While stimulation of the peripheral nerves increases the pain threshold, chronic pressure stimulation of the sciatic nerve is associated with sciatica. We recently found that acute pressure block of the sciatic nerve inhibits pain. Therefore, we propose that, the pain pathology-causing pressure is chronic, not acute. Here, we report a novel self-administered method: acute pressure block of the sciatic nerves is applied by the patients themselves for short-term relief of pain from dental diseases.This was a randomized, single-blind study.Hospital patients.Patients aged 16–60 years with acute pulpitis, acute apical periodontitis, or pericoronitis of the third molar of the mandible experiencing pain ≥3 on the 11-point numerical pain rating scale.Three-minute pressure to sciatic nerves was applied by using the hands (hand pressure method) or by having the patients squat to force the thigh and shin as tightly as possible on the sandwiched sciatic nerve bundles (self-administered method).The primary efficacy variable was the mean difference in pain scores from the baseline.P ≤ 0.001). The analgesic effect of the self-administered method was similar to that of the hand pressure method.One hundred seventy-two dental patients were randomized. The self-administered method produced significant relief from pain associated with dental diseases (The self-administered method is easy to learn and can be applied at any time for pain relief. We believe that patients will benefit from this method. Stimulation of peripheral nerves increases the pain threshold 1–3. Theoretically, the larger peripheral nerve is stimulated, the stronger inhibition is. The sciatic nerve is the largest peripheral nerve, but pressure stimulation of the sciatic nerve is associated with hyperalgesia It is unclear why the application of different types of pressure to the sciatic nerve has such strikingly different effects, with chronic pressure causing hyperalgesia and acute pressure providing significant pain relief. A hypothesis that may explain this phenomenon is that acid-sensitive ion channels (ASIC) are expressed in the neurons of the mammalian central and peripheral nervous systems. These ASICs have been proposed to be part of the mechanoreceptors and play an important role in the response to mechanical stimuli 14–17. So far, four ASIC proteins have been found to be expressed in the sciatic nerve Pain may occur at any time, such as at home, while traveling, during meetings, and at the farm, and no immediate method is available to relieve it. Herein, we present a novel self-administered analgesic method of an applying acute pressure block to the sciatic nerve and two clinical trials of the method. We believe that patients will benefit from this self-administered method.The two randomized trials were conducted in Department of Dentistry, Nanfang Hospital, Southern Medical University, China . The open registration information of the trials of this study was ACTRN12611000747921. The pilot studies of the method were conducted in multiple centers (as indicated in the Acknowledgments section). All enrolled patients had pain from a dental disease  and were sequentially recruited by participating physicians using sealed envelope randomization method. None of the patients had previous experience with either method, and none used an analgesic medication in the previous 12 hours before participating in the experiment. The age range was 16–60 years, and all patients had an educational level higher than middle school. The allocation ratio is 1:1. Informed written consent was obtained, and subjects were instructed in use of the numerical rating scale (NRS), in which pain was scored from 0 (no pain) to 10 (maximum pain). Pain was assessed immediately before the intervention (baseline pain), and 1, 5, and 15 minutes after the intervention. The time of each intervention  was 3 minutes.The present experiments were conducted without following the minimum sample size because subjects are easy to collect due to the simple design of the study, short duration, and noninvasiveness of the intervention.Among 703 dental patients screened for the two trials Figure , 531 ineThe self-administered method: Figure The placebo intervention for the study of the self-administered method: Patients sat on a soft chair, with their arms surrounding their knees and their head and neck inclined slightly forward.The hand pressure method: A pressure of 10–20 kg per hand was applied to the sciatic nerve at the backs of both thighs for 3 minutes while the patients were in the prone position, according to the reports by He et al. 10–13.2 test and t-test. The NRS were assessed within groups or between groups using Mann–Whitney U-test. All tests were two sided, and a P value of <0.05 was considered to indicate significance. The analysis included the per-protocol data. All statistical analyses were performed by using SPSS statistical software .The baseline scores, sex, and age of the participants were compared between the self-administered method and placebo groups, or the self-administered method and hand pressure method groups by using the χ#P < 0.001 for all three time points between the two groups, Figure P < 0.001)  Figure . In cont) Figure . In the P < 0.001 for the three time points), acute apical periodontitis , and pericoronitis of the third molar of the mandible .We further analyzed the analgesic efficacy of the self-administered method on different patient subgroups. The demographic characteristics of the patient subgroups  in experiment 1 are shown in Table #P < 0.001 for all the three time points after intervention for pulpitis and acute apical periodontitis, and #P = 0.04 and 0.02 at 5 and 15 minutes, respectively, after intervention for pericoronitis.The self-administered method provided greater pain relief compared with the placebo method for all three types of disease. The difference between acute pressure relief and the placebo relief was significant: In our previous reports that utilized the hand pressure method, pressure applied to the sciatic nerve at the back of both thighs provided significantly greater relief of pain compared with same amount of pressure applied to parallel regions on the front of the thighs. Effective pressure on any accessible area along the sciatic nerve provides pain relief, and the relief is reduced if the pressure is applied at a distance from the sciatic nerve 11–13,19. Herein, we compared the analgesic efficacy of the self-administered method with the hand pressure method. Table Stimulation of peripheral nerves elevates the pain threshold. Thus, for the purpose of inhibition of pain, stimulation of the sciatic nerve is a conceivable idea, given the large size of the sciatic nerve. We introduce a simple self-administered method to relieve dental pain. With a right squatting down as introduced, the entire sciatic nerve receives pressure; pain was relieved immediately and significant.After our method spread out from the study centers, several doctors even contacted us about learning from their patients, that pain occasionally disappeared when their patients squatted down for a few min. We reasoned that the relief was due to an acute pressure blockade of the sciatic nerve, similar to what we recorded in this study. In contrast, a tingling sensation or intolerable pain often occurs when a subject sits in a cross-legged position for an extended period. This observation may be similar to the hyperalgesia caused by chronic pressure on the sciatic nerve.Spinal dorsal horn the wide dynamic neurons (WDR) are the first synaptic relay point for afferent pathways, and they play an important role in modifying the transmission of noxious input Interestingly, acupressure, a form of acupuncture, applies pressure to the Yao Yang Guan acupuncture point to relieve acute sciatica pain and low back pain For the hand pressure method, a pressure of 10–20 kg/hand is required to provide pain relief 11–13. The self-administered method involves squatting down; therefore, the pressure to the sciatic nerve, per unit area, should be much smaller than the 10–20 kg/hand pressure administered by the hand. However, in the self- administered method, the entire sciatic nerve receives pressure; therefore, the total pressure to the sciatic nerve should be greater than the 10–20 kg, which results from the hand pressure method. Thus, the extent of the nerve area that receives pressure appears to be an important factor in pain relief for this method.We used a 3 minutes of intervention for the self-administered pressure method, instead of 2 minutes used in He et al.'s studies, because our pilot studies shows that some patients need more time for pain relief. Usually, a sample size of 20 subjects was enough to reach significance in tests of dental diseases. However, the present experiments were conducted without following the minimum sample size because subjects are easy to collect due to the simple design of the study, short duration, and noninvasiveness of the intervention.The first limitation of this study was the small sample size, which limited the subgroup analysis. The second limitation is that sitting on a chair may be not a good control for the self-administered method, even though the positions of the patients for the control method is similar to that for the self-administered method, with patients' arms hugging the legs. The third limitation was the single-blind design. We did not conduct a double-blinded study because the method appeared to be highly effective for reducing pain; thus, the doctors were easily able to identify the placebo or the treatment group during the experiment. However, a double-blind study could demonstrate the efficacy of the treatment and could provide results that are more precise. Thus, a double-blind study would be a help to confirm our results.


