One patient expired in the hospital during palliative treatment while the largest proportion of the patients i.e. 44% was lost to follow-up after one or more visits to the radiotherapy clinic or pain clinic. Except one patient, no details regarding patients' death were found in their records.The median duration of follow-up was 20.8 weeks with a range from as short as five days to as long as 230 weeks.In 22 cases who received PRT, a very good response to PRT was observed during their follow-up in the clinic and they were considered for further RT till the radical doses .This study needs to be seen with caution as it is retrospective in nature and was done in a referral center of an apex institution, where pain clinic and PCU are available in-house. The scenario is not similar in most other centers in India where such facilities are not available. Moreover, the total number of patients needs to be higher to reach to any definite conclusion. However, this study clearly shows the overall pattern of palliative care and referral trend in such a cancer center.In our study, a disproportionately large number of male patients was included which could be largely due to the maximum cases being of head and neck region, which is the commonest cancer among males in India. The other contributory factors may be the socio-cultural importance of males being the earning member sin the family.As expected, about three-fourth of our cases belonged to Stage IV disease which is quite common in the patients receiving palliative treatment.Overall, the incidence of pain was observed in 61% of our cases, which is consistent with the incidence of pain in the advanced cancer patients reported in the literature. In the medical notes recorded by radiation oncology physicians, there was no mention of the severity of pain in any objective form. This makes the overall assessment of pain impossible and audit difficult. So there is a need to sensitize physicians regarding the importance of proper documentation and to make them familiar with the pain assessment scales and charts.Out of the total patients who had pain, 30% were not referred to the pain clinic. One reason for this may be the prescription of analgesic treatment by the radiation oncologist himself in cases with mild pain. But this cannot be assumed in the absence of any documentary proof.One unexpected observation was the excellent compliance of the patients in reporting to the pain clinic after they are advised to do so. Out of the total 56 patients referred to the pain clinic, 55 patients were actually seen in the pain clinic. Thus, it is clear from this study, that if the patient is counseled properly and pain and palliative facilities are available in-house, the dropout rate during transition from the definitive to the palliative phase can be reduced significantly.The referral to the hospice was very low among our patients (< 5%). This may be due to the existence of in-house PCU or due to under-documentation of these referrals because most of these referrals are made from the central casualty  where the patient's record file is not available for putting notes when such decisions are made. The overall follow-up and death recording was suboptimal with 29% of the patients being lost to follow-up or having unknown status at the last follow-up. Only one patient had his death documented in the hospital records.The median pain score was 8. There were very few patients with a pain score of 5 or less. This again may be due to the patients with mild pain being managed by radiation oncologists themselves. The opioids were liberally used in our patients in the pain clinic with 96% of the cases being prescribed some form of the opioid. This was due to the availability of these drugs in the in-house pharmacy, which is a key factor in optimizing the use of opioids. But, in spite of the high use of opioids, only 30% cases experienced adequate pain relief. In as many as 40% cases, the response to analgesic treatment was not documented properly. This observation clearly indicates the importance of proper assessment and follow-up of patients who are started on opioids so that their doses can be titrated properly. In a large study from Netherlands, over 1400 cancer patients were surveyed in five hospitals and the prevalence of cancer pain was 55%, VAS > 4 was 25% and according to the pain management index, it was inefficiently treated in 42% of all patients.[Overall, the findings of our study indicate a clear need for accurate recording of pain and related symptoms as an essential part of the management of patients receiving palliative oncological treatment. These results suggest that although the standard of pain management was satisfactory at our center, we need to improve upon the proper assessment and follow-up of our patients.Although the idea of PCUs was initially conceived to provide compassionate care, helping patients die peacefully and with dignity, providing care for families, and for alleviating pain, there are several misconceptions still prevailing regarding these institutions. Various studies have suggested that a negative image of the PCU and hospice is recognized as the most important barrier by patients, families, and medical staff. They areIt is evident from various reports that continuity of care has proven to be a major challenge in comprehensive cancer care, with a number of shortcomings. Oncology physician is often not informed when patients are discharged from the PCUs. This break in the informational continuity has an adverse effect on the quality of follow-up.In addition, the