Parecoxib sodium is the first parenteral COX-2 inhibitor used for pain management licensed for postoperative pain. However, no study has assessed the usage of parecoxib for acute traumatic pain in the emergency department (ED). The objective of this study was to investigate a potential alternative analgesic agent in the ED by determining the mean reduction of pain score between acute traumatic pain patients who were administered with intravenous (IV) parecoxib sodium versus IV morphine sulfate. The onset of perceptible analgesic effect and side effects were also evaluated.A randomized, double-blinded study comparing IV parecoxib 40 mg versus IV morphine at 0.10 mg/kg was conducted in adult patients presented with acute traumatic pain with numeric rating scale (NRS) of 6 or more within 6 hours of injury. Patients were randomized using a computer-generated randomization plan. Drug preparation and dispensing were performed by a pharmacist. Periodic assessment of blood pressure, pulse rate, oxygen saturation, and NRS were taken at 0, 5, 15, and 30 minute intervals after the administration of the study drug. The primary outcome was the reduction of NRS. Side effect and drug evaluation was conducted within 30 minutes of drug administration.P = 0.095). The mean NRS for patients treated with IV morphine were 7.1 at 0 minutes, 4.5 at 5 minutes, 3.1 at 15 minutes, and 2.0 at 30 minutes. Whereas mean NRS for patients who received IV parecoxib were 7.8 at 0 minutes, 5.7 at 5 minutes, 4.7 at 15 minutes, and 3.9 at 30 minutes. The onset of perceptible analgesic effects could be seen as early as 5 minutes. Dizziness was experienced in 42.9% of patients who received IV morphine compared to none in the parecoxib group.There was no statistically significant difference in the reduction of mean NRS between patients in the IV parecoxib group or IV morphine group (There was non-significant trend toward superiority of IV morphine over IV parecoxib. Looking at its effectiveness and the lack of opioid-related side-effects, the usage of IV parecoxib sodium may be extended further to a variety of cases in the ED. Parecoxib sodium is the first parenteral COX-2 inhibitor available for clinical use in pain management . Based oThe efficacy of parecoxib sodium was established in multiple postoperative pain studies including gynecology and orthopedic surgery -7. The aIn the United Kingdom, IV parecoxib sodium is licensed for short-term treatment for postoperative pain . A studyThe appropriate usage of IV parecoxib sodium in the emergency department (ED) is not well established. To the best of our knowledge, there was no study regarding parecoxib sodium usage in the ED for acute traumatic pain. Therefore, the objective of this study was to investigate a potential alternative analgesic agent in the ED by determining the mean reduction of pain score between acute traumatic pain patients who were administered with IV parecoxib sodium versus IV morphine sulfate. Since time is essential in the ED, the onset of perceptible analgesic effect was determined and the side effects were evaluated.A randomized, double-blinded study comparing IV morphine sulfate at 0.10 mg/kg versus IV parecoxib sodium 40 mg was conducted in adult patients in the ED of Hospital Universiti Sains Malaysia (HUSM) from 1st August 2010 until 31st March 2011. HUSM is a tertiary centre located at the northeast of Peninsular Malaysia with 750 beds availabile for adult and pediatric patients. The annual census of the ED in 2009 was 56,662 cases, including all trauma and non-trauma cases. The annual census for orthopedic cases was 1,685 cases, which represents 3% of the total cases per annum [Adult patients (aged 18 years and above) with significant acute traumatic pain who presented to the ED of HUSM within 6 hours of trauma were included. Significant acute traumatic pain was defined as pain score based on numeric rating scale (NRS) of 6 or more following trauma that involved bony fracture or soft tissue injury. Head injury cases with Glasgow Coma Scale ratings less than 15/15, intoxicated patients, pregnant patients, hemodynamically unstable patients, patients with a significant language barrier, or patients allergic to morphine, parecoxib sodium, or any non-steroidal anti-inflammatory drug or on any type of analgesia within the preceding 6 hours, were excluded.All patients in the ED were triaged and the triager would alert the researchers once traumatic patients with a NRS of 6 or more had presented. Patients were brought to the treatment area by researchers and written informed consents were obtained. Focused history and physical examination were carried out by emergency residents on duty. Immobilization and splinting of the limbs and dressing of wounds were done according to the injuries. In the meantime, the pharmacist in charge was alerted regarding the patients’ body weight for drug randomization and preparation. All patients were randomized using a computer-generated randomization plan to receive IV parecoxib sodium 40 mg or IV morphine sulfate 0.1 mg/kg. To ensure researchers, emergency residents on duty, nurses, and patients were blinded to the treatment, the randomization was conducted by the pharmacist and he/she was responsible for preparation and dispensing of the study drug. The study drugs were administered by emergency residents once it was ready.Periodic assessment of blood pressure, pulse rate, oxygen