A k-means clustering algorithm revealed that, after 4 weeks of treatment, 42% of the patients moved from the arachnophobic to the nonarachnophobic cluster. Six months after concluding the treatment, a follow-up study showed a substantial consolidation of the recovery process where 92% of the arachnophobic patients moved to the nonarachnophobic cluster.We describe a new arachnophobia therapy that is specially suited for those individuals with severe arachnophobia who are reluctant to undergo direct or even virtual exposure treatments. In this therapy, patients attend a computer presentation of images that, while not being spiders, have a subset of the characteristics of spiders. The Atomium of Brussels is an example of such an image. The treatment group ( According to the DSM-IV manual (American Psychiatric Association ), specifSpider phobia is one of the most common specific phobias . ArachnExisting therapies range from those that confront the patient with the real spider, such as “in vivo” exposure therapy (Ost ), to thoThe treatment proposed here (SLAT: spiderless arachnophobia therapy) does not use any spider, neither real nor virtual or imaginary. It is specifically oriented to those patients with severe arachnophobia that would not undergo any kind of therapy involving a spider. This treatment makes use of the idea that aversive information does not need to be perceived consciously to trigger an emotional response. Nonconscious processing mechanisms of emotionally relevant stimuli are sufficient to activate the autonomic components of a phobic reaction . FrThe thalamus and amygdala are, according to LeDoux et al., responsible for recognizing fearful stimuli and triggering subsequent autonomic responses such as increased heart rate, respiration, and sweating  met DSM-IV criteria of specific phobia  and from the fear of spider questionaire (FSQ); see k-means multivariate analysis, the 29 control subjects were classified as nonphobic. One of the 26 volunteers was characterized as nonphobic by the k-means analysis and was eliminated from the study leaving 25 arachnophobic patients. The mean age and standard deviation of the arachnophobic patients and controls were 31.3 ± 7.4 and 32.6 ± 8.2 years, respectively. The duration of phobia among the patients was 23.0 ± 8.6 years. The five measurements (see the following section) that were used as inputs in the k-means algorithm were (a) the distance tolerated to a real tarantula in a BAT; (b) the distance tolerated to a photo of a tarantula in a BAT; (c) the subjective percentage of anxiety according to the subjective units of disconfort scale (SUDS), using a real tarantula; (d) the percentage of anxiety with a photo of a spider; (e) the numerical result of the FSQ test.Regarding the last criterion, the k-means algorithm is that it uses a multivariateapproach  in order to separate phobic from nonphobicsubjects. This procedure is more robust than adopting only one measurement,such as the BAT or the result of the FSQ, as conventionally used for separatingphobic from nonphobic subjects. It is also important to remark that the k-meansalgorithm does not use any arbitrary parameter that can bias the results.The chief advantage of the To assess the degree of spider phobia, three different instruments were used. As described, the SCID  was usTo verify that patients met DSM-IV criteria for specific phobias (300.29), all of them underwent an SCID .The BAT is a widely used measurement of clinical improvement in specific phobias  and afterwards with a real tarantula. In both cases the phobic object was placed at the end of a 25-meter long corridor. Before beginning the test, an assistant read the instructions to the subject: “This is a behavioral assessment test and is not part of the therapy. You are free to refuse my suggestions. Walk the farthest you are able to approximate to the spider at the end of the corridor without forcing yourself. I will remain at this point until you stop.” When the subject stops less than one meter from the object, the assistant says: “Touch the photo” or “Touch the cage” in the case of the real tarantula.Note that instead of asking the patient to approach as much as possible to the spider, the patient is asked to approach to the spider as much as possible without forcing himself. This kind of suggestion guaranteed complying with the desire of patients of not confronting in any way the phobic object.The BAT was rated by measuring the distance from the subject to the phobic object, starting at 25 meters. The BAT score ranged from 26 if the subject refused to do the test, to −1, if the subject opened the lid of the cage. When subjects stopped, the assistant applies the SUDS by saying: “Please, rate you anxiety from 0% to 100%, 100% being the greatest fear you have had in your life.”P < .01, F(1.76) = 13.28, P < .01, respectively (Szymanski and O'Donohue [t(37) = 4.38, P < .01, t(79) = 5.09, P < .01, resp.). When applied to nontreated subjects, the instrument did not show improvement from pretest to posttest. This instrument has an internal consistency of 0.92 with a split half reliability of 0.89.The fear of spiders questionnaire (FSQ) assesses the subjective perception of spider fear (Szymanski and O'Donohue ). It is'Donohue ). It alsThe presentation used in the SLAT consists of an initial set of 165 images, 124 of them having some features that resemble any of the characteristics  of a spider and were selected as explained in The remaining 41 images were neutral and were selected with the purpose of making it more difficult for the subject to realize there were SLAT images in the presentation.The placebo group presentation consisted of a sequence of images without arachniform features. Among the selected figures, there were abstract or surreal paintings that might induce placebo subjects to think there was something hidden in the figures.The images were selected from the Internet. We chose 132 images with spider features and 44 neutral images. The features that were selected in the images were related, for example, to the radial symmetry of spiders, the design of their webs, their texture, the way they articulate their legs, the hook-like shape of their extremities, or the fact that they hang from a string.For validating our selection, 43 nonarachnophobic persons were asked to rate, on a 0 to 10 scale, the content of spider features in all the images. Not to bias the process of rating the images, no instructions related to what features to consider in rating the images were given to these persons.It was necessary to establish a threshold in this scale for separating SLAT images from neutral images. This threshold was obtained by means of the Bayes decision rule that yields a threshold of 0.92. Images with a greater rate were classified as SLAT images, and images with a lower rate were classified as neutral. According to this rule, 8 of the figures initially classified as SLAT images were neutral, and 3 neutral figures were SLAT images. Therefore, a total of 11 images were excluded from the final therapeutic repertoire. To apply the Bayes decision rule, a histogram was created giving the probability of finding a SLAT image inside intervals of 0.6 unit length in the 0 to 10 “arachniform scale.” The same was done with neutral images. We replaced both histograms by two curves after smoothing the histograms by using interpolation by splines. The intersection of the two curves yielded the value of 0.92 that served to discriminate between SLAT and neutral images.One of the assumptions that served to delineate the SLAT (see assumption (a) in We adopted the following procedure.Tad, of each one of theimages. The patient was instructed as follows: “Each one of the followingimages will be presented by default for 5 seconds. If you do not like theimage, press the “Enter” button to passto the following image sooner. The sooner you press the button, the morefearful we will understand the image to be for you.”(a) Once the entire set of figures had been shown to the patient in a preparatorypresentation, we asked the patient to see the figures once more and collaboratewith us to determine the adjusted duration, Which images, if any, are intolerable?Which images are tolerable?Which images are so nice that you might place them in your bedroom?(b) After seeing all images the subjects were asked:Tad, in the presentation. As some patients were faster than others in pressing the “Enter” button, the average time Tm for each subject served as the patient's unit of time. With all this information, nine rules were applied to obtain the final duration of each image, T0, T1, and so on were set as arbitrary multiples of Tm. The adjusted duration of each image, Tad, was obtained by multiplying the duration chosen by the subject in the preparatory presentation, T, by a coefficient calculated as follows.In the following rules, times T0 = Tm/5, T1 = Tm/2, T2 = Tm/3.We defined three thresholds: T < T0, the image was eliminated from the presentation.If T < T1 were also eliminated.Intolerable images with Tad = 0.2 ∗ T in intolerable images with T > T1.Tad = T for tolerable imageswith T < T2.Tad =1.5 ∗ T for tolerable images with T1 > T > T2.Tad = 1.8 ∗ T fortolerable images with T > T1.Tad = 2 ∗ T in images deemed nice.T.Other images, not included in previous groups, maintained their time Tad was multiplied by 12 and divided by the total duration (in minutes) of the presentation.To make the total presentation time equal to 12 minutes, eachAll procedures were the same for the placebo group.This research was approved by the Ethics Committee on Research of the Institute of Psychology of the University São Paulo.n = 13) and placebo (n = 12).As mentioned in After adjusting the timing of the presentation, a personalized CD was prepared for each patient. In the following session, this CD was given to the patient. The patient was then instructed to run the presentation twice a day at home preferably during moments in which she/he was not tired or under stress. Prior to each presentation run, the patient was given one question to answer at the end of the run. These