Postoperative pain associated with removal of mandibular third molars has been documented from moderate to severe during the first 24 hours after surgery, with pain peaking between 6 and 8 hours when a conventional local anesthetic is used. Dental pain is largely inflammatory, and evidence-based medicine has shown that nonsteroidal anti-inflammatory drugs are the best analgesics for dental pain. The aim of this study was to compare the analgesic, anti-inflammatory and anti-trismus effect of a single dose of diclofenac and meloxicam after mandibular third molar extraction.A total of 36 patients were randomized into two treatment groups, each with 18 patients, using a series of random numbers: Group A, was administered 100 mg of diclofenac; and Group B, 15 mg of meloxicam. Drugs were administered orally 1 hour prior to surgery. We evaluated pain intensity, analgesic consumption, swelling, as well as trismus.P=0.04) and better aperture than those receiving 100 mg of diclofenac (P=0.03). The meloxicam group presented less swelling than diclofenac group; however, significant statistical differences were not observed.The results of this study showed that patients receiving 15 mg of meloxicam had less postoperative pain (Data of this double-blind, randomized, parallel-group clinical trial demonstrated that patients receiving 15 mg of preoperative meloxicam had a better postoperative analgesia and anti-trismus effect compared with who were given 100 mg of diclofenac after third molar extractions.Key words:Diclofenac, meloxicam, dental pain, trismus, third molar surgery. In the majority of cases, removal of third molars will lead to a significant degree of tissue trauma, causing an inflammatory reaction. The patient develops the common postoperative symptoms and signs of pain, facial swelling, dysfunction, and limited mouth opening (trismus). The pain is typically brief and will peak in intensity in the early postoperative period. Facial swelling and trismus will reach their characteristic maximum 48 to 72 h after surgery .Evidence-based medicine has shown that Non-steroidal anti-inflammatory drugs (NSAID) comprise the best analgesic for dental pain . The effThe aim of this pilot study was to compare the analgesic, anti-inflammatory and anti-trismus effect of a single dose of diclofenac and meloxicam after mandibular third molar extraction.- DesignThis study was designed as a double-blind, randomized, parallel-group clinical trial, and was conducted in accordance with the Declaration of Helsinki. The Ethics Committee approved the study design. All of the subjects were informed of possible risks of oral surgery and experimental treatments, and they signed an institutionally approved consent form.- Selection criteriaInclusion criteria were age 18-30 years, either sex, free of systemic disease, clinical and radiographic diagnosis of a mandibular impacted third molar with no pain associated up to the day of the surgery, and difficulty of extraction . Exclusion criteria included use of analgesics 1 week before the procedure, gastritis, peptic ulcer, pregnancy or lactation, and known hypersensitivity to the medications used.- Randomization and blinding A total of 36 patients from the Department of Maxillofacial Surgery of the School of Dentistry at Cuauhtémoc University, San Luis Potosí, México, were recruited. The patients were randomized into two treatment groups, each with 18 patients, using a series of random numbers: Group A, was administered 100 mg of diclofenac; and Group B, 15 mg of meloxicam. Drugs were administered orally 1 hour prior to surgery. The algorithm is shown in , the patients returned the unused tablets. The pills were counted to determine the number of pills consumed. Patients having no pain relief 30 min after taking 2 acetaminophen tablets orally were given a 30 mg tablet of sublingual ketorolac as rescue analgesic procedure due to therapeutic failure. Total analgesic consumption  was evaluated.A 10 cm Visual Analog Scale (VAS) was employed to assess pain. The VAS consisted of an interval scale ranging from 0, representing no pain or discomfort, to 10, representing maximal pain or discomfort. The VAS report was recorded each hour for 12 hours after completion of surgery, and the last evaluation was conducted at 24 hours.et al., (2003)  . DistancA standardized independent evaluator measured these parameters  at each time point.- Statistical methodsp value <0.05 was considered a significant statistical difference.Data were expressed as mean and Standard Deviation, medians and ranges, or frequencies. For numerical variables with normal distribution, the Student t test was used, while for numerical variables without normal distribution and ordinal variables, the Mann-Whitney U test was utilized. For categorical variables, the Fisher exact test was employed. A A total of 36 patients were enrolled in the study, and all patients were included in the statistical analysis. There were no statistically significant differences between the study groups with regard to the number of patients included and their age distribution, sex, height, and weight. Surgical variables that could have influenced postoperative pain intensity were considered homogeneous between the groups, including length and difficulty of the surgical procedure .Time of first rescue analgesic medication, the number of patients taking acetaminophen at 3, 6, 9, 12 and 24 hours, analgesic consumption, and the number of patients requiring rescue analgesic procedure with sublingual ketorolac due to therapeutic failure was similar in the two treatment groups .P=0.04), , Fig. .As mentioned previously, seven facial anatomical distances, measured pre- and post-surgery, were employed to determine facial swelling and the possible anti-inflammatory effects of the medications tested. However; no statistical differences were observed .In both treatment groups, aperture before surgery was 5 cm and after surgery; this decreased about 40% at 24 hours post operatively and, incrementing as time went on. Trismus scores were superior in patients who took meloxicam when compared with those patients receiving diclofenac Fig. .Finally, there were no complications associated with the surgical procedure itself, and none of the patients reported adverse events associated with the medications.This clinical trial evaluated the efficacy of a single dose of diclofenac and meloxicam administered by oral route for control of pain, inflammation and trismus after a mandibular third molar surgery. Duration of analgesia for diclofenac was in agreement with previous reports ,17. HoweThe practice of initiating administration of analgesic drugs preoperatively is particularly controversial. The current tendency is to start treatment at an earlier stage than in the past, because it has been shown that postoperative pain can be avoided almost entirely through analgesic pre medication . In our One of the problems of evaluating the analgesic, anti-inflammatory and anti-trismus efficacy of a drug is related to the pharmacokinetics and pharmacodynamics of the drugs. Another important factor to be taken into account is the evaluation period. In effect, with the introduction of long-acting analgesics, prolonged observation periods have become necessary in the context of single dose studies .et al., (2005) carried out a random, single-blind study to compare the analgesic efficacy of diflunisal, naproxen, meloxicam, acetaminophen and rofecocixib in oral surgery. Nevertheless, the authors found no differences related with analgesic efficacy or adverse effect  reported nausea, vomiting, bleeding in surgical site, allergy, and gastrointestinal symptoms when meloxicam was used in oral surgery (In this study no patients reported adverse effects in relation to the use of these drugs. Nevertheless, clinical trials using diclofenac in third molar surgery have reported adverse effects over the digestive and nervous system ,23,24. M surgery .In conclusion, data of this pilot study suggest that the preoperative administration of a single dose of meloxicam produces superior postoperative analgesia and anti-trismus effects compared with diclofenac after mandibular third molar extraction.


Objective: To investigate the incidence of serious adverse events (SAE) of subthalamic deep brain stimulation (STN-DBS) in elderly patients with Parkinson's disease (PD).Methods: We investigated a group of 26 patients with PD who underwent STN-DBS at mean age 63.2 ± 3.3 years. The operated patients from the EARLYSTIM study (mean age 52.9 ± 6.6) were used as a comparison group. Incidences of SAE were compared between these groups.Results: A higher incidence of psychosis and hallucinations was found in these elderly patients compared to the younger patients in the EARLYSTIM study (p < 0.01).Conclusions: The higher incidence of STN-DBS-related psychiatric complications underscores the need for comprehensive psychiatric pre- and postoperative assessment in older DBS candidates. However, these psychiatric SAE were transient, and the benefits of DBS clearly outweighed its adverse effects. Deep brain stimulation (DBS) is widely used as a neurosurgical treatment for Parkinson's disease (PD), because it improves the motor manifestations of PD and reduces the need for antiparkinsonian medication . The records were analyzed for a period of 2 years after STN-DBS. The inclusion and exclusion criteria from the EARLYSTIM study  who underwent STN-DBS from January 1, 2008 to June 30, 2013, were selected for the analysis .In each patient, Medtronic 3389 electrodes were stereotactically implanted into the STN bilaterally under local anesthesia with the aid of intraoperative microelectrode recording and test stimulation, after coordinate- and visually-based target selection and trajectory calculation with the aid of preoperative CT and MRI scans. The pulse generator was implanted subsequently under general anesthesia.Patients with PD who were scheduled for DBS underwent interdisciplinary assessment  before and, in general, every 6 months after the procedure. The results of these assessments were stored in the hospital's clinical and research databases and were compiled for this analysis. Whenever a patient needed his/her family doctor's assistance for problems potentially related to Parkinson's disease or to DBS, but was not admitted to the hospital for these problems, the family doctor reported such cases to the clinical and research database. The interdisciplinary assessment performed within the 14 days before the STN-DBS will be referred to as the “baseline assessment,” while that performed 24 months later will be referred to as the “2-year assessment.”The following variables were analyzed: subscales II and III of the Unified Parkinson's Disease Rating Scale (UPDRS), the Brief Psychiatric Rating Scale (BPRS), the Beck Depression Inventory II (BDI II), and the levodopa equivalent daily dose (LEDD). In some cases, diagnoses made by other medical specialists  were used in addition as an indication of the patient's general medical condition.SAE were defined according to the Medical Dictionary for Regulatory Activities, version 14.1, as any registered events that led to death, disability, or prolonged or new hospitalization with serious health impairment. The list of SAE was adjusted to the list of SAE described in the EARLYSTIM study. Thus, the SAE were grouped in the following categories: (1) suicide, (2) life-threatening events, (3) events related to medication or stimulation, (4) events related to surgery or device, (5) events related to PD. We calculated the number of reported SAE in each category for each patient within the 24 months after STN-DBS.t-test. The numbers of patients with SAE were compared with the chi-squared test with Yates correction to prevent overestimation of statistical significance for small data; significance was set at p < 0.05. Linear regression models were applied to adjust for potential confounders in statistically significant differences.Statistical calculations were done with the R version 3.1.2 open source software. Baseline mean and standard deviations of the demographic and clinical parameters of the groups were compared with an unpaired Student's The results of the comparison of the demographic and clinical features of the two groups are shown in Supplement p = 0.03) and in its subcategory “psychosis and hallucinations” . The characteristics of psychosis and hallucination of the patients in the BASEL group are shown in Table The results of the comparison of SAE incidence between the two groups are shown in Table We found a higher incidence of psychosis and hallucinations after STN-DBS in a sample of PD patients who were about 10 years older than those of the EARLYSTIM study.The effects of DBS on mental functioning are not clear, and the pattern and expression of neuropsychiatric symptoms in operated patients with PD are highly