saturation, and NRS were taken at 0, 5, 15, and 30 minute intervals after the administration of the study drug. The assessment was conducted by the researchers who were kept blinded about the treatment. After 30 minutes of observation, if the NRS was 6 or more, a rescue drug (IV morphine sulfate 0.1 mg/kg) was administered to the patient by the emergency resident on duty. Side effects of the study drug were evaluated within 30 minutes of drug administration by asking the patients about any unwanted symptoms. Radiological investigation of the affected limb was taken, if indicated after 30-minute period of observation was over. Patients were then referred to the respective teams at the end of the study according to their injuries.The primary outcome in this study was the reduction of pain score based on the NRS. The satisfaction of the study drug was assessed by asking patients “In terms of your satisfaction, how would you rate this pain medication?” 30 minutes after IV administration, using the scale “poor”, “fair”, “good”, and “excellent”.t-test, and repeated measure ANOVA.We hypothesized that there would not be a significant trend towards IV morphine being superior to IV parecoxib for pain reduction in acute trauma pain in the ED. Data entry and analysis were done using the Statistical Package for Social Science (SPSS) version 12.0 software. The statistical analysis included descriptive analysis such as mean, standard deviation, percentage, paired The parecoxib sodium used in this study was manufactured by Pharmacia & Upjohn Kalamazoo, Michigan, USA; it was produced for Pfizer using the trade name of Dynastat. Each vial of Dynastat contains 40 mg of parecoxib sodium for reconstitution. After reconstitution, the final concentration of parecoxib is 20 mg/mL. IV morphine sulfate was manufactured by Duopharma (M) Sdn Bhd, Selangor, Malaysia. Each milliliter of injection contained 10 mg of morphine sulfate. The dosage for IV morphine was 0.1 mg/kg. Once the dosage was calculated based on body weight, the pharmacist would prepare the morphine solution and dilute it to 2 mL of volume; this made parecoxib and morphine appeared identical.A total of 32 patients, including 26 males and 6 females, were enrolled in the study. The youngest patient was 19 years old whereas the oldest was 65 years old. Eighteen patients received IV parecoxib sodium as an analgesic whereas 14 patients received IV morphine. Patients with a bone fracture were equal in number for both groups. Soft tissue injuries were administered parecoxib and morphine in 10 cases and 6 cases, respectively. Mean NRS were 7.1 ± 1.3 for the morphine group and 7.8 ± 1.3 for the parecoxib group (Table P = 0.095). The mean NRS for patients that were treated with IV morphine were 7.1 at 0 minutes, 4.5 at 5 minutes, 3.1 at 15 minutes, and 2.0 at 30 minutes. Mean NRS for patients who received IV parecoxib were 7.8 at 0 minutes, 5.7 at 5 minutes, 4.7 at 15 minutes, and 3.9 at 30 minutes  in the parecoxib group. All patients in the morphine group evaluated morphine as an excellent or good drug whereas only 15 patients in the parecoxib group evaluated parecoxib as an excellent or good drug  whereas that for the morphine group was 2.4 (SD ± 1.4). Even though there was no statistically significant difference between these two groups, patients who received IV morphine were able to achieve better pain control than those in the parecoxib group. All patients in the IV morphine group evaluated it as an excellent or good drug.Both groups were also able to achieve significant pain reduction based on time within their groups Table . PatientBased on the pain management research, both drugs had achieved minimal clinically significant difference (MCSD) of pain after treatment, even at 5 minutes after drug administration. Bijur et al. concluded that MCSD for NRS was 1.3 , whereasHowever, almost 50% of patients who received IV morphine developed side effects of dizziness, whereas none in the parecoxib group did. This is comparable with a previous study that found no association with opioid related side-effects in the parecoxib group . NeverthThe present study was limited by the small sample size and it was likely underpowered to detect a significant difference. Furthermore, its observation period of 30 minutes was probably too short to determine the efficacy and side effects of parecoxib as its peak effect occurs within 2 hours of IV administration.IV parecoxib has potential as an analgesic alternative to morphine in acute trauma pain in the ED. Looking at its effectiveness and lack of opioid-related side-effects, the usage of IV parecoxib sodium may be extended further to a variety of cases in the ED. Its morphine-sparing effects are also an advantage to minimize the dose of morphine should the patient require opioids during the continuation of care in the emergency setting.ED: Emergency department; HUSM: Hospital Universiti Sains Malaysia; IM: Intramuscular; IV: Intravenous; MCSD: Minimal clinically significant difference; NRS: Numeric rating scale.The authors declare that they have no competing interests.KAB, NAH and SFAW designed the study, collected the data and analyzed the data. KAB and NAH drafted the manuscript. RA revised the study design, interpreted the results of the data analysis and revised the manuscript. NHNAR revised the data analyzed and revised the manuscript. All authors read and approved the final manuscript.