questions were intended to distract the patient from arachniform features in the images. Examples include: “In how many images there is an animal?” or “In how many images there is a rounded object?” When answering the question, the patient was instructed to write, beside the answer, the date and time she/he ran the presentation. Every week these data were checked out in order to verify the rate of cooperation of patients and to encourage noncooperative patients, if any. In all subjects, the cooperation was satisfactory and no statistics were deemed necessary to measure the rate of cooperation.To assess progress during the treatment, placebo and treatment subjects underwent the BAT (including the SUDS) each week. In the last week, the FSQ was also applied. Experiments were carried out in three stages. In stage 1, data collected during these first four weeks were used to compare placebo and treatment groups. A period of four weeks was established prior to the experiment with the intention of minimizing the duration of the experiment in order to avoid drop out. In stage 2, the treatment group (but not the placebo) was asked (and luckily agreed) to continue for two more weeks to assess if this additional time might help the treated group to achieve a more substantial recovery. They were evaluated at the end of the 6th week.In stage 3, after the fourth week, placebo subjects were invited to receive the SLAT. The ten subjects that were accepted were treated for 6 weeks and evaluated after the 4th and 6th weeks.n = 12) and treatment (n = 13) groups at the beginning of the study in the following demographic and clinical variables: age, F = 0.3315, P = 0.5703; duration of phobia, F = 3.8758, P = .0611. No significant differences were found in behavioral variables during the initial BAT test with the real spider BAT: F = 0.0015, P = .9692; SUDS, F = 0.0739, P = .7881; or with the spider photo BAT, F = 1.6764, P = .2082; SUDS, F = 0.0003, P = .9866. No significant difference was found in the subjective measure of fear of spiders, FSQ: F = 0.020, P = .8895.There were no difference between the placebo  higher in the treatment than in the placebo group.P < .0001, and the significant group effect F = 4.5678, P = .04344 show the effectiveness of the treatment. The significantly different time-course of the improvement in the two groups is also reflected in a significant group × time effect F = 4.4217, P = .0026. In order to evaluate how the test with the real spider and the test with the spider photo contribute to these results, a 2-group, ×5 times, multivariate ANOVA was performed, first with the BAT and SUDS of the real spider and then with the BAT and SUDS of the spider photo. The test with the real spider yielded a significant group × time interaction: F = 7.981610, P = .009598, MS = 1369.772 while the test with the spider photo yielded a moderate group × time interaction F = 2.908077, P = .101608, MS = 750.1708. The FSQ also yielded a nonsignificant 2 (groups) ×2 (time = pretreatment versus post treatment) interaction F = 1.833, P = .188. The difference between BAT and SUDS tests and the FSQ test results are analyzed in the discussion.A 2 (group) × 5 (times) repeated measure multivariate ANOVA  was conAfter the four weeks in which placebo and treated subjects were compared, treated subjects continued receiving the SLAT for two more weeks, achieving 76.6% improvement in the BAT and 45.6% in the SUDS with the real spider. With the spider photo, there was an 88.5% improvement in the BAT; a 61.4% improvement in the SUDS, and a 40% improvement in the FSQ.The results of the treated placebo were consistent with the results of the treatment group .A six-month follow-up study was also performed. It showed a substantial consolidation of previously obtained results. There was 90.2% improvement in the treatment group in the BAT test: patients were capable of approaching a live tarantula at 2(3.9) meters (on average), six patients opened the lid of the tarantula cage and, of these, three patients touched the tarantula .A During the four weeks of treatment, 41.7% of individuals in the treatment group and 25% of the placebo group moved over to the normal condition. When the placebo group was treated, 50% fell in the normal group.A more substantial improvement was evident in the follow-up, six months after the conclusion of treatment: 91.7% of individuals in the treatment group and 90% of the treated placebo group were classified as nonarachnophobes. These results are discussed below.In this section, the following topics will be discussed:the hypothetical assumptions taken into consideration to elaborate the therapy;the neurocomputational background of the therapy;the influence of the BAT assessment test in the efficacy of SLAT;the delay of improvement in the FSQ;the therapeutical limitations of the procedure;suggestions for further studies.Two hypothetical assumptions that are consistent with neurological findings served to delineate the methodology of SLAT. The results of the therapy, however, are not intended to assess the validity of these preliminary assumptions, which would require much further confirmation. (a) The first assumption is that some connections from thalamus to amygdala are abnormally potentiated in phobic patients, possibly because of a process in which a conditioned stimulus (CS), the phobic object, is associated with an unconditioned stimulus (US) such as a loud sound or an acute pain. The possibility of plastic changes taking place in the thalamo-amygdala pathway is supported by the work of Doyére et al. , in whicRegarding the degree to which plastic changes would take place in the thalamo-amygdaloid pathway, it is worth mentioning that postsynaptic voltage value is critical to determining whether a synapse is reinforced or depressed . AccordWe conjectured that the effectiveness of SLAT depends on activating neurons that project from thalamus to amygdala in such a way that they are inside the depression interval. Unfortunately, depression intervals vary for each synapse according to a synaptic property called metaplasticity. The same postsynaptic activity may produce potentiation in one synapse and depression in another while leaving a third unaltered. We were also unable to directly evaluate the postsynaptic activity that a given SLAT figure produced in these neurons.Despite all these difficulties, we conjectured that the fear reaction produced by SLAT figures was correlated to the postsynaptic activity in neurons in the thalamo-amygdaloid pathway. To avoid potentiation and favor depression, fearful images were omitted from the presentation see . The dur(b) The second hypothetical assumption that served to delineate SLAT is related to the nature of the archetypal information that, according to LeDoux, is relayed from the thalamus to the amygdala. Morris et al. found thNeurocomputational models  arAccording to the first assumption, a way of depressing thalamo-amygdaloid synapses would be by avoiding high post-synaptic potentials in thalamo-amygdaloid neurons by means of reducing the intensity of phobic stimuli . A possInstead of reducing the duration or intensity of spider images, we propose to reduce the number of arachnoid features present in each image. According to the second assumption, when the number of arachniform features in the input pattern is reduced, the activation of intralaminar neurons (computing the sum of these features) is also reduced. This lower activation of intralaminar neurons contributes to reduce the activation of the neurons in the thalamo-amigdaloid axis, so that their synapses would undergo depression instead of potentiation. Therefore, when, instead of the spider code, a code with a smaller repertoire of arachniform features is relayed, neurons in the thalamo-amigdaloid pathway are hypothetically less activated, their synapses more prompted to undergo depression rather than potentiation.Both treatment and placebo groups underwent BAT and SUDS assessment test weekly. Volunteers were told to approach the spider without forcing themselves. The purpose of this instruction was to adhere, during the BAT and SUDS tests, to the principles that inspired the therapy, that is, to avoid any stimuli that could contribute to enhance thalamo-amygdala connectivity.It could be argued that the BAT assessment test could, by itself, have a therapeutical effect over arachnophobia. This effect might be thought to be responsible for the improvement observed in the placebo group. However, as shown in Many patients reported that they did not realize that they had lost their fear of spiders until they were confronted to a real spider during their daily life. They had the strange sensation of not reacting with fear when, for the first time after treatment, they saw a real spider. Since during daily life, a real confrontation with a spider is an unpredictable event, the realization of having lost the fear varies from individual to individual. The BAT assessment test, independently of its possible placebo effect, could contribute to accelerate this process of realization.Related to this, we observed that the improvement in the FSQ was delayed in comparison to the improvement in the automatic responses measured by the BAT and SUDS. This is consistent with the reasonable supposition that patients did not realize that they had lost their fear until they actually confronted a real spider during their daily life situations. Depending on the frequency with which they actually confronted a spider in their daily lives, the realization of recovery took a shorter or longer time in the different patients. This fact was reflected in the follow-up study that was carried out six months after the conclusion of the treatment.Although the 25 subjects that took part in the experiment came from a very large sample of 160 arachnophobic volunteers, there were no volunteers above the age of 46. Taking into account that neural plasticity depends on age (Burke and Barnes ) and thThe 160 arachnophobic patients that contacted us were classified in terms of their degree of arachnophobia. Among the six with the