variable  has been found to be comparable to STN-DBS in terms of efficacy and safety  were transient, occurring mainly in the early postoperative period. The benefits of DBS clearly outweighed its adverse effects in this group of patients.VC: conceived and designed the study and was responsible for its execution, wrote the first draft, performed data analyses, contributed core ideas, and was involved in critically revising the manuscript; ME: supervised the neuropsychological evaluations, contributed core ideas, and was involved in critically revising the manuscript; UG: conceived and designed the study and was responsible for its execution, performed data analyses, was responsible for the psychiatric and psychological assessments, contributed core ideas, and was involved in critically revising the manuscript; FH: performed neurologic assessments, managed the database infrastructure, contributed core ideas, and was involved in critically revising the manuscript; AM: was responsible for the psychological assessments, contributed core ideas, and was involved in critically revising the manuscript; AUM: supervised the neuropsychological evaluations, contributed core ideas, and was involved in critically revising the manuscript; MS: contributed core ideas and was involved in critically revising the manuscript; ET: performed the DBS procedures, contributed core ideas, and was involved in critically revising the manuscript; PF: conceived and designed the study and was responsible for its execution, contributed core ideas, was involved in critically revising the manuscript.Supported by the Parkinson Schweiz, the Bangerter-Rhyner Foundation, the Gossweiler Foundation, the Freie Akademische Gesellschaft Basel, and the Camelia Botnar Foundation. These institutions had no further role in the study design or data evaluation and interpretation.VC: grant from the Camelia Botnar Foundation; ME: grant from Vifor Pharma; UG: grants from the Parkinson Schweiz, the Gossweiler Foundation, the Freiwillige Akademische Gesellschaft Basel, the Bangerter-Rhyner Foundation, the Swiss National Science Foundation, the Camelia Botnar Foundation, the Hedwig Widmer Foundation, unrestricted grants from: UCB Pharma AG, Abbvie AG, General Electrics; FH: grant from the Freiwillige Akademische Gesellschaft Basel; AM: grant from the Hedwig Widmer Foundation; AUM: grants from the Alzheimer Forum Switzerland, the Swiss Alzheimer's Association, Vifor Pharma, Advisory Boards: MSD, AC Immune, Takeda, Zinfandel Pharma; ET: grant from the Swiss National Science Foundation; MS: has nothing to declare; PF: grants from the Parkinson Schweiz, the Gossweiler Foundation, the Freiwillige Akademische Gesellschaft Basel, the Bangerter-Rhyner Foundation, the Swiss National Science Foundation, the Swiss Multiple Sclerosis Society, the Camelia Botnar Foundation, the Hedwig Widmer Foundation, unrestricted grants from: UCB Pharma AG, Roche AG, Abbvie AG, General Electrics, Advisory Board: Biogen Inc.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The objective of the present study was to explore whether the possibility of offering facilitated access to an alcohol electronic brief intervention (eBI) instead of delivering brief face-to-face advice increased the proportion of consulting adults who were screened and given brief advice.The study was a 12-week implementation study. Sixty primary healthcare units (PHCUs) in 5 jurisdictions  were asked to screen adults who attended the PHCU for risky drinking.A total of 120 primary healthcare centres from 5 jurisdictions in Europe.746 individual providers  participated in the study.Change in the proportion of patients screened and referred to eBI comparing a baseline 4-week preimplementation period with a 12-week implementation period.The possibility of referring patients to the eBI was not found to be associated with any increase in the proportion of patients screened. However, it was associated with an increase in the proportion of screen-positive patients receiving brief advice from 70% to 80% for the screen-positive sample as a whole (p<0.05), mainly driven by a significant increase in brief intervention rates in England from 87% to 96% (p<0.01). The study indicated that staff displayed a low level of engagement in this new technology. Staff continued to offer face-to-face advice to a larger proportion of patients (54%) than referral to eBI (38%). In addition, low engagement was seen among the referred patients; on average, 18% of the patients logged on to the website with a mean log-on rate across the different countries between 0.58% and 36.95%.Referral to eBI takes nearly as much time as brief oral advice and might require more introduction and training before staff are comfortable with referring to eBI.NCT01501552; Post-results. There is a lack of studies on implementing referral to an alcohol electronic brief intervention (eBI) by healthcare staff in primary healthcare as reported in the present study.The strength of this study is the participation from five jurisdictions, enabling us to study the variability of referrals to eBI.In addition, the high number of participating providers and primary healthcare units (PHCUs) is seen as a strength.Limitations include the failure of some jurisdictions to implement referral to the eBI as intended, as well as the lack of access and trust in internet-based health promotion among patients (that might be due to the age of the population screened in some jurisdictions).Alcohol continues to be a leading cause of disease globally.5–7As access to the internet has increased, electronic brief advice websites (electronic brief intervention (eBI)) for risky drinkers have been developed and made available online. Research indicates that they can have beneficial effects equivalent to face-to-face interventions depending on the content of the eBI and the target group.Optimising the use of electronic health behavioural interventions in the population at large is a major challenge.14One of the few published studies involving the offer of an eBI in a primary care setting was undertaken in the UK where staff at 18 primary healthcare centres agreed to refer patients with risky drinking to an electronic alcohol intervention.Research on referral of patients by healthcare staff to internet applications promoting healthy lifestyle such as low-risk drinking is still in its infancy; only a few studies have been conducted in the UK and Sweden, and a few more studies are underway.16The Optimizing Delivery of Health Care Interventions (ODHIN) trial was designed to evaluate the effect of three implementation strategies  on implementation of alcohol screening and brief intervention in primary healthcare: (1) financial reimbursement (FR), (2) training and support (TS) and (3) facilitated access to an eBI as an alternative to face-to-face intervention.The objective of the present study was to explore whether the possibility of offering facilitated access to an eBI instead of delivering oral brief advice in the ODHIN study increased the proportion of consulting adults who were screened and the proportion given brief advice using data from the ODHIN study. The study also examines differences in the levels of implementation among the various participating jurisdictions in the trial and adherence to referral to eBI among the patients.This study is a subanalysis of the data obtained during the ODHIN RCT.et al. Submitted to Addiction). A total of 120 PHCUs in Catalonia, England, the Netherlands, Poland and Sweden were randomly allocated to one of the eight groups using computerised randomisation, stratified by jurisdiction. In total, 746 individual providers  agreed to participate in the trial and gave written informed consent after a 30–45 min introductory meeting explaining the evidence base on alcohol screening and brief interventions.The results of the 12-week implementation of the ODHIN RCT will be described in a forthcoming article ). After formal agreement with the PHCU to take part in the trial, baseline measurements took place over a 4-week period. After a gap of 2–6 weeks, the 12-week implementation period began; the start date for each jurisdiction was between November 2012 and May 2013. All seven intervention groups received the same basic input as the controls together with additional components. Providers in PHCUs allocated to referral to eBI  had a mean age of 47.1 years  and 76% were women. The mean age of the providers was lowest for the Netherlands (44.1 years) and highest for Poland (48.9 years). The proportion of women varied from 68% in the Netherlands to 90% in Sweden.Staff in each PHCU were asked to screen adult patients (≥18 years of age who attended the PHCU for any reason) for risky drinking, using a paper version of the Alcohol Use Disorders Identification Test—Consumption (AUDIT-C)Screen positives were defined in Catalonia and England as men and women who scored ≥5 on AUDIT-C, and in Poland, the Netherlands and Sweden as men who scored ≥5 and women who scored ≥4 on AUDIT-C. The providers in all eight arms were asked to deliver brief alcohol advice to screen positives, with the length and format of the advice based on country-specific guidelines or existing routines. In addition, the eBI arms were given the option of referring to an eBI website. No demographic data concerning the patients were collected.Providers in PHCUs allocated to referral to eBI  were offered the opportunity to refer patients to an online brief alcohol intervention as an alternative to a face-to-face brief intervention, but were advised that they could continue to offer face-to-face intervention if they so wished to do so. Providers were advised that referral should consist of taking a few minutes to encourage screen-positive patients to log on to the designated eBI package. All providers in this arm of the trial were trained in how to offer the eBI to the patients using a designated script and were asked to spend time familiarising themselves with the website before referring patients to the intervention. Unique log-on codes were used to trace whether they actually did so. Patients referred to the eBI were handed a leaflet containing a unique log-on code for an approved eBI online intervention. The eBI website used in each jurisdiction was required to meet the following criteria: (1) customised as an ODHIN website, (2) log-on facility to allow monitoring of patient log on, (3) suitable brief screening tool with the ability to calculate a score and give feedback , (4) appropriate information on sensible drinking guidelines, (5) information on the impact of alcohol on health and well-being and (6) a drink diary facility. In each country, the eBI package was selected from existing programmes with the exception of Poland where the WHO eBI programme was used.The tally sheet with the AUDIT-C score and registration of brief advice activity  was used to calculate the proportion of patients screened, the proportion of screen-positive patients who were offered brief advice in any of the following formats: oral advice, given an informative leaflet about sensible drinking, referral for oral advice by other staff or referral to eBI.The staff were asked to indicate on the tally sheet which forms of brief advice activity were offered to the patients. In jurisdictions using paper tally sheets, it was possible to tick (and therefore deliver) several forms of brief advice to one patient in a single consultation, whereas in Catalonia, just one option was recorded on the electronic record. Staff were also asked to note on the tally sheet if the patient did not want to be referred to eBI or had no computer, and to take note of any other reason for not offering advice during the consultation, including lack of time. On the paper version, it was possible to tick more than one activity, but for Catalonia, only one option could be selected.The proportion of patients screened was calculated as the number of patients screened divided by the number of patients eligible for screening per participating provider times 100.The proportion of screen-positive patients given brief advice was calculated as the number of screen-positive patients who received oral brief advice and/or were given a leaflet, were referred to another provider in or outside the practice or were referred to eBI divided by the total number of screen-positive patients per participating provider times 100.The proportion of patients logging on to the eBI was calculated as the number of patients who logged on to the intervention per PHCU divided by the number of eBI referral cards handed out  times 100. The number of patients logging on to the eBI was retrieved from the eBI system in each jurisdiction. Each patient could be traced using the log-on number unique to an individual provider.After the implementation period, staff were asked to complete a questionnaire as part of a monitoring process of