data appearing in medical files is often primarily of medical nature, with psychosocial issues often being less well documented.Current training in palliative oncology seems inadequate in terms of providing comprehensive care. Caregivers are often ill-prepared for confronting the experience of death, and providing supportive care and attention to a patient with advanced cancer. Education in India is good, but information alone may not be sufficient to change the physician's attitude and practice.There is lack on the part of institutions in providing protocols regarding referral guidelines for patients who require pain clinic, PCU or hospice referral. These issues being subjective in nature and often influenced by the clinical judgment and socio-cultural background of an individual physician, need to be considered with utmost care.There is a paucity of well-designed studies in the literature regarding referral patterns and trends of cancer patients during their advanced disease. Many attempts at conducting performing well-designed studies have failed. The literature is littered with poor or failed studies. Specific challenges include difficulty in recruiting patients, small samples, higher attrition rates, rapidly changing clinical situations, limited duration of survival and gate-keeping by the healthcare professionals. Gate-keeStudies to date have suggested that if family caregivers are not adequately prepared for their role in controlling their relative's pain, it may never be possible to achieve the ultimate goal of palliative care. Thus, considerable potential may exist for improving pain management outcomes by supporting and developing caregivers' capacity to be involved in their relative's pain management.It would be relevant to develop more efficient mechanisms for transferring information amongst healthcare professionals so as to facilitate the coordination of care and to ensure its continuity. Beaulieu proposed setting up an effective, formal, shared file system to ensure that all the information regarding a patient can be shared amongst his caregivers. In the yThe use of a case manager (or “navigator”) is another alternative that could improve the transfer of information. The case manager would serve as a central resource of information. By taking charge of the patient's file, he  would supervise patient care over the course of the disease and would be able to ensure better continuity of care.In order to enhance appropriate patient follow-up, care delivery system must be carefully and logically structured. Promoting the in-house pain clinics and PCUs may be of great importance in this regard. Establishing hospices in close proximity to comprehensive cancer care centers with dedicated beds and logistic support  can improve the compliance of the patients.A smooth, gradual approach helps to better prepare patients for the shift to the palliative phase of their illness by reducing their fear and anxiety. Nowhere should the referral from one phase to the other be abrupt and sudden. Healthcare professionals can encourage patients to express their feelings and give them the opportunity, wherever possible, to meet the palliative care team before such a transition is made.When dealing with problems related to the referral process, various authors have suggested formalizing referral protocols between members of the care team. This approach will reduce the ambiguity and confusion encountered while the decision regarding a patient's referral is taken. A well-designed protocol which is accessible to all the residents, nursing staff and other hospital staff should be available so that patients can be guided from time to time with min To ensure the quality of referral trends and palliative care, a localized, reliable, and efficient quality audit tool for clinical practice is greatly needed. These quality audits can serve to monitor, evaluate, and ultimately improve the quality of care.Several authors have suggested implementing more comprehensive training programs for caregivers by organizing workshops, conferences, seminars etc to improve their skills in delivering care to the advanced cancer patients. Less experienced colleagues should be supported by the superiors or the pain services.It is important to encourage well-designed studies involving issues in palliative oncology. It is important that the concerns of healthcare professionals are identified and addressed to improve trial recruitment and subsequently patient care.Various authors have recognized the importance of continuity of care for cancer patients during various phases of their treatment. While it is important to gain insight into these problems, it would also be useful to understand how such problems have arisen over time. A major problem is the attitude of the patients, physicians, and the society as a whole toward cancer pain. Hence, we need to intervene at various levels to solve this problem. At the national level, the solution includes information campaigns to oppose the patient's and physician's “opiophobia”, and to relax our legal intricacies to enhance the availability of morphine and other opioids. On the institutional level, clear policies must be promoted for better pain management. Institutions should promote the use of graphic tools to make pain visible. At an individual level we need to change our attitude towards cancer pain and palliative care.To correct the misconception prevailing in the society regarding PCUs and hospices, it is important to disseminate accurate information to the general population, patients, and families.


