The use of opioid medications as treatment for chronic non-cancer pain remains controversial. Little information is currently available regarding healthcare providers' attitudes and beliefs about this practice among older adults. This study aimed to describe primary care providers' experiences and attitudes towards, as well as perceived barriers and facilitators to prescribing opioids as a treatment for chronic pain among older adults.Six focus groups were conducted with a total of 23 physicians and three nurse practitioners from two academically affiliated primary care practices and three community health centers located in New York City. Focus groups were audiotape recorded and transcribed. The data were analyzed using directed content analysis; NVivo software was used to assist in the quantification of identified themes.Most participants (96%) employed opioids as therapy for some of their older patients with chronic pain, although not as first-line therapy. Providers cited multiple barriers, including fear of causing harm, the subjectivity of pain, lack of education, problems converting between opioids, and stigma. New barriers included patient/family member reluctance to try an opioid and concerns about opioid abuse by family members/caregivers. Studies confirming treatment benefit, validated tools for assessing risk and/or dosing for comorbidities, improved conversion methods, patient education, and peer support could facilitate opioid prescribing. Participants voiced greater comfort using opioids in the setting of delivering palliative or hospice care versus care of patients with chronic pain, and expressed substantial frustration managing chronic pain.Providers perceive multiple barriers to prescribing opioids to older adults with chronic pain, and use these medications cautiously. Establishing the long-term safety and efficacy of these medications, generating improved prescribing methods, and implementing provider and patient educational interventions could help to improve the management of chronic pain in later life. The use of opioid medications to treat chronic non-cancer pain (hereafter referred to as chronic pain) in older patients remains controversial -3. Two rLittle information is available regarding healthcare providers' attitudes and practices regarding the use of opioids as a treatment for chronic pain in older adults. Provider concerns have been identified in prior studies that did not focus on older adults -10. ConcIdentifying primary care providers' barriers to the use of opioids as a treatment for chronic pain among older adults could identify possible targets for intervention, and ultimately improve pain management in this expanding patient population. Accordingly, we sought to elucidate primary care providers' perceived barriers and facilitators to prescribing opioids as a treatment for chronic pain among older adults. We also sought to characterize providers' experiences and attitudes towards using this class of medications in older patients.This was a qualitative, cross-sectional study that employed focus groups to generate discussions among health care providers.Focus groups were conducted at the Columbia Presbyterian Allen Pavilion Division of Geriatrics and the NewYork-Presbyterian (NYP) Wright Center on Aging. These sites serve predominantly older Latino and non-Hispanic white patients, respectively. Both practices provide care to patient populations that are older (mean age in the mid 80s) and predominantly female and were selected because they include providers with substantial experience caring for older adults. Many patients seen at the practice have significant functional and/or cognitive impairments. However, most patients live independently in the community, while about 10% reside in assisted-living facilities. Neither practice provides outpatient care to residents of long-term care facilities. Physicians provide longitudinal patient care, while the nurse practitioners see "walk-ins," but do not provide longitudinal care. To increase the diversity of study sites, one focus group was also conducted with providers from three community health centers within the NYP Ambulatory Care Network that serve predominantly Latino patients. In these three practices, virtually all patients live independently in the community. Because the health centers serve patients across a broad range of ages, fewer patients have functional or cognitive deficits relative to the geriatric care practices described above. The study was approved by the Weill Cornell Institutional Review Board.All physicians and nurse practitioners (NP) providing care in the above practices were eligible to participate, i.e., no exclusion criteria were employed. Recruitment at the Allen Pavilion and the Wright Center for volunteers occurred during routine staff meetings. Participants were recruited based upon their interest and availability to attend one of the focus group sessions. Each participant selected a time that was convenient from the groups offered. Medical directors at the three community health centers were contacted to recruit providers at these practices. Of 38 eligible providers at the five practices, 26 (68%) participated in a focus group. Participants attended a focus group that was convenient for them. There was no attempt to ensure homogeneity of participants  across the various groups. Of the 12 providers who did not participate, all cited scheduling conflicts as a reason for not participating. Participants did not differ from nonparticipants with respect to age, gender, race/ethnicity status, or years of training.One of two investigators (MCR or AS) introduced the study, explained the focus group objectives and process and then moderated a semi-structured discussion using open-ended questions and follow-up probes that were created based upon a review of the literature and pilot tested prior to use in the current study. Providers were asked to share their experiences using opioids in older adults with chronic pain, characterize their use of these medications, describe perceived barriers and facilitators to prescribing opioids prescribing to their older patients, voice any legal/regulatory or abuse/misuse concerns, and finally describe their comfort level(s) prescribing opioids for older patients with chronic pain and those receiving palliative or hospice care. Demographic and practice-relevant data were collected at the end of each focus group via a self-administered questionnaire.All focus groups were audiotape recorded, transcribed, and analyzed via directed content analysis . The quaSix provider focus groups were conducted, ranging in size from three to eight participants and lasting from 35 to 60 minutes. Table Table These medications work when given to the right patient, those who can understand the regimen and can anticipate the side effects. I have many people, one of whom was here today, who are getting relief from it and I think being able to live a life because of it.Participants reported considering numerous patient factors when deciding whether to prescribe an opioid. Factors that increased the likelihood of prescribing included a reliable patient, the presence of a reliable caregiver in the home, an identifiable etiology of pain, and a history of benefiting from opioids in the past Table . ConversTable The most commonly reported barrier to initiating opioid therapy (reported by 77% of participants) was a fear of causing harm or that the potential harms outweighed the potential benefits Table . As one I just have a hard time prescribing opioids in my older patients. I get frightened with 80+ year olds; how are they going to respond? Am I going to absolutely drop them to the floor even with a small dose?Fear of causing harm was often related to previous clinical experiences:One of my 96 year-old female patients got an opioid and went to sleep for three days after taking it. It really clouded her sensorium, so that was a negative experience for her as well as for me.Related to the fear of causing harm was the guilt some physicians experienced (or might experience) on account of opioid-related adverse events, causing them to think carefully before prescribing an opioid:If something does happen to them, you feel guilty and want to crawl under a table when they're in the emergency room and you get the call that they fell while on the fentanyl patch you gave them. That kind of experience is powerful and definitely factors into the equation.Another frequently cited barrier (by 62%) was the subjectivity of patients' pain reports, which was often associated with an inability to establish an organic cause of pain. Providers remarked that the subjective complaint of pain was sometimes a manifestation of some psychosocial problem:I have a lot of patients who come in and always have pain, and there is no physical reason for it; I think much of it is psychological.Other providers remarked that patients' pain complaints/pain scores often did not correspond with their behavior during the visit, which contributed to provider skepticism about the amount of pain patients were experiencing and reluctance to prescribe opioids:[I have patients who report that] their back hurts all the time, but then they jump right up onto the exam table, I don't get that.Or as another physician recounted:If I were in 10 out of 10 pain, I would be crying. I would be either in a fetal position, unable to make noise or crying hysterically and screaming. To me, 10 out of 10 is the worst pain I could imagine. And so it's really hard not to judge your patient who tells you, "Oh my pain's 10 out of 10 for sure, but the first thing I want to talk to you about is the fungus on my toenails because they're ugly."Of the 23 physician participants, only 9% reported concerns about possible legal or regulatory sanctions as a consequence of prescribing opioids as treatment for chronic pain. However, all three nurse practitioners voiced substantial apprehension about possible sanctions because of writing a high volume of prescriptions, often refilling prescriptions on days the patient's physician was not present in the practice.Only one participant voiced concerns about the possibility of older patients abusing opioids, while four shared concerns about older patients using the medication to treat non-pain symptoms or conditions , a type of medication use that all four providers characterized as opioid misuse. Three participants relayed concerns about abuse/misuse, not by patients but by their caregivers (e.g. home attendants or family members).Eight providers reported either low (or no) concern for addiction or dependence in older adults. As one stated:I have a patient who continues to complain about her pain. She doesn't even want to take Tylenol #3. She is in her 80s and says, "No narcotics! No, no, no! Don't give me anything like that!" I would love to give her something, but [to the patient] an addiction is an addiction. I mean she's 80-something, how addicted is she going to get?One physician with low concern for addiction also emphasized that pain control is imperative to improving quality of life in later years and that he counseled patients saying:Chronic pain restricts social activity and your activity choice. If pain is not as severe, you are better able to do things you want to do.Table A majority of providers (69%) reported that many older patients were very reluctant to take opioids because of multiple concerns, including bothersome side effects, concerns about costs, and worries about addiction. Several providers felt that patients' reluctance to try an opioid medication acted as a barrier to prescribing this class of medication to future patients:It's [the side effects] in addition to their knowledge that these meds are addictive. That might make it so that even when we get over our barriers to giving them, there are barriers on the patient side, and that reinforces [the notion that] they don't want it anyway. So, I'm not going to bother offering it to the next patient [who presents with significant pain].Twelve percent of participants also reported that older patients' family members functioned as a barrier at times by voicing their own concerns about having the patient take an opioid. More than half (58%) reported that "stigma" was a barrier, causing many patients to avoid opioid therapy altogether. As one physician working in a community health center noted:Patients hear the word codeine or some [other opioid] that they recognize and they think of it as a street drug, and don't want to be associated with that. I think in this population, when street crime is so rampant, and they have families who have been hurt by street crime or family members who are in jail because of selling, patients are very hesitant.Stigma could also lead patients to stop taking an opioid medication altogether. Another physician relayed that:Patients have told me, they're respectable people mind you, that they would go into the pharmacy and [the pharmacist] would yell out "we don't have any methadone" in front of all the people waiting in the pharmacy.An analysis of the themes by practice site revealed that stigma