Patients with severe, painful injuries and illnesses treated in the emergency department are commonly administered opioid medications. Intravenous administration provides the most rapid onset of pain relief and is readily titrated. Fentanyl, administered intravenously, is well documented as an effective medication for pain management in the emergency department. It is preferred in many settings due to its minimal hemodynamic effects, as compared to other commonly used opioids. However, not all patients require intravenous access. These patients are given orally administered pain medications. The oral route is effective at minimizing pain but has a much slower onset of action when compared to the intravenous route. As an alternative to the slower onset of action seen with oral opioids, this paper discusses the use of fentanyl buccal tablet for pain management in the emergency department. Fentanyl buccal tablets are readily absorbed, with a bioavailability of approximately 65%, and have a more rapid onset of action than achieved with traditional oral opioids used in the emergency department. The relief of acute pain secondary to minor orthopedic injuries is often delayed and inadequate in the emergency department , 2. ThisOral NSAIDS and opioids are commonly used in patients with minor orthopedic injuries, but with several disadvantages. The many risks of NSAIDs have been well described, and NSAID therapy has consequences specific to orthopedic injuries (nonunion) . AlthougIntravenous opioids are often chosen for their rapid onset among other benefits. While intravenous access is typically easy to obtain in the emergency department, it may be otherwise unnecessary in many patients with minor orthopedic injuries. In these instances, obtaining intravenous access not only exposes the patient to increased discomfort but further delays medication administration. The time to pain relief in patients with minor orthopedic injuries could be significantly reduced by an alternative analgesic. This alternative would ideally have a rapid onset and be administered in a simple fashion via a nonparenteral route. With these goals in mind, the authors propose an off-label indication for fentanyl buccal tablet (FBT) as a novel form of analgesia in the emergency department for patients with isolated minor orthopedic injuries.Fentanyl is an intravenous analgesic commonly used in the emergency department (ED). The intravenous dosage form exhibits linear pharmacokinetics. Another dosage form of fentanyl, the FBT, also reflects linear pharmacokinetics, in a nearly dose-proportional manner, over the 100 mcg to 800 mcg dose range. FBT is absorbed readily with a bioavailability of 65%. The buccal mucosa is the initial location of absorption, with peak plasma concentrations occurring within an hour of administration. Transmucosal absorption accounts for approximately 50% of the total administered dose. Swallowing contributes to the other 50% of the total dose absorption, over a prolonged period, in the gastrointestinal tract. As a comparison, FBT exhibits an approximately 28% greater bioavailability over the oral transmucosal fentanyl citrate , FBT 65% and OTFC 47%. This difference is likely due to the FBT exhibiting approximately 55% more of the total dose absorbed transmucosally than with OTFC. This difference also results in the inability to substitute at an equal dose these two transmucosal forms of fentanyl. In a study comparing OTFC with oral oxycodone for pediatric outpatient wound care, the investigators found that transmucosal administration of opioids produced similar sedation and analgesia to other opioid delivery methods [Fentanyl, including transmucosal forms, is highly lipophilic. It is also greatly bound, 80–85%, to plasma protein. Alpha-1-acid glycoprotein is the main binding protein, but fentanyl also binds to albumin and lipoproteins. The mean steady-state volume of distribution is 25.4 L/kg. Fentanyl is metabolized by the cytochrome P450 3A4 system in the liver to norfentanyl, a pharmacologically inactive metabolite. Inactive metabolites account for more than 90% of the elimination of fentanyl, with less than 7% of the total dose administered, excreted unchanged in the urine.Intravenous fentanyl is frequently used in acute care and has a proven track record. A rapid onset, short duration of action, good response to opiate antagonists, and minimal hemodynamic effects make fentanyl a very desirable option in the acute care setting , 8. WhilAlthough oral transmucosal fentanyl has been frequently used in the emergency department for pediatric procedural sedation, the transbuccal forms have been shown to have both greater bioavailability and a more rapid onset –11. IntrUse of the fentanyl buccal tablet has traditionally been reserved for breakthrough pain in cancer patients. This is the only Federal Drug Administration (FDA) approved indication for this dosage form of fentanyl. This population has been well studied, and transbuccal fentanyl has been shown to have a more rapid onset when compared to immediate release oxycodone in these patients . TransbuP = .0001). The reported adverse effects were minimal in this study. There was one episode of vomiting in the oxycodone/acetaminophen group and 13% of patients overall experienced nausea . Only one case of nausea was described as being greater than slight nausea. In addition, some subjects described feelings such as “woozy” or “dizzy,” but this had an approximately equal frequency between the groups and is not unusual with the use of narcotics. Vital signs were monitored and no other adverse effects were noted.Currently, the literature regarding fentanyl buccal tablet use in the ED setting consists of the Fentanyl Administered Intraorally for Rapid Treatment of Orthopedic Pain in the ED (FAIRTOP) trial . In thisThe investigators of the FAIRTOP trial acknowledged both its limitations and the need for further investigation. First, while the sample size was large enough to demonstrate a significant difference in time to primary endpoint, reduction in pain level, the low sample size provided limited information concerning side effects. Secondly, there was some question as to whether an equianalgesic dose of fentanyl and oxycodone/acetaminophen was used. Lastly, although there was no known source for selection bias, it is a concern due to convenience sampling. Despite these limitations, the results are very promising. That being said, with the limited data in the published literature, further investigation is needed to more clearly define both safety and efficacy and to guide decision making prior to widespread transbuccal fentanyl use in the ED setting.The FAIRTOP II trial aims to further define the benefits of FBT. As a secondary objective, this new trial intends to provide more information regarding side effect rates and a comparison of the time to onset between a 200 mcg dose of FBT to 2, oxycodone/APAP 5 mg/325 mg tablets. There is a need for future studies to examine the effects of doses greater than 100 mcg and 200 mcg in the prehospital and ED population, for patients experiencing severe pain.


In this article we look at the aetiology of plantar fasciitis, the other common differentials for heel pain and the evidence available to support each of the major management options. We also review the literature and discuss the condition.A literature search was performed using PubMed and MEDLINE®. The following keywords were used, singly or in combination: ‘plantar fasciitis’, ‘plantar heel pain’, ‘heel spur’. To maximise the search, backward chaining of reference lists from retrieved papers was also undertaken.Plantar fasciitis is a common and often disabling condition. Because the natural history of plantar fasciitis is not understood, it is difficult to distinguish between those patients who recover spontaneously and those who respond to formal treatment. Surgical release of the plantar fascia is effective in the small proportion of patients who do not respond to conservative measures. New techniques such as endoscopic plantar release and extracorporeal shockwave therapy may have a role but the limited availability of equipment and skills means that most patients will continue to be treated by more traditional techniques. Pain at the medial plantar prominence of the calcaneum impacts on the lives of millions of people around the world. It is estimated that 7% of people over 65 years of age report tenderness in the heel, and that the diagnosis and treatment of plantar heel pain accounts for over 1 million visits to physicians per year in the US.Patients usually complain of pain at the anteromedial prominence of the calcaneum. The pain is exacerbated by passive dorsiflexion of the toes. Symptoms may have been present for weeks or months at the time of presentation. The pain is worse when first standing after rest, typically early in the morning. Once the patient starts walking, the pain tends to recede. The pain eases but never fully resolves throughout the course of the day and is exacerbated by activities such as prolonged walking or exercise, particularly on hard surfaces.Obesity and reduced ankle dorsiflexion are recognised risk factors for the condition.The plantar fascia is a broad band of connective tissue that supports the arch of the foot. It includes a thick central component and thinner medial and lateral components. Functionally, the plantar fascia provides a windlass effect on the sole of the foot and helps maintain the longitudinal arch. It attaches proximally to the medial tubercle of the calcaneus. Extending distally, it divides into five digital bands that insert to the base of the periosteum of the proximal phalanx of each toe and the metatarsal heads. Fibres from the plantar fascia also blend in with the dermis, the transverse metatarsal ligament and the flexor sheath.Hicks showed that the plantar fascia is tensioned during the latter weight bearing stage and, as the metatarsophalangeal joints dorsiflex, this applies a tractional force at its point of insertion on the calcaneum.Remarkably for such a common condition, the underlying pathological changes in plantar fasciitis are not understood. Even the term plantar fasciitis is something of a misnomer since the plantar fascia is an aponeurotic rather than a fascial layer.It has been suggested that plantar fasciitis represents a form of tennis elbow at the heel with the condition being caused by repetitive microtrauma at the point of insertion.At night, the foot usually falls into a plantar flexed position and when a patient alights from bed in the morning, the foot moves into dorsiflexion during walking. The plantar fascia slightly contracts in bed and the initial stretching associated with early morning waking is probably responsible for initiation pain.et al looked at 50 cases of plantar fasciitis that had been treated with heel spur surgery and failed to find histological evidence of inflammation.In older patients, histology on the plantar fat pad shows gradual atrophy. These changes may be accelerated by repeated steroid injections. Lemont In view of such findings, it is perhaps surprising that so many patients seem to respond to local steroid injections and oral anti-inflammatory drugs. However, this paradox