Background: Pancreatic pseudocyst endoscopic drainagehas been described as a good treatment option,with morbidity and mortality rates that are lowerthan surgery. The aim of our study is to describe theefficacy of different forms of endoscopic drainageand estimate pseudocyst recurrence rate after shortfollow up period.Patients and Methods: We studied 30 patients withpancreatic pseudocyst that presented some indicationfor treatment: persistent abdominal pain, infectionor cholestasis. Clinical evaluation was performedwith a pain scale, 0 meaning absence of painand 4 meaning continuous pain. Pseudocysts werefirst evaluated by abdominal CT scan, and afterendoscopic retrograde pancreatography the patientswere treated by transpapillary or transmural (cystduodenostomyor cystgastrostomy) drainage. Pseudocystresolution was documented by serial CTscans.Results: 25/30 patients could be treated. Drainagewas successful in 21 (70% in an ‘intention to treat’basis). After a mean follow-up of 42±35.82 weeks,there was only 1 (4.2%) recurrence. A total of 6 complicationsoccurred in 37 procedures (16.2%), and allbut 2 were managed clinically and/or endoscopically:there was no mortality related to the procedure.Patients submitted to combined drainageneeded more procedures than the other groups.There was no difference in the efficacy when wecompared the three different drainage methods.Conclusions: We concluded that pancreatic pseudocystendoscopic drainage is possible in mostpatients, with high success rate and low morbidity.


Intra-articular corticosteroid injection in juvenile idiopathic arthritis (JIA) is often associated with anxiety and pain. Recent reports advocate the use of nitrous oxide (NO), a volatile gas with analgesic, anxiolytic and sedative properties.To prospectively evaluate the effectiveness and safety of NO analgesia for intra-articular corticosteroid injection in JIA, and to assess patients and staff satisfaction with the treatment.NO was administered to JIA patients scheduled for joint injection. The patient, parent, physician and nurse completed visual-analog scores (VAS) (0–10) for pain, and a 5-point satisfaction scale. Change in heart rate (HR) during the procedure was recorded in order to examine physiologic response to pain and stress. Patient's behavior and adverse reactions were recorded.54 procedures (72 joints) were performed, 41 females, 13 males; 39 Jewish, 13 Arab; mean age was 12.2 ± 4.7 year. The median VAS pain score for patients, parents, physicians and nurses was 3. The HR increased ≥ 15% in 10 patients. They had higher VAS scores as evaluated by the staff. The median satisfaction level of the parents and staff was 3.0 and 5.0 respectively. Adverse reactions were mild.NO provides effective and safe sedation for JIA children undergoing intra-articular injections. Intra-articular corticosteroid injection is one of the cornerstones of treatment for children with juvenile idiopathic arthritis (JIA), particularly oligoarthritis . Major sSeveral techniques are used in an effort to reduce pain including conscious sedation using intravenous benzodiazepine or general anesthesia . RecentlFew studies have reported on the safety and efficacy of NO in JIA. Cleary et al, showed that a fixed mixture of oxygen and NO, given using a self-delivery device was safe and effective for intra-articular injection in JIA .Using NO by continuous flow method facilitates its' use in younger patients, and can also enable the administration of variable NO concentrations up to 70% .Our study aim was to evaluate the effectiveness and safety of NO analgesia for intra-articular corticosteroid injections in JIA, and to assess patients and staff satisfaction with the treatment.NO was administered to healthy JIA patients older than 3 years of age who were scheduled for joint injection, and whose parents consented to participate in the study. Since this procedure requires cooperation patients younger than 3 years were not included in this study. They were injected under general anesthesia. The institutional ethics committee approved the study.20 mixer® that allows various concentration of NO to be used with a minimum O2 level of 30%, and also has a non-rebreathing circuit. NO was