highest scores, three of them suffered thyroid hormone impairment. We wondered whether this coincidence might be a possible psycho-somatic effect produced in the long run by arachnophobia. A similar case of thyroid hormone alteration was found in the literature  among According to our theoretical assumptions, the SLAT acts at subcortical levels. Neuroimaging studies could help to evaluate this assumption by comparing the brain activation before and after the SLAT. A similar comparison was done by Paquette et al. , in whicA novel technique for treating spider phobia, that does not require any use of spiders, was described and tested. In the SLAT, here described, each patient is given a personalized presentation in a compact disk, containing a set of images that, although not containing spiders, present subsets of spider characteristics. The degree to which each image evokes a spider in different patients is different. The most evocative images are excluded from the personalized presentation whereas the less evocative images are presented to the patient during a longer interval see . RegardiP = .0096).To compare the evolution of the placebo and treatment groups, a four-week experiment was designed. Treatment and placebo groups went through their corresponding presentation twice a day and came once a week to the university to apply the BAT and SUDS tests. To carry out these tests, instead of encouraging the subjects to approach as much as possible to a spider, they were told to approach the spider, but without forcing themselves. They could also refuse to do the test, which was the case of three treatment subjects in their initial evaluation see . This kk-means algorithm, six patients of this group opened the lid of the tarantula cage, and, of these, three touched the tarantula.In the follow-up study performed after six months, 91.7% of the patients in the treatment group were classified as nonarachnophobes by the The therapy proposed here was aimed at subconscious, automatic responses, while behavioral or psychoanalytic therapies emphasize the rational control of fear reactions. According to LeDoux , the altSLAT is particularly appropriate for, but not exclusive to, those patients who, because of the severity of their arachnophobia or whatever other reason, are unwilling to undergo therapies that involve any real, imagined or virtual spider. The theoretical basis of the therapeutic strategy was aiming to produce plastic changes in the thalamo-amygdaloid circuit responsible for the subconscious, automatic reactions triggered when the subject sees a spider. The therapy might have been effective for other, fortuitous, reasons, but the consistency with the theoretical basis that motivated it Sections and 4.2


In Tanzania, oral health services are mostly in the form of dental extractions aimed at alleviating acute dental pain. Conservative methods of alleviating acute dental pain are virtually non-existent. Therefore, it was the aim of this study to determine treatment success of emergency pulpotomy in relieving acute dental pain.Setting: School of Dentistry, Muhimbili National Hospital, Dar es Salaam, Tanzania.Study design: Longitudinal study.Participants: 180 patients who presented with dental pain due to acute irreversible pulpitis during the study period between July and August 2001.Treatment and evaluation: Patients were treated by emergency pulpotomy on permanent posterior teeth and were evaluated for pain after one, three and six week's post-treatment. Pain, if present, was categorised as either mild or acute.Of the patients with treated premolars, 25 (13.9%) patients did not experience pain at all while 19 (10.6%) experienced mild pain. None of the patients with treated premolars experienced acute pain. Among 136 patients with treated molars 56 (31%) did not experience any pain, 76 (42.2%) experienced mild pain and the other 4 (2.2%) suffered acute pain.The short term treatment success of emergency pulpotomy was high being 100% for premolars and 97.1% for molars, suggesting that it can be recommended as a measure to alleviate acute dental pain while other conservative treatment options are being considered. In Tanzania, it is estimated that over 85% of dental patients seek dental care due to painful tooth conditions, and that over 90% of the treatment rendered is tooth extraction . A totalPrevious studies -6 have sTherefore, the aim of this study was to determine the level of success of emergency pulpotomy in relieving acute dental pain resulting from pulp exposure due to dental caries.A total of 180 patients aged ≥ 15 years, who had dental pain due to acute pulpitis, which under current circumstances would have been extracted, were included after obtaining an informed consent. Enrolment was done consecutively, including all eligible patients who were attended at the Restorative Department of the Muhimbili National Hospital (MNH) during the study period between July and August 2001. Patients were excluded if found to have any of the following: Teeth that had grossly destroyed crowns and/or clinical or radiographic signs of pulp degeneration or third degree mobility.During the first visit to the clinic emergency pulpotomy was done on premolars or molars pending an alternative conservative treatment such as root canal treatment.Pulpotomy involved administration of local anaesthesia  followed by the removal of the coronal portion of the pulp using a round carbide bur. Haemostasis was achieved by pressing a sterile cotton pellet against the site of amputation for 2–3 minutes. The pulp chamber was irrigated with 2.5% sodium hypochlorite and was dried with a sterile dry cotton pellet. A sterile cotton pellet moistened with eugenol solution was then placed against the remaining pulp tissue. The access cavity was sealed with reinforced zinc oxide eugenol cement and the occlusion checked. All the clinical work was done by JWN.Evaluation of treatment included clinical and radiographic examination done after one, three and six week's post-treatment using evaluation forms. The final outcome was taken after results of evaluation on third visit. Presence of acute pain, apical periodontitis (acute or chronic), tooth mobility, radiographic evidence of pulp degenerative changes or loss of vitality was regarded as an indicator of a failed treatment. Patients were also questioned on the presence or absence of pain and the degree of pain experienced. Pain was regarded as being mild if it was not discomforting or prevent the patient from sleeping and did not require the prescription of analgesics. Acute dental pain was that pain that was difficult to bear and was very disturbing to the patient necessitating the use of analgesics or further intervention. All successful cases were scheduled for root canal treatment and restoration at appropriate intervals.Data was entered into computer and analysis was done using a calculator by calculating percentages of the different outcomes.Verbal consent was obtained from all the participants and ethical clearance was obtained from the Muhimbili University College of Health Sciences (MUCHS) ethical committee.There were 180 patients who had teeth that were treated with emergency pulpotomy, of whom majority (69.4%) were less than 40 years of age  reported in other studies ,9. This 9% reportWith this success rate it can be suggested that emergency pulpotomy if widely employed could potentially reduce the present number of extracted teeth in Tanzania and probably other neighbouring countries with similar situations by approximately 90%. In Tanzania dental personnel at the district and regional levels could do pulpotomy as an emergency measure. However, this will require the dental therapists, who carry out the bulky of primary oral health services to be re-trained . These eThe author(s) declare that they have no competing interests.JWN took part in data collection, data handling and preparation of the manuscript, MIM participated in organising and preparation of the manuscript, ENMS took part in data entry and the preparation of the manuscript.The pre-publication history for this paper can be accessed here:


Little is known about the procedures used by German dental and maxillofacial surgeons treating patients suffering from chronic orofacial pain (COP). This study aimed to evaluate the ambulatory management of COP.Using a standardized questionnaire we collected data of dental and maxillofacial surgeons treating patients with COP. Therapists described variables as patients' demographics, chronic pain disorders and their aetiologies, own diagnostic and treatment principles during a period of 3 months.Although only 13.5% of the 520 addressed therapists returned completely evaluable questionnaires, 985 patients with COP could be identified. An orofacial pain syndrome named atypical odontalgia (17.0 %) was frequent. Although those patients revealed signs of chronification, pain therapists were rarely involved (12.5%). For assessing pain the use of Analogue Scales (7%) or interventional diagnostics (4.6%) was uncommon. Despite the fact that surgical procedures are cofactors of COP therapists preferred further surgery (41.9%) and neglected the prescription of analgesics (15.7%). However, most therapists self-evaluated the efficacy of their pain management as good (69.7 %).Often ambulatory dental and maxillofacial surgeons do not follow guidelines for COP management despite a high prevalence of severe orofacial pain syndromes. Many heterogeneous diseases lead to orofacial pain syndromes. Descriptions such as jaw (temporomandibular) joint pain, facial pain, and dental pain characterise these syndromes with regional anatomic descriptions. The International Headache Society -3 distinchronic orofacial pain [A perseverance of pain longer than 6 months and emerging signs of chronification, as a strong association with psychosocial problems, frequent changes of therapists, localisation of pain in other parts of the body, defines ial pain -7. Chronial pain .The female gender is affected, mostly. References show that prevalences of orofacial pain syndromes vary from a 6 month period