is hardly unique to plantar fasciitis. Both lateral and medial epicondylitis respond to similar treatments in spite of the inability of modern histologists to find inflammatory changes at the site of tenderness. It must also be remembered that histology is not obtained on all patients with heel pain and the absence of inflammation in the subgroup (less than 1%) that comes to surgery may not be an accurate representation of plantar fasciitis patients as a whole.A branch of the lateral plantar nerve passes between the heel spur and the deep surface of the flexor digitorum brevis. This structure has also been implicated in plantar pain of this kind. This pain can be more focal and does not get worse with passive dorsiflexion of the toes. The pain may also be more diffuse. In a series of patients presenting with heel pain, a neurogenic cause for plantar pain was identified in a significant proportion.While 80% of patients with heel pain are suffering from plantar fasciitis, there are a number of other differential diagnoses. Ankylosing spondylitis, Reiter’s syndrome and osteoarthritis can all produce these symptoms. When symptoms are bilateral, rheumatoid arthritis becomes more likely in women. In men, however, one should consider ankylosing spondylitis or Reiter’s syndrome. An abscess in the soft tissues is more likely in patients with diabetes mellitus. Constitutional symptoms such as weight loss, night pain and fever are suggestive of neoplasia or infections, particularly in neuropathic patients, although primary neoplasia in the foot is extremely rare. Other differential diagnoses include entrapment of the first branch of the lateral plantar nerve or the medial calcaneal nerve,First and foremost, the diagnosis of plantar fasciitis is a clinical one. Further investigations should be tailored depending on the clinical picture. Plain x-ray is the most commonly requested investigation. X-ray shows a calcaneal spur in 50% of patients. The spur is not related to the plantar fascia and is the attachment of the quadratus plantae muscle. Thirteen per cent of heels x-rayed for conditions other than plantar fasciitis also have a plantar spur and many authors regard the heel spur as an incidental finding.Technetium bone scintigraphy is positive in plantar fasciitis, with the maximum area of uptake at the point of maximum tenderness on the heel. Bone scintigraphy also shows an area of increased uptake in the presence of an occult fracture. Electromyography may be helpful if a neurogenic cause is suspected such as S1 nerve root entrapment, tarsal tunnel syndrome or entrapment of the lateral plantar nerve. Magnetic resonance imaging is not a routine investigation in plantar fasciitis but can identify other soft tissue lesions such as soft tissue tumours or the marrow oedema associated with infection or if an occult fracture is suspected.The vast majority of patients recover without surgery although the indolent course of this condition is often frustrating. Patient education into the expectation and duration of treatment from the outset is important. Plantar fasciitis would appear to be an overuse phenomenon and, in the first instance, avoiding high impact activities seems sensible.Oral analgesics are also traditional. In a randomised, prospective, placebo controlled trial, 29 plantar fasciitis sufferers were randomised to treatment with heel cord stretching, viscoelastic heel cups and night splinting to a placebo or a non-steroidal anti-inflammatory drugs (NSAID) group.Steroid injections are often effective in the short termStretching is an easy implementable treatment option. A randomised controlled trial has investigated the role of specific Achilles tendon versus plantar fascia stretching exercises in patients with established chronic plantar fasciitis.Night splints hold the foot in a neutral position, preventing the contracture of the fascia during sleep, which helps to alleviate symptoms in the morning according to observational studies. However, there has been no randomised controlled trial to prove that symptoms are alleviated. Casting is a prolonged version of this and forces complete rest.et al showed that after six months, 82% of patients had responded to time and conservative therapy.Heel inserts are quite popular and can be beneficial in relieving heel pain. Wolgin The response to conservative measures is usually very good. A case series of 116 patients in which only two patients required surgery suggested that the proportion of patients requiring surgery is of the order of 1–2%.Work looking into the effect of botulinum toxin injections to treat plantar fasciitis has shown apparently good effect although this is still far from mainstream.In recent years, some units have used extracorporeal shockwave therapy (ESWT). Although the technique has been investigated extensively, it is mostly performed in specialist centres. Proponents of ESWT believe that the shockwaves cause microdisruption of the thickened plantar fascia, resulting in an inflammatory response, revascularisation and recruitment of growth factors and therefore a soft tissue reparative response.At present there is a lack of good quality evidence to support the efficacy of protein rich plasma injections in the treatment of plantar fasciitis. The patient’s own plasma is spun in a centrifuge and a specific fraction is then reinjected into the tender area. The treatment is discussed widely on the internet although there are still no clinical trials on PubMed to report.Patients not responding to conservative measures after a year or more may require surgery. There is controversy as to which procedures are most likely to produce a good result, in part because of the limited scale of many published series.Less than 50% of the plantar fascia is sectioned. Any more than this risks secondary collapse of the longitudinal arch and lateral-sided foot pain.Carefully selected patients probably benefit from simultaneous release of the lateral plantar nerve branch. However, there must be clear evidence of neurological symptoms to justify this.Removal of the spur is not warranted. A large cadaveric study found that in about half of cases, the bony spur is not actually in the same layer as the plantar fascia, suggesting that it does not have a causal role in the condition.Endoscopic surgery requires specialist equipment and skills, and is still not widely used.Plantar fasciitis is a common and often disabling condition that benefits from appropriate treatment. Because the natural history is not fully understood, it is difficult to distinguish between those patients who have recovered spontaneously and those who have responded to formal treatment.Surgical release of the plantar fascia is effective in the small proportion of patients who do not respond to conservative measures. Removal of the plantar heel spur remains a tradition in some units but is probably irrelevant.New techniques such as endoscopic plantar release and ESWT may have a role but the limited availability of equipment and skills means that most patients will continue to be treated by more traditional techniques.Treatments that appear to be effective are in part traditional since the large scale randomised trials have still not been performed. The patients labelled as suffering from heel pain are likely to represent a diverse group and those referred for surgery may represent a different cohort of people from those responding rapidly to conservative measures.


Easy access favours the informative role that pharmacists play in Poland with regard to the proper use of medicinal products as well as preventing illness and promoting health. The aim of the present study was to define situations in which patients ask a pharmacist for advice and to identify the most important factors that affect the patients’ decisions in seeking advice from a pharmacist.n all, 101 patients  aged 19–67 years participated in the study. The study was conducted using a structured interview research method. Patients were asked to answer a set of closed-ended questions related to their habits regarding the purchase of medicines and the factors that affected their decision to seek the advice of a pharmacist.Factors determining the choice to contact a pharmacy.Patients seldom asked pharmacists for advice: 77 of the patients “rarely” or “never” went to a pharmacy to consult the pharmacist. When patients did ask the pharmacist for advice, it was mainly concerning the choice of over-the-counter medicines. The most important reason for patients visiting a pharmacy for advice was the large number of pharmacies in Poland and their ease of access; the long queues of people in busy pharmacies and the lack of confidentiality in the pharmacy were considered negative factors. The current advisory role of pharmacists in Poland seems of minimal importance to the public. To make full use of pharmacists, Polish customers should be aware of the advisory role of pharmacists. Therefore, pharmacy associations should undertake initiatives to increase patients’ awareness of the advisory role of pharmacists.The programme of pharmaceutical studies or education in Poland must place greater emphasis on the development of pharmacist counselling skills.In Poland, a patient’s privacy and confidentiality need to be better protected, i.e., through the use of separate, private counselling areas.On the first appearance of the symptoms of a disease, more than half of Poles attempt to carry out the treatment themselves, using home remedies or over-the-counter (OTC) medicines , 2. MajoIntensive advertising campaigns for OTC medicines as well as media reports  on health and self-medication with regard to minor ailments may mislead consumers or create the false impression that taking a particular type of medicine is necessary . As a coThe aim of this study was to define situations in which consumers ask pharmacists for advice and to indicate the key factors that affect the consumer’s decision about whether to seek such advice in a pharmacy.Three community pharmacies located in different socioeconomic areas of Warsaw were selected for the study. Study pharmacies constituted a convenient sample. In all, 101 patients  aged 19–67 years  took part in the study. In Table The questionnaire comprised two parts: the first part included questions on the patient’s habits with regard to purchasing medicines; the second part related to factors that may have influenced the patient’s decision to seek the advice of a pharmacist. The patients’ attitudes to various aspects of consultations with a pharmacist were determined based on a five-point Likert scale. The patients were asked to describe how often and why they visited a pharmacy, what influenced the selection of a particular pharmacy, the factors that either encouraged or discouraged the patients in seeking a pharmacist’s advice, and the situations under which the patients asked a pharmacist for advice. The questions used in the questionnaire were based on a literature review and the results of focus group discussions. The questionnaire was pretested for repeatability and validity using a convenience sample of nine people. Answers obtained in the pretest were not included to the study.p < 0.05. The statistical analysis was carried