administered in the pediatric day unit by a specially assigned pediatrician who underwent formal training for sedation and a PALS course. Oxygen saturation, heart rate (HR), and respiratory rate were all constantly monitored and recorded by a team member not participating in the injection itself. NO concentration was gradually increased up to a level of 30–50% that was then maintained during the entire procedure (no age related differences in NO concentration). EMLA  was placed in all patients at least one hour before the procedure. Patients were not restrained, and when possible the mask was self held. At the end of the procedure 100% oxygen was administered for 3–5 minutes.There was no comparison group. The apparatus used to administer NO was the MDM- Matrx NAssessment of the procedural pain was made by the patient, parent(s), participating nurse and physician using an age specific visual analog score (VAS) with a scale of 0–10 . The satAll adverse effects were recorded and scored, as was patient behavior during the procedure.Data analysis was performed using standard software (Sigmastat). One-way analysis of variance on ranks was used to compare between VAS scores of the patients, parents and staff. Rank sum test was used to compare the patients with and without a significant increase in HR during the procedure.54 procedures (72 joints) were performed in 43 patients, 31 females, 12 males; 32 Jewish, 11 Arab; mean age was 12.5 ± 4.8 years (range 3.7–18). Twenty of the patients were under 10 years of age and twelve were under age 7 years. Six patients had 2 separate procedures, one had 3, and another had 4 procedures. The majority were injections of large lower extremity joints, only 3 were of small joints of the hands.All parents, 93% of physicians and 89% of nurses reported that NO eased the child's pain, and made the procedure easier to perform. The median pain VAS for the patients, parents, physicians and nurses was 3 Figure . There wThe HR increased ≥ 15% in 10 patients. These patients had significantly higher VAS as assessed by the physicians (p = 0.006) and nurses (p = 0.010) Table . When weOur study reemphasizes the efficacy of NO as an optional sedation for JIA intra-articular injections with low VAS scales assigned by patients, parents and the medical staff. We found a good correlation between the VAS recorded by the medical staff and objective physiological parameters such as the increase in the HR. This finding can be used for better pain monitoring during the procedure.Children with JIA suffer from pain from procedures including joint injections, and pain related to their arthritis. We offer this procedure for all children, even adolescents, as NO is easy to use in our ambulatory service. Effectively reducing procedural pain can reduce the anxiety with each procedure which itself can exacerbate arthritis pain . Pain reRelaxation before and a comfortable atmosphere during sedation, make the procedure easier to perform. It is possible that better relaxation techniques used by Cleary et al. explain their lower VAS scores  than in our study [In the group of children who underwent more than one procedure (N = 8) we did not demonstrate less pain or stress in subsequent injections despite our assumptions from the childhood cancer data . The smaAs in other studies ,11,12, NNO provides an effective and safe sedation for children with JIA undergoing intra-articular injections.The author(s) declare that they have no competing interests.YU – senior author – participated in the study design, coordination of the study, and writing the manuscript.GC – participated in the design of the study and performed the statistical analysis, and helped to draft the manuscript.MR – participated in the design of the study, coordination data collection, and helped to draft the manuscript.TT – participated in the design of the study, data collection, and helped to draft the manuscript.JP – data collection, and helped to draft the manuscript.LH – data collection, and helped to draft the manuscript.PJH – participated in the design of the study, and writing the manuscript.All authors participated in writing and reading the manuscript and approved the final version of the manuscript.