prevalence of 12 to 22% to a 12 month prevalence of 20% -15.The management of orofacial pain remains difficult. Often therapists cause a vicious circle by applying inadequate invasive treatment principles resulting in persistent pain conditions which then, for their part, force therapists to carry out further invasive procedures ,16.pain therapy methods was not the objective of these studies [Only few investigations are publicized on the management of patients with orofacial pain treated by general physicians, pain therapists dental, or maxillofacial surgeons. A detailed assessment of  studies ,5,12,17.interdisciplinarity' and 'multimodality'. Furthermore, this investigation should describe demographic patterns of patients suffering from chronic orofacial pain syndromes.Therefore, this investigation aims to evaluate the ambulatory management of chronic orofacial pain syndromes by dental and maxillofacial surgeons within a defined German regional area, adjacent to our clinic. By assessing various diagnostic and therapeutic procedures we intended an evaluation of the realisation of the principles 'This investigation was designed as a descriptive, observational and cross-sectional case study.In the 3rd quarter of the year 2001, the investigators sent questionnaires to all 508 dental surgeons and all 12 maxillofacial surgeons working in ambulatory capacities in a German county in the Rhine area containing 882,000 residents, called Rhein-Sieg-Kreis and Bundesstadt Bonn.Questions referred to the number of patients suffering from orofacial pain during the 2nd quarter of the year 2001, their gender, age (expressed in decades), general medical characteristics, the classification of headaches and orofacial pain according the International Headache Society (IHS), and the aetiologies of pain. For the assessment of diagnoses, etiological factors, and the durations of pain we used standardised forms based on the IHS and the International Classification of Diseases, Version 10 (ICD-10).Further points were the course of diagnostic procedures, including specialised diagnostic procedures, as radiological, neurophysiological, – especially electromyography -, and interventional procedures, as diagnostic blocks, or local anaesthesia. The investigators asked explicitly whether therapists knew or used visual analogue or numerical rating scales for assessing pain.Other questions involved the use and prescription of analgesics – such as nsaids, opioids, anticonvulsants, antidepressants, and muscle relaxants – and surgical procedures, such as tooth extractions, or interventional procedures, such as local anaesthesia or sympathetic blocks. All therapists were given the opportunity to rate the efficacy of their management of orofacial pain syndromes in a three step scale .For the evaluation of the principle 'interdisciplinarity', all disciplines of therapists, including all medical and non-medical therapists, involved in the treatment of the patients experiencing orofacial pain were recorded.Data were analysed descriptively by means of absolute numbers and percentages. Based on the total number of patients with chronic orofacial pain a three month prevalence was calculated for this sample.Seventy-two of the 520 surveyed ambulatories returned completely evaluable questionnaires (13.5%). They reported 985 patients with orofacial pain being treated in the quarter in question. The calculated 3 month prevalence of orofacial pain based on 882,000 residents in the investigated county was 0.1%.66.8% of patients with orofacial pain were female. Table 1 describes the distribution of the age decades of the sample. We found 81.1% of patients with an age between 20 to 60 years . No data on age was documented for 35 patients.Patient diagnoses are listed in Table 2. Temporomandibular disorders (TMD), orofacial pain associated with headache syndromes and atypical odontalgia were very frequent.Etiological factors of orofacial pain could be revealed in only 546 cases (55.4%). Detailed information is given in Table 3.392 patients (39.8%) demonstrated co-morbidity. This involved orthopaedic (130 patients/33.2%), internal (127 patients/32.4%), psychosomatic (89 patients/22.7%), neurological (11 patients/2.8%), and psychiatric (14 patients/3.6%) causes.Individual durations of orofacial pain were documented in 681 patients (69.1%). Pain persevered longer than 6 months in 61.1%, longer than 3 years in 21.3%, and longer than 5 years in 5.3%.In most cases, diagnostics were carried out in the form of patient history and a general examination. Only 17.0% of the therapists knew of numerical rating or visual analogue scales as methods for assessing pain intensity. Only 7% used this device regularly. Specialised procedures, e.g. diagnostic local diagnostic blocks (4.7%), or neurophysiological procedures (5.7%), were rarely applied. However, radiological diagnostics were more frequent (52.4%).Nevertheless, in 28.7% of patients the delay of diagnostic procedures lasted longer than one year. The diagnostics of three patients had not been completed over 15 years. Table 4 gives more details.538 patients (54.6%) taking part in the survey had changed therapists before attending the ambulatory. 60.6% of these had changed their therapist more than three times.Table 5 describes the enrolment of other disciplines in pain therapy. Further therapists were involved in diagnostics and therapy 761 times. Most frequently maxillofacial surgeons and pain therapists were involved, but the number of non-medical therapists exceeded the number of pain therapists. These consisted of physiotherapists and non-medical practitioners, a profession with permission to treat patients which exists in Germany only. Non-medical practitioners regularly use alternative medicine, such as traditional Chinese or Ayurvedic medicine, or homeopathy.Although 985 patients suffered from chronic orofacial pain, only 635 received a documented treatment, as can be seen in Table 6. The use of further surgical procedures, e.g. tooth extraction, treatment of dental roots, was more frequent than the use of physiotherapy, analgesics or the treatment of a malocclusion. Eighty patients (8.1%) received nsaids, 9 (0.9%) opioids, 6 (0.7%) muscle relaxants and 4 (0.4%) anticonvulsants. The use of local anaesthesia was documented in 16 patients. Further interventional procedures, such as sympathetic blocks, were not used at all.Responding colleagues self-evaluated the therapeutic efficacy of their methods applied in 885 cases (89.8%). In their perception, pain conditions of most patients improved. Pain rarely worsened, while no change was observed in nearly one-in-five patients, as listed in Table 7.The use of a questionnaire is an established method for assessing the management of pain syndromes in patients, but the quota of respondents taking such an approach typically is small ,6,12,17,However, with nearly 1,000 patients currently being treated in 72 ambulatory dental and maxillofacial surgeries experiencing orofacial pain syndromes, the number was unexpectedly high compared to other studies . On the We could not define etiological factors in nearly 50 % of patients with chronic orofacial pain. Surgical procedures, – especially if explorative and not correctly indicated -, revealed their harmful impact on chronification of pain.atypical odontalgia including phantom tooth pain was unexpectedly high [The frequency of TMD diagnosis corresponded to other investigations, but the number of patients with the diagnosis dly high ,15,18-22dly high ,21 coulddly high ,11. PossAtypical odontalgia is a severe and chronic pain disorder characterised by persistent pain with apparent clinical normal teeth. Clinical and radiographic examination does not reveal any pathologic findings. Neuropathic signs as allodynia and hyperalgesia are common and suggest a neuropathic origin of this pain. Heat, cold, pressure do not necessarily modulate pain. Local anaesthetics often have no impact. There is an elevated risk of chronification, as therapists often attempt vain interventional or surgical procedures -25.Atypical odontalgia can be associated with atypical facial pain. Some authors consider atypical odontalgia to be a subgroup of atypical facial pain . On the The high number of patients involved in the working process underlines the possible socio-economic impact of orofacial pain. Unfortunately, socio-economic parameters  could not be documented. Nevertheless, patients with chronic orofacial pain revealed signs of chronification or an association with psychosomatic complaints. Other authors ,18,28,29This investigation showed that ambulatory therapists rarely followed the guidelines for the management of orofacial pain published by the American Academy of Orofacial Pain (AAOP)  and the According to other references this investigation demonstrated another central neglect: the exclusion of an analgesic mediation in favour of surgery is an important etiological factor of the chronification of pain . AlthougContradictory, dental and maxillofacial surgeons high-rated the efficacy of their procedures. The high number of 'successful' treatments contrasts with other references -7,23. PoIn the current management of patients suffering from orofacial pain syndromes ambulatory dental and maxillofacial surgeons ignore the principles of a multimodal and interdisciplinary pain therapy, despite their publication in various guidelines. A standardised concept of surgical, interventional and analgesic procedures has not been implemented so far. Therapists apply surgical procedures as tooth extractions or other surgical techniques rather than analgesics, minimal-invasive pain therapy, physiotherapy or other conservative procedures, although severe pain syndromes, such as atypical odontalgias, seem to be frequent in the sample population. Further prospective investigations and educational and communicative efforts should contribute to improving this situation.The author(s) declare that they have no competing interests.All authors were equally involved in the study design, data extraction, data analysis, and preparation of the manuscript.