out using STATISTICA 9.1 software.Statistical analysis of the survey was carried out using nonparametric statistical tests. The choice of this approach was determined by the type of data obtained  and the lack of need to make assumptions about the distribution of the population. Interrelated variables were preliminarily identified by means of nonparametric correlation tests . After dividing the population according to grouping variables , hypotheses concerning statistically important differences were verified by means of the Kruskal–Wallis test (a nonparametric test for more than two groups). The level of significance was set at Ethical approval was not required for this study.Of the surveyed participants, 40 regularly visited a pharmacy several times a month. The remaining participants said that they went to a pharmacy once in a while, i.e., a few times a year. A quarter of the surveyed patients (26) declared that they suffered from chronic diseases.Half of the surveyed participants 52) said that their choice of pharmacy was a deliberate one. The remainder declared that they had no preference for a particular pharmacy. When choosing a pharmacy, the patients generally took into account the convenience of the location, e.g., in a shopping centre, close to their home or to a main road . The second-most important factor determining the choice of pharmacy was the price of the medicine . Table  said thaThe surveyed patients most frequently visited a pharmacy to get a prescription filled  or to buy a specific OTC medicine (60). The surveyed participants “rarely” or “never” went to a pharmacy to consult a pharmacist (77 of those surveyed gave such answers). When the patients did go to a pharmacy to consult a pharmacist, they usually asked for assistance in choosing an appropriate OTC medicine . The surveyed participants over 50 years of age asked for the pharmacist’s advice when they needed a non-prescription medicine more frequently than patients aged under 34 years .Patients with a basic vocational education stated (answering “I agree” or “I definitely agree”) that they asked the pharmacist for advice when they had a minor complaint more frequently than patients with other levels of education  and they have easy access to the pharmacist. The possibility of obtaining advice on the spot without having to make an appointment was cited by 31 of those surveyed.The most important factors that discouraged patients from consulting a pharmacist were queues in the pharmacy (42 of the participants answered “I agree” or “I definitely agree” to this point). In addition, no sense of confidentiality between the patient and pharmacist owing to the presence of other people who might overhear the conversation was cited by 32 of those surveyed. Table Polish patients prefer buying medicines in pharmacies , 8. TheyIn view of the fact that pharmacies in Poland are relatively widespread and easily accessible, Polish patients often rely on the pharmacist’s recommendation when choosing OTC medicines  and dietOur results suggest that patients in Warsaw seek the advice of pharmacists, mainly in choosing an appropriate non-prescription medicine. However, the consultative role of the pharmacist would appear to be of minor importance among the surveyed patients. This conclusion seems to be consistent with the result of another survey, which showed that only one in five respondents take expert advice into consideration when choosing where to buy products. In the same survey, only 7 % of respondents indicated that pharmacists readily provide information on medicines and treatment . CustomeIn the course of the survey, patients explained that they felt ill at ease when there was a queue in the pharmacy, and so they then opted not to consult the pharmacist. The lack of confidentiality during a consultation with the pharmacist was found to be an important factor that discourages patients from asking the pharmacist for advice. Earlier studies have also demonstrated that lack of privacy appears to be the most important factor that discourages patients from asking questions about medicines , and it The major shortcoming of the present study was that the study sample may not be representative of the population of Warsaw. The study was conducted in pharmacies, not among a representative population of Warsaw inhabitants; this may explain the relatively high prescription use among the participants. Furthermore, a high proportion of the participants had tertiary-level education. Warsaw has a significantly higher percentage of inhabitants with tertiary education and a significantly lower percentage of inhabitants with a basic vocational education than the rest of the country. According to 2002 data from the Central Statistical Office, around 30 % of people aged 19–65 years had tertiary education (including 38 % of people aged 25–34) . UnfortuIn view of the specific characteristics of the surveyed group , it is necessary to carry out this survey in rural areas to verify the results obtained.This study demonstrates that it is necessary for the public to become more aware of the advisory role of pharmacists. However, to fulfil patients’ needs, pharmacists need to be able to provide patients with comprehensive information about medicines and health-related issues. In addition, the pharmacy must be properly prepared and adequately equipped to assure that patient confidentiality is respected.


Refractory chronic migraine (RCM) is often associated with disability and a low quality of life (QOL). RCM ranges in severity from mild to severe. There would be a benefit both clinically and in research use in categorizing RCM patients according to severity. This study utilized a unique RCM severity rating scale, tracking the clinical course over 10 years. A total of 129 patients, ages 19–72, were assigned a severity rating of 2–10 (10 = worst). Pain level and QOL were assessed. Over the 10 years, 73% of all pts. had a 30% or more decline in pain. Pain levels improved 45% in mild pts., 42% in mod. pts., and 36% in severe pts. Pain was the same, or worse, in 4% of mild, 15% of mod., and 18% of severe pts. QOL in the mild group improved 35% over 10 years. In moderate pts., QOL improved 32%, while for the severe group QOL improved 33%. While pain and QOL improved across all three groups at the end of 10 years, the severe group remained with significantly more pain and decreased QOL than in the milder groups. The medications that helped significantly included: opioids (63% of pts. utilized opioids), frequent triptans (31%), butalbital (17%), onabotulinumtoxinA (16%), stimulants (12%), and other “various preventives” (9%). RCM pts. were rated using a refractory rating scale with the clinical course assessed over 10 years. Pain and QOL improved in all groups. In the severe group, pain and QOL improved, but still lagged behind the mild and moderate groups. Opioids and (frequent) triptans were the most commonly utilized meds. Refractory chronic migraine (RCM) is often a debilitating illness with an enormous impact on QOL. The Refractory Headache Special Interest Section (RHSIS) of the American Headache Society (AHS) has provided a forum for physicians on this crucial topic. Chronic migraine occurs in approximately 2% of the population ; the preMuch work has been accomplished on the definition of RCM . A summaThis study assessed pain and quality of life (QOL) in RCM patients over a 10-year period. A novel RCM “severity rating scale” was used for the evaluation of these patients.This was a retrospective chart review of 129 RCM patients. RCM was diagnosed according to criteria suggested by the Refractory Headache Special Interest Section of the AHS , were assessed.A refractory scale of this author’s design was utilized for assessment. The scale ranges from 2 (least severe) to 10 (most severe) (see Table The patients were assigned a number (2–10) as of the year 2000, and this assignment of severity was not reassessed after the initial date.The severity groupings were as follows: score of 2, 3, or 4: mild RCM, score of 5, 6, 7: moderate RCM, and score of 8, 9, 10: severe RCM.Quality of life QOL was measured by adding pain, functioning, and mood scores . The QOL rating scale ranged from 3 (best) to 30 (worst). Pain was assessed via a visual analog scale of 1–10 (10 = worst). Functioning was determined by the level of the work and/or home activities. Mood determinates included depression, anxiety, and insomnia. These were assessed using DSM-IV criteria.Pain level Pain was assessed using a visual analog scale, 1–10 (10 = worst).Data collection This is a retrospective study. Data were collected by the treating physician. Data were “de-identified” and collected as anonymous “batch” data. Informed consent was obtained. A local IRB was consulted.t tests were calculated for each severity group. Finally, Cohen’s effect size formula [(mean1 – mean2)/(the average of standard deviation1 + standard deviation2)] was used for paired sample t tests.SPSS  was used for the statistical analyses. Difference scores for QOL1-QOL2 and pain ratings time1–time2 were calculated. To analyze if these pre–post scores differed across the three pain severity groups , a one-way analysis of variance (ANOVA) was conducted. To determine if treatment was significantly effective in decreasing level of pain and improving QOL, pre–post paired sample N = 129 patients; 108 F, ages 19–72, 21 M, ages 31–69, average age 49) were initially categorized according to the refractory scale . QOL  = 4.31, p = 0.02]. Bonferroni post hoc results showed that improvements in QOL after treatment were significantly larger for the severe group compared to the mild group (p = 0.045) and for the severe group relative to the moderate group (p = 0.03). Change scores for the mild to moderate group did not significantly differ.ANOVA revealed significant mean change score (time1–time2) differences for QOL ratings between severity groups [In the mild group, 80% of the pts. had a decline in pain levels of 30% or more over the 10 years. In the moderate group, 72% had a decline in pain levels of 30% or more. The severe group had 71% of pts. with a decline in pain of 30% or more over the 10 years.Pain levels were the same, or worse, over the 10 years in only 4% of mild pts., 15% of moderate, and in 18% of the severe pts. ANOVA findings for the change scores in pain ratings failed to yield any between severity group differences.60% of pts. had an improvement in QOL by 30% or more (over the 10 years), 15% of pts. saw no change, or suffered a decrease, in QOL, 73% of pts. had pain levels decrease by 30% or more, and 14% of the pts. reported no improvement, or an increase in pain levels over the 10 years.t tests were conducted for each severity group between assessment periods. Regarding the mild group, QOL ratings significantly improved after treatment, t(23) = 11.88, p < 0.001, ES (Cohen’s d) = 2.07, and pain ratings significantly decreased, t(23) = 10.15, p < 0.001, ES = 2.55.Paired sample t(66) = 9.95, p < 0.001, ES = 1.30, and pain levels significantly decreased, t(66) = 13.36, p < 0.001, ES = 2.26. Finally, results for the severe group revealed a statistically significant increase in QOL after treatment, t(37) = 9.51, p < 0.001, ES = 1.50, and a significant