was the only theme to be more frequently endorsed by providers in practices serving Hispanic patients. All remaining themes were equally endorsed across the 5 practice sites.Seventy three percent of the sample stated that they were much more comfortable prescribing opioids to patients receiving palliative or hospice care, as compared to patients receiving treatment for chronic pain. Reasons included the indefinite period of treatment (for patients with chronic pain), divergent goals of care  and a different perceived risk-benefit ratio for the two groups. As one physician confided:It might be that you are treating for a limited amount of time, just like acute pain, you're just getting them through the last few weeks, months, or few years... so maybe we feel more comfortable [treating palliative care patients with opioids], whereas the patient with chronic back pain you don't how long you're going to be treating him or her, the patient can be 60 and treated for 35 years with narcotics, so yes, I think it's a risk-benefit issue.While not related directly to opioid use in older adults, a theme of frustration treating patients with pain was identified. As one of the 8 physicians who endorsed this theme described:Treating pain is one of the most frustrating things we do, there's a lot of pressure to treat pain, I mean we do the pain scale, we're mandated to do the pain scale, every time I go to a continuing medical education class, they're always telling me how little we treat pain, but the problem is, we don't know how to treat pain. And so everybody is telling me I'm not treating pain well, but nobody is helping me figure out how to treat the pain.This investigation focused on primary care providers attitudes' and practices regarding opioid use as a treatment for chronic pain in older adults. Our study extends research in this area by documenting new prescribing barriers and facilitators, and highlights interventions that could, if implemented, possibly improve appropriate use of opioid therapy. First, older patient and family reluctance to try an opioid medication was perceived to be a major barrier. Many physicians described cases where they were unable to overcome patients' reluctance to try an opioid medication, whereas others recounted having patients in substantial pain who took the prescription, but would not fill it. Furthermore, almost 40% of providers reported that they had encountered resistance from a family member/caregiver when attempting to prescribe an opioid medication. Over half of all participants felt that interventions that educated patients and family members about the benefits and risks of opioid analgesic  could facilitate use of opioids in this age group. Establishing the long-term risks and benefits of therapy and generating validated tools to estimate risk for adverse outcomes were also judged to be important facilitators of future opioid use.This study is also the first to document that opioid abuse/misuse by family members or caregivers constitutes a potential prescribing barrier. This concern was endorsed by 12% of providers. According to a recent study  friends,Our study suggests that the primary barrier to prescribing opioid analgesics among older adults with chronic pain is a fear of causing harm. A recently published guideline for managing chronic pain in older adults  encouragPrior investigations ,24 suggeOur results also differ from prior related studies in several important ways. First, prior investigations -14, whicManaging older patients with chronic pain is frequently a complex and challenging task, which is often compounded by feelings of helplessness and an inability to optimally manage pain on the part of healthcare providers ,32. ManyWhat types of research/initiatives could help to address the frustration that a significant minority of providers endorsed regarding managing patients with chronic pain? Providers viewed future studies that ascertain the long-term safety and efficacy of these drugs and how different subgroups of older patients respond to varying opioid medication regimens to be particularly relevant. These data could be used to develop evidence-based guidelines and algorithms for opioid prescribing in later life. Such data, along with improved training , may insOur results also provide support for future efforts to improve provider training and access to peer support. Preliminary testing of a clinical decision support system to facilitate opioid prescribing for chronic pain in primary care is encouraging . AdditioThere are several limitations to this study. Although all participants engaged in the focus group discussions, because of group dynamics and the participants' relationship as colleagues, these data may not have accurately captured the full extent of participants' views on this topic. Additionally, the actual prescribing patterns and clinical impact of the perceived barriers are unknown. We did not formally calculate an index of inter-coder agreement when analyzing our qualitative results. However, disagreement between raters occurred rarely when coding the themes reported in this paper, indicating that overall inter-rater agreement was high. The sample was small, non-random, and limited to providers at two academically affiliated and three community-based primary care practices in New York City. Finally, most providers cared for predominantly older adults of White or Hispanic origin. Our findings may not generalize to other race/ethnicity groups or non-elderly populations.In conclusion, this study demonstrated that primary care providers perceive multiple barriers to the use of opioids for older adults with chronic pain and use opioids cautiously for this purpose. Newly identified barriers include older patient/family member reluctance to take an opioid and the possibility of opioid abuse by caregiver . Further work directed at addressing the identified barriers and optimal ways to facilitate decision making when tolerance levels for risk vary between providers and patients/caregivers will be needed.AS assisted with study design, collected data, conducted analysis and interpretation, and drafted the manuscript. AAM conceptualized and designed the study, and commented on the manuscript. MP conceptualized and designed the study, collected data, and commented on the manuscript. EG conceptualized and designed the study and commented on the manuscript. BJT conceptualized and designed the study, and commented on the manuscript. MCR conceptualized and designed the study, collected, analyzed and interpreted data, and drafted the manuscript. All authors read and approved the final manuscript.The authors declare that they have no competing interests.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/11/35/prepub