In the last 25 years, assessment of orthopaedic intervention has become patient focused, with the development of self-completion patient-centred outcome measures. The Oxford hip score (OHS) is a joint specific outcome measure tool designed to assess disability in patients undergoing total hip replacement (THR). Although the psychometric properties of the OHS have been rigorously examined, there is little research on the patient's perspective of the OHS. Therefore, the aim of this study is to assess whether the OHS is an adequate disability measure from the patient's perspective using qualitative analysis of annotations written on the OHS by patients.In total, 276 orthopaedic patients completed an OHS between April 2004 and May 2005. One hundred and fifty six pre-operative patients listed for a THR completed the OHS during a pre-admission assessment clinic, and 120 post-operative patients completed the OHS postally in the home setting. Patient's unprompted annotations in response to the questions on the OHS were recorded and grouped into thematic categories.In total, 46 (17%) patients made 52 annotations when completing the OHS. These annotations identified five main areas of difficulty that patients experienced: lack of question clarity (particularly concerning the use of aids), difficulty in reporting measurements of pain, restrictive and irrelevant questions, the influence of co-morbidities on responses, and double-barrelled questions.Although the OHS is a useful short tool for the assessment of disability in patients undergoing THR, this study identified several problem areas that are applicable to patient-centred outcome tools in general. To overcome these current limitations, further work is underway to develop a more individualised patient-centred outcome measure of disability for use in patients with osteoarthritis. During the last decade, the assessment of outcomes in orthopaedic surgery has shifted from the success or failure of an implant towards patient satisfaction and quality of life . InitialThe OHS is a patient-centred questionnaire that is designed to assess functional ability and pain from the patient's perspective. It is a short, twelve-item questionnaire developed for completion by patients undergoing THR  and is eAlthough the OHS has been shown to have internal consistency and produce data of high reliability and validity , there iBetween April 2004 and May 2005 patients attending orthopaedic preadmission assessment clinic at the Avon Orthopaedic Centre, under the care of one consultant orthopaedic surgeon (IDL), and awaiting THR, were administered an OHS as part of a routine questionnaire pack used in the clinic. These patients were sampled as they were expected to be unfamiliar with the OHS, as the introduction of this questionnaire into routine clinical care in this clinic was initiated in April 2004. Between January 2005 and May 2005, consecutive patients with 12-months follow-up, who received a THR under the care of a consultant orthopaedic surgeon (IDL), completed a postally administered OHS as part of their on-going clinical care. In addition, all patients that had an IPS Stem (DePuy) between 1997 and 2004, under the care of one consultant orthopaedic surgeon (IDL) complete a postal OHS as part of another study. During administration the patients were not instructed to annotate or comment on the questions on the OHS.The OHS consists of 12 questions about pain and disability experienced over the past four weeks. Each item has five response categories, given a score of between 1–5 (low disability to high disability). Scoring involves summating the total for each item to produce a final score between 12–60, with a higher score indicating greater disability. In this study the OHS was presented on a double-sided sheet of A4 paper, with six questions on each side. The response categories to each question were formatted as a Likert scale  and the mean post-operative OHS was 24.1 . Patients who completed the OHS after surgery had a mean follow-up period of 24 months . The sample consisted of 169 women (61%) and 107 men (39%) with a mean age of 58 years . Patient's diagnoses are listed in Table During the past 4 weeks, for how long have you been able to walk before pain from your hip becomes severe (with or without a stick)?" most frequently elicited annotation, whereas question eleven, which asks "how much has pain from your hip interfered with your usual work (including housework)?" was the only question that was not annotated by any of the patients. The annotations were broadly grouped into five main categories, each highlighting difficulties the patients experienced when completing the OHS (Table Forty-six (17%) patients annotated a total of 52 questions ?", acknowledges that many individuals need to use a walking stick. However, it is not specified in the question whether the patients should provide a response for actual or relative disability. Consequently, inconsistent results were obtained, with patients providing two answers i.e. distance walked with and without a walking stick. Therefore, the score becomes dependant on whether the respondent chooses to take account of the walking stick. These findings suggest that many respondents perceive the question as ambiguous. Further evidence for the lack of question clarity is based upon a large study of pre-operative patients, who most frequently omitted question six when completing the OHS [The aspect of the OHS that appeared to cause the greatest difficulty for the patients, with 29% of annotations, was the lack of question clarity. Within this theme, the predominant area of uncertainty was whether the questions were enquiring about actual level of disability or the level of disability after accounting for the use of aids or specialised devices, such as long handled shoehorns or helping hands. When responding to question four, which asks respondents "eviously . Questio the OHS .In summary, it appears that the predominant area of ambiguity due to lack of question clarity on the OHS is whether patients should take into consideration the use of aids or specialised devices when responding to questions. Not taking consideration of the use of aids and devices, and indeed any assistance in activities, is a common oversight of many patient-centred measures of disability, such as the WOMAC . IndividNearly a quarter of all the annotations provided an explanation of the nature of pain. Frequently patients commented that the intensity of pain can fluctuate greatly over four weeks and that the level of pain is heavily dependant on factors such as medication and activity. As a consequence, several patients felt they could not give an 'average' level of pain for the last four weeks. Therefore, a limitation of the OHS is that it attempts to categorise patients into a single category of pain when in fact pain, predominantly arthritic pain, is not static, but rather a dynamic entity. In a previous study, when interviewed about difficulties encountered when completing the OHS, individuals explained that they learned to ignore the pain, and that it could be masked by medication, and as a consequence struggled to complete the questions referring to pain . Thus quTwenty three percent of annotations were descriptive or explanatory comments, supplementing the information recorded by the question. These annotations included descriptions of pain or how activities had to be modified as a consequence of disability, such as climbing stairs backwards, and the causes of pain. Furthermore, inadequate response categories resulted in 16 arrows being drawn between boxes, indicating patients were unable to place themselves into a single category. The original article on the OHS does not indicate how these responses should be scored . Althoug"have you been able to climb a flight of stairs?", suggest that climbing stairs is not applicable to everyone as some individuals have stair lifts installed or they live in a bungalow. In reply to question nine, "have you been limping when walking because of your hip?", a respondent answered that they don't limp but explained this was a result of them being confined to a wheelchair. Although the questionnaire accounts for people that cannot drive by asking about difficulty travelling by public transport in question three, this question was not applicable to a patient who used an adapted taxi. The OHS appears to restrict individual's answers and fails to allow them to express themselves adequately, as well as including questions that are not relevant to all individuals.Expansion of answers was necessary for several patients to explain that, although they had answered the question, it was not applicable to them. Comments written in response to question seven, which asks The OHS was designed as a site-specific outcome measure for orthopaedic evaluation, and as such, has been favoured over more generic outcome measures ,21. HoweIn addition to the influence of diffuse co-morbidities, patients found it difficult to distinguish between pain originating from bilateral hips, highlighting a limitation of the OHS in considering only a single joint, which does not reflect the pattern of OA. In a sample of 500 OA patients, 53% of patients had more than one symptomatic joint . Recentl"have you had any trouble getting in and out of a car or using public transport because of your hip?". Several patients answered the two parts of the question separately as it is common to use both modes of transport. Similarly, question four asks three questions in one: "have you been able to put on a pair of socks, stocking or tights?". Again some patients answered this as three questions, with women often finding tights harder to put on than socks.During the validation process it is advisable to eliminate any double-barrelled questions , yet queThe OHS is a useful short tool that is frequently utilised to assess the patient's perception of hip function, mobility and pain. It is quick both for the patient to complete and the clinician to score. Although the OHS is a widely used and validated patient-centred outcome tool, it appears that the OHS is not without problems, in concordance with previous findings . It is uwhat degree of difficulty do you have with getting in/out of bath/shower?". In addition, the WOMAC items have been found to be influenced by other co-morbidities, such as low back pain [It could be argued that the difficulties patients experience with the OHS are due to the brevity of the scale, and could be reduced by the inclusion of additional questions. However, although there is little research on the problems experienced by patients while completing longer scales, such as the WOMAC  or HOOS ack pain . Previouack pain . This laack pain . Hence, VW was involved in the acquisition, analysis and interpretation of the data, and drafted the manuscriptIDL was involved in the conception of the study, revision of the manuscript and gave final approval of the version to be publishedVJC was involved in the conception and design of the study and revision of the manuscript