decrease in pain levels, t(37) = 10.42, p < 0.001, ES = 2.16. Overall, the results suggest that the treatment was effective in improving QOL and reducing level of pain for all severity groups , frequent triptans (31%), butalbital compounds (17%), and onabotulinumtoxinA (16%)  of the pts. had at least a 30% improvement in QOL, while 73% also experienced a 30% (or more) improvement in pain levels. While the severe pts. also improved over 10 years, they still had significantly lower QOL, and higher pain scores than the mild or moderate patients. In this refractory group, opioids and frequent triptans were the most commonly used medications.The refractory rating scale presented here is an initial attempt to classify RCM pts. according to severity. A refractory scale may be beneficial for both clinical and study purposes. Patients with mild RCM will generally be easier to treat than those with severe RCM. Therapeutic studies on those with RCM may be less likely to succeed if the patients have severe RCM versus milder RCM. The individual components of the scale reflect various elements of refractoriness, including comorbidities. This author awarded more weight to “refractory to preventives” 2 points) or “refractory to abortives” (2 points) than to the other components (1 point each), primarily because refractory to preventives or abortives are central hallmarks of RCM. In virtually all of the published RCM classification papers, refractory to preventives and refractory to abortives are the main criteria for labeling a patient as having refractory headache  points o. TherefoBecause the plasticity of the brain may be an important factor in refractoriness, it is important to include the length of time of headache (selected for this study at >10 years). The average number of headache days per month is important, with 25+ days probably being more refractory than 15–24. Those with every day (defined as 30 days per month) headache are significantly more refractory than those with 15–25 days per month, and this group may deserve 2 points (vs. the current one) in our scale. This is particularly true for those with 24/7, 365 days per year of RCM and should be considered in future papers.Associated medical comorbidities often occurring in those with chronic migraine were included. These conditions may complicate treatment, and add to refractoriness. For this study, we included the following: IBS, fibromyalgia, TMD, chronic pelvic pain, painful bladder syndrome, and chronic fatigue.Psychiatric comorbidities, commonly seen in RCM patients, certainly complicate treatment. Significant abuse in childhood may predispose one to RCM. Important comorbidities include anxiety, depression, the bipolar spectrum, personality disorders, somatization, and post-traumatic stress disorder , 9. For Disability should be a part of a refractory scale. Those who function at a low level, at work or at home, often are more resistant to treatment. Patients exhibit a wide range of coping and resilience. Resilience is a combination of nature and nurture; one can almost predict resilience based upon the shape of the serotonin transporter gene. This author believes that disability, or a chronically low level of functioning, renders it less likely that the RCM will improve. The level of functioning should factor into a refractory rating scale.Medication overuse headache (MOH) is a remarkably complicated concept; MOH must be distinguished from medication overuse without resulting headache. It can be exceedingly difficult to determine who has MOH . For thiThe medications utilized by patients in this study included: opioids, , frequent triptans, butalbital, onabotulinumtoxinA, and stimulants. Virtually all of the patients in this study consumed at least one daily medication for the entire 10 years.The author has published on most of these subjects , 11. ForThe frequent triptan users were screened and assessed for “triptan rebound headache”. These patients were given triptan-free “drug holidays” to ascertain if they were in the rebound state. If they worsened due to triptans, or improved off of the triptans, the triptan medications were withdrawn.The small number of patients in the mild group may limit conclusions.The refractory scale is not yet validated. This is an initial attempt to utilize such a scale and additional work needs to be done.In the refractory scale Table , the assThe QOL tool included pain, functioning and moods. This specific tool for measuring QOL has been previously utilized, but is not yet well-validated.Patients who stopped treatment at the clinic over the 10 years of the study were not included. Follow-up of these dropouts would strengthen  our conclusions.The deficiencies of this article include:RCM constitutes a small but important subset of migraine patients. For clinical and study purposes, it is helpful to categorize RCM patients as to the degree of refractoriness. After 10 years, the severe patients remained behind the other groups regarding QOL and level of pain. However, over the 10 years, all of the groups  improved in their QOL and level of pain. This initial attempt to create a refractory rating scale should be refined and improved with further study and research.


Chronic abdominal pain (CAP) is a serious medical condition which needs to be approached with great attention. Chronic abdominal pain may be caused by entrapment of cutaneous branches of intercostal nerves (ACNES).The aim of this study is the surgery for abdominal wall pain which caused by cutaneous nerve entrapment in children during last 5 years.In all children with ACNES, we tried conservative treatment with anesthetic and steroid injections. In children who were refractory to conservative treatment, we received surgical procedure like sectioning the entrapped nerve to obtain relief.In 12 pediatric patients with chronic abdominal pain, we diagnosed ACNES. Each presented with abdominal pain and a positive Carnett sign. Local nerve blocks using anesthetic and steroid injections are the treatment. In all patients, we tried with local nerve block. In 3 patients, pain improvement occurs in the few minutes, and they were without pain after 5 days. In other 4 patients required a reinjection for pain recurrence. In one patients pain was gone. The maximum reinjection was 3. In other 5 patients, we did operative treatment like sectioning the entrapped nerve.Some children with CAP have ACNES. In all children with ACNES, we recommended local nerve blocks. If the local block in 3 times is not helping, neurectomy of the peripheral nerve is method of choice. Chronic abdominal pain (CAP) refers to the pain originating from the abdominal wall which is often misdiagnosed as arising from inside the abdominal cavity. When pain is chronic with no relationship to eating or bowel function but often relationship with posture, the abdominal wall should be suspected as the source of pain. Before the diagnosis was made, children were treated by pediatricians and made expensive and often unpleasant tests and treatment. When they did not find the cause of pain in the abdomen began to think about the pain at anterior abdominal wall. The first description of the above diseases was published in the international literature by JP Frank in 1792 . In mostThe aim of the present study is the surgery for abdominal wall pain which caused by cutaneous nerve entrapment in children during last 5 years.In the last 5 years, we had 12 patients with ACNES and who needed medical attention. In the last 5 years, we have had 426 patients who were treated for chronic pain in the abdomen. Of 426 patients, 311 had no organic disease; only 12 patients  had ACNES and should have additional treatment . Of the Steroids presumably reduce inflammation or result in the thinning of connective tissue around painful nerve roots. In all 12 patients with ACNES, we attempted treatment with injections of analgesics (1mL of a 2% lidocaine solution). Lidocaine with steroids, we attempted in 3 patients where we believed that inflammation may be present. Frequent use of corticosteroids should be avoided because repeated injections or larger doses of the corticosteroid can cause thinning of the fascia and result in a hernia. None of the patients who had ACNES had surgery in the abdomen.Sometimes more than one injection may be required. In 3 patients, we had the disappearance of pain after the first injection, at 2 after the second and the 2 after the 3rd injection. In 5 patients, there were not improvements after 3 curative injections, and we had to do surgery . It has Abdominal pain is overlooked problem in patients having chronic abdominal discomfort. These patients often go to the doctor and doing unnecessary tests, thus wasting time and spending money. Many authors have previously thought that the cause of chronic abdominal pain on anterior abdominal wall trauma or a consequence of surgery , 10. In


Medication overuse headache (MOH) has been recognized as an important problem in headache patients although the pathophysiological mechanisms remain unclear. The diagnosis of MOH is based on clinical characteristics defined by the International Headache Society. The aim was the evaluation of the diagnostic criteria of MOH in a mixed population of chronic pain patients to gain information about the prevalence and possible associations with MOH.Data of all patients referred to the interdisciplinary pain clinic at the University Hospital of Zurich between September 2005 and December 2007 were retrospectively analyzed. Demographic data , as well as data about duration of pain disease, category of pain disease , use of medication, history of trauma, and comorbidity of depression and anxiety have been collected.Totally 178 of 187 consecutive chronic pain patients were included in the study. A total of 138 patients (78%) used analgesics on 15 or more days per month. Chronic headache was more prevalent among patients with analgesic overuse (39.8%) than without analgesic overuse (18%). The prevalence of MOH was 29%. The odds ratio (OR) for a patient with medication overuse to have chronic headache was 13.1 if he had a history of primary headache, compared to a patient without a primary headache syndrome. Furthermore, history of headache , history of migration  and comorbid depression  were associated with overuse of acute medication, in general.Primary headaches have a high risk for chronification in patients overusing analgesics for other pain disorders. Whereas history of headache, history of migration and comorbidity of depression are independentely associated with analgesic overuse in this group of patients. Medication overuse headache (MOH) is considered to be an important problem among headache patients worldwide with an estimated prevalence of 1–1.5% in the general population . AlthougMOH is a concept based on clinical observations first described in the late 1950s . The undNew diagnostic criteria vor MOH were introduced in 2006 ,22. ThisThe objective of the present study was to examine the prevalence of MOH as defined in the new ICHD-II-Appendix criteria in a population of patients with chronic pain different than headache. Our hypothesis was that chronic headache would be more prevalent in patients with analgesic overuse (AO), especially when additionaly suffering from primary headaches, such as migraine or tension type headache.The interdisciplinary pain clinic at the University Hospital of Zurich is a tertiary referral center for chronic pain patients. Participating specialists are an anesthesiologist, a neurologist, a psychiatrist and a rheumatologist. Patients were referred directly by General Practitioners and Specialists from the whole region of Zurich without selection bias from any of the participating specialists. Upon referral, every patient is examined by each specialist separately in the course of one week. The examination consists of a careful and pain-specific history taking and a physical examination. Headache diagnosis of all affected patients are made by a well trained neurologist (PS) according to ICHD-II and ICHD-II-Appendix criteria regarding MOH, respectively ,29. At tThe study was approved by the local ethical committee and conducted according to the principles of the Declaration of Helsinki. All patients had signed an informed consent to allow subequent use of their data for study purposes. For the study period (September 2005 to December 2007) data were collected from the comprehensive reports retrospectively. If necessary, additional demographic data, information about pain symptoms, pain scores, mood disturbances and drug intake, or specialists’ examination protocols was taken from the patients charts.Data of all patients referred to the interdisciplinary pain clinic were screened. Exclusion criteria were: headache as the sole pain symptom; incomplete examination  and missing data on medication intake. The information collected for this study included demographic data regarding age; gender; history of migration ; duration (years) of pain suffering; history of head and/or neck trauma, and use and type of acute medication. The disorders were categorized into: “neurologic”, “rheumatologic”, “psychiatric” and “other”. Headache diagnosis and comorbidity of “depression” and “anxiety” were additionally recorded.For comparative analysis, patients were categorized in two subgroups “analgesic overuse (AO)” and “no analgesic overuse (noAO)”, in analogy to the criteria for medication overuse headache (MOH) defined by the ICHD-II Appendix . Age, gender, years of pain suffering, history of migration, history of headache, history of accident (subsequently refered to as “accident”), depression and anxiety were defined as possible associated factors for analgesic overuse.t-test was performed for normally distributed and a Mann–Whitney-U-Test for not normally distributed data. For all significant factors, OR with 95%-confidence interval was provided. A significance level of p < 0.05 was defined. For multiple testing Bonferroni-corrected p-values were used. Regarding associations for medication overuse, a multiple logistic regression was performed with all factors significant at univariate analysis, and OR with 95%- confidence interval provided.For the analysis of the primary hypotheses, Fisher’s exact test comparing binary variables was performed. For the univariate analysis of associations the Fisher-Test was applied for binary and nominable variables. For continous variables, a Data of 187 consecutive patients were screened and 178 patients were included in the study. Nine patients were excluded: in seven patients headache was the only pain disease, one patient had an incomplete examination and one patient had incomplete data regarding medication intake. Five patients were not evaluated by the psychiatrist and were therefore excluded from classification of disease categories and analysis of depression and anxiety as associated factors for analgesic overuse.Of the 178 patients, 91 (51%) were female. The mean age was 46 ± 13 years (range 18 to 81 years). A total of 112 (63%) patients had a history of migration. The mean duration of pain suffering was 7.8 ± 9.2 years (range 0 to 50 years) (Table Only 28 of 178 (16%) patients did not take any acute medication at all and 12 (7%) patients took analgesics on less than 15 days per month. NSAIDs were the most commonly used drugs , followed by opioids  and paracetamol . Triptans and ergotamins drugs were consumed by 8 (5%) and 1 (1%) patients respectively. Out of the 138 patients overusing analgesics, 131 (95%) had a daily intake. Of them 56 (41%) took one analgesic, 52 (38%) took two different types, 27 (20%) three different types and 3 (2%) patients four different types on analgesics.p = 0.012), and to the overall population (63%). While 31% of patients with analgesic overuse reported a previous accident, this was similar to the incidence of in non-analgesic overusers (28%) and the overall sample population (30%). In patients with AO 59% had been diagnosed with anxiety and/or depression, in the noAO 20% only.Of 178 patients, 138 (78%) were overusing analgesics as defined by criterion B in the ICHD-II-Appendix classification . In the While 62 patients in the sample reported chronic headaches (CDH: headaches on 15 or more days per month), a total of 52 patients fullfilled the ICHD-II-Appendix criteria  for mediHistory of previous headache, history of migration, and comorbid depression were identified as significantly associated in the univariate analysis. The multiple logistic regression resulted in odds ratios of 2.5  for a history of primary headache, 2.9  for a history of migration, and 3.5  for comorbid depression (see Table 4) for a So far, five studies on MOH in chronic pain patients have been published -28. Lanccan draw from this controversy is that in some headache patients the headache will chronify as a consequence of the medication overuse, while in others the chronification is caused by other factors.The prevalence of 29% for MOH in our pain population is higher than previously reported. Different reasons may explain our finding. First, ICHD-II-Appendix criteria enable more patients to be diagnosed with MOH at the time of the examination. The rationale behind this is to increase awareness for the problem and to allow more patients to benefit from specific treatment . ReportsComorbid depression, history of migration, history of headache and have been identified as independently associated factors for analgesic overuse in general, this is in line with previous studies -35. The In summary, our study showed that MOH might be more prevalent in chronic pain patients than previously suggested. ICHD-II-Appendix criteria proved to be a good screening instrument to detect MOH, leading instantly to the first and most important therapeutic step of drug withdrawal. Our data also suggest that headache chronification may be associated with other factors than medication overuse. Finally, chronic pain patients are a population at risk for developping analgesic overuse; therefore, careful recording of drug intake is mandatory in these patients, especially in the ones with a history of migration, a history of headache and/or depression. There is no simple answer as to how to treat those patients correctly. Whether to stay i.e. untreated on low back pain instead of developping chronic headaches is an issue, which has to be discussed in depth with the individual patient at risk, and a clear aim of the treatment should be defined in any case.CWS: no. KM: Received travel support for consulting or lecturing from the following companies: Pfizer AG, Zurich, Switzerland; Bristol-Myers Squibb SA, Baar, Switzerland; Mundipharma Medical Company, Basel, Switzerland; Janssen-Cilag AG, Baar, Switzerland; UCB, Bulle, Switzerland; Medtronic, Bern, Switzerland; Boston Scientific AG, Solothurn, Switzerland; B. Braun Medical AG, Sempach, Switzerland; Grünenthal Pharma Schweiz, Mitlödi; Switzerland; St. Jude Medical AG, Zurich, Switzerland. DMS: no. EA:Received honorarium and travel support for consulting or lecturing from the following companies: Grünenthal GmbH, Aachen, Germany and Mitlödi, Switzerland, Pfizer AG, Zürich, Switzerland. DRS: His academic department is receiving grant support from the Swiss National Science Foundation, Berne, Switzerland (grant numbers: 33CM30_124117 and 406440-131268), the Swiss Society of Anesthesiology and Reanimation (SGAR), Berne, Switzerland (no grant numbers are attributed), the Swiss Foundation for Anesthesia Research, Zurich, Switzerland (no grant numbers are attributed), Bundesprogramm Chancengleichheit, Berne, Switzerland (no grant numbers are attributed), CSL Behring, Berne, Switzerland (no grant numbers are attributed), Vifor SA, Villars-sur-Glâne, Switzerland (no grant numbers are attributed). DRS was the chairman of the ABC Faculty and is a member of the ABC Trauma Faculty which both are managed by Thomson Physicians World GmbH, Mannheim, Germany and sponsored by an unrestricted educational grant from Novo Nordisk A/S, Bagsvärd, Denmark and CSL Behring GmbH, Hattersheim am Main, Germany. In the past 5 years, DRS has received honoraria or travel support for consulting or lecturing from the following companies: Abbott AG, Baar, Switzerland, AMGEN GmbH, Munich, Germany, AstraZeneca AG, Zug, Switzerland, Bayer (Schweiz) AG, Zürich, Switzerland, Baxter S.p.A., Roma, Italy, B. Braun Melsungen AG, Melsungen, Germany, Boehringer Ingelheim (Schweiz) GmbH, Basel, Switzerland, Bristol-Myers-Squibb, Rueil-Malmaison Cedex, France and Baar, Switzerland, CSL Behring GmbH, Hattersheim am Main, Germany and Bern, Switzerland, Curacyte AG, Munich, Germany, Ethicon Biosurgery, Sommerville, New Jersey, USA, Fresenius SE, Bad Homburg v.d.H., Germany, Galenica AG, Bern, Switzerland , GlaxoSmithKline GmbH & Co. KG, Hamburg, Germany, Janssen-Cilag AG, Baar, Switzerland, Janssen-Cilag EMEA, Beerse, Belgium, Merck Sharp & Dohme-Chibret AG, Opfikon-Glattbrugg, Switzerland, Novo Nordisk A/S, Bagsvärd, Denmark, Octapharma AG, Lachen, Switzerland, Organon AG, Pfäffikon/SZ, Switzerland, Oxygen Biotherapeutics, Costa Mesa, CA, Pentapharm GmbH (now tem Innovations GmbH), Munich, Germany, ratiopharm Arzneimittel Vertriebs-GmbH, Vienna, Austria, Roche Pharma (Schweiz) AG, Reinach, Switzerland, Schering-Plough International, Inc., Kenilworth, New Jersey, USA, Vifor Pharma Deutschland GmbH, Munich, Germany, Vifor Pharma Österreich GmbH, Vienna, Austria, Vifor  AG, St. Gallen, Switzerland. ARG: Received honoraria or travel support for consulting or lecturing from the following companies: Allergan, Astra Zeneca, Eli Lilly, Merck Sharp & Dohme-Chibret AG, Pfizer, Sandoz AG, furthermore he received academic research grants from Allergan and Almirall. PS: Research Support: Swiss National Foundation; Janssen Cilag; Selo Foundation; „Erwin Schrödinger-Stipendium“, Research Funds of RehaClinic Bad Zurzach and the Cantonal Hospital Baden; Employee of RehaClinic Bad Zurzach; Consultant – Advisory Boards of Pfizer, Allergan; Speaker‘s Bureau – Allergan, Almirall, Pfizer.Possible conflicts of interest  for each author include the following: Conception and design: PS, CWS, KM, EA. Analysis and interpretation of the data: CWS, KM, ARG, PS, DMS, DRS, EA. Drafting of the article: CWS, KM, ARG, PS, DMS. Critical revision of the article for important intellectual content: PS, EA, DRS. Collection and assembly of data: CWS, PS. Statistical expertise: KR, KM, ARG. All authors read and approved the final manuscript.