Dear Editor,We read with interest your article on the use of gabapentin pain control after burn debridement . Gabapenet al. , there are several additional characteristics that can significantly affect pain, both pre-and post-operatively. Burn severity, type of burn  and location on the body are not addressed here. In addition, the extent of debridement must also be considered, with regard to both surface area and depth. Conditions such as infection or other complicating medical conditions are also not mentioned in the article, which can be common in burn patients, and which can significantly affect patient outcome. Secondly, neuropathic pain induced by burns can lead to chronic and debilitating pain; this should be evaluated, depending on the feasibility of follow-up. The authors state that “Fassoulaki In summary, this study provides important support for the use of gabapentin in postoperative pain, and represents one of the only studies to address its use in burn patients. However, several questions regarding the clinical condition of patients  must be considered; long-term sequelae with regard to chronic pain must also be addressed. All of these variables must be taken into account before the true impact of gabapentin in these patients can be determined.


The intra-articular (IA) application of pulsed radiofrequency (PRF) for pain in small and large joints represents a recent development that has proven to be effective in many cases. We performed a retrospective study of 89 such procedures in 57 consecutive patients with chronic articular pain.The aim of this retrospective study is to evaluate the effectiveness of intraarticular PRF in a group of 57 consecutive patients with chronic joint pain.Patients with intractable joint pain for more than 6 months were treated with IA PRF 40-45V for 10-15 min in small joints and 60V for 15 min in large joints using fluoroscopic confirmation of correct needle position. A total of 28 shoulders, 40 knees, 10 trapezio-metacarpal, and 11 first metatarso-phalangeal joints were treated. Results were evaluated at 1, 2, and 5 months. The procedure was repeated after 1 month in 10 patients with initial suboptimal results. Success was defined as a reduction of pain score by at least 50%.All groups showed significant reductions in pain scores at all three follow-up visits. Success rates were higher in small joints  than large ones . Interestingly, IA PRF was successful in 6 out of 10 patients who had undergone previous surgery, including 3 with prosthetic joint replacement and in 6 of the 10 repeated procedures. There were no significant adverse effects or complications.IA PRF induced significant pain relief of long duration in a majority of our patients with joint pain. The exact mechanism is unclear, but may be related to the exposure of immune cells to low-strength RF fields, inducing an anti-inflammatory effect. The success rate appears to be highest in small joints. We recommend additional research including control groups to further investigate and clarify this method; our data suggest that it may represent a useful modality in the treatment of arthrogenic pain. Pulsed radiofrequency (PRF) has initially been used as an alternative to continuous RF in the treatment of nerves that transmit painful stimuli and for treating peripheral nerves that cause neuropathic pain -4. In 20Articular pain is an important socioeconomic problem. For example, the prevalence of knee pain in the 40 to 79 year old community of the United Kingdom is about 25.3% , 9. CytoRadiofrequency (RF) has been used for decades to heat the tip of an electrode to high (70 – 90 °C), destructive temperatures. The method is used in the treatment of chronic pain to destroy small nerves conducting nociceptive stimuli, for tumor ablation, and in cardiology to ablate abnormal atrioventricular connections. During PRF, RF current is delivered in short pulses. The recommended parameters are a pulse width of 20 msec and a rate of 2 Hz, but shorter pulse widths (5-10 msec) and frequencies of up to 5 Hz are also commonly used. During the pulse, the oscillating frequency is 420,000 Hz. Following PRF procedures there can be some mild tissue destructions around the electrode , 23, butThis retrospective study of 57 consecutive patients with chronic articular pain treated with intraarticular PRF aims to evaluate the effectiveness of this new technology and the duration of the benefit superior to the use of steroid infiltrations.Fifty-seven consecutive patients with articular pain of the shoulder, knee, trapezio-metacarpal (TMC), and first metatarso-phalangeal (MP I) joints underwent 89 procedures with intra-articular PRF between January 2007 and July 2010. The material in this paper constitutes a retrospective review of our experience with intra-articular pulsed radiofrequency for these four types of joint pain. Written informed consent for the procedure as well as for use of the data was obtained from all cases, and the review was done in concordance with internationally accepted ethical principles. Since the study is retrospective, an exemption to IRB approval was granted by the local ethics committee. The basic demographics are shown in Patients were questioned about previous trauma, professional and leisure activities, and daily habits. The history is obviously important in order to rule out metabolic, infectious, and autoimmune causes of pain. If there was any doubt as to the etiology, the patient was referred to a rheumatologist prior to PRF treatment. Numerous clinical tests can be employed to examine joints, especially the shoulder, knee, and hip. The tests used to examine our patients were the Mc Murray- and Steinmann I/II tests for knees; the shoulder-joint was checked with the Appley-test and performance of active and passive abduction, external rotation and adduction. The Grind-test was applied for TMC- and manual examination for MP 1- joints. A further important diagnostic procedure is the manual examination of