Although clinical guidelines generally portray chronic low back pain as a condition with a poor prognosis this portrayal is based on studies of potentially unrepresentative survival cohorts. The aim of this study is to describe the prognosis of an inception cohort of people with chronic low back pain presenting for primary care.The study will be an inception cohort study with one year follow-up. Participants are drawn from a cohort of consecutive patients presenting with acute low back pain (less than 2 weeks duration) to primary care clinics in Sydney, Australia. Those patients who continue to experience pain at three months, and are therefore classified as having chronic back pain, are invited to participate in the current study. The cohort will be followed up by telephone at baseline, 9 months and 12 months after being diagnosed with chronic low back pain. Recovery from low back pain will be measured by sampling three different outcomes: pain intensity, interference with function due to pain, and work status. Life tables will be generated to determine the one year prognosis of chronic low back pain. Prognostic factors will be assessed using Cox regression.This study will determine the prognosis of chronic non-specific low back pain in a representative cohort of patients sourced from primary care. The results of this study will improve understanding of chronic low back pain, allowing clinicians to provide more accurate prognostic information to their patients. Chronic low back pain .All participants in the acute pain cohort who still have pain 12 weeks after the onset of their symptoms will be invited to participate in the study of the cohort of patients with chronic low back pain.There is no universally accepted definition of recovery from low back pain. We will use three definitions of recovery that differ in that they depend on pain intensity, interference with function due to pain, or work status. Outcomes will be assessed at baseline, 9 months and 1 year with simple questions suitable for telephone interview and mail survey of a large cohort of patients.The first two questions are adaptations of items 7 and 8 of the SF36 [1. "How much low back pain have you had in the past week?" 2. "During the past week, how much did low back pain interfere with your normal work (including both work outside the home and housework)?" The subset of subjects who were employed at the time of onset of symptoms will be asked to rate their work status on a scale adapted from Kenny.1. Full time, Full duties2. Full time, Selected duties3. Part time, Full duties4. Part time, Selected duties5. Employed, Sick leave6. Unemployed7. Retired or Not currently seeking paid employment8. Maternity leave, Long service leave9. Other, please specifyPrognostic factors are measured at the onset of the acute episode and also at the onset of chronicity. Baseline data will be collected by the treating clinician and follow-up data will be collected by the research assistant by phone or mail. The predictors are measures of socio-demographic characteristics, general health, low back pain history and psychological characteristics. To minimise burden on the participants most constructs are assessed with brief questions designed for phone administration.More extensive measures of three additional constructs  will be determined for each of the three recovery measures.Cox regression will be used to evaluate putative prognostic factors. The independent variables for the regression will be chosen from among those collected at baseline. A correlation matrix will be inspected to determine relationships between candidate variables and outcome. Variables with strong correlations (p < 0.10) will be identified and entered into the regression model. Linear regression will be used to predict continuous outcomes such as days off work. If necessary, dependent variables will be transformed so that they satisfy assumptions of normality of residuals and heteroscedasticity. If there is evidence of non-linear effects, quadratic or higher order terms will be added to the regression model.Patients with chronic low back pain (i.e. low back pain of 12 weeks duration) will be recruited from the primary care professions who most frequently manage low back pain in Australia. By sampling incident cases of chronic low back pain from a larger cohort of people with acute low back pain we will be able to study a representative cohort of patients. The choice of outcome measures reflects a standardised definition for an episode of low back pain proposedThe study has been designed to minimise bias. Most importantly, we will sample from an inception cohort of chronic low back pain patients, and strategies will be used to minimise loss to follow-up. It is nA particular strength of this study is that the prognostic factors related to the initial acute episode are measured at the time of the initial acute episode rather than relying upon recall. Beyond the obvious problem of poor memory introducing error or missing values there is evidence that participant's current health state biases their recall of their previous health state. With regard to recall of pain/disability intensity it has been found that errors in recall increase with time and recalled intensity is biased by current levels of pain/disability,16.The author(s) declare that they have no competing interests.All authors participated in the design of the study. LCMC, CGM and LOPC drafted the manuscript with input from the other authors. All authors read, revised and approved the final manuscript.The pre-publication history for this paper can be accessed here:Table 1. Constructs measured as predictors. All features associated to the participants measured, the timing of the measure and the measurement tool/question used are listed in this file.Click here for file


Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales  were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility. In the last decade, there has been a growing interest in pain among elderly people. Pain among nursing home residents is a common and major problem. Statistics indicate that pain is twice as likely to occur in individuals aged 60 and older as in younger persons -3. The pMore than 50% of US nursing home residents have substantial cognitive impairment or dementia . This siDementia, caused by a variety of conditions, has been defined as a complex of symptoms characterized by progressive global deterioration of cognitive functioning . The impThere is evidence that pain assessment is currently inadequate and that elderly people with dementia are being undertreated ,6,18-21.Pain can be assessed by means of self-reports, behavioural or physiological measures. Self-reporting is often considered as the 'gold standard' in pain assessment. A broad range of self-report scales is currently available to assess pain in the elderly, most of which have been developed for and tested in a different setting before being used among elderly people with dementia . The mosA substantial proportion of elderly people living in institutions are unable to understand and answer even simple yes/no questions, and therefore cannot self-report pain ,6. In thIn recent years, research in the field of pain among elderly people with severe dementia has increasingly focused on understanding expressions indicating possible pain ,29,9. HoWe reviewed the relevant publications based on an extensive search strategy, involving computer searches of Medline, Psychinfo and Cumulative Index to Nursing and allied Health Literature (CINAHL) to identify the literature. The keywords we used and the search results are listed in Table th, 8th, 9th and 10th International Association for the Study of Pain World Congresses were screened for relevant publications.In addition, citations and references in selected journal articles were screened to supplement the search strategy. Unpublished manuscripts were collected by approaching colleagues working in the field of pain among the elderly. Finally, the abstract books of the 7The review focused on publications that have appeared over the last 17 years, from 1988 to January 2005. The following selection criteria were used to screen relevant publications:~ Publications had to describe an assessment instrument/scale for elderly patients with dementia or a subgroup of elderly patients with dementia, for example, Alzheimer patients.~ The assessment scale had to have been used to measure pain by means of self-reports by patients or behavioural measures.~ Publications had to be in English, Dutch, German or French.~ Publications had to be other than case reports or secondary sources/reviews.Our search yielded a large number of publications  is a behavioural scale evaluating pain in elderly people [The y people -35. The y people  for youny people . A scorepatient was significant (p < 0.001) and DOLOPLUS2 demonstrated good sensitivity. There was satisfactory stability on the retest. A t-test analysing the intra-observer differences found no significant differences for the total score or for item scores. An inter-rater correlation test between two physicians showed no significant difference (p < 0.001), and good levels of internal consistency (α = 0.82) were found. Closer examination of the scale reveals that little information is provided about several aspects of the tool and tool construction. These limitations include a lack of information on correlation coefficients  and of information about the determination of cut-off scores and the impairment level of the participants. In acute settings, its value might be limited because patients must be well known to the nurses who have to complete the DOLOPLUS2, whereas the value of a scale becomes greater if it can be used without in-depth knowledge of the patient [Several studies have been conducted in geriatric centres and palliative care units to validate the scale, investigating test-retest reliability, concurrent validity and inter-rater reliability ,38. The  patient . AlthougL' échelle Comportementale pour Personnes Agées (ECPA) by Alix et al. is a behavioural scale for non-communicating elderly people [y people ,41. Freny people  versionsThis scale was also inspired by the Douleur Enfant Gustave Roussy (DEGR) scale  for younThe homogeneity of the items (Cronbach's α = .70), convergent validity between the VAS and ECPA  and inter-rater reliability (Intra-class reliability = .80) have been preliminarily tested in a sample of hospitalised patients in a long-term stay department . Its cliSimplified Behavioural Scale (ECS) was published in 1995 by Baulon and colleagues to detect changes in behaviour in geriatric patients with and without communicative limitations [The itations . ECS wasObservational Pain Behaviour Tool by Simons & Malabar (1995) is an assessment tool designed specifically for everyday use with elderly patients in hospital settings [The settings . The toosettings . The toosettings . The autThe Checklist of Nonverbal Pain Indicators (CNPI) by Feldt is a behavioural observation scale for non-verbal residents with severe cognitive impairment [pairment . The scapairment , from whpairment . The tooPain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) by Fuchs et al. intends to be a clinically useful scale for assessing pain in patients with dementia [The dementia ,48. PACSAdditional refinement and psychometric testing  of the PACSLAC is essential. This should include an assessment of its value in clinical situations and in larger samples. The checklist is long and covers a broad range of possible pain cues, included specifically for elderly people with limited communication abilities due to dementia. A major disadvantage is the fact that no patients participated directly in the studies undertaken to construct the scale. Instead, participating caregivers reported from memory on patients they had cared for . It is qPain Assessment IN Advanced Dementia Scale (PAINAD) by Warden et al (2003) was developed to assess pain in individuals with advanced dementia [The dementia ,50. The dementia  and DS-Ddementia ) and condementia ,50. Intedementia ,50. HoweThe Pain Assessment for the Dementing Elderly (PADE) by Villanueva et al. (2003) was developed to measure pain in individuals with advanced dementia [dementia . The scaAlthough it seems a long list, authors stated that, with practice, PADE requires 5–10 minutes to complete . Given tRating Pain in Dementia (RaPID) by Sign and Orrell (2003) was developed to rate pain in elderly people with dementia. It was developed from expert advice (N = 38 experts) and reviewed research literature [terature . It consObservers score each item based on complaints, symptoms and signs occurring during one week, prior to using clinical judgements from a range of information such as clinical notes and interviews with staff, patient, and carer. To establish concurrent validity, RaPID scores were compared with the McGill Pain Questionnaire and a VAS. Findings showed that the instruments correlated highly with each other. In addition, good internal consistency of the total scale (α = .79) and good inter-rater reliability were found (mean .97). Similar high scores were found for test-retest reliability (ranging from .84 to .98) . Closer Abbey Pain Scale by Abbey et al. is a brief assessment scale for people with end-stage dementia [The dementia . The scadementia  and Simodementia  and modidementia . The scaThe Non-Communicative Patient's Pain Assessment Instrument (NOPPAIN) by Snow et al. (2004) consists of four sections and combines information about pain behaviour , care conditions and a Likert scale of pain intensity [ntensity . Informantensity  focuses pain assessment scale for use with cognitively impaired adults [Davies et al.  recently developed the d adults ,57. The The clinical utility of the scale has been pilot-tested in a small sample (N = 27 cognitively impaired elderly patients of a dementia care unit and a psycho-geriatric unit) by implementing the scale in practice over a three-month period. The tool was often not fully completed by respondents and was reported to be complex and time-consuming. There was a strong tendency to skip the section that relates to physiological assessment strategies, like blood pressure . Before Table The purpose of the present study was to review behavioural pain assessment tools available to assess pain in elderly people with severe dementia, and to evaluate the psychometric quality of these tools.This systematic review revealed that at least 12 behavioural pain assessment tools currently exist. We conclude from the results of our review that at present, none of these assessment scales is convincingly the most appropriate, and therefore preferable, scale for assessing pain in elderly people with dementia. Our findings  demonstrate that PAINAD, PACSLAC, DOLOPLUS2 and ECPA show the best psychometric qualities. It should be stressed, however, that none of these tools scored more than 12 points out of a maximum quality score of 20, so their overall psychometric quality can be regarded as moderate. The tools therefore still await confirmation of various aspects of their psychometric properties.Our review of the studies on behavioural assessment scales identified several general issues and weaknesses that need to be addressed, including methodological issues and practical limitations. First, to achieve the required validity, most instruments were correlated with a VAS or alternative intensity scale filled in by a proxy (mostly nurses). In the absence of self-reports, the interpretation of pain by a significant other has been frequently discussed, and the legitimacy of this approach  is questionable. The assumption that caregivers' pain impression can be quantified by tools like VAS could only be legitimated if nurses' perceptions are comparable to patients' own perception of pain. Differences in pain rating between nurses and patients have been identified as an issue affecting pain measurement and management in elderly people . If nursThere are also some methodological concerns about sample sizes and the indicators collected to construct pain scales. We must be aware of the fact that the pain indicators collected for this purpose may be influenced by the type of pain focused on in collecting the items and the setting in which indicators are collected. Given the fact that some scales contain a large number of items, many of the studies used small samples of participants or a limited number of pain situations. In addition, articles do not always provide information about the frequency of endorsement of certain items in the population examined. Not providing information about the importance of items at rest and during a painful situation can affect results. Furthermore the current scales are heterogeneous in terms of items used to assess pain. The overlapping items of the scales might be the most common and important ones, while unusual items might be more characteristic of the target group but less useful for a general pain scale for elderly people with dementia. In other words, item responsiveness to pain adds to further item reduction and refinement of a scale.In view of the limited qualities of the scales, including PAINAD, PACSLAC, DOLOPLUS2 and ECPA, further research is essential for additional refinement and development. It may therefore be questioned if recommendations can at this stage be made for the implementation of one of these tools in clinical practice. In answering this question, two further criteria could be added.The first criterion concerns the ability of items in the scale to detect subtle changes in behaviour. These specific items add important information and help nurses to create a certain pain image of the non-verbal patient. Therefore, we would expect that indicators which focus on subtle behaviours should be adequately covered by the items in the pain scale. While PAINAD, DOLOPLUS2 and ECPA tend to focus on main indicators like facial expression, PACSLAC is the only scale that primarily focuses on these subtle changes in behaviour. Notably, PACSLAC is one of the few instruments in which the item collection is based on pain items specifically geared towards elderly persons with dementia, instead of items adjusted from existing scales developed for use in different patient groups (like paediatrics). In view of the special needs of the heterogeneous group of elderly people with dementia, this is a more suitable procedure to use in creating an item bank specifically for the target group.The second criterion relates to the clinical utility of the scales. Ramelet et al.  stated tAfter adding these criteria to the psychometric properties, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available.Before recommendations for further research can be formulated, there are some limitations of the present systematic review that need to be addressed. To begin with, it must be noted that the studies reviewed above show considerable heterogeneity in terms of design (retrospective vs. prospective), method , research population  and conceptualisation of pain, making their results hard to compare. Aspects that make the studies difficult to compare include differences in format/structure and scoring method. DOLOPLUS2, PADE and PACSLAC, for example, are extremely different in these respects. Although we used a set of criteria to arrive at an overall judgement to make our review more objective and systematic, quality judgement scores should always be interpreted with caution, because the use of some criteria inevitably involves a subjective element derived from the reviewer's expertise. Each criterion used to evaluate the quality of the scales was given an equal weight of 1 . It is important to realize that this weighting approach inevitably has consequences for the quality judgement scores.The findings of this review have important implications for future research and for everyday practice. Pain assessment is recognized as a significant area for future research and for the improvement of nursing care . Pain asAlthough huge progress has been made over the last decade, and studies of pain assessment among cognitively impaired elderly people have yielded promising results, studies have so far been limited. Assessment in the severely demented elderly remains difficult, and diagnosing pain continues to be a daily challenge to nurses. Although using a pain assessment scale is an important resource in detecting pain, it is often an element of a more comprehensive approach that also uses other resources, like physical examination and information from close relatives. These explorations of various resources can add information to solve the pain problem and therefore remain necessary.In recent years, there has been growing interest in pain among cognitively impaired elderly people, which is illustrated by the fact that more than half of the 12 scales included in this review were published after 2002. Evidently, the number of newly developed scales has grown very rapidly. In view of this proliferation of behavioural tools and the promising quality of some of the scales reviewed here, we recommend improving these scales on the basis of further testing of their validity, reliability and clinical utility. It is the researchers' as well as the funding agencies' and journals' responsibility to prevent excessive growth of newly developed tools. Thus, further psychometric evaluation of existing scales should be given priority over developing new scales for future use. Valid, practical and reliable scales can add to the body of knowledge about pain and help