Currently, notalgia paresthetica (NP) is a poorly-understood condition diagnosed on the basis of pruritus, pain, or both, in the area medial to the scapula and lateral to the thoracic spine. It has been proposed that NP is caused by degenerative changes to the T2-T6 vertebrae, genetic disposition, or nerve entrapment of the posterior rami of spinal nerves arising at T2-T6. Despite considerable research, the etiology of NP remains unclear, and a multitude of different treatment modalities have correspondingly met with varying degrees of success. Here we demonstrate that NP can be caused by long thoracic nerve injury leading to serratus anterior dysfunction, and that electrical muscle stimulation (EMS) of the serratus anterior can successfully and conservatively treat NP. In four cases of NP with known injury to the long thoracic nerve we performed transcutaneous EMS to the serratus anterior in an area far lateral to the site of pain and pruritus, resulting in significant and rapid pain relief. These findings are the first to identify long thoracic nerve injury as a cause for notalgia paresthetica and electrical muscle stimulation of the serratus anterior as a possible treatment, and we discuss the implications of these findings on better diagnosing and treating notalgia paresthetica. Notalgia paresthetica (NP) is a poorly-understood condition presenting with pruritus, pain, and paresthesias in an area medial to the scapula and lateral to the thoracic spine. In addition, patients commonly report hyperpigmentation of the skin and other skin abnormalities. It was first described by Astwazaturow in 1934, but both etiology and prevalence of NP are unclear . PreviouThe long thoracic nerve arises from branches of cervical nerve roots C5-C7 and innervates the serratus anterior muscle. Injury to the long thoracic nerve or its cervical roots leads to dysfunction of the serratus anterior, with consequent scapular winging or loss of normal scapular protraction. We describe four cases of NP with known injury to the long thoracic nerve or the cervical roots giving rise to the long thoracic nerve, where transcutaneous electrical muscle stimulation (EMS) to the serratus anterior in an area far lateral to the area of pain and pruritus Figure  resultedAll patients reported pain with or without pruritus between the thoracic spine and medial scapula which grew progressively worse throughout the day. Furthermore, all reported exacerbation with activities requiring forward flexion of the arms such as driving, typing, washing dishes, or putting objects on a shelf. Patients did not report skin abnormalities, and no hyperpigmentation was observed. When temperature sensation in the area of maximal pain was tested with ice and compared to the contralateral region, all patients reported reduced sensation of cold without frank numbness. All had injury to the long thoracic nerve or the cervical roots at C5-7 giving rise to the long thoracic nerve, despite the absence of clinically-apparent scapular winging. There was no evidence of hyperpigmentation or other dermatologic symptoms. Prior to treatment with EMS all patients had seen multiple physicians and physical therapists, and tried multiple medications without relief. EMS of the serratus anterior muscle was conducted at 70 Hz with a pulse width of 300 μs to induce tetany of the serratus anterior. Stimulation was prescribed to be 30 seconds on and 30 seconds off for 15 minutes twice a day. All patients reported relief of pain beginning within days upon starting EMS, recurrence of pain if they discontinued stimulation for any prolonged period, and maintenance of analgesic effects with only intermittent stimulation necessary.The patients described in this case series provided informed consent for the manuscript and/or accompanying images to be published.A 39-year-old male presented with pain and pruritus medial to the left scapula several months after sustaining an ipsilateral broken clavicle and multiple rib fractures in a bicycle accident. He reported a marked increase in pain with activity utilizing his arms. Unlike his other pain complaints which improved following the accident, over time his left mid-scapular pain became more persistent and refractory. At 60 mg of duloxetine his medial scapular pain was replaced by a sense of itching, and then at 120 mg disappeared completely, although he ultimately could not tolerate duloxetine due to "personality changes". Electrodiagnostic studies revealed cervical root dysfunction at C5, C6, and C7 suspected to be a traction injury from landing on his shoulder after going over the handlebars of his bicycle. The patient began electrical stimulation of the serratus anterior muscle in fall 2007. He reported using the stimulation approximately 15 minutes once a day. He discontinued using it after attaining significant relief only to find that within several weeks the pain reappeared. Upon resuming intermittent stimulation his pain relief returned. By follow-up email in April 2009, he characterized his ongoing relief as "a highly significant improvement in the quality of my life.... Since I started to use [the