Acute chest pain is a frequently occurring symptom in patients with medical emergencies and imposes potentially life threatening situations outside hospitals. Little is known about the epidemiology of patients with acute chest pain in a primary care setting in Norway, and we aimed to obtain more representative data on such patients using data from emergency medical communication centres (EMCCs).Data were collected prospectively during three months in 2007 from three EMCCs, covering 816 000 inhabitants. The EMCCs gathered information on every situation that was triaged as a red response , according to the Norwegian Index of Medical Emergencies. Records from ambulances and primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes and The National Committee on Aeronautics (NACA) System scores were assigned retrospectively. Only chest pain patients were included in the study.5 180 patients were involved in red response situations, of which 21% had chest pain. Estimated rate was 5.4 chest pain cases per 1000 inhabitants per year. NACA-scores indicated that 26% of the patients were in a life-threatening medical situation. Median prehospital response time was 13 minutes; an ambulance reached the patient in less than 10 minutes in 30% of the cases. Seventy-six per cent of the patients with chest pain were admitted to a hospital for further investigation, 14% received final treatment at a casualty clinic, while 10% had no further investigation by a doctor ("left at the scene").The majority of patients with acute chest pain were admitted to a hospital for further investigation, but only a quarter of the patients were assessed prehospitally to have a severe illness. This sheds light on the challenges for the EMCCs in deciding the appropriate level of response in patients with acute chest pain. Overtriage is to some extent both expected and desirable to intercept all patients in need of immediate help, but it is also well known that overtriage is resource demanding. Further research is needed to elucidate the challenges in the diagnosis and management of chest pain outside hospitals. Acute chest pain is an important and frequently occurring symptom in patients with medical emergencies outside hospitals -3. ChestIn Norway, patients in need of acute medical assistance are recommended to come in contact with the emergency health care system by calling the health specific national three digits emergency number 113, thereby reaching the nearest emergency medical communication centre (EMCC). Similar three digits emergency numbers also exist for the fire department (110) and the police (112). When a call reaches the EMCC, trained nurses use a decision tool, the Norwegian Index of Medical Emergencies , to clasLittle is known about the epidemiology of acute chest pain outside hospitals in Norway. A recent study from a single island municipality documented an incidence of 27 medical emergencies per 1 000 inhabitants per year, with an incidence rate of acute chest pain and suspected myocardial infarction of about 4.8 patients per 1 000 inhabitants per year [In a previous study  we preseThe aim of the present analyses was to obtain representative data on the epidemiology of acute chest pain outside the hospitals in Norway, by a more detailed investigation of the data from our EMCC study.Three EMCCs, located at Haugesund, Stavanger and Innlandet hospitals, were involved in the study, with the three corresponding districts covering 816 000 inhabitants . Data were collected prospectively from October 1 to December 31 2007.not the individual patient). The AMIS form contains information about the incident, the patient  and all available logistics, including date, time of day, and to where the patients are transported . Prehospital response time is also registered, defined as the time period from when the caller calls 113 until the nearest available ambulance reaches the patient [All 19 EMCCs in Norway use a software system called Acute Medical Information System (AMIS) to record all incoming cases. Usage of the AMIS results in an electronic form with registration of each incident  gives the incident one clinical criteria code and one response level according to the Index . The IndCopies of all AMIS forms involving incidents classified as red response were sent to the project manager every other week throughout the study. The EMCCs also sent copies of ambulance records from all red responses which involved ground or boat ambulances. In cases where doctors on-call, casualty clinics, primary care doctors or air ambulances had been involved, copies of medical records were requested and collected separately. This collection of medical records continued also after the study period, until October 2008. To secure a uniform use of the variables in the AMIS program, a meeting was held between the persons in charge of the participating EMCCs.The severity of the medical problem was classified using The National Committee on Aeronautics (NACA) Score System based on all available information . In the Based on information from all available forms and medical records the cases were also classified into symptom groups according to the International Classification of Primary Care - 2 (ICPC - 2) . The anaThe statistical analyses were performed using Statistical Package for the Social Sciences (SPSS version 15). Standard univariate statistics, including median and percentiles, were used to characterise the sample. Median, with 25th-75th percentiles, was used to analyse data where normal distribution was not present. Rates are presented as numbers of red responses per 1 000 inhabitants per year with a 95%-confidence interval (CI). Mann-Whitney U test was used for comparing age between males and females, for other comparisons the Pearson Chi-Square test was used. A P-value of < 0.05 was considered statistically significant.Approval of the study was given by the Privacy Ombudsman for Research, Regional Committee for Medical Research Ethics, and the Norwegian Directorate of Health.A total of 5 738 AMIS-forms were collected from the three participating EMCC-districts during the three month period, of which 5 105 AMIS-forms with 5 180 patients (each form could include more than one patient) were included in the study : 65 (53-79)), 56% males with a median age of 61 (25th-75th percentile: 52-75), and 44% females with median age 70 (25th-75th percentile: 