attitudes to dealing with heavy drinkers that was established throughout the ODHIN trial. This questionnaire also enquired about the average time spent delivering screening and oral advice as well as screening and referral to eBI.2 test.For descriptive purposes, the proportion for categorical variables and the mean values for quantitative variables were calculated. Differences in the proportion of providers familiarising themselves with the content of the eBI website were compared between active and non-active providers using the χet al. Submitted to Addiction), in which  coding was used, resulting in the outcome regression coefficients having half the effects. The eBI factor was coded as follows: eBI=−1 for the control, FR, TS and TS+FR arms and +1 for the eBI, eBI+TS, eBI+FR and eBI+TS+FR arms.The main ODHIN trial had a factorial design , models were analysed with PHCU nested within country as random-effect variables. Evidence for interactions between TS, FR and eBI was investigated. There was an interaction between FR and eBI for screening rates, and the interaction term FR×eBI was entered in the models. There was an interaction between TS, FR and eBI for brief advice rates, and the interaction term TS×FR×eBI was entered in the models. The outcome rates were estimated marginal means per provider with 95% CIs, accounting for provider within PHCU within jurisdiction. When examining the impact of the factors on the 12-week screening and brief advice rates, examination of residuals found them to be not symmetrically distributed around 0, so log-transformed data, which provided a better fit, were used. Before logging, rates with a value of 0 were assigned a value of 0.001. Differences in the coefficients with and without the factor were tested by t-tests in the MIXED procedure.et al. Submitted to Addiction).Ethical approval for the study was obtained within each jurisdiction from the relevant approval bodies  providers from 56 different PHCUs participated actively in referral of patients to the eBI by handing out at least one eBI referral card to the patients. The remaining 172 (49%) providers from 41 different PHCUs did not hand out any eBI referral cards.2 25.39, df 1, p=0.0001).Of the 350 providers, 252 (72%) never familiarised themselves with the content on the eBI website. Of the 178 active providers referring patients to the eBI, 71 (40%) familiarised themselves with the eBI website in contrast with the 172 non-active providers, of whom only 27 (16%) logged on to the website  of the 9619 patients screened were found to have a positive AUDIT-C score and of these, 1286 (38%) from 56 of the 60 PHCUs were referred to eBI.Calculations for the proportion of referred patients logging on to the eBI were obtained from 54 of the 60 PHCUs, excluding 4 PHCUs that did not refer any patient to eBI and 2 PHCUs for whom no log-on rate was reported . A total of 17 of the 60 PHCUs had a log-on rate of 0 despite having referred patients to the eBI; 9 PHCUs in Catalonia, 5 in the Netherlands and 3 in Poland.The number of providers, referrals to eBI and mean log-on rates are presented in One of the aims of the study was to explore whether the possibility of referring to the eBI would increase the proportion of patients screened and receiving brief advice (among screen positives). In general, little evidence of this was found . The eBIProviders who had familiarised themselves with the content on the eBI website had a slightly higher proportion of screening during the 12-week implementation period, controlling for baseline proportions , than providers who had not , but this difference was not significant .Although the providers in the eBI arm were encouraged to refer patients to the eBI, they were still able to offer face-to-face advice, hand out a leaflet about sensible drinking and/or refer patients to other staff at the PHCU or outside the PHCU, who would then deliver oral advice. The distribution of the type of advice offered in the eBI arms among AUDIT-positive patients is presented in A little more than half of the 3405 cases with a positive AUDIT score received face-to-face advice (n=1837), whereas about one-third (1286) were referred to the eBI.Separate analysis showed that about half of the patients (608) referred to the eBI received this as the only intervention activity. For each jurisdiction, the proportion of referrals to the eBI as the only intervention was as follows: Catalonia 15.0%, England 7.1%, the Netherlands 3.3%, Poland 41.1% and Sweden 10.6%. However, for Catalonia, only one option could be selected on electronic tally sheet.Furthermore, among the 1837 patients receiving face-to-face advice, 616 (34.6%) were also referred to eBI. The log-on rate was somewhat higher among these patients  compared with those only being referred to the eBI . A total of 8.6% of the patients refused referral to the eBI or rejected this option because of lack of access to a computer. Only a small minority of the patients were referred to other staff within or outside the practice, meaning that, in most cases, the staff who screened the patients also delivered the advice. Only 114 (3.3%) of the patients who screened positive did not get any advice because of lack of time.The distribution of the various forms of interventions offered is presented by jurisdiction in One of the reasons for including eBI as an arm in the trial was an expectation that referral to an eBI advice system would take less consultation time than delivering brief advice face to face. However, this was not found to be the case. Although the mean self-reported time per provider for referring a screen-positive patient to an eBI programme  for those providers in the eBI arms was less than the mean time  for delivering face-to-face brief advice for those providers not in an eBI arm, this difference, accounting for the multilevel nature of the data, was not significant . When examining the time differences by country, time spent on referral to an eBI advice system was significantly less than time spent delivering face-to-face brief advice in Poland  and Sweden . However, these time benefits were not associated with improvements in screening or brief advice rates in either Poland or Sweden .The study found little evidence to support the main hypothesis that the possibility of referring to an eBI would increase the proportion of patients screened and receiving brief advice. The eBI was not associated with any increase in the proportion of patients screened. However, it was associated with an increase in the proportion of screen-positive patients receiving brief advice from 70% to 80% of the screen-positive sample as a whole (p<0.05), mainly driven by a significant increase in England from 87% to 96% (p<0.01).Furthermore, the findings in the study indicate that staff displayed a low level of engagement and perhaps mistrust in this new technology. Only 28% of all the participants in the eBI arms of the trial familiarised themselves with the eBI; this proportion increased to 40% among those who referred at least one patient (51% of the providers), suggesting that those who were familiar with the eBI package were more likely to recommend its use. Staff continued to offer face-to-face advice to a larger proportion of the patients (54%) than referring to the eBI (38%).A wide variability in engagement  was seen among patients both between and within jurisdictions.Our findings are in line with previous research that has repeatedly shown the challenges of competing tasks  facing staff in primary healthcare are often a hindrance when implementing new methods, not least implementing new methods for working with risky drinkers.22Engagement of the referred patients varied to a high degree both within and across jurisdictions. In two jurisdictions, Catalonia and the Netherlands, a high number of PHCUs had a log-on rate of 0, that is, patients did not log on, despite having being referred to the eBI. However, in Poland, and in particular in England and Sweden, eBI referrals seem to have been implemented without any major problems . Lack of15Facilitated access or referral has been shown to reduce attrition in psychological online interventions targeting anxiety and depression.Our findings concerning the engagement of the patients are in line with a recent review in which it was concluded that the few projects published so far on referral to eBI have not been able to show a satisfactory level of engagement and sustainability. Referral to eBI seems only to succeed if the healthcare provider offers personal engagement in promoting the referral, ensuring that the patients log on and adhere to the online intervention.16Staff in this study were given the option of referring patients to the eBI, but they could also offer face-to-face advice, hand out a leaflet or refer patients to another professional within or outside the PHCU, except for Catalonia where only one option could be recorded in the electronic record. Only half of the patients referred to eBI were given this as the only option and thus did not receive oral advice. This means that half of the patients referred to eBI were also given oral advice using referral to eBI as an adjunct to oral advice. Whether this was due to lack of familiarity with or mistrust of the eBI or simply implies that when referring to eBI, oral advice becomes a part of the referral talk is not known. However, we asked staff to take a few minutes to encourage and motivate patients to log on to the eBI so the latter is highly probable. This is also supported by a somewhat higher log-on rate to the eBI among those who received oral advice and eBI (log-on rate of 22% vs 17%).Referral to eBI was meant to save time, and on average, the staff spent 12% less time (7.25 min compared with 8.28 min on average) when referring to eBI than when giving oral advice. The reason why more time was not saved could be that staff first had to screen the patients with the pen-and-paper AUDIT-C questionnaire  and then, based on the results, had to explain to the patients why they were recommending that the patient log on to the eBI intervention.Differences in the level of implementation among the participating jurisdictions were seen with regard to the proportion of AUDIT-C-positive patients referred to eBI; Poland referred most of their patients (80%) in contrast with the Netherlands where only 10% were referred.Assuming that a 0 log-on rate reflects the ability to motivate the patients to use the eBI, it seems that patients in Catalonia were less compelled to use the eBI because only 1 of the 12 PHCUs reported a log-on rate >0. We did not study the reason for this, but it could be due to a different culture among patients in Catalonia towards internet use and trust in websites. In the Netherlands, only 5 of the 12 PHCUs reported a log-on rate >0 and 2 PHCUs did not refer a single patient. However, in Poland, 9 of 12 PHCUs reported a log-on rate, 10 of 12 in England and all 12 PHCUs in Sweden . This miNot much progress has been reported on engagement by healthcare staff in alcohol interventions during the last decade.28To our knowledge, this is one of the first studies on implementing referral to an alcohol eBI by healthcare staff in primary healthcare. The strength of this study is the participation from five jurisdictions, enabling us to study the variability of referrals to eBI. In addition, the high number of participating providers and PHCUs is seen as a strength. Limitations include the failure of some jurisdictions to implement referral to the eBI as intended, as well as the lack of access and trust in internet-based health promotion among patients (that might be due to the age of the population screened in some jurisdictions). However, the main ODHIN study was not designed to study the reasons for failure in implementing referral to eBI, but a forthcoming qualitative study with participants from the ODHIN project will enable us to answer some of the questions raised by the present study.The study shows that it was difficult to get staff engaged in referring to the eBI, a fact that is reflected in the low proportion of staff familiarising themselves with the eBI intervention. The referred patients showed a low level of engagement in logging on to the eBI intervention, although there was a high degree of variation in engagement by patients across and within jurisdictions, perhaps as a consequence of the low level of engagement from the staff, the age of the patients and access to the internet.What can be learnt from this implementation study? Referral to eBI takes nearly as much time as brief oral advice; less than one-fifth of referred patients actually log on the website; all staff are not ready to refer to eBI and might require more introduction and training before they are comfortable with referring to eBI. Finally, a follow-up routine would also reduce the risk of no advice being delivered.