the joint, which can indicate involvement of the surrounding ligaments and tendons, bursitis, or the presence of trigger points, which can mimic articular pain. Overall, 68.4% of the patients had undergone plain X-ray and/or MRI investigations. In all but a few cases with clear pain-producing pathology, the radiologic images were not helpful in determining which part of the joint was generating the pain.A NeuroTherm NT-1100 lesion generator was used. Following local anesthesia with 1% lidocaine, the PRF needle  was inserted into the joint under fluoroscopic guidance in two planes. All procedures were performed under aseptic conditions in the operating room and following a standardized protocol to avoid unnecessary exposure to radiation. The mean X-ray exposure time was around 60 sec per joint.For shoulders a posterior or anterior approach and for knees a superior, medial, or lateral retropatellar approach was employed. The type of approach was chosen so that it enabled insertion of the PRF cannula as close as possible to the painful area within the joint. The small joints were entered using a “tunnel-vision” fluoroscopic approach, taking care to clearly visualize the intra-articular space. The lateral view is necessary for determining the depth of the needle in the joint. Intra-articular PRF was repeated in 5 shoulders, 4 knees, and 1 MP I joint in patients who had less than 50% pain relief after 1 month and who requested a second treatment. All other patients underwent a single treatment. The parameters that were used are shown in Joint pain was evaluated at 1, 2, and 5 months after the PRF procedure. Patients with a successful outcome at 5 months were interviewed by telephone shortly before this article was prepared. The NRS scores and global perceived effect were evaluated on a 7-point Likert-scale. Success was defined as a reductionof NRS score by at least 50%.The results are given as incidence of success at the 5-month follow-up  and averThe procedure was well tolerated, with minimal to no postoperative discomfort during the first few days. No complications have been observed.This is a retrospective study. All procedures were performed in the practice of the first author, and the organizational environment did not permit comparison of the data to a control group. Conclusions should thus be drawn with reservations. Nevertheless, the results are encouraging because they did not in anyway contradict our first impression  or a pre


Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit. The complex and multifactorial processes of aging can encompass all human organ systems. Secondary to cumulative effect(s) of comorbid condition(s) and diminished physiologic reserve, perioperative stresses can interfere with physiologic homeostasis and lead to potential deleterious adverse effects (AE). With an increase in number of elderly patients undergoing surgery, it is important to determine optimal perioperative therapies to improve recovery while minimizing AE for older surgical patients. A contribution to development of perioperative complications for patients is improper/inadequate postoperative pain therapy. Inadequate postsurgical pain management can be associated with poor interventional outcomes with potential higher rate(s) of medical complications, decreased perioperative pain anesthesia/analgesia experience for patients, and patient and family member dissatisfaction associated with their surgical encounter , 2.Planning an anesthetic technique and perioperative pain regimen requires consideration of several interventional details. However, debate continues over the optimal approach to anesthesia and analgesia in the elderly. It is always important to consider patient age, preexisting comorbidities, anticipated surgical procedure, and postoperative analgesic requirements when deciding upon appropriate perioperative pain management strategies for older patients. Perioperative pain management methods examined and explored in this paper are regional anesthesia, including neuraxial and peripheral nerve blockade, along with multimodal drug therapy.Older patients have age-related physiological and pharmacological differences that are unique. In addition, many geriatric patients suffer from poor perioperative health status and comorbid disease, varying degrees of physical de-conditioning , and compromised organ reserve capacity. Cardiovascular, nervous, pulmonary, endocrine, and immune systems can all be affected by human aging processes. Systemic changes that accompany aging are carefully reviewed in order to determine some suggested optimal techniques for perioperative pain management.The number and extent of any coexisting disease(s) and medical condition(s) are more directly related to perioperative risk than to chronological age for elderly patients. Therefore, patient age alone should no longer be considered a major risk factor for anesthesia and surgery. More important factors and better predictors for the elderly include issues such as overall physical status, medical history, and disease state along with patient condition  and type of surgery. Complication rates for perioperative anesthetic and pain management choices increase very little with the advancing age in absence of coexisting disease. However, there is often an increased incidence of disease and existing comorbidity(s) in older surgical patients. Four-fifths of older patients have at least one complicating medical condition and 1/3 have 3 or more coexisting diseases. There are also several medical conditions that are predictive of higher surgical risk such as hypertension, diabetes mellitus, and ischemic heart disease [There are several types of regional modalities available  and inveClinically, RA appears to be a very effective and safe technique in elderly surgical patients. Several established and theoretical benefits of RA are listed in For a host of reasons and despite advances made in analgesia and newer analgesic techniques, monotherapy