56-82). The males were significantly younger than the females (p < 0.0001), and males dominated the age group 30-69 years with 63%, while the females constituted the majority (54%) in the age group > 70 years  of the cases, of which the doctor responded with an emergency call out in about a third. The doctors' responses and choices of action are shown in Table Median prehospital response time was 13 minutes (95% CI 9-20), and over 90% of the patients were reached by an ambulance in less than 30 minutes. Figure NACA-score could be classified in 971 (88%) of the patients  of the cases, and a helicopter with an anaesthetist was sent to assist in 34 (3%) of the patients. Air ambulance service was not requested in any patients with NACA 0-1. In the group with potentially or definitely critically ill patients (NACA 4-6), a helicopter was requested in 16% of the cases, and actually sent to assist in 10%.Analyses of the patients' whereabouts revealed that the large majority of the patients with acute chest pain categorised as "red response" were residing at home or at private facilities, 9% were in public areas and 6% at their general practitioner's surgery when the red response was triggered table . The vasThe cases were also classified with an ICPC-2 code, with the codes A11 "Chest pain" (56%) and K01 "Heart pain" (32%) constituting the vast majority. The remainder 12% were spread over 35 different ICPC-2 codes, with A06 "Fainting/syncope" accounting for 3% of the cases, and R02/R04 "Dyspnoea/Breathing problem" 2%. An ICPC-2 code from the psychiatry-chapter (P01-P29) was used in 1%.This prospective population based study showed an estimated rate of 5.4 acute chest pain cases involved in a red response per 1000 inhabitants per year. This corresponds to approximately 10 patients with acute chest pain in need of immediate medical help each week in an out-of-hours district covering 100.000 inhabitants. Over 20% of all contacts to the EMCCs ending in a red response involved chest pain as the main symptom. Males constituted a majority of the patients, and were significantly younger than the females. NACA-scores indicated that only a fourth of the patients were in a potentially or definitely life-threatening medical situation (NACA ≥ 4), but more than three quarters were admitted to a hospital for further investigation and treatment.The main strength of our study is the large register of data collected, where we were able to prospectively collect a complete material of more than 5 000 red responses during the three month period, based on a population close to 820 000 inhabitants, about 20% of the Norwegian population. Limitations include NACA-scores in most of the cases being assessed retrospectively based on medical records, which might give a lower accuracy when registering the severity of the illness. Severity assessment in patients with chest pain can be difficult from medical records alone, but the records included the patients' symptoms and clinical findings, making it possible to achieve reliable registrations. Ideally the study would have included on-going clinical evaluation by the physicians on-site, in addition to results and diagnoses from the investigations for the patients admitted to the hospital. Our results are based solely on patients in an emergency situation defined by the EMCCs using the Index (red response), and thus undertriaged patients would not be included. Patients with chest pain assigned with a yellow response might be at risk of being undertriaged , supporting the need for further studies on all patients with chest pain outside hospitals. The degree of urgency was set by trained nurses using the Norwegian Medical Index of Emergencies, but little is known about the validity of the Index and how the Index is used in the different EMCCs. A throughout evaluation and validation of the Index is needed.The rate of acutely ill patients with chest pain in our study is similar to the findings in two other studies from Norway, reporting rates of 4.8  and 5.4 A substantial number of the patients were not in a life threatening medical situation. This sheds light on the challenges for the EMCCs in deciding the appropriate level of response in patients with acute chest pain. Overtriage is to some extent both expected and desirable to intercept all patients in need of immediate help, but it is also well known that overtriage is resource demanding. Almost 10% of the patients were not brought to a doctor for further investigation or treatment. This indicates that the patient's medical condition was not as severe as initially assessed, supported by our results showing that all of these patients were given a NACA-score of ≤ 3. Norwegian health authorities and cardiologists have called attention to the importance of patients calling the three digits emergency number "113" directly when experiencing acute chest pain. Our study shows that in almost half of the calls to EMCC the call was made from health personnel, representing a possible system delay for patients with chest pain of cardiac origin in need of immediate diagnosis and treatment. Still, as the vast majority of patients with acute chest pain seem not to be in need of immediate hospital care, the primary care doctor on-call at the casualty clinic should still play an important role after the first contact to the EMCC. Primary care doctors are usually experienced in differentiating between severe and non-severe illness. As a group, they also hold a clinical background and competence making them a valuable asset in the initial management of patients with acute chest pain outside hospitals.A white paper concerning the organisation of the emergency services in Norway  have defThe majority of patients with acute chest pain were admitted to a hospital for further investigation, but only a quarter of the patients were assessed prehospitally to have a severe illness. Little is still known about the extent of patients with chest pain as their main symptom outside hospitals in Norway, including diagnostic measures, how they are treated and rates of admission to the hospital.The authors declare that they have no competing interests.EZ and SH planned and established the project, including the procedures for data collection. RAB designed the paper, performed the analyses and drafted the first manuscript. All authors took part in rewriting and approved the final manuscript.The project was partly funded by the National Centre for Emergency Primary Health Care, Uni Health, Bergen. RAB has received a research grant from the Norwegian Medical Association's fund for Research in General Practice.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-227X/11/9/prepub