Postoperative pain control after total knee arthroplasty (TKA) remains a great challenge. The management of pain in the immediate postoperative period is one of the most critical aspects to allow speedier rehabilitation and reduce the risk of postoperative complications. Recently, periarticular infiltration anesthesia has become popular, but the outcome is controversial. Some studies have shown transient effects, “rebound pain”, or no effectiveness in pain control. Continuous intra-articular infusion technique has been introduced to improve these transient effects, but more clinical studies are needed. Furthermore, the potential risk of early periprosthetic joint infection is causing concerning. We plan to compare continuous intra-articular infusion anesthesia with epidural infusion anesthesia after TKA to assess the effectiveness of this technique in reducing pain, in improving postoperative function, and to look at the evidence for risk of early infection.n = 214) will be randomized into two groups: to receive continuous intra-articular infusion anesthesia (group C); and epidural infusion anesthesia (group E). For the first 3 postoperative days, pain at rest, active range of motion (A-ROM), rescue analgesia and side effects will be recorded. At 3-month and 6-month follow-up, A-ROM, C-reactive protein, erythrocyte sedimentation rate, and synovial fluid cell count and culture will be analyzed.This trial is a randomized, controlled study. Patients (The results from this study will provide clinical evidence on the efficacy of a continuous intra-articular infusion technique in reducing pain, postoperative functional improvement and safety. It will be the first randomized controlled trial to investigate infection risk with local anesthesia after TKA.ChiCTR-TRC-13003999ClinicalTrials.gov identifier:  Pain after total knee arthroplasty (TKA) is usually severe. It causes a state of discomfort that may directly influence patients' functional recovery. The pain involved has specific characteristics: a 55 to 60% incidence at rest and up to70% upon mobilization; high or very high intensity; and pain peaking at 3 to 6 hours after surgery and continuing for the following 72 hours ,2. AnestThere is some controversy surrounding periarticular infiltration anesthesia. Some studies, using single-dose or combined-dose periarticular infiltration, have shown transient effects, “rebound pain”, or no effectiveness in pain control ,18-21. TFor this purpose, the aims of our study were: (1) to analyze the efficacy of continuous intra-articular infusion anesthesia in postoperative pain control and functional recovery compared with epidural analgesia; and (2) to investigate PJI markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), synovial fluid cell count and culture during follow-up, to determine whether the risk of early PJI increases with a continuous intra-articular infusion procedure.This is a randomized, controlled prospective study. The trial protocol has been approved by the Research Ethical Committee of Guangdong Provincial Hospital of Traditional Chinese Medicine (TCM) . The trial will be conducted in accordance with the Helsinki Declaration, and will be monitored by the trial agency at Guangdong Provincial Hospital of TCM.Patients scheduled for primary TKA at the Department of Orthopedic Surgery, Guang Dong Provincial Hospital of TCM, will be recruited, with a target sample size of 214 subjects. All candidates will go through a standardized interview process and receive more information about the study and the treatments. The participants’ written consents will be obtained. The purpose and procedures, and potential risks and benefits, of the study will also be explained thoroughly to the participants. Participants are able to withdraw from the study at any time without consequence. The trial will be executed from February 2014 to December 2015 including enrollment and follow-up  physical status I-II;• Scheduled for unilateral TKA;• Patients aged 50 to 80 years old.• Willingness to give written informed consent and willingness to participate in and comply with the study.Participants meeting one or more of the following criteria will be excluded:• Unwillingness of the patient;• Presence of neuropathic pain or sensory disorders in the leg to be operated on;• Intolerance to the study drugs;• Failure of spinal anesthesia;• Previous major knee surgery, re-operation or trauma to the knee within the study period.All recruited patients will receive combined spinal and epidural anesthesia at the L3-4 level. For all the patients, cefamandole (2 g) will be administered intravenously 30 minutes before and after surgery. Low-molecular-weight heparin  for thromboprophylaxis will be administered subcutaneously 8 hours postoperatively and then once daily until week 2. In group E, the heparin administration will be delayed until epidural catheter withdrawal on postoperative day (POD) 2. A standardized intraoperative regimen for fluid administration will be applied which consists of 0.9% saline at 5 ml/kg per hour and colloid  at 7.5 ml/kg per hour.For multi-model pain management, preoperative oral doses of 400 mg celecoxib daily will be administered from day 2 before surgery. Postoperatively, all patients will receive 40 mg of parecoxib sodium twice daily intravenously until POD 3, followed by oral doses of 200 mg celecoxib every 12 hours until discharge. Tramadol hydrochloride injection will be applied for rescue analgesia.The same surgeon will perform all operations. A Gemini MK II prosthesis  will be inserted via a standard medial parapatellar approach in all patients.Cocktail anesthetic will be prepared for continuous intra-articular infusion, containing 150 mg ropivacaine (20 ml), 3 mg morphine sulfate (0.3 ml), 30 mg ketorolac tromethamine (1 ml), 0.5 μg 1:1000 epinephrine (0.5 ml), mixed with normal saline into a total volume of 150 ml.In group C, 50 ml of cocktail anesthetic will be applied via periarticular infiltration before insertion of the prosthesis. A multi-holed catheter will be placed into the lateral parapatellar gutter. The remaining 100 ml will be used as continuous intra-articular infusion with a patient-controlled analgesic (PCA) pump  at a speed of 2 ml/hour. After the wound is sutured, the catheter will be connected to the PCA pump which is activated after surgery and removed 48 hours later. The PCA pump will be set to deliver a 0.5-ml dose with a 15-minute lockout interval.In group E, the epidural catheter position will be checked with a test dose of 3 ml lidocaine-adrenalin (20 mg/ml and 5 μg/ml), followed by a bolus of 7 ml ropivacaine (2 mg/ml). A PCA pump containing 200 mg of ropivacaine (2 mg/ml) and 4 mg of morphine (0.04 mg/ml) will be connected with a flow rate of 2 ml/hour for 48 hours postoperatively. The PCA will be programmed to provide a 0.5-ml dose with a lockout interval of 15 minutes.Random assignment was performed before surgery by using a computer generated, blocked random-allocation sequence with a 1:1 ratio. This study cannot be blinded because the different catheter placement is obvious.The visual analog scale (VAS) has been used extensively for rating pain intensity in previous studies -24. PostUsually the need for supplementary treatment with systemic opioids is a reliable indicator when concerned about postoperative pain control. In previous studies, it has been argued that the use of strong or long-term rescue analgesia in both treatment groups may have reduced pain too much and “washed out” any differences between the two treatments. In this study, we use tramadol hydrochloride injection, which is a mid-intensity analgesic that will facilitate observing the differences in pain control between groups. The frequency and total consumption during the first 3 postoperative days will be recorded.Traditionally, range of motion has been used as an outcome measure after TKA to evaluate functional recovery and the success of the type of analgesia used -6,12. HoEarly diagnosis of PJI is challenging; at the present time, diagnosis of PJI remains dependent on clinical judgment and reliance on standard clinical tests including serologic tests, analysis of aspirated joint fluid, and interpretation of intraoperative tissue and fluid test results. During 3-month and 6-month follow-up, the CRP, ESR, synovial fluid culture, white blood cell (WBC) count and polymorphonuclear cell percentage (%PMN) will be measured.The presence of side effects during the postoperative period will be recorded, including nausea, vomiting, constipation and other adverse events.t-test. We plan to enroll a total of 214 participants with 107 in each group, allowing for a 15% withdrawal rate.Calculation of sample size was based on two previous studies ,25. We at-test. VAS and A-ROM will be analyzed with repeated measures for general linear models and multivariate analysis of variance. Data will be expressed as means (standard deviation), absolute numbers, and frequencies, when appropriate. P < 0.05 will be considered statistically significant for all comparisons.The statistical analysis will be performed using SPSS (Version 17.0) software . Normally distributed continuous variables will be compared using Student’s This study will provide clinical evidence on the efficacy of a continuous intra-articular infusion technique in reducing pain and improving postoperative function. In TKA, this remains a significant problem in the early postoperative period. Reduction of the patient's discomfort is the primary goal; reduction of the cost of narcotic use is a secondary goal. The epidural analgesia has been regarded as the gold standard in postoperative pain management, and it is associated with potential problems such as motor block, urinary retention and epidural bleeding (with anticoagulation therapy), and necessitates intensive observation of patients. The primary purpose of our study is to evaluate the efficacy of a continuous intra-articular infusion technique in relieving postoperative pain, reducing the need for postoperative narcotics, and improvement in postoperative function.This study will be the first randomized controlled trial to investigate infection risk with a continuous intra-articular infusion technique after TKA. There has been concern about the risk of early PJI with periarticular multimodal drug injection and use of intra-articular catheters after TKA. Previous studies of local infiltration analgesia after unicompartmental knee arthroplasty or TKA have not found any increase in infection ,15,20,26Recruitment will commence in February 2014, and the trial is scheduled to end in December 2015.A-ROM: active range of motion; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; PCA: patient-controlled analgesic; PJI: periprosthetic joint infection; %PMN: polymorphonuclear cell percentage; TCM: Traditional Chinese Medicine; TKA: total knee arthroplasty; VAS: visual analog scale; WBC: white blood cell; POD: postoperative day.The authors declare that they have no competing interests.JL conceived the study and prepared the initial protocol, and was in charge of coordination. DG drafted the manuscript and participated in the study design. XWC participated in the protocol and performed surgery. WWO and JKP helped to develop the study analysis. JWL made amendments and participated in designing the trial protocol. All authors read and approved the final manuscript.