Dear Editor,We have examined attentively the latest manuscript by Yeganeh Mogadam et al. entitled “Comparison of Analgesic Effect between Gabapentin and Diclofenac on Post-Operative Pain in Patients Undergoing Tonsillectomy” available in Archives of Trauma Research . Ninety Diclofenac is highly bound to serum proteins ≥ 99.5%) and has a relatively low volume of distribution (0.12 to 0.17 L/kg) . Diclofe% and hasIn the case of the pain intensity, authors stated on the background section that the post-operative pain in patients undergoing tonsillectomy may be as high as 70 in the scale of visual analog scale. However, the pain intensity in the present study was very low (from 1.53 to 3.43). Therefore, the effects of gabapentin and diclofenac appear very scarce or nil. On the other hand, the comparison of pain intensity in the three groups in the manuscript seems wrong. Whereas authors state that the patients’ pain in gabapentin group was significantly less than that of the placebo group (P < 0.05) and the mean pain intensity in diclofenac group at 6 hours after the surgery was significantly less than that of the placebo group (P < 0.05). Data shows that the pain intensities at 6, 12 and 24 hours in the gabapentin and diclofenac groups were bigger than in the placebo group. Only the pain intensities at 2 hours in the treated groups were lower than in the placebo group. This mistake was probably a measurement mistake, made by the authors.


Studying women’s quality of life, we come across some harmful effects that factor such as dysmenorrhea caused by endometriosis leaves on their lives, their ability to work, their familial relations, and their self-confidence. Due to the repeated medical follow-ups and the side effects of medical therapies and endometriosis surgeries, many patients tend to use less expensive, nonmedical, and nonaggressive methods. The present study aimed to assess the effects of massage therapy, one of the aforementioned methods on endometriosis caused dysmenorrhea.This was a semi-empirical clinical trial. Considering inclusion criteria, 23 patients suffering from endometriosis visited the Infertility Center of Isfahan, who were later confirmed by laparoscopy or laparotomy were picked as the sample through a simple method. The visual analog scale and McGill questionnaires were used once before and twice after the end of intervention for each patient. The data were analyzed using SPSS software.There was a statistically significant difference between the intensity of pain before the intervention started, immediately after, and also six weeks after it (p < 0.001).According to the results of this study and confirmations of other ones, it seems that massage therapy can be a fitting method to reduce the menstrual pain caused by endometriosis. Women form the most important fundamentals of a society’s health and hygiene; however, they face many various crises and problems throughout their lives that can critically affect the general hygiene of the society.87French not only name the painful menstruation as one of the common problems during the childbearing ages that force women to take days off work, but also emphasizes the necessity of utilizing methods to remove the problem.9Wurn et al showed that massage therapy reduces uterine spasms and cervix adhesion.18Wurn et al also examined the effects of massage on various points of abdominal and pelvic soft tissues; they concluded that this procedure reduces the pelvic pains, in addition to increasing fertility in women who are infertile (due to adhesion and dysfunction in their reproductive organs).19The results of some articles declare that massage therapy can be effective, but the exact extent of its effects on treating endometriosis or its reduction is not quite identified yet.1620Massage therapy is a safe, nonaggressive, and simple method that carries very few, yet reversible side effects.1618Today, the only treatment for endometriosis is surgery with costly medical procedures. Since the quality of life has positive effects on the individual’s health, mental condition, independency level, social relations, and other aspects, we analyzed massage therapy as a simple, nonaggressive method on reducing dysmenorrhea caused by endometriosis especially among those patients who did not will to go under surgery or could not afford to; or the ones who had, but were still suffering from the disease.21 was used to measure the severity of pain and McGill questionnaires for personal/fertility information were used to collect other data.This was a semi-empirical clinical trial with cross-sectional method. It was a three-step research in which 30 patients were enrolled according to inclusion criteria. They were women between the ages of 15 to 49 years suffering from dysmenorrhea and there was no other diagnosed reason for their illness but symptomatic endometriosis diagnosed via laparoscopy or laparotomy. The visual analog scale (VAS)After reviewing the patients’ files and observing the registered diagnosis of endometriosis, they were invited to the Infertility Center to receive the complete explanation of the research. Among the participants in the first session, those who willed to take part in the study were interviewed to complete the questionnaires. This initial invitation went on several times for the 30 patients to be picked using a simple method. The researcher was not in any way biased in picking the patients, since the limited number of patients was a major factor in picking the ones who wished to participate. Thus the number of chosen sample units was more than the calculated number so that if anyone declared unwillingness to continue working and left the study, the researcher would not face a shortage in samples.The questionnaire was completed once before the beginning and twice after the end of the intervention (once immediately after the first post-intervention menstruation and once six weeks after that). The intervention consisted of 20 twenty-minute sessions of massage on some specific points of abdomen, sides, and the back (sacrum) of patients. The researcher did the massage after a few minutes when the patient had drifted off to make her relax. To do this, hands were drenched in oil and massaged the patient’s abdomen, sides, and back.The researcher had been trained for twenty sessions to correctly utilize the massage skills. After being approved for her massage skills  and receiving the certificate, the researcher performed the first step during which the required observations were made to secure the process. The massage therapy technique consisted of pressuring 24 specific point of abdomen and 10 points on the sacrum each one for two minutes while hands keep moving on the abdomen, sides, and sacrum.The Cronbach’s alpha coefficient was used to validate the questionnaire. The questionnaire was confirmed with a Cronbach’s alpha coefficient of 0.7.The data was analyzed by descriptive and inferential statistical methods (Wilcoxon signedrank test). The VAS measured data were compared by Friedman test. The Wilcoxon signedrank test was used to compare data too. Statistical analysis was done by SPSS software.2. 69.6 percent of the patients felt dysmenorrhea after and during their menstruation and 60.9 percent of them took analgesics before the study.Considering the loss of sample units due to their unwillingness to continue participating in the study the number dropped from a total 30  to 23. The sample units were all of ages 21-40 years, the majority of whom were 26-30 years old and the average age was 28.2 ± 4.2 years. Most of the patients had a normal body mass index (BMI) around 22.96 ± 3.59 kg/mThe highest frequency of menstrual pain before the beginning of the intervention was that of “severe pain” (52.3 percent); while the highest frequency of menstrual pain for “no pain” was that of immediately after the intervention and six weeks after the intervention (34.8 and 65.2 percent respectively). The Friedman test showed that the severity of pain was significantly in three studied times (p < 0.001). The Wilcoxon test also showed that the severity of pain during those three times have a significant difference (p < 0.001) with each other. Also the severity of the pain before intervention had a significant difference (p < 0.001) with that after it and this difference persisted after six weeks (p < 0.001). In addition, the severity of pain immediately after the end of intervention shows a significant difference from that of after six weeks (p = 0.001). The t-test showed a significant difference between before the intervention and immediately it  and also between before the intervention and six weeks after  .The findings of this research showed that the effects of the massage therapy are more at six weeks after it, when the body has adjusted itself to the new conditions. Wurn et al concerning the reduction of the pelvis pains and the pain during the intercourse stated that body needs two weeks time after therapy to adjust to the changes.19In all the previous studies on the effects of massages on pelvis pains, such as the menstrual pain and the pain during intercourse, the effects of massage have been evaluated only before and six weeks after the intervention; but in this study, we evaluated this effect immediately after the intervention too, in order to be able to evaluate the speed of intervention’s effectiveness. The findings showed a significant change in the level of pain immediately after the intervention, while the effects of massage increased six weeks after the intervention and the level of analgesia reached 65.2% (six weeks after the intervention) from 34.8% (immediately after the intervention) and none of the patients has experienced severe pain after the intervention. Wurn et al studied the menstrual pain caused by endometriosis after massage during the three phases of ovulation, before menstruation, and during menstruation and observed significant reduction in the menstrual pain in all three phases (p = 0.014).20Ebrahim zadeh, also examined the effects of acupressure on 216 teenage girls suffering from dysmenorrhea. He found that the severity of dysmenorrhea after the acupressure therapy decreased significantly (p < 0.001).17According to the findings of this study, it can be stated that massage therapy can result in reducing the menstrual pain caused by endometriosis. Massage therapy can also be used as an inexpensive therapy in medicine and an alternative to reduce the pain in patients suffering from endometriosis. It can also be considered as a complementary therapy with no side effects. Thus, by teaching these techniques to the midwifery groups we can improve women’s health and develop the skills of this profession. By improving women’s health, their positive role in the society would become clearer, their sense of capability would be strengthened, and they would be more effective in taking care of the family health.In this study, the standard of the research was having menstrual pain regardless of the endometriosis level of the patients, it is suggested that in the future studies, endometriosis level be considered as a variable.The authors declare no conflict of interest in this study.