stimulator] again I have been largely pain free". Treatment with muscle stimulation on an intermittent basis continues after 20 months follow-up.A 52-year-old male presented with chronic right shoulder and mid-scapular pain and pruritus of 20 years duration, status post ipsilateral thoracotomy and multiple shoulder surgeries, the most recent of which was 2 years previous. The thoracotomy scar ran perpendicularly across the expected path of the long thoracic nerve. He had failed therapy with amytriptyline, valium, skelaxin, fentanyl, dilaudid, methadone, gabapentin, and tizanidine. He reported no intercostal pain, and his notalgia paresthetica scapular pain was located several inches medial to the posterior margin of the thoracotomy scar. He began electrical stimulation of the serratus anterior muscle in July 2008. In a follow up by email in April 2009, he reported pain relief as an "8 on a scale of 10" and continues daily use of the stimulator. Follow-up after 9 months demonstrated ongoing use of the stimulator and continuing relief.A 40-year-old male physician presented with itching, paresthesias, and when symptoms were severe, pain medial to the right scapula of 20 years duration, status post a thoracotomy performed while a child. The ipsilateral thoracotomy scar ran across the expected course of the long thoracic nerve. He reported no intercostal pain, and his NP symptoms were located several inches medial to the posterior margin of the thoracotomy scar. Past treatments included topiramate and over-the-counter analgesics. He reported 70% relief of symptoms within the first two weeks of using EMS to the serratus anterior muscle and continues daily use as of September 2009. He continues to use the stimulator intermittently after 9 months of follow-up.A 34-year-old female presented with pain and pruritus medial to the right scapula, status post cervical fusions of C4-5 and C5-6 in 2006 due to degenerative joint disease. She also presented with neural foraminal stenosis in C6-7. Electrodiagnostic studies were consistent with dysfunction of C5, C6, and C7. Nonetheless, she denied radicular symptoms into the arms. Past treatments included gabapentin, desipramine, and multiple opioids. Stimulation of the serratus anterior muscle began in fall 2007. As of April 2009 she uses the stimulation for 15 minutes a day but is only intermittently compliant. When she discontinues stimulation the pain gets steadily worse prompting her to reinitiate stimulation, and continue until improvement of symptoms once again leads to discontinuation. Follow-up at 20 months following initiation of serratus stimulation revealed the patient to be using the stimulator intermittently with continued benefit.The effectiveness of EMS, applied directly to the serratus anterior, in providing significant pain relief supports our conclusion that notalgia paresthetica can be caused by long thoracic nerve injury and consequent serratus anterior dysfunction. These findings are the first to identify the association of long thoracic nerve and serratus anterior dysfunction as a possible cause for NP, with EMS as a possible treatment. Serratus dysfunction following long thoracic nerve injury and the resulting loss of scapular protraction is well understood to lead to scapular winging. Although scapular winging was not clinically apparent in these cases, subtle shoulder girdle asymmetry was appreciated following knowledge of the diagnosis. We hypothesize that even in the absence of obvious winging, loss of protraction may result in subtle retraction of the scapula. This in turn may generate either traction or compression of the cutaneous medial branches of the thoracic dorsal primary rami of spinal nerves as they course to the skin through muscles attached to the non-protracted scapula such as the rhomboid and trapezius. Traction on these nerves would be expected to refer pain to the area between the scapula and the spine, the region of symptoms in NP.This hypothesis would explain 1) the finding of long thoracic nerve and serratus anterior dysfunction in patients presenting with pain medial to the scapula; 2) the finding that the pain was exacerbated by activities with the arm flexed in front of the body, which loads the serratus; 3) the loss of temperature sensation in the area of pain medial to the scapular edge; 4) analgesia medial to the scapula in response to muscle stimulation of the much more lateral serratus; and 5) previous reports of the efficacy of anti-neuropathic pain medications such as gabapentin  and oxcaWe suspect that EMS contracts the denervated serratus which is over-stretched under the load of the arm in the chronic absence of physiologic contraction. The intermittent contraction associated with the direct electrical muscle stimulation results in a durable but ultimately reversible shortening of these overstretched muscle fibers leading to a serratus muscle of shorter length, more closely approximating its normal resting length. This shorter serratus muscle, while still unable to contract physiologically, may nonetheless hold the scapula in a more anatomically correct position compared to the