Upper limb disability is a common musculoskeletal condition frequently associated with neck pain. Recent literature has reported the need to utilise validated upper limb outcome measures in the assessment and management of patients with neck pain. However, there is a lack of clear guidance about the suitability of available measures, which may impede utilisation. This review will identify all available measures of upper limb function developed for use in neck pain patients and evaluate their measurement and practical properties in order to identify those measures that are most appropriate for use in clinical practice and research.This review will be performed in two phases. Phase one will identify all measures used to assess upper limb function for patients with neck pain. Phase two will identify all available studies of the measurement and practical properties of identified instrument. The COnsensus-based Standards for selection of health Measurement INstrument (COSMIN) will be used to evaluate the methodological quality of the included studies. To ensure methodological rigour, the findings of this review will be reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline.Optimal management of patients with neck pain should incorporate upper limb rehabilitation. The findings of this study will assist clinicians who seek to utilise suitable and accurate measures to assess upper limb function for a patient with neck pain. In addition, the findings of this study may suggest new research directions to support the development of upper limb outcome measures for patients with neck pain.CRD42015016624PROSPERO  Upper limb dysfunction is a common musculoskeletal condition . The pren = 103), 80% reported upper limb functional limitation [It is not clear what proportion of neck pain sufferers in the general population experience associated upper limb disability, but among patients with neck pain, upper limb function is often impaired -11. An eet al. [r = 0.799, P < 0.001, n = 151). These studies indicate that the impact of neck pain on upper limb function can be substantial and severe.In their prospective cohort study, McLean et al.  investigClinicians should carefully assess upper limb functional capacity during the examination of patients with neck pain and, where indicated, incorporate upper limb rehabilitation in their management ,11. ThisThe proposed review will be conducted in two phases. Phase one will identify all measures used to assess upper limb function for patients with neck pain. Phase two will identify published and unpublished studies of the measurement and practical properties of the identified measures. The methodological quality of the developmental and evaluative studies will be assessed against the COnsensus-based Standards for selection of health Measurement INstrument (COSMIN) guidelines ,16. To eThe following databases will be searched from their inception: Allied and Complementary Medicine Database (AMED) (OvidSP), CINAHL Complete (EBSCO), the Cochrane Library (Wiley), MEDLINE (EBSCO), PubMed , PsycINFO (ProQuest), SPORTDiscus (EBSCO), Web of Science (Thomson Reuters).A search strategy combining title/abstract words and, where available, database-controlled vocabulary terms relating to upper limb function and neck pain will be used to locate all measures used to assess upper limb function in neck pain patients.n =adjacency within x words; “” = phrase search.The search strategy is detailed below. Explanation of the syntax used:/= MeSH; * = denotes any character/s; .AND.A RefWorks database will be used to manage all references. Two reviewers will independently screen the titles and abstracts of the studies retrieved from the literature search. In the case of disagreement between the two reviewers, a third reviewer will be used to make the decision regarding inclusion of the study. Any study will be considered for inclusion without restriction of design or publication date if 1) they involve adults, age ≥ 18, with neck pain, which is defined here as a dysfunction of the cervical structure and 2) at least one of the measures aimed to measure upper limb disability, which is defined here as any difficulties or limitations an individual may have in executing upper limb activity [The search in this phase will aim to identify studies related to the development or evaluation of measures identified in phase one. The databases identified in phase one will be used to perform further specific searches for each of the identified measures. If required, a sensitive search filter  for locaSelected studies in this review will be evaluated in accordance with the modified COSMIN checklist ,16, and Data extraction will capture information regarding 1) study sample , intervention, setting, country, and recruitment methods), 2) instrument general characteristics ), and 3) instrument properties, which will seek evidence of the following measurement and practical properties: reliability , measurement errors , minimal important change (MIC)), validity , responsiveness , precision (measurement floor and ceiling effect), acceptability , and feasibility .The methodological quality of the included studies will be assessed against the COSMIN checklist, which was developed specifically for evaluating the methodological quality of studies on health-related outcome measurements ,16. A foet al. (see Table Best evidence synthesis will be performed in this review as reported in other similar reviews -22. ThisFor the purpose of methodological rigour, the results of this study will be reported in accordance with the PRISMA guidelines . This wiIn clinical practice, the availability of valid and reliable upper limb measures of upper limb disability will support the recommended assessment and management of patients with neck disorders ,11. This


To evaluate whether the acute pain experienced during in-hospital recovery fromthoracotomy can be effectively reduced by the use of intraoperative measures. We selected 40 patients who were candidates for elective thoracotomy in theThoracic Surgery Department of the Federal University of São Paulo/Paulista Schoolof Medicine, in the city of São Paulo, Brazil. The patients were randomized intotwo groups: conventional thoracotomy  and neurovascular bundlepreservation . All of the patients underwent thoracic epiduralanesthesia and muscle-sparing thoracotomy. Pain intensity was assessed with avisual analog scale on postoperative days 1, 3, and 5, as well as by monitoringpatient requests for/consumption of analgesics.  On postoperative day 5, the self-reported pain intensity was significantly lowerin the NBP group than in the CT group . No significant differences were found between the groups regarding thenumber of requests for/consumption of analgesics.  In patients undergoing thoracotomy, protecting the neurovascular bundle prior topositioning the retractor and preserving the intercostal nerve during closure canminimize pain during in-hospital recovery. In addition, chronic pain is a common cause of prolonged work absenteeismbecause it often prevents patients from performing their regular activities for monthsafter the surgical procedure. Many studies have shown that the presence of severe painin the immediate postoperative period is associated with a higher occurrence of chronicpain.(-)A thoracotomy is one of the most painful procedures in surgical practice. The pain thatpatients experience in the immediate postoperative period and in the late postoperativeperiod constitutes a constant concern among thoracic surgeons, because it is wellestablished that patients with severe postoperative pain are at an increased risk ofdeveloping complications, including atelectasis and pulmonary infection.Postoperative pain assessment is based on individual perception, the subjective natureof pain and the difficulty in measuring pain intensity making it difficult tostandardize studies addressing the issue of postoperative pain.Pain resulting from the stimulation of receptors is designated nociceptive pain. Nociceptive pain after thoracotomy might be due to any of the following: skinincision; muscle retraction; rib spreading; trauma to sternocostal and costovertebraljoints; intercostal nerve compression; damage to the lung parenchyma; and damage to theparietal pleura. Intercostal nerve injury can lead to the formation of a localizedneuroma that can cause persistent stimulation and, consequently, hyperalgesia (painresulting from noxious stimuli) and allodynia . In such cases, pain is designated neuropathic pain. Post-thoracotomy painsyndrome can therefore be defined as a combination of nociceptive and neuropathicstimuli.Many thoracic surgical procedures are currently performed as video-assistedthoracoscopic procedures; however, pulmonary resections, including those for thetreatment of lung cancer, are not, despite numerous studies showing the advantages ofvideo-assisted thoracoscopy. According to the American Association for Thoracic Surgery,video-assisted procedures account for less than 20% of all major pulmonary resectionsrecently performed in the USA and less than 10% of all major pulmonary resectionsrecently performed in Europe.During conventional thoracotomy, two intercostal nerves can be injured unless theneurovascular bundle is preserved: one by the Finochietto retractor and one bythoracotomy closure. On the basis of the assumption that post-thoracotomy pain isprimarily due to intercostal nerve injury, postoperative pain can be reduced by avoidingintercostal nerve crushing.There are currently three thoracotomy closure techniques: intracostal suture closure(whereby stitches perforate the rib); subperiosteal suture closure  having reached similar conclusions; some have attributed the reduction inpain to the protection provided by the muscle flap containing the bundle, whereas othershave attributed it to the thoracotomy closure technique.Cerfolio et al.9 compThe present study was designed to compare, in a systematic manner, different techniquesfor neurovascular bundle preservation (NBP), in an attempt to determine their efficacyin reducing pain in the immediate postoperative period and during the in-hospitalpostoperative period.This was a prospective randomized clinical trial of candidates for elective thoracotomyin the Thoracic Surgery Department of the Federal University of São Paulo/PaulistaSchool of Medicine, located in the city of São Paulo, Brazil. The trial was conductedbetween January of 2009 and January of 2010. All patients were blinded to the techniqueused. We initially selected 142 patients requiring thoracotomy. The inclusion criteriawere being 18 years of age or older and agreeing to participate in the study. Most ofthe patients who were initially selected were excluded during the perioperative periodon the basis of the following criteria: need for thoracoplasty or pleurectomy;occurrence of rib fractures caused by retractor placement; impossibility of performingepidural anesthesia; impossibility of using a visual analog scale in the postoperativeperiod (because of prolonged intubation); and need for reintervention.The study was approved by the Research Ethics Committee of the Federal University of SãoPaulo (Protocol no. 1323/09).Before the surgical procedure, all patients underwent thoracic epidural anesthesia in asitting position (puncture at the level of T5-T6), followed by local anesthetic infusionand epidural catheter placement. The incision was 8-10 cm in length. The latissimusdorsi was dissected and reflected posteriorly. The serratus anterior was identified,dissected, and reflected medially.The intercostal muscles were separated midway between the upper and lower rib edges. Amedium-sized Finochietto retractor with 4-cm blades was used in all procedures.The patients were randomized into two groups of 20 patients: the conventionalthoracotomy group and the NBP group. In the group of patients undergoing conventionalthoracotomy, the retractor was placed immediately after separation of the intercostalmuscle. After the surgical procedure, intercostal