The physiotherapy profession has undergone a paradigmatic shift in recent years, where a ‘biopsychosocial’ model of care has acquired popularity in response to mounting research evidence indicating better patient outcomes when used alongside traditional physiotherapy. However, research has not examined how this new dimension to traditional physical therapy is implemented within the therapeutic consultation.The study aimed to investigate physiotherapists’ reported approaches to back pain care in the context of increasing pressure to address patients’ psychosocial concerns. A secondary analysis of semi-structured qualitative interviews with 12 UK physiotherapists was conducted. Respondents were sampled from a national survey, to include a broad mix of physiotherapists. Data were analysed thematically, adopting the constant comparative methodology.The combination of traditional physical therapy with a broader biopsychosocial approach presented significant challenges. Physiotherapists responded by attempting to navigate patients’ biopsychosocial problems through use of various strategies, such as setting boundaries around their clinical role and addressing lay health beliefs of patients through the provision of reassurance and lifestyle advice.As psychosocial issues, alongside biomechanical factors, command a prominent place within the back pain consultation, physiotherapists may benefit from further specific training and mentoring support in identifying specific strategies for combining the best of traditional physiotherapy approaches with greater focus on patients’ beliefs, fears and social context. The National Institute for Health and Clinical Excellence  has callMore recently, the term patient-centred care has been used in policy documents such as The Health and Social Care Bill 2011 in the UK , and is Within physiotherapy an increasing body of opinion implicates the importance of physical, cognitive, affective and socio-occupational factors in the overall presentation of the patient which has prompted a call for a theoretical model shift within which to base the principles of physiotherapy . The calThe qualitative research reported in this paper was part of a larger study, the BeBack study (‘Beliefs about Back pain study’) aimed at understanding the attitudes, beliefs and behaviours of GPs and physiotherapists in the UK about managing patients with low back pain (LBP). The research comprised a national survey and an embedded qualitative interview study. The survey questionnaire included demographic and practice items, a measure of attitudes and beliefs about back pain, and items on intended clinical behaviour. Clinical practice behaviour was contextualised by providing a vignette describing a patient with uncomplicated non-specific low back pain, but who was not at work due to their back pain . RespondSemi-structured interviews with practicing physical therapists were conducted. Interviews were nested within a large national survey of the self-reported clinical management of healthcare professionals. In total 4,000 physiotherapists and GPs in the UK with recent experience of managing patients with LBP, were sampled randomly from national databases. From a total of 580 responding physiotherapists participating in the survey (response rate = 55%) 14 physiotherapists were purposefully sampled for the primary interviews according to their demographics (e.g. gender and age), time since qualification, clinical seniority or grade, and previous experience of managing LBP, as well as their treatment orientation and reported behaviour from the survey results. Purposive sampling was employed for maximum variance. From fourteen physiotherapists who were approached by an invitation letter and information sheet, 11 consented to an interview (by telephone), after which time no new insights emerged from the data. We also interviewed an additional physiotherapist, from a local physiotherapy clinic (providing informed consent) for a pilot interview prior to commencement of the interviews, and the data from the pilot interview were used as part of the secondary analysis presented in this paper, though not as part of the primary data analysis. The respondent characteristics are summarised in Table A secondary analysis of the data was conducted by a researcher (TS) who was not involved in the original interviews, and had not seen the previous findings. This provided a degree of objectivity to the analysis. The coding and early findings were discussed at regular intervals with the other authors, to check the data for reliability and credibility. An inductive approach to the secondary analysis was adopted, where themes and interconnections between them were derived from the data . PotentiA key theme arising from the secondary analysis was the distinction respondents made between mechanically focused and psychosocial care, which we contrasted across all interviews and were able to describe similarities and differences in relation to the distinctions they made. We also identified several sub-themes which overlap to varying degrees.The stance we take here, by the nature of the methods employed in the study (therapists’ perceptions of practice) is that physiotherapists’ views are not necessarily a true reflection of their behaviour in clinical practice, though they do offer important clues about how clinicians understand their role. Here, we report re-interpreted interview material relating to the psychosocial and physical management of patients with LBP. The quotations were selected to illustrate the main themes and not to provide a representative selection of quotations across all respondents. The results are divided into two broad sections describing the perceived obstacles to recovery and physiotherapists’ responses to them.a) The importance of psychosocial factorsLBP was thought to give rise to negative emotional responses in sufferers, such as panic, fear and anxiety. For this reason physiotherapists sought to ‘resolve’ some of these emotional reactions in patients. Although they considered such responses to be common amongst people consulting with LBP, they also thought that they should be properly addressed and patients offered reassurance about their symptoms.B5332: Just through experience, you know, is that there are some joints that physios would call emotional joints… there’s a lot of panic with patients as well and you know and fear. They don’t know what’s going on. “Could it be serious? Could it not be?” and I think what they’re looking for is for you to say “look, this isn’t serious, it’s mechanical, we can help you.”The management of physical symptoms was thought to be closely connected with patients’ lay beliefs about the causes and manifestations of LBP. While physiotherapists recognised the psychosocial aspects of the LBP experience and the associated link with these factors and chronicity, they claimed to lack sufficient training to effectively address these concerns with patients.5960: But I’m not claiming that I can help all those patients. I mean there is a limitation to what I can achieve with regard to my, say, counselling skills and my skills of helping them with modifying their pain behaviour and helping them with their cognitive, you know, construct if you like, regarding low back pain. So, and in those cases if it’s outside my area of outside my boundaries if you like, I tend to involve other professionals as well.This therapist recognised the importance of addressing patients’ psychosocial concerns. However, physiotherapists struggled to find strategies to integrate the clinical explanations within a broader biopsychosocial framework that made sense to patients.b) Legitimacy of LBPLBP is often associated with work absence. Thus it may be unsurprising that wider cultural connotations influenced the beliefs of our respondents towards some patients, and perhaps reinforced the view that they could not always be helped by physiotherapy management alone. Some physiotherapists suggested that they felt certain patients were financially dependent on having LBP. The following respondent alluded to the possibility that patients in receipt of financial support for their back pain or disability could be less likely to follow treatment advice from physiotherapists.B5332: I suppose, I mean, if you really went down to it, you could talk about those people who are, or you know, poverty in patients, little money, sometimes, is quite, you know, they’re quite willing to be ill, if you understand me?Interviewer: Yeah, yeah, and the reasons for that?B5332: Maybe their own benefits, they will be earning more through that way rather than going back to work.Interviewer: Right, right. So then that makes it, yeah, quite.B5332: Yeah, but although I’m saying that, it’s very hard to prove anything. You only have your suspicions. There’s nothing you can actually, you can’t turn round and accuse patients of being like that.These factors clearly impacted on the way physiotherapists viewed patients, and how far they were prepared to persist with those who perhaps were not making progress as expected or who were unwilling to follow clinical recommendations. Lack of progress was sometimes construed as refusal by the patient to follow the physiotherapist’s clinical recommendations. These responses may reflect a wider perception of LBP as attracting largely negative stereotypes of sufferers, and which potentially detract from a person-orientated approach to management. Such views could lead to the marginalisation of patients’ concerns, with greater clinical attention invested in those who appear to want to follow clinical advice. In such circumstances, physiotherapists may find it helpful to open up discussion with patients about these sensitive topics, in order to fully understand patients’ motivation to follow the clinical recommendations.a) Negotiating psychosocial problemsPhysiotherapists found patients’ unrealistic expectations about the likely success of treatment difficult to manage during consultations. Although they recognised the importance of discussing psychosocial obstacles to recovery with patients, they also stressed that patients had a duty to follow the physiotherapy advice and acknowledge responsibility for their own LBP rehabilitation.B5997: You certainly get a gut feel of the ones that you’re wasting your time on…They perhaps think they’re coming to me for a massage or something to be done to them to make them feel better, and I won’t go along that line. So they are difficult and there are times when I’ve had to say “well, look if you don’t want to follow what I’m saying I’m afraid I can’t help you.”The need to identify key psychosocial obstacles to recovery was stressed by physiotherapists, though they expressed difficulty in fully dealing with and managing these obstacles, perhaps preferring to maintain a level of professional detachment. Some patients sought a quick resolution and did not recognise the non-physical ‘obstacles’ to their LBP recovery. Physiotherapists conceded that pursuing a full recovery from LBP could be futile in these cases.B5499: It could be things the patient has been told about their problem that makes them feel it’s something more serious than it is and you can’t, no matter how much you explain that, you don’t actually get through to them. So that can mean that the treatment you think is going to work doesn’t.It was thought that LBP can acquire central prominence in a sufferer’s life, and encouraging deeper discussion and providing a more in depth explanation about what is expected of patients during the consultation was considered important to redress the balance.B5332: I suppose when I when I first qualified, patients became more dependent on me because of the way I treated them but now it’s trying to get them to say, “look,” well, yeah “you have to help yourself. I can give you the information and I can