completely stretched, unstimulated serratus seen following denervation. Further work is needed to confirm or refute these speculations.Our results are consistent with a case of NP and comorbid scapular winging reported in 2004, in which NP naturally resolved several months before scapular winging [Although our reports focus on long thoracic nerve and consequent serratus anterior dysfunction as an etiology for the clinical syndrome of NP, it is possible that serratus dysfunction is sufficient but not necessary. We have seen pain of similar presentation among those with high thoracic disk disease, and in two patients with severe scoliosis in whom the scoliosis appeared to result in impingement of the dorsal primary rami between two adjacent transverse processes. Our experiences, along with radiographic findings by others , also suAdditionally, while serratus anterior dysfunction may lead to improper scapular stabilization, an imbalance of other stabilizers such as the trapezius or other posterior scapular stabilizers may provide the same symptoms. The authors suggest a defect in scapular stabilization is just one of a variety of causes of irritation to the medial cutaneous branches of the dorsal primary rami, yielding pain and pruritus in the region between scapula and spine. This hypothesis on the pathophysiology of NP would predict that the injury to other motor nerves stabilizing the scapula  or the stabilizing muscles they innervate might lead to a similar clinical syndrome.Our findings highlight the need to establish normal scapulothoracic stabilization in patients presenting with NP. In cases of NP with a well-defined etiology of injury to the serratus anterior, the long thoracic nerve, or the cervical roots it arises from, EMS of the serratus anterior muscle may be a promising treatment modality for notalgia paresthetica.While pain and pruritus were both present in our patients, we note the lack of hyperpigmentation or other visible skin abnormalities which commonly accompany descriptions of notalgia paresthetica. It is unclear whether these skin abnormalities cause or are a result of the pain and pruritus in the symptomatic area. Immunohistochemical findings in NP have been inconclusive, with discordant conclusions on distributions of nerves in the symptomatic area -11. FurtIt is possible that analgesia from electrical muscle stimulation is a result of transcutaneous electrical nerve stimulation (TENS). A study investigating TENS for relief of NP symptoms where TENS was applied to the symptomatic area medial to the scapula found roughly 30% improvement in pruritus over two weeks , highligWe describe a novel and well-defined etiology of long thoracic nerve injury with consequent serratus anterior dysfunction in notalgia paresthetica, and EMS of the serratus anterior as a long-acting and effective treatment conferring the advantage of a once-daily treatment regimen. Future work might expand on this case series by: 1) conducting randomized blinded trials of serratus stimulation for NP; 2) conducting case-control studies among patients with NP to evaluate the association of NP and long thoracic nerve injury; 3) performing quantitative sensory testing (QST) to document the presence of nerve injury in the area of pain among patients with NP and potential QST improvements after treatment; and 4) exploring if loss of scapular stabilization by other means, e.g. injury to the dorsal scapular nerve and spinal accessory nerve, leads to a similar clinical syndrome with respect to NP. We also note that future studies of notalgia paresthetica would benefit immensely from a multidisciplinary approach integrating the expertise of dermatologists, neurologists, orthopedic surgeons, and pain management specialists.Notalgia paresthetica is a poorly-understood condition in which patients present with pain with or without pruritus and paresthesias in an area lateral to the spine and medial to the scapula. To date, there have been various proposed etiologies of NP and a multitude of different treatment approaches which have met with varying degrees of success. We describe a novel and well-defined etiology of long thoracic nerve injury with consequent serratus anterior dysfunction in notalgia paresthetica, and EMS of the serratus anterior as a long-acting and effective treatment conferring the advantage of a once-daily treatment regimen. The authors hypothesize that abnormal scapulothoracic stabilization creates traction or compression of the cutaneous medial branches of the thoracic dorsal primary rami. This then gives rise to the symptoms of this syndrome. EMS of the serratus anterior muscle is a possible treatment for NP that deserves further study.The authors declare that they have no competing interests.AG conducted all electrodiagnostic studies and treated patients clinically. IRC treated patients clinically. MB and SM helped with manuscript preparation, literature review, and background context for the manuscript. SM additionally provided material resources. CKW led the literature review and prepared the manuscript. All authors critically read and approved the final manuscript.