Intracompartmental pressure (ICP) as the diagnostic gold standard in the management of chronic compartment syndrome (CCS) is debated. We present a diagnostic protocol in which the decision to operate can be based upon clinical findings alone. The aim of this study was to examine whether patients who underwent surgery for CCS based on clinical findings experienced significant long-term pain relief.A standardized clinical examination, including skin sensitivity, was performed in patients with bilateral leg pain and/or cramps. Before and after a symptom-provoking step test, ICPs were measured. The primary outcome was self-reported leg pain measured on a visual analogue scale. Secondary outcomes were satisfaction with the treatment result and health-related quality of life (HRQL) measured with the SF-8 questionnaire. Postoperative data were collected after 2 years.Follow-up was completed for 37 of 40 patients. ICP was increased in 80.5% of the compartments examined before surgery, but did not correlate with the degree of leg pain. The remaining compartments were diagnosed as CCS based on clinical findings, despite ICPs below the threshold. Leg cramps occurred in 32 of 37 (86.5%) patients during physical activity and at night. Leg pain improved from a score of 8.0 ± 1.5 to 2.3 ± 2.1, P < 0.001. Satisfaction with the treatment result was reported by 81.1% of the patients, accompanied by normalized HRQL.The diagnostic protocol led to a fasciotomy in all compartments of both legs, which was associated with substantial and sustained relief of leg pain, improved HRQL, and patient satisfaction. Chronic compartment syndrome  is a disorder that is most often encountered and described in soldiers and athletes -5, but iIn this paper, we present a diagnostic protocol in which the decision to operate can be based upon clinical findings alone. The primary aim of this study was to examine whether patients who underwent surgery for CCS, based upon this diagnostic approach, experienced significant long-term pain relief. Satisfaction with the treatment results and health-related quality of life (HRQL), measured with the SF-8 questionnaire, were secondary outcomes.In this case series study, 43 patients with suspected CCS in both legs were examined in a 2-year period (August 2007 to November 2009). Twenty-seven patients with unilateral CCS were excluded because inclusion might have led to reduced external validity. Also excluded were 17 patients who, prior to this study, had undergone fasciotomy of three compartments of both legs, but returned during the study period for fasciotomy of both deep posterior compartments, one at a time. The primary inclusion criterion was a diagnosis of CCS in both legs. Exclusion criteria were the presence of vascular disease, arteriosclerosis, and/or neurological diseases. Three patients were excluded, one because of arteriosclerosis and two due to sciatica. Forty patients fulfilled the inclusion criteria and underwent surgery, but only 37 agreed to participate in the study. The present series was derived from a larger group by eliminating patients who had suspected CCS in only one leg or in whom less than four compartments were affected. The patients were seen in the outpatient clinic and were later operated on by one consultant (JRO). Prior to surgery, all available conservative treatments had proven ineffective over a period of years; i.e., medication, physiotherapy, acupuncture, chiropractic, and cognitive treatment. Data were collected from the medical records. The written patient information, methods and data storage of the study was approved by the National Committee for Medical and Health Research Ethics of Norway (trail number: 20091302).The occurrence of pain and cramps in daytime, produced by exertion such as walking or running and relieved by rest, was noted, as well as nocturnal leg cramps, illustrated by pain drawing. Bilateral leg pain was typically characterized by patients as pressure or congestion. The use of medications and the presence of other diseases prior to surgery were assessed from the patients’ medical records as either present or not present. Physical examination included assessments of the spine and hips, the vascular status of the lower extremities, and blood pressure. The presence of systemic diseases was explored. All patients underwent magnetic resonance imaging (MRI) of the spinal canal. ICPs were measured with a water-based transducer in accordance with the user manual  with patients in the supine position, both before and 1 minute after a step test. Patients were asked to alternate quickly between standing high on their heels and on their forefeet for 3 minutes, as if they were walking while remaining in one spot. Pressures were measured in both legs and in three compartments; the deep posterior compartment was omitted due to the risk of deep bleeding weeks prior to surgery. Measurements of postoperative pressure did not seem to be indicated. In four persons, pain led to the step test being halted within 3 minutes; in two, the test had to be prolonged by 1–3 minutes until symptoms were reproduced. Palpation to determine muscle tenderness and examination of skin sensitivity by cotton swab and pin prick were also repeated. Normal dermatome sensitivity proximal to the knee level and reduced sensitivity in the area supplied by the nervus fibularis profundus and the nervus fibularis superficialis indicated CCS of the anterior and/or lateral compartments, whereas reduced sensitivity in the area of the tibial nerve indicated chronic posterior compartment syndrome. Finally, data from the clinical examination were compared with the pressures that were measured. Palpation of the tarsal tunnel and examination of sensitivity in the areas of the plantar nerves were also performed to identify coexistent tarsal tunnel syndrome.In summary, a diagnosis of CCS required: (1) the occurrence of leg pain, (2) compartment-specific muscle tenderness, and (3) reduced skin sensitivity. If these findings were not confirmed by increased ICP , the decision to operate was based on clinical findings alone.General anesthesia was used except in one case, in which spinal anesthesia was employed. As illustrated in Figure Self-reported leg pain was assessed with a visual analogue scale (VAS) before and after surgery; 0 indicated no pain and 10 the worst possible pain. This method of assessing leg pain has been shown to be valid for patients undergoing surgery for