with opioids remains the mainstay of treatment for perioperative pain. Opioids  provide powerful dose-dependent relief of pain. Opioids are the most commonly used medication for postoperative pain delivering good analgesic effect. Unfortunately, opioids can alter central nervous system (CNS) activity and lead to physical and psychological dependence with longer-term use, especially in the elderly. They may also be burdened with several potential adverse effects such as nausea, sedation, constipation, ileus, dysphoria, respiratory depression, and risk of abuse . These oWith dependence on opioid monotherapy, results may reveal inadequate postoperative pain management and can often be of limited value due to associated AE's. Opioid mono-therapy can lead to requirements of higher doses to achieve adequate pain control and with higher dosages, more side effects become possible as well as intensity of AE that often prove to be dose dependent. In the very recent past, use of multimodal drug therapy has gained value and utility as being a more effective strategy in perioperative pain control for all patients . MultimoConsidering the aspect of less dependence on one medication treatment modality often provides the practitioner with an ability to use lower drug dosage of individual analgesics along with less reliance on one specific agent so as to limit AE from any single medication as well as possibly reducing tolerance and dependence. Physicians find this approach to perioperative pain management beneficial, as it can often permit less reliance on only opioids. Multimodal analgesia incorporating RA may also enhance recovery while enabling optimal rehabilitation, quicker transfer to an outpatient setting and more expeditious return to activities of daily living following major surgery. RA as part of multimodal analgesia may in turn reduce use of healthcare resources, help to minimize cost and provide value to end users of procedure-specific pain management treatment modalities. Models of multimodal analgesia can be designed to include fast onset of action, reduced AE's, tailored toward improved safety profiles in certain patient populations as well as effective reduction in pain levels by medication and analgesic delivery directed from multiple routes by different receptor interfaces. RA as part of multimodal anesthesia has been shown to be efficacious in multiple studies and may also improve outcome by reducing opioid use for optimal pain control in a wide variety of surgical interventions. In addition, since surgical patients rarely present with pure nociceptive or neuropathic pain issues , a rational and multimodal approach proves necessary to target both peripheral and central pain pathways.The exact pathophysiology of postoperative delirium (POD) and cognitive dysfunction has not been completely defined nor has all the potential pathways been determined. Both postoperative delirium and cognitive dysfunction have a higher incidence in the elderly surgical population. However, it has been theorized, that by avoiding or reducing centrally acting general anesthesia agents and centrally acting opioids (when possible), RA, along with multimodal analgesia (nonopioids) may optimize perioperative pain management. Therefore, such an anesthetic/analgesic patient-directed and procedure-targeted plan may serve to reduce emergence delirium and postoperative cognitive dysfunction (POCD) in the elderly.Incorporating general anesthesia has a potential pathogenic factor towards brain toxicity, inflammation, and POCD , 8. SuchDependence on opioids as the major role for pain management in the elderly can result in a host of well-known AE . NarcotiPain management can be challenging to treat effectively in those suffering from perioperative cognitive changes. Stroke is one possible cause for negative influences on cognition in patients but occurs relatively infrequently . CognitiN = 1200) older than 60 years had a 25.8% incidence of cognitive impairment postoperatively at one week and, in some patients (9.9%), if the impairment persisted for 3 months following surgery [Older individuals with certain coexisting medical illnesses, patients with preoperative cognitive dysfunction, geriatric patients undergoing certain high-risk surgeries, and surgical candidates of advanced age are at higher risk for development of postoperative cognitive disorders and potential for long-term cognitive dysfunction. Cognitive disorders in high-risk elderly patients occur more frequently than anticipated as is evident in one study in which patients , unmet postoperative analgesic needs, unplanned discharge to a skilled care facility, and even premature death . PatientConditions involving cognitive dysfunction in the elderly are identified in Cognitive status often relates directly to a patient's functional ability which can be a determining factor in rehabilitation, pain management, and whether or not a patient is discharged to home or will require a skilled care facility for recovery. Therefore, functional status of elderly surgical patients may be more relevant than their medical morbidity outcomes following surgery. In addition, functional status serves as a strong predictor of mortality as a result of hospitalization . DecreasAnesthesia choices using regional techniques can provide targeted pain relief and reduce dependence upon amounts of systemic opioids during the perioperative period. Multimodal nonopioid medication regimens using local anesthetics provide analgesia and reduce reliance on opioids and their many associated AE in the elderly. Optimal postoperative analgesia is achieved when regional analgesics are placed in close proximity to the corresponding dermatome distribution of the surgical site –26.Analgesic agent choices used with regional anesthesia/analgesia  can influence patient outcome. Central-neuraxial opioids prove effective in controlling postoperative pain, but only neuraxial local anesthetics  have the ability to attenuate