space closure was achieved withpericostal sutures . In the NBP group, theintercostal muscle was dissected together with the neurovascular bundle, over a lengthof 5 cm, with the use of an osteotome and electrocautery, being therefore freed from theupper rib; the muscle flap was subsequently tied by a Penrose drain  and retrA visual analog scale ranging from zero to ten  was used for postoperative pain assessment. Patients usedthe visual analog scale to rate their pain on postoperative days 1, 3, and 5. Allratings were performed at 8:00 a.m. before any manual handling of patients, includingbathing, physical therapy, and radiological examinations.Objective postoperative pain assessment consisted of measuring the consumption ofanalgesics by patient demand .Analgesia was achieved by the administration of 0.25% bupivacaine with 2 mg of morphinevia an epidural catheter between 10:00 a.m. and 12:00 p.m. on postoperative days 1, 2,and, 3, the catheter being then removed. We analyzed the following parameters: durationof surgery; length of hospital stay; duration of chest tube drainage; pain intensity;consumption of analgesics by patient demand; and complications. Complications includedsegmental or lobar atelectasis, pneumonia, prolonged air leak , and surgical wound complications, including seroma, hematoma, andinfection. the mean and standard deviation being taken into consideration; theexpected response was 30%, with a value of p < 0.05. A descriptive analysis wasperformed with calculations of arithmetic means and standard deviations.Statistical analysis was performed with the chi-square test and the Student's t-test.Sample size was calculated by comparison with similar studies,Of the 142 patients requiring elective thoracotomy during the study period, 40 (28%)were included in the study. Patients were excluded for the following reasons: lack ofthoracic epidural anesthesia, in 38 patients; rib fracture during the intraoperativeperiod, in 24; impossibility of assessing pain intensity (because of prolongedintubation), in 15; history of chronic analgesic use, in 12; chest wall invasion by lungcancer, in 8; and need for reintervention, in 5.2 in the former and 22.8 ± 4.5kg/m2 in the latter. Of the 20 patients in the conventional thoracotomygroup, 11 were male, and 7 were smokers. Of the 20 patients in the NBP group, 10 weremale, and 8 were smokers. The 40 patients included in the present study were randomized into two groups of 20patients: the conventional thoracotomy group and the NBP group. The mean age was 48.3 ±14.5 years in the conventional thoracotomy group and 48.8 ± 17.3 years in the NBP group.The body mass index was 24.6 ± 3.7 kg/mWe analyzed the duration of surgery, length of hospital stay, and duration of pleuraldrainage in the two groups of patients . We founRegarding the subjective assessment of postoperative pain, mean visual analog scalescores were higher in the conventional thoracotomy group than in the NBP group (p =0.04). Although postoperative pain intensity on postoperative days 1, 3, and 5 was lowerin the NBP group than in the conventional thoracotomy group, the difference wassignificant only on postoperative day 5  by patientdemand was lower in the NBP group than in the conventional thoracotomy group, thedifference was not significant. The mean consumption of tramadol hydrochloride was 1,025± 464 mg in the conventional thoracotomy group and 834 ± 568 mg in the NBP group (p =0.22). The mean consumption of dipyrone was 16.67 ± 12.06 g in the former and 15.71 ±11.73 g in the latter (p = 0.98).Regarding the occurrence of postoperative complications, there were no significantdifferences between the conventional thoracotomy and NBP groups . In addition, none of the complications were attributable to the intervention.Although post-thoracotomy pain is a topic of great interest to thoracic surgeons, fewstudies have examined it. This might be due to the lack of objective data to quantifypost-thoracotomy pain. In the present study, we sought to answer a simple question: whatcan surgeons do to minimize the pain of patients undergoing thoracotomy?Although thoracic epidural anesthesia is still considered the gold standard forpostoperative analgesia in thoracic surgery, it can cause nausea, vomiting, dizziness,and torpor , as well as muscle weakness and urinaryretention, in 15-20% of cases.Thoracic epidural anesthesia is contraindicated in patients with coagulation disordersand depends on the skill and experience of the anesthesiologist. Thirty-eight patientswere excluded from the present study because of the impossibility of performing epiduralanesthesia . We do not question the benefits of thoracic epidural anesthesia, which isroutinely used at our facility. However, it is sometimes impossible to use it.In such cases, one alternative is intercostal nerve block under direct vision, coveringone intercostal space above the incision and one below it, which can be beneficialwithin the first 24 h after surgery. whereas others have reported that it significantly reduces postoperativepain. In our study, muscle-sparing thoracotomy was used in both groups, whichwere therefore not compared in terms of the technique.Muscle-sparing thoracotomy is a variant of posterolateral thoracotomy, which is an openprocedure rather than a laparoscopic procedure. During muscle-sparing thoracotomy, thelatissimus dorsi and serratus anterior muscle fibers are separated rather thansectioned. Although most pulmonary resections can be performed via a muscle-sparingthoracotomy, the efficacy of this approach in reducing postoperative pain remainscontroversial; some authors have suggested that it is ineffective in reducingpostoperative pain,The purpose of our study was to determine the extent to which the techniques thatprotect the neurovascular bundle from being compressed by the Finochietto retractor andthe modified intercostal space closure technique can reduce postoperative pain. demonstrated the advantages of intracostal suture closure over conventional suture closure.Cerfolio et al.9 demoFew studies have examined the issue of intercostal nerve compression by the Finochiettoretractor. Retractor-related factors contributing to the severity of post-thoracotomypain include the amount of rib spreading, the size of the blades, and the area ofcontact between the retractor and the intercostal nerve. proposed that an intercostal muscle flap containing the neurovascularbundle be harvested before placement of the retractor. The study included 114 patients,who were randomized to conventional thoracotomy or thoracotomy with intercostal muscleflap to protect the intercostal nerve. The authors found that the latter techniquereduced postoperative pain.In a study conducted in 2005, Cerfolio et al.10 proThe chest tube is known to play a role in postoperative pain, chest tube removal beingoften associated with a reduction in pain. In the present study, we found no significantdifference between the two groups in terms of the duration of chest tube drainage. Theresults might have been different if we had. sought to determine whether the combination of intracostal suture closurewith intercostal muscle flap provided better pain relief than did intracostal sutureclosure alone. Pain intensity was assessed by a visual analog scale in the periodbetween postoperative day 1 and postoperative day 7, as well as in the period betweenpostoperative week 2 and postoperative week 12. The combination of intracostal sutureclosure with intercostal muscle flap did not reduce postoperative pain when comparedwith intracostal suture closure alone.In a prospective randomized study of 144 patients undergoing pulmonary resection, Wu etal. and that is similar to the present study, 60 patients underwent intercostalmuscle flap and intracostal suture closure  and 60underwent conventional thoracotomy. Postoperative pain intensity was assessed by avisual analog scale and by analgesic consumption and was found to be lower atpostoperative week 1 and at postoperative month 1 in the group of patients who underwentintercostal muscle flap and intracostal suture closure.In a prospective randomized study that involved 120 patients11 and(-) We believe that this is due to the fact that postoperative pain is quitecommon and therefore a factor that is not relevant to discharge planning.In the present study, the two groups of patients were found to be similar in terms ofthe length of hospital stay. This finding shows that the intervention reducespostoperative pain but not the length of hospital stay. This was not taken intoconsideration in studies similar to ours.In the present study, the two groups were similar in terms of complication rates, andthe intervention was ineffective in preventing the most common post-thoracotomycomplications. Atelectasis and pneumonia are chief among the complications on which areduction in pain might have any impact. In the present study, atelectasis occurred in 3of the patients in the conventional thoracotomy group and in 2 of those in the NBPgroup. This difference might have reached statistical significance had our studyinvolved a larger sample size. None of the complications observed in the present studywere attributable to the intervention performed.We conclude that the harvesting of an intercostal muscle flap before placement of theretractor and thoracotomy closure with subperiosteal sutures are measures that are notassociated with additional morbidity or longer duration of surgery and can reducein-hospital postoperative pain in patients undergoing thoracotomy.  Por outro lado, a dorcrônica é um motivo frequente do afastamento prolongado do trabalho, pois muitasvezes impede o paciente de exercer suas atividades habituais por meses após aoperação. Muitos estudos apontam que a presença de dor intensa no pós-operatórioimediato está relacionada a uma maior ocorrência de dor crônica.(-)A toracotomia pode ser considerada um dos procedimentos operatórios mais dolorosos daprática cirúrgica. A dor observada nos pacientes, tanto no pós-operatório imediato,quanto no tardio, se constitui em uma preocupação constante por parte dos cirurgiõestorácicos, pois está amplamente demonstrado que pacientes com dor intensapós-operatória têm um risco aumentado para o desenvolvimento de complicações, entreelas, as atelectasias e infecções pulmonares. Para estudar a dor pós-operatória dependemos da percepção individual de cadapaciente, o que dificulta a padronização dos estudos, seja pelo aspecto dasubjetividade, seja pela dificuldade de mensurar sua intensidade.A dor relacionada à estimulação dos receptores, chamada de dor nociceptiva, pode estar relacionada a inúmeras situações que ocorrem nos diversostempos da toracotomia . A agressão aonervo intercostal pode induzir à formação de um neuroma localizado que pode gerarestímulos persistentes, ocasionando os sintomas de hiperalgesia (definida como umador semelhante àquela sofrida por uma estimulação nociva) e alodinia (quando umestímulo tipicamente indolor é capaz de produzir dor). Nessa situação, a dor édenominada dor neuropática. A síndrome dolorosa pós-toracotomia pode ser entãoexplicada por uma combinação de estímulos nociceptivos e neuropáticos.Atualmente, muitas operações torácicas são realizadas por videotoracoscopia; porém,ao analisarmos as ressecções pulmonares, entre elas, aquelas relacionadas aotratamento do câncer de pulmão, mesmo com inúmeros estudos que dia a dia sãopublicados, enaltecendo as vantagens da videotoracoscopia, a realidade é diferente.Observa-se que, nos últimos anos, menos de 20% e de 10% das ressecções pulmonaresmaiores realizadas nos EUA e na Europa, respectivamente, são assistidas por vídeo,segundo dados da Associação Americana de Cirurgia Torácica.Em uma toracotomia convencional, quando não se adotam medidas para preservar o feixeneurovascular, potencialmente ocorre a lesão de dois nervos intercostais, um por açãodo afastador de Finochietto e outro por compressão na sutura intercostal. Separtirmos do pressuposto que a dor pós-operatória está principalmente