CCS . The patt-test was used to study changes in the VAS pain score and SF-8 scores after the operation. The SF-8 scores of the sample were considered to be within the normal range if the means were ± 0.5 SD of those of the general population [The paired pulation . The genpulation . SpearmaThe participation rate was 92.5% (37 of 40). There were 20 women and 17 men, and the average age was 37.2 ± 16.8 years. CCS was diagnosed in all compartments of both legs in all patients. Data on ICPs were available for 35 patients. Elevated ICPs were found in 80.5% of the compartments examined, and all patients had at least one positive finding of elevated ICP , but their preoperative pressures were not significantly different from the other patients . We also observed that pain relief was achieved by decompression in compartments in which elevated pressure was not found.The VAS pain score improved from 8.0 ± 1.5 to 2.3 ± 2.1 (P < 0.001) (Figure Postoperatively, there was a hematoma in one leg and a DVT in one leg. Prior to surgery, two women, aged 16 and 26 years, had been incapable of even walking. Immediately after surgery, they both increased their physical activity from hardly any to extensive walking, running, dancing, and mountain climbing, resulting in physical overactivity that necessitated months of physiotherapy and medication to treat foot and leg tenoitis and tenoperiostitis.CCS was diagnosed in all leg compartments of the patients in this series. Leg cramps appeared to be associated with CCS. Satisfaction with the treatment result was reported by 81.1% of the patients. The mean improvement in leg pain as measured by VAS was 5.7 points; this result is statistically significant and represents considerable improvements in quality of daily life. The seven patients who were uncertain about satisfaction with the overall treatment result had more pain after surgery, but their preoperative ICPs were not different from those of the other patients.To the best of our knowledge, this study was the first to evaluate patient-related outcomes in a general population of patients with CCS and improvements after fasciotomy of all leg compartments. Our findings suggest that decompression of most compartments is indicated more often than we had anticipated prior to the current study; however, clinical findings must be present before the decision is made to perform extensive decompression surgery. That decompression of most or all compartments should be performed more often than indicated by current guidelines is supported by the fact that 17 patients, who were excluded from this study because they had previously undergone fasciotomy of three compartments of both legs, returned to undergo surgery for decompression in the last two compartments.Although our results appear to be promising, the study has limitations, such as the lack of randomization and the lack of ICP measurements for the deep posterior compartments. Furthermore, muscle tenderness upon palpation is a subjective parameter; however, when muscle tenderness in the lower leg was compared to that above the knee, the difference seemed marked. Our sample may also differ from those presented by others. Thus, further studies should be performed to determine the external validity of our findings.Our diagnostic approach requires the presence of compartmental tenderness upon palpation combined with decreased sensitivity of one or both rami of the fibular nerve and/or the plantar nerves. If these signs are absent from the outset, an exertional step test may provoke them. Frequently, distinct tenderness was initially present in one anterior leg compartment only, but after the step test, increased muscle pain occurred in all compartments. Often, anticipated referred pain, as depicted in pain drawings, extended towards the knee, hip, and lumbar region; this pain mostly disappeared after both legs had been operated on.The sensitivity of dermatomes proximal to the knee was compared to that of the innervated areas of the peripheral nerves in the forefoot. Sensitivity changes in these areas would be expected in patients with both a spinal lesion and leg cramps. In our experience, even CCS patients without positive findings on spinal MRI can develop spinal problems later on. In particular, a spinal lesion should be suspected if symptoms occur in a single compartment other than the anterior compartment. One must discriminate between CCS and L5 nerve root impingement as the cause of tender muscles and pain in the anterior compartment. Nonspecific peripheral neuritis must also be eliminated; however, coexisting neuritis could also camouflage symptoms of CCS.Information about leg cramps associated with CCS is scarce in the literature, but it has been reported before . In the Coexistent tarsal tunnel syndrome, which can cause pain or cramps in plantar muscles similar to that caused by CCS, was recognized by palpation of the tarsal tunnel combined with findings of reduced sensitivity in the areas of the medial and/or lateral plantar nerves; the diagnosis was subsequently confirmed by ultrasound . ConcomiIn the opinion of regional vascular surgeons, because of the low average age of these patients, palpation of arteries in the foot, ankle, and groin, together with inspection of varicose veins, was sufficient to assess the vascular status of the legs. The symptoms of claudicatio intermittens are clearly different from those of CCS.Measurement of ICP at rest and during exercise has been considered necessary to establish a diagnosis of CCS, but these methods are complex and often yield uncertain results . MoreoveIt is possible that there were errors in the ICP measurements. However, the ICP measurements of Pedowitz et al.  were strClinical examinations revealed symptoms of CCS in all four compartments of both legs, while elevated pressures were found in 80.5% of the compartments measured. Statistically, there was no association between leg pain and the degree of ICP. Pain relief was also achieved in decompressed compartments without elevated pressure. The prognosis based on patient-related outcome after fasciotomy on all compartments in both legs was good in 81.1% of the patients. Thus, our data support previous research that suggested clinical examination without pressure measurement may provide an accurate diagnosis of CCS . The difThe authors declare that they have no competing interest.All the authors participated in the design of the study and in drafting the manuscript. All authors read and approved the final manuscript.Co authors: Jarle Øen and John Roger Andersen.