adverse pathophysiological responses that can contribute to perioperative morbidity . NeuraxiDespite the lack of conclusive, long-term evidence that regional versus general anesthesia provides improved outcomes, there are studies that can demonstrate improved elderly patient results secondary to reducing organ dysfunction. For example, amelioration of negative pathophysiologic events and improved analgesia with the use of perioperative regional modalities as part of a multimodal pathway for rehabilitation can create fewer stresses on organ function . Postoperative regional analgesia as part of a perioperative multimodal approach in patients undergoing abdominal-thoracic esophagectomy can result in a shorter time to patient extubation, earlier return of bowel function, superior analgesia, and earlier fulfillment of discharge criteria from an intensive care unit . PatientBrain sensitivity to anesthetic and analgesic agents increases with age and is unique to each drug. Pharmacokinetic changes that accompany aging and the geriatric nervous system can explain some components of analgesic drug responses seen in the elderly. The mechanisms that define altered brain pharmacodynamics to anesthetics and analgesics in the elderly are unclear at the present, although altered brain kinetics may provide some direction. Age related altered brain sensitivity might result from changes in receptors, signal transduction, and homeostatic mechanisms of the CNS. In addition, alterations of brain phospholipid chemistry associated with changes in second messengers, such as diacylglycerol, are evident . TherefoSome major signs and symptoms of an altered nervous system in the elderly include altered reflexes, deteriorations of gait and mobility, altered sleep patterns, impairment of memory and intellect, and decrement of the senses. In older individuals, there is a continual loss of neuronal substance and diminished supply of neurotransmitters leading to reductions in brain reserve. Such reductions increase the likelihood of impaired sensitivity to systemic anesthetic and analgesic medications, symptoms and signs of perioperative neurologic dysfunction, increased risk of POCD, and decreases in functional activities of daily living. These negative attributes of systemic drug administration upon brain reserves in the geriatric patient may be reduced with analgesic modalities that focus on pain management in the periphery .The autonomic nervous system dictates involuntary physiological functions of the body by way of sympathetic and parasympathetic divisions and this system can experience alterations secondary to the aging process. Aging of the autonomic nervous system is characterized by (a) limited adaptability to stress; (b) net increase in the activation of the sympathetic nervous system; (c) decreased basal activity of parasympathetic nervous system; (d) decreased baroreflex sensitivity; and (e) slowing and weakening of homeostatic functions, all of which may play a role in achieving good perioperative pain management. In addition, there are changes that can occur in the older patient's somatic nervous system and include (a) peripheral nerve deterioration; (b) dysfunction of genes responsible for myelin sheath protein components; and (c) decreased myelinated nerve fiber conduction velocity to identify a few of the changes.In older individuals, the aging autonomic nervous system has reduced abilities to respond to physiologic changes, stresses, surgery, pain, and anesthesia. Likewise, increases in the sympathetic nervous system activity may be more pronounced and are organ specific with the gastrointestinal (GI) system and skeletal muscle as targets. Neuronal noradrenergic reuptake is reduced in the elderly resulting in an increased sympathetic tone of the heart and an increase in basal adrenal secretions. There is a loss of beat-to-beat heart rate variability during respiration in the elderly due to a reduced respiratory vagal modulation of the resting heart. Decreased baroreflex sensitivity is due to increased arterial stiffness and age-associated alterations of the autonomic nervous system. The autonomic nervous system and its effectors play an important role in responses to hemodynamic challenges. Therefore, any imbalance of homeostatic mechanisms in patients of advanced age can result in clinical compromise  that may be reduced by implementing RA/analgesia.Age related changes in the peripheral nervous system (PNS) and CNS may affect functional outcomes during the perioperative period and should be considered in patients' preoperative evaluation. Normal aging results in biochemical and anatomical changes of the brain and spinal cord along with qualitative and quantitative effects on the nervous system . TherefoDaily living activities can be dramatically affected by age-related memory decline but are not inevitable. Deficiencies of specific neurotransmitters  often occur in geriatric patients. Memory deterioration can occur in more than 40% of people older than 60 years of age, and progressive loss of intellectual activity along with mental deterioration (senile dementia) happens in 14% of the population aged greater than 75 years . ChangesN = 68,723) on Medicare patients found an association of significantly lower odds ratio of death at both periods of 7 and 30 days when using postoperative epidural analgesia [N = 2427), it was found that patients who received an epidural  had a reduced incidence of perioperative myocardial infarction. And, in those instances when a thoracic epidural was maintained for analgesia longer than 24 hours, results showed significantly fewer postoperative myocardial infarctions [Patients undergoing various orthopedic procedures under neuraxial blockade for perioperative anesthesia and/or analgesia had a one-third reduction in overall mortality from a recent meta-analysis of randomly controlled trials . Anothernalgesia . In yet arctions .Aging of the heart and vascular system in older surgical patients