to improve pain treatment in this important and growing population.Scherder and colleagues ,61,62 coA final recommendation concerns the Behavioural and Psychological Symptoms of Dementia (BPSDs) in relation to pain. BPSDs can confound pain assessment. Until now, little is known about the interaction between pain symptoms and these behavioural problems. Therefore, the relation between pain and BPSDs needs to be explored. Further research will be needed to determine its sensitivity in relation to these other concepts, as well as the way pain affects these symptoms and how these symptoms affect pain expression.The author(s) declare that they have no competing interests.All authors critically reviewed the manuscript, read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Low back pain can diminish jet pilot concentration and function during flight and be severe enough to ground pilots or cause decreased flying time. The objective of this case report is to present an example of the integration of chiropractic care with conventional treatments for the management of low back pain in a F/A-18 aviator.The patient had insidious severe low back pain without radiation or neurological deficit, resulting in 24 hours of hospitalization. Spinal degeneration was discovered upon imaging. Four months later, it still took up to 10 minutes for him to get out of bed and several minutes to exit the jet due to stiffness and pain. He had discontinued his regular Marine Corps fitness training due to pain avoidance. Pain severity ranged from 1.5–7.1 cm on a visual analog scale. His Roland Morris Disability Questionnaire score was 5 out of 24. The pilot's pain was managed with the coordinated efforts of the flight surgeon, physiatrist, physical therapist, and doctor of chiropractic. Following this regimen he had no pain and no functional disability; he was able to fly multiple training missions per week and exercise to Marine Corps standards.A course of care integrating flight medicine, chiropractic, physical therapy, and physiatry appeared to alleviate pain and restore function to this F/A-18 aviator with low back pain. Low back pain (LBP) is a common problem associated with significant losses in work time in the general population . While LInvestigators are curious about aviators' use of alternative treatments to medicine to manage LBP, however little research is reported in this area. Three studies mention alternative management strategies and chiropractic care is mentioned briefly in 2 of these. Simon-Arndt et al  specificA 36-year-old male USMC F/A-18 aviator instructor with 15 years of flying experience had a severe episode of acute LBP without radiation or neurological deficit. The patient did not recall any specific traumatic incident that initiated the pain, but he did have a history of multiple LBP events, some of which included radiation into the legs. When the LBP began he immediately consulted the squadron flight surgeon and was prescribed naprosyn, diazepam and hydrocodone/acetaminofen for pain control, confined to quarters to rest and imaging was obtained. The pain worsened, resulting in hospitalization later that day. He was observed for 24 hours and given a methylprednisone dosepack. Upon discharge from the hospital, he was confined to quarters for 72 hours and not allowed to return to flying until cleared by the flight surgeon. The flight surgeon cleared the patient to fly and ordered consults to neurosurgery and physical therapy for further evaluation and treatment.Plain film radiographs showed mild narrowing of the L4–L5 intervertebral disc space and mild sclerotic changes of the posterior elements of L5. MRI demonstrated a loss of normal height and signal involving the L4–L5 disc and a broad-based left paracentral disc bulge contacting the thecal sac and causing mild narrowing of the central spinal canal at the L4–L5 level with mild to moderate left neural foraminal narrowing and L5 nerve root contact Fig . A lesseThe flight surgeon coordinated the ordering and follow up of the patient's various clinical consults. The flight surgeon instructed the patient to take the anti-inflammatory medication as needed and gradually returned him to non-impact exercise, including walking and working out on an elliptical machine to pain tolerance.Following neurosurgical evaluation the patient was provided concurrent consultations with the hospital physiatrist and physical therapist. The physiatrist provided osteopathic manipulation and home exercises, including prolonged prone lumbar extension and hip adductor stretching, which provided some pain diminishment. Acupuncture was attempted once, wherein he reported an increased sensation of lumbar muscle spasm. Acupuncture was discontinued.The physical therapy regimen was begun 2 weeks after hospitalization and included McKenzie exercises (standing and prone repetitive standing lumbar extension), stretching  and an educational self-treatment booklet. The patient experienced some relief with the McKenzie exercises, hamstring stretching and self mobilization/stretching of the gluteal muscles and spine by drawing his leg over to the opposite side of his trunk. His pain and range of motion improved approximately 50%. A course of moist heat packs and mechanical lumbar traction  was attempted to further his progress. He continued doing the prescribed exercises and noted some improvement but pain elimination was refractory. At this time, the physical therapist discussed the case with the chiropractor, who is located in the same clinic at the air station, and subsequently ordered a consultation for chiropractic.During the chiropractic consultation, the patient's pain was located in the lumbar region bilaterally, described as "intense spasm", and without any radiation or symptoms of neurological involvement. His pain was consistently worse in the morning; he reported that it would take up to 10 minutes for him to get out of bed due to stiffness and pain. He was concerned because this episode of LBP was of longer duration (4 months) than any prior episodes. He had discontinued his regular Marine Corps fitness training  because of pain exacerbation. He experienced increased pain after basic fighter maneuver flights, reporting that it would take as long as 15 minutes to get out of the jet and climb to the ground after flying. He stated that even though he was on flying status he would sometimes ask to be removed from the flight schedule because his back hurt too much to fly; on these days he would stay at work and perform other tasks. He rated the severity of pain at 1.5 cm on a 10 cm visual analog scale , 7.1 cm The chiropractor and flight surgeon discussed the case to insure that the flight surgeon was informed of the course of care. The chiropractor and the physical therapist discussed the case to insure that the care that the patient was receiving was complimentary and that any duplicate home exercises were planned redundancy. Thus, at this point in time, the patient was receiving care from the flight surgeon, physical therapist, and chiropractor and had 1 follow up visit scheduled with the physiatrist.The 3 goals of chiropractic care were: 1) pain control; 2) ability to continue flight duties and USMC fitness training; 3) maintenance of aerobic fitness. Table th chiropractic treatment the patient reported there were no episodes of sharp "muscle spasm" pain in the previous week but periodic stiffness was experienced upon waking in the morning or after long periods of time in the jet. He was on regular flying status and he had discontinued taking any medication. The patient reported that the physiatrist had provided him with a home TENS unit for pain control, which provided relief at the end of long days in the jet or after prolonged sitting. At this point in time he was released from care by both the physiatrist and physical therapist and instructed to continue his home exercises and to return for care if symptoms worsened. Functional spinal stability was assessed by the chiropractor at the fifth office visit and the patient exhibited difficulty stabilizing his spine when asked to perform simple non-weight bearing movements called dead bug exercises [By the 5xercises . He had Subsequent chiropractic office visits focused on furthering the patient's torso function and insuring coordinated care between the flight surgeon and the chiropractor. These office visits were supplemented with some form of manipulation/mobilization as deemed necessary. Therapeutic exercises were made more difficult and targeted strength, endurance and proprioception of the lumbar extensors, oblique abdominal muscles and other torso stabilizers . Tight pAt a follow-up visit 1 month after his last treatment he was pain free and had full function. He was flying multiple training missions per week including high G flights and sorties of several hours in duration and had passed his required physical fitness test  the week prior with no pain. He felt that the only provocative factor for minimal LBP at that time was flying the jet. The physical examination was normal; he was released from care and encouraged to maintain his core stabilization and overall fitness program.The physical demands of the F/A-18 aviator are extreme. In addition to the physical requirements necessary to pilot the jet, US Marines must also maintain a high degree of physical fitness that is tested twice a year in a physical fitness test. Therefore, the management plan for this patient was directed at restoring his work capacity both in the jet and on the ground without having him restricted from flight by a light or limited duty status. Strategies to develop fitness of the lumbar region of aviators have been suggested, including postural, stretching exercises and core stability exercises . Yet, noG forces are commonly cited as a cause of back pain in high performance aircraft pilots ,16. HoweTime and resources allocated to training and maintaining fighter aviators are extensive. For these reasons, as well as peer-pressure, self-esteem and pay, pilots are reluctant to disclose back pain for fear of being grounded . Flight The natural history of LBP must be considered as a plausible explanation for this patient's recovery. There is relatively little quality information available on the natural history of LBP . PatientThe addition of chiropractic care to the multidisciplinary management of this F/A-18 aviator with chronic LBP appeared to help alleviate pain and restore function. An appropriately powered prospective study would help determine the value of this type of treatment approach in this unique population.The first author is a contracted health care provider to the US Navy; there are no other competing interests to declare.BNG conducted the literature review and drafted the manuscript. JS and RA assisted in drafting the manuscript. All authors read and approved the final manuscript.