Though well recognized in the West, palliative care and quality of life are relatively newer concepts in a developing country like India. The aim of this study was to assess the effect of palliative care on pain and quality of life and to identify the association between the two.Observational prospective study.Patients with advanced cancer, receiving palliative drug therapy, were recruited from a tertiary care hospital. City of Hope Medical Center Quality of Life Survey and visual analog scale (VAS) were used to assess the quality of life and cancer pain severity, respectively.P<0.001) after 1 month in 93 patients; 7.06 ± 2.1 vs. 2.47 ± 2.1 (P<0.001) after 1 month and 2.02 ± 1.9 (P<0.001) after 2 months in 51 patients]. Also, significant improvement in the quality of life scores  was obtained. There was a high correlation between the average change of pain intensity and quality of life scores . Overall, a reduction in pain resulted in significant improvement in the quality of life (P<0.001).A total of 100 patients were included in the study. Palliative drug therapy produced a significant reduction in pain scores expressed as mean ± SD in VAS [7.13 ± 2.2 vs. 2.62 ± 2.1 (This study emphasizes the role of palliative care and, more importantly, pain management in improving the quality of life of advanced cancer patients. Fifty percent of cancer patients suffer an from advanced stage of disease that unfortunately is not responsive to curative treatment; however, with palliative care, even these patients may live for years. Patients with advanced cancer may suffer from innumerable symptoms like pain, anorexia, nausea or vomiting, depression, dyspnea, malnutrition, dry mouth, anxiety, skin problems and sleeplessness. The onlyt-test was used for analyzing the difference of pain and quality of life scores at baseline and subsequent follow-up. The Pearson correlation coefficient was used to analyze the association between the mean changes in pain levels and mean changes in quality of life scores. Significance for all analyses was taken at the 5% level. Changes of pain scores at baseline and follow-up were compared against the change of quality of life scores by analysis of variance.The study was conducted in the Oncology Clinics of a tertiary care teaching hospital. It was an observational cohort prospective/follow-up study of patients with advanced cancer, undergoing palliative drug therapy. A total number of 100 advanced cancer patients were included in the study. Approval for the study was obtained from the hospital’s institutional research committee. After informed consent was obtained, patients with advanced cancer were recruited and followed up monthly for 2 months. Upon recruitment, demographic data, relevant medical history and previous drug therapy were all recorded. During the 2-month period, patients received medical treatment as judged necessary by responsible physicians and no effort was made to alter or modify the course of treatment. The effect of the palliative care was evaluated on mainly two parameters, namely, pain and quality of life. The instruments used to evaluate the patients included visual analog scale (VAS) for pain and the City of Hope Medical Center Quality of Life Survey for quality of life measurement. VAS is a scale presented as a horizontal row of equidistant numbers from 0 to 10, with the ratings given as “no pain” at 0 and “pain as bad as you can imagine” at 10.The quality of life instrument used in the study was the City of Hope Medical Center Quality of Life Survey. It is a multidimensional instrument developed to evaluate quality of life as a measure of pain management outcome in individual patients. It consiP<0.001)], whereas in 51 patients, there was 65% reduction in mean pain intensity [7.06±2.1 vs. 2.47±2.1 (P<0.001)] after 1 month and 71% [7.06±2.1 vs. 2.02±1.9 (P<0.001)] after 2 months. Similarly, significant improvement in the quality of life scores  was observed [r= −0.53, P<0.001). Overall, a reduction of pain results in statistically significant improvement in quality of life [A total of 100 patients were enrolled for the study. One-month follow-up of only 93 patients was available. Three patients expired and four were lost to follow-up. Only 51 patients were available for 2-month follow-up, as most of the patients were receiving only symptomatic palliative therapy and were mostly provided home care, hence lost for follow-up in the subsequent months. observed . There w of life .Patients suffering from advanced cancer have numerous symptoms, which require comprehensive treatment. Palliative care aims to improve the quality of life in these patients by adequate symptom management. Pain was the most common symptom experienced by the patients in our study. This was in accordance to study done in a palliative care clinic in India, where the prevalence of pain was nearly 90%. Advanced9A significant decrease in overall pain intensity parallel to quality of life improvement was achieved in the study but was far from complete. It is globally recognized that there is a high prevalence of inadequate pain relief in a variety of clinical settings among cancer patients. Our findThe present study has several limitations as well. First, the differentiation of pain and quality of life scores with respect to different sites of cancer were not analyzed. Also, the cause of pain, whether related to tumor or treatment, was not looked upon. Second, the quality of life scale was administered by the researcher, which may bias the results. Third, cultural difference between the developed country where the instrument was developed and the developing country where it was applied was not measured. Finally, these data come from a single institution study and therefore do not represent overall palliative care in hospitals throughout India. The shortcomings in the management of the patients in the study like incomplete pain relief are attributed to the lack of specialized palliative care services in our country as compared to the West. Further research is needed to find out the impact of comprehensive palliative care on quality of life. Studies done in the West have already demonstrated that the existence of a palliative care services results in improved standards of care.The present study demonstrates the evaluation of quality of life as an important tool even for a populations living in a developing country. Nonetheless, the present study represents the first report on quality of life assessment in Indian population. These data are important for health care workers and patients living in other developing countries who have limited access to health care.