has clinical implications for treatment of postoperative pain management. Morphological and functional changes of the cardiovascular system occur with the aging process . There iPreoperative placement of a continuous epidural in elderly patients for hip fracture surgery (versus a regimen of systemic opioids) has also demonstrated better perioperative pain management and a reduced incidence of adverse cardiac events . In addiPerioperative deleterious cardiovascular events such as congestive heart failure, myocardial infarction, cardiac arrhythmias, and sudden cardiac death can occur with an increased frequency within the first several days of a major surgical intervention , 41. ActArmed with an understanding of the multiple respiratory system changes in older patients, clinicians should always titrate analgesic medications carefully and assess patients frequently for any evidence of potential adverse respiratory effects. For example (a) a greater decrease in arterial oxygen tension and/or an increase in carbon dioxide is necessary to increase minute ventilation in the elderly; (b) elderly patients may not adequately increase their minute ventilation to meet respiratory demands induced by hypoxia and hypercarbia under the stress of illness or injury; and (c) furthermore, this effect is exacerbated by the use of opioids, benzodiazepines, and inhalational anesthesia that can promote respiratory depression , 43. TheIt remains intuitively reasonable and clinically prudent to consider that older patients could benefit from regional techniques due to minimal sedation requirements, better postoperative pain control, and preservation of pulmonary function. Yet analysis of several studies reveals that choice of anesthetic shows no significant long-term effect on perioperative respiratory morbidity and mortality within any age group. However, by preserving or quickly restoring respiratory function, epidural anesthesia appears to decrease morbidity, reduce length of hospital stay, and lower healthcare costs. In addition, any adverse respiratory effects from inhalational anesthetics and airway manipulation can be avoided. Therefore, the decision to perform regional anesthesia/analgesia must be assessed on a case-by-case basis considering a patient's pulmonary function, type and duration of planned surgery, and anesthesiologist expertise, along with consideration and reflection of the elderly patient's health status and pulmonary reserve.General anesthesia may reduce functional residual capacity (FRC) by 15–20% with duration of effect that can last 7–10 days following surgery . Followi2) are higher on post-op day 1 when using epidural anesthesia/analgesia as compared to systemic opioids for perioperative pain management [Studies have shown that older adults undergoing lower extremity orthopedic procedures have fewer respiratory complications when combining epidural plus general anesthesia compared to general with postoperative intravenous morphine analgesia for pain management. Hypoxic events are diminished and measured levels of pulmonary arterial oxygen , patient readmission for treatment of perioperative pain, and so forth. Acute pain should always be expected in postoperative patients. With aging of the US population, more surgeries are being performed annually that translates into a higher absolute number of older surgical patients where pain management continues to pose a challenge for clinicians. As discussed, inadequate pain management can have profound and even long-lasting negative implications . Therefore, increasing evidence shows that uncontrolled or inadequately controlled pain (pain of higher intensity and for longer periods) after surgery serves as a risk factor for the development of organ system compromise and that efforts to manage pain in the perioperative period may be very effective in reducing such a burden.There are a host of well-known advantages in addition to many other potential benefits associated with RA in the elderly surgical patient. However, the incidence of central-neuraxial neurologic compromise resulting from hemorrhagic complications is not completely known. The incidence of neurologic compromise (hemorrhagic injury) cited in the literature is estimated to be less than 1 in 150,000 for epidurals and less than 1 in 220,000 for spinal anesthetics, and recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations . In addition, the risk of clinically significant bleeding increases with advanced age, the presence of an underlying coagulopathy, associated abnormalities of the spinal cord and vertebral column, difficulty during neuraxial needle placement (ex. multiple attempts), and presence of an indwelling neuraxial catheter during sustained prophylactic anticoagulation.The American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation and developed practice guidelines/recommendations that summarize evidence-based reviews and provide expert opinion in response to patient safety issues surrounding coagulation concerns during RA . Since tNonpharmacologic methods may also be useful in elderly perioperative pain medicine including heat or ice therapy as well as psychological support. Pain is a complex experience that is influenced not only by the surgical insult, but also by the individual's cognition, culture, experiences, and behavior. Patients can learn coping mechanisms such as relaxation and imagery to decrease muscle tension, reduce emotional distress, and distract from pain .In addition to regional analgesic modalities using local anesthetics, non-opioid multimodal analgesic options will complement such an initiative with reduced reliance upon unimodal therapy with opioids. Adjuvant drugs such as antidepressants, topically applied single- or multiagent analgesics, corticosteroids, anticonvulsants, skeletal muscle relaxants, and alpha 2 agonists were agents developed with clinical indications for treatments other than for pain, but they have also been discovered to provide