I can help, maybe, get rid of your acute period at this point, but you’re the one who has to help yourself, here.” You know, so its trying to just reinforce that bit, doing it in a nice way and you know, and being empathetic with them. They have got pain, but they have to realise that they have to then maybe do some pain management as well. That we might not be able to take the pain away fully but you need to get on top of it, break your kind of cycle here.b) Addressing lay health beliefsIllness beliefs can influence decisions to engage or abstain from health enhancing activities -21. HealB5544: If we say “you’ve got a degenerating spine” I think if people think that using it is going to degenerate faster, and unless you actually tell somebody that’s not the case then you can’t blame them for believing that…This physiotherapist recognised the potentially negative impact of the language used during LBP consultations, and stressed the need to ensure patients were not misinterpreting the clinical message. Several physiotherapists claimed that many people still believe that exercise is ‘harmful’ for LBP, and the most helpful approach during physiotherapy management is one that reinforces the message that exercise and physical activity are actually central to recovery.B5997: Well, she’s had this for four weeks. The benefit of having time off at this stage is minimal compared to maybe the first week of the back pain, and it would be more important to make sure that her work posture is correct, rather than just to avoid work. I think at this stage four weeks after the initial onset she needs to be mobile, not resting.Quite to what extent physiotherapists relayed this message to patients during interactions is unclear as we did not conduct observations. Despite recognising the importance of the psychosocial dimension of LBP, physiotherapists questioned the appropriateness of engaging patients in such discussions and anticipated a certain level of resistance. The following quote provides an example of how one physiotherapist did engage with a patient’s ‘unhelpful’ reaction to her LBP, (i.e. anxiety and fear of movement) which is presented as something to be corrected through specific advice.B5324: With this lady there’s anxiety problems there, she’s demonstrating past coping mechanisms, she’s got a fear of flexion. These are all things that you can address by explaining to her that that’s exactly the wrong way of going about dealing with back-pain, and then its whether they then actually buy into that and accept that and start doing it.The emphasis was on helping the patient derive a realistic understanding of their back problem to facilitate recovery. This was achieved through presenting ‘hard’ ‘evidence’ such as MRI results to objectively demonstrate the presence or absence of serious spinal pathology.B5393: With the chronic ones who tend to be imaged to death, so you can be quite sure that we know there’s nothing wrong with you because, you know, you’ve been scanned; you know, you’ve had an MRI, you’ve had a CT (scan), whatever. You know, as far as medicine’s concerned you’ve had blood tests; there’s nothing wrong with you, so, we know what it is and we could get on with it and if you buy into this we’ll get there.Psychosocial issues were perceived central alongside biomedical factors, to managing back pain by our participants. However, the aim was to discourage the behaviours or attitudes of patients that could prevent recovery, through promoting health enhancing practices such as losing weight.B5332: I think you’ve just got to ‘plug away’ at them; just got to say, “well” you know “you might think you’re right, but evidence is suggesting that if you lose some weight then we can make a difference in your back.”Physiotherapists encouraged people to live with their pain, rather than attempt to understand the underpinning reasons for their ‘negative’ beliefs. Others encouraged patients to describe their concerns and fears in the hope that they could be redressed through discussion. Again the emphasis seemed to be on putting ‘negative’ beliefs to rest through reassurance. However, reassurance alone may be insufficient to eradicate the intractable psychosocial problems.putting that to rest.B5544: I probably won’t treat you today. I may not even going to look at you today. “I’m going to listen to you” and by letting them talk and letting them tell me absolutely everything, and keeping it as unstructured as possible, hopefully, as I say, we’ll find these little bits of things that have either been missed or have never ever come out in the open, you know and it can be the smallest, smallest little fear that’s niggling away in somebody’s head and you can have dramatic effects just by c) Setting boundariesDiscussing and negotiating lay health beliefs with patients was one strategy used by physiotherapists to aid recovery. However, such an approach was not always successful because patients either did not appreciate the advice or resorted to old ways of thinking about their back pain and its management. Consequently, a further strategy was for physiotherapists to place boundaries around the management of psychosocial problems, in the realisation that the negotiated approach was not always effective.B5324: If there’s a relationship issue and things like that, that’s stuff that I won’t add, won’t necessarily address, because I don’t think that’s my area. I mean, I’m not going to start saying to patients, you know, how is your relationship with your husband at the minute, because I don’t think that’s the, it’s certainly relevant, but what am I going to do about it, if you know what I mean? If they start ‘bringing up’ those sorts of issues?Physiotherapists were reluctant to engage in discussion regarding patients’ personal lives in the absence of the necessary skills with which to offer appropriate advice. Involving other professionals with greater knowledge of psychological problems was one solution.B5499: looking at why the patient’s anxious, why they’re not doing things. Sleep patterns, all those kind of things that you look at but I think its limited as to how far you go with that. The patient’s presenting with a very chronic pain pattern and I think if that’s the case, they’re better treated with a multi-professional input because I think the outcomes then are much better than just seeing the patients as a sole professional.Others claimed that in certain circumstances, for example where people received financial benefits as a consequence of their disability, the challenge of assisting patient recovery from their back pain was thought to be too great. This was because patient’s wanted to maintain a ‘back pain identity’ with which to justify the presence of incapacity, and hence demonstrate inability to resume normal activities.B5544: I’ve got one gentleman, at the minute, all he wants is his benefits and you know, realistically you can find absolutely nothing wrong from an assessment but all he wants “I want my…” you know “I want my benefits, I can’t work because you know I had this injury 15 years ago.”. OK yeah but that was 15 years ago, but he’s now got a full range movement of his spine and he could, quite happily work, but he doesn’t want to. He wants to stay quite disabled and, you know we’re on to a non-winner with that one…Others claimed that physiotherapists perpetuated a ‘back pain identity’ in patients by reinforcing their physical ‘incapacity’ rather than their ability to adapt to life with pain.B5317: We keep asking them, “well, how long can you walk for?” or “how many of these can you do before your pain comes on?” and then they go and analyse that and they’re actually looking for the pain constantly. So, I think, sometimes we in breed that in people.The implication was that physiotherapy practice should be an approach that does not focus on the pain response. In this case, boundary setting was a strategy with a dual purpose for physiotherapists; to help define their scope of practice more explicitly for greater clarity about their clinical role, and to aid patient recovery through a focus on patient self-care by encouraging them to focus less on pain symptoms and limitations and more on function and activities they can achieve. In other words, a greater focus on what they can do rather than what they cannot do.The management of LBP using a biopsychosocial approach has been endorsed by institutions such as the National Institute for Health and Clinical Excellence , and steThe dominant characteristic of the physiotherapy paradigm which is focused on biomechanically oriented treatment approaches shaped therapists’ thinking about psychosocial issues. Addressing behaviour change rather than exploring lay health beliefs is wholly consistent with this paradigmatic approach . FacilitPhysiotherapists also set boundaries for their clinical role in helping patients’ LBP, which allowed them to practice within their areas of confidence, focusing on physical issues  in favour of psychosocial obstacles to recovery. Though both components were perceived as important to patient care, during routine clinical practice they were largely considered as distinct issues. The unpredictability of the course of LBP and response to treatment exacerbated the feeling amongst physiotherapists that it could pose an intractable problem. This has been reported previously . Jeffreyhealth beliefs, which may be more difficult to moderate. Consequently, there is a need for physiotherapists to both recognise patients’ health beliefs, and respond with appropriate clinical advice. Providing advice without fully understanding patients’ beliefs could lead to poor ‘concordance’ or recovery from back pain. This is because patients may respond negatively to clinical recommendations that do not sufficiently connect with their experiences of living with back pain. The STarT Back trial showed benefits from stratified care in outcomes such as back disability/function as well as key psychological obstacles to recovery like fear avoidance [The findings confirm the recognition by physiotherapists of the need to identify and address the social and psychological obstacles to recovery that patients with low back pain experience. They struggled, however, to find ways to understand and address these psychosocial factors, and often claimed that these problems fell outside of their immediate scope of practice. It is important to recognise the distinction between psychosocial factors or obstacles affecting patients’ ability to manage their back pain, and their voidance . Health This secondary analysis was based on interviews carried out with a sample of physiotherapists. The central issue is the integration of the best of what we know about mechanical components of back pain with the best of what we know about the key psychosocial factors. Studies show that factors such as satisfaction with care often improve with a psychosocial focus in the consultation ,27. MoreThe physiotherapists in our study were sampled purposively from respondents to a national survey ensuring that we captured a breadth of characteristics . The finThe findings show that physiotherapists recognised the centrality of patients’ psychosocial context and the ‘social’ mediators of back pain, such as work absence, which played a key part in affecting patient recovery. The implications of these findings are that in order to achieve concordance with patients physiotherapists will need to use best practice recommendations in ways that take account of patients’ pain experiences . In otheThe authors declare that they have no competing interests.TS conducted the initial steps/components of the secondary analysis and drafted the manuscript. NEF and BNO contributed to the analysis and all authors contributed to interpretation. All authors read, contributed to, and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/65/prepub