relacionada alesões dos nervos intercostais, medidas que evitem essa compressão poderão minimizaresse sintoma.Em relação às técnicas de fechamento da toracotomia, existem três possibilidades:sutura intracostal (os pontos perfuram a costela), sutura subperiostal  chegando a conclusões semelhantes, alguns imputando a melhora àdissecção e proteção do retalho contendo o feixe, e outros imputando a melhorasomente à técnica de fechamento da toracotomia.Cerfolio et al.9 inicO presente estudo foi desenhado de forma a comparar, de maneira sistemática, astécnicas de abordagem do feixe neurovascular, avaliando se realmente o uso de algumatécnica traz benefícios na minimização da dor no pós-operatório imediato eintra-hospitalar.Foi realizado um ensaio clínico prospectivo e randomizado, no qual foram estudadostodos os pacientes candidatos a toracotomia eletiva na Disciplina de CirurgiaTorácica da Universidade Federal de São Paulo/Escola Paulista de Medicina, em SãoPaulo (SP), no período entre janeiro de 2009 e janeiro de 2010. Todos os pacientesforam cegados em relação ao tipo de técnica utilizada. Inicialmente, foramselecionados 142 pacientes com indicação de toracotomia. Esses pacientes preencheramos seguintes critérios de inclusão: ter idade = 18 anos e concordar em participar doestudo. Os critérios de exclusão, aplicados durante o períodoperioperatório/operatório, foram responsáveis pela exclusão da maioria dos pacientesinicialmente selecionados: ser submetido a toracectomia ou pleurectomia; ocorrerfratura de costela na abertura do afastador, ser impossível realizar anestesiaperidural, ser impossível aplicar a escala visual analógica no pós-operatório (devidoa intubação prolongada) e haver necessidade de reintervenção.O estudo foi submetido ao Comitê de Ética em Pesquisa da Universidade Federal de SãoPaulo, sendo aprovado sob o número 1323/09.Em relação à técnica operatória utilizada, antes do início da operação, em posiçãosentada, os pacientes foram submetidos a anestesia peridural torácica (punção aonível de T5-T6), seguida da infusão de anestésico local e posicionamento de cateterperidural. A incisão variou entre 8 e 10 cm de extensão, o músculo grande dorsal foidissecado e rebatido posteriormente, assim como o músculo serrátil anterior foiidentificado, dissecado e rebatido medialmente.A musculatura intercostal foi aberta à meia distância entre os bordos inferior esuperior das costelas. O afastador de Finochietto utilizado foi o de tamanho médio,com pá de 4 cm, sendo esse padrão seguido em todas as toracotomias.Os pacientes foram randomizados para entrar em um dos dois grupos de estudo. Nospacientes no grupo submetido à toracotomia convencional (TC), o afastador eraposicionado imediatamente após a abertura do músculo intercostal. Após a realizaçãoda cirurgia, o espaço intercostal foi fechado com fio absorvível de poliglactina 1,por sutura simples, pela técnica pericostal. Nos pacientes do grupo com preservaçãodo feixe neurovascular (PF), foi realizada a dissecção do músculo intercostaljuntamente com o feixe neurovascular, numa extensão de 5 cm, liberando o músculo dacostela superior, sendo utilizados rugina e eletrocautério; a seguir, o retalhomuscular era laçado por dreno de Penrose  e afastaPara a avaliação da dor, foi utilizada uma escala visual analógica de zero a dez. Os pacientesclassificaram a dor que estavam sentindo utilizando a escala analógica no 1º, 3º e 5ºdias pós-operatórios. As avaliações foram padronizadas para ocorrer às 8 h da manhã,antes de qualquer manipulação do paciente, tais como banho, fisioterapia ou examesradiológicos.Na avaliação objetiva, foi medido o consumo de analgésicos por demanda dos pacientes,os quais eram prescritos e somente administrados quando solicitados pelo paciente deacordo com a dor que estava sentindo.A analgesia por cateter peridural foi feita pela administração de solução debupivacaína a 0,25% associada a 2 mg de morfina, entre as 10-12 h da manhã, no 1º, 2ºe 3º dias pós-operatórios, quando então o cateter era retirado. Foram estudados osseguintes parâmetros: tempo de cirurgia, tempo de internação, tempo de drenagem,escala de dor, quantidade de analgésico utilizada e complicações. Foram consideradoscomo complicações os seguintes achados: atelectasia segmentar ou lobar, pneumonia,escape aéreo prolongado (superior a 3 dias) e complicações da ferida operatória. considerando sua média e desvio-padrão; a respostaesperada era de 30%, considerando-se um valor de p < 0,05. A análise descritivafoi realizada com as respectivas médias aritméticas e desvios-padrão.A análise estatística foi realizada utilizando-se os testes do qui-quadrado e t deStudent. O cálculo do tamanho da amostra foi feito através da comparação com estudossemelhantes,No período de estudo, dos 142 pacientes com indicação de toracotomia eletiva, 40(28%) foram incluídos no estudo. A exclusão dos pacientes ocorreu pela não realizaçãode anestesia peridural torácica, em 38 pacientes; fratura de arco costal no períodointraoperatório, em 24; impossibilidade de aplicação de escore de dor devido aintubação prolongada, em 15; história pregressa de uso crônico de analgésicos, em 12;invasão de parede torácica por tumor de pulmão, em 8; e necessidade de reintervenção,em 5.2 e 22,8 ± 4,5 kg/m2. Nos gruposTC e PF, 11 e 10 pacientes eram do sexo masculino, respectivamente, enquanto 7 e 8eram tabagistas ativos. A Dos 40 pacientes incluídos no estudo, esses foram randomizados em dois grupos com 20pacientes (grupos TC e PF). A média de idade dos pacientes dos grupos TC e PF foi de48,3 ± 14,5 anos e 48,8 ± 17,3 anos, respectivamente, enquanto o índice de massacorpórea foi de 24,6 ± 3,7 kg/mForam analisados o tempo de cirurgia, o tempo de internação e o tempo de drenagempleural nos dois grupos . Não houEm relação à avaliação da dor através da escala visual analógica, o grupo TCapresentou escores de dor maiores que o grupo PF, quando considerado o maior valormédio . A avaliação da dor no 1º, 3º e 5º dias pós-operatórios mostrouvalores menores no grupo PF, mas somente houve diferença significativa no 5º diapós-operatório , apesar de o consumo dessester sido menor nos pacientes do grupo PF, não houve diferenças significativas entreos dois grupos. A média de consumo de cloridrato de tramadol foi de 1.025 ± 464 mg e834 ± 568 mg nos grupos TC e PF, respectivamente (p = 0.22), enquanto a de dipironasódica foi de 16,67 ± 12,06 g e 15,71 ± 11,73 g .=0,58), não sendo observada nenhuma complicação que possa ser atribuída àintervenção .Em relação à ocorrência de complicações pós-operatórias, não houve diferençassignificativas entre os grupos TC e PF , assim como fraqueza muscular e retenção urinária, alcançando índicesque variam de 15-20% de ocorrência.A realização da anestesia peridural torácica possui algumas contraindicaçõesprincipalmente relacionadas a distúrbios de coagulação e é dependente da experiênciae destreza do anestesiologista. Em nosso estudo, 38 pacientes foram excluídos pelaimpossibilidade da realização da anestesia peridural, seja por contraindicaçãomédica, seja por dificuldade técnica. Não temos dúvidas dos benefícios da anestesiaperidural torácica e, rotineiramente, utilizamos esse tipo de anestesia em nossoserviço. Entretanto, somos privados de sua utilização com certa frequência.Na impossibilidade de realização da anestesia peridural torácica, uma alternativa é arealização da anestesia do nervo intercostal sob visão direta, abrangendo um espaçointercostal acima e um abaixo da incisão, que pode trazer benefícios nas primeiras 24h de pós-operatório. enquanto outros relatam um impacto significativo na suaredução. Em nosso estudo, a técnica poupadora da musculatura foi aplicada nosdois grupos, não sendo, portanto, um fator de comparação.Em relação à técnica operatória, nas cirurgias torácicas ditas abertas, isto é,quando não se usa o aparato da videotoracoscopia, uma variante da técnica datoracotomia posterolateral é a técnica de preservação muscular. Essa abordagem, naqual os músculos grande dorsal e serrátil anterior têm suas fibras afastadas e nãoseccionadas, permite a realização da grande maioria das ressecções pulmonares, masseu impacto em termos de minimização da dor ainda é controverso; alguns autoresapontam sua ineficácia na diminuição da dor pós-operatória,O propósito de nosso estudo foi avaliar em que proporção as técnicas que preservam ofeixe neurovascular antes de esse ser comprimido pelo afastador de Finochietto, assimcomo a modificação no tipo de fechamento do espaço intercostal, podem influenciar nador pós-operatória. demonstraram as vantagens da técnica intracostal em relação aofechamento convencional .Em relação à técnica de fechamento, Cerfolio et al.9 demoQuando analisamos a compressão do nervo intercostal pelo afastador, não existemmuitos estudos que avaliem isoladamente essa questão, e possíveis variáveis podemcontribuir para a intensidade da dor, como o tamanho da abertura do afastador, otamanho da pá do afastador e a consequente maior ou menor superfície de contato com onervo intercostal, entre outras. propuseram a dissecção do retalho intercostal contendo o feixeneurovascular antes da colocação do afastador. Seu estudo incluiu 114 pacientesrandomizados para toracotomia convencional ou para dissecção de retalho muscular e,quando a dor pós-operatória foi analisada, os resultados mostraram um amplo benefícioda técnica de proteção do nervo intercostal.Em 2005, Cerfolio et al.10 proQuando nos propomos a avaliar a dor pós-operatória, é fato que o dreno de tóraxexerce influência, pois é observação frequente o relato de diminuição da dor após aretirada do dreno. Em nosso estudo, não observamos uma significância estatísticaentre os dois grupos em relação ao tempo de permanência do dreno de tórax, fato quepoderia comprometer nossos resultados. em um estudo prospectivo com 144 pacientes randomizados, compararam atécnica do retalho de músculo intercostal associada à técnica de fechamentointracostal com a técnica de fechamento intracostal isoladamente. A intensidade dador foi medida do 1º ao 7º dia pós-operatório e de 2 a 12 semanas do pós-operatórioatravés de uma escala visual analógica. A dissecção do retalho não foi eficiente emreduzir a dor pós-operatória quando comparada ao grupo do fechamento intracostalisoladamente.Wu et al.,12 em  semelhante ao nosso com 120 pacientes, 60 foram submetidos a dissecçãode retalho intercostal e fechamento intracostal, e 60 foram operados pela técnicaconvencional. Os resultados obtidos demonstraram uma redução da dor, avaliada porescala visual analógica e consumo de analgésicos, na 1ª semana e no 1º mêspós-operatórios nos pacientes submetidos a medidas de proteção do nervointercostal.Em um estudo prospectivo e randomizado11 sem(10-12) pois acreditamos que a queixa de dor, por ser muitofrequente no pós-operatório, não se constitui em um fator relevante na altahospitalar.Quando avaliamos o tempo de internação hospitalar, obtivemos resultados semelhantesnos dois grupos, mostrando que a intervenção, apesar de reduzir a dor, não diminui otempo de internação. Esse dado não foi considerado em estudos semelhantes aonosso,Os índices de complicações também foram semelhantes nos dois grupos, e a intervençãonão se mostrou eficaz na prevenção das complicações mais comuns no pós-operatório datoracotomia. Consideramos que, entre as complicações que possivelmente poderiam serinfluenciadas pela a diminuição da dor, a atelectasia e a pneumonia seriam as maisimportantes. No nosso estudo, observamos 3 e 2 pacientes com atelectasia nos gruposTC e PF, respectivamente; talvez em um estudo com um número maior de pacientes, essesachados possam atingir significância estatística. Não observamos nenhuma complicaçãoque possa ser atribuída à intervenção realizada.Concluímos que a dissecção do retalho de músculo intercostal antes da colocação doafastador, associado à técnica de fechamento da toracotomia por sutura subperiostal,não agrega morbidade, bem como não aumenta o tempo operatório, e possibilita aredução da dor no período intra-hospitalar.