analgesia. They should be considered to contribute and improve regional perioperative pain management, reduce dependence on opioids, and limit potential AE from opioids in the elderly. Many of the adjunct analgesics (non-opioid) can be recommended when toxic limits of opioid analgesics are approached or when the therapeutic benefit of a primary analgesic appears to have plateaued. In addition, these medications can be used in the presence of other nonpainful disabling complaints of the elderly such as depression, anxiety, insomnia, and fatigue .Nonsteroidal anti-inflammatory drugs (NSAID) are the most widely prescribed and used medication in the US. NSAID administration is a common non-opioid drug alternative and has been included in multimodal anesthesia/analgesia practice guidelines for acute pain management in the perioperative setting . McDaid Several other adjuvants can provide beneficial value to regional anesthesia/analgesia in the elderly surgical patient. Acetaminophen  should be considered as a management therapy for pain. It is ideal for postsurgical therapy because of its platelet sparing properties (recent availability of an intravenous formulation) and reduced concerns during neuraxial and RA administration . Incorporation of antidepressant medications into perioperative pain management also has advantages that compliment regional techniques used in the elderly. In addition to their value as an analgesic, antidepressants improve a patient's sense of well-being, reduces fatigue, and do not disrupt the normal sleep cycle. Certain antidepressants (treatment of neuropathic pain characterized by damage/dysfunction of CNS and/or PNS) have become popular as a non-opioid medication in the treatment of postoperative pain as a multimodal component in combination with regional anesthesia. Anxiolytics can be included in a multimodal perioperative pain management regimen. Pain can cause anxiety and, in turn, anxiety often exacerbates the perception of pain. Therefore, anxiolytics may provide a mechanism to break this cycle and indirectly help to relieve pain in combination with regional anesthesia/analgesia.Other commonly used drugs for the treatment of pain (neuropathic) included in multimodal therapy for acute pain management are anticonvulsant medications. Skeletal muscle relaxants, another adjunct in pain management regimens, have multiple modes of action. The comparative efficacy of these drugs is not well known in the elderly however, evidence from clinical trials is limited and a distinction that needs to be understood is that skeletal muscle relaxants consist of antispasticity and antispasmodic agents. Therefore, skeletal muscle relaxant choice should be based on indication, patient tolerability, and potential AE profile when used in combination with regional anesthesia/analgesia.Perioperative pain management in older patients can often be associated with specific complicating elements surrounding perioperative events, especially during major surgery. Geriatric patients typically suffer from a greater number of comorbid diseases, have lower organ function reserve, and demonstrate altered physiologic and pharmacologic reactions to analgesic medications. There are also challenges in pain management and assessment that remain unique in elderly patients. For example, it may require more time for older patients to understand the pain scale due to barriers such as vision, hearing, or cognitive defects. In addition, elderly patients also tend to underreport pain and effective perioperative pain management requires careful assessment of pain and sensible dosing of analgesics along with implementation of regional techniques. It is also crucial to be aware of potential AEs secondary to analgesic options and to keep a close watch for their development, but a focus on reducing or eliminating such events and patient care compromise will yield better surgical outcomes for older patients.Perioperative regional anesthesia/analgesia as part of multimodal drug therapy may prove to be the most effective approach to perioperative pain management in the elderly, cognitively impaired patients with comorbid disease, and so forth, with the least amount of physiological compromise. Regional anesthesia may benefit older patients by reducing postoperative neurological, pulmonary, cardiac, and endocrine complications and potentially improve upon immediate postoperative pain control, but it has yet to be conclusively proven to improve long-term morbidity and surgical outcome. Multimodal drug therapy incorporating regional options provides a potentially advantageous choice toward perioperative pain management that utilizes a variety of analgesics in order to minimize dosages and reliance of any single agent while maximizing analgesic effect in the older surgical patient population.Therefore, it remains necessary to implement carefully thoughtout perioperative pain medicine therapies and to continue the search for development of new methods of pain management for all patients, especially the growing elderly surgical population. In addition, if healthcare services are to demonstrate that the many reports of inadequate perioperative pain management  are bec


Due to the heterogeneous nature of chronic low back pain (CLBP), it is necessary to identify patient groups and evaluate treatments within these groups. We aimed to identify groups of patients with CLBP in the primary care setting.We performed a k-means cluster analysis on a large data set (n = 634) of primary care patients with CLBP. Variables of sociodemographic data, pain characteristics, psychological status , and the patient resources of resilience and coping strategies were included.We found three clusters that can be characterized as “pensioners with age-associated pain caused by degenerative diseases”, “middle-aged patients with high mental distress and poor coping resources”, and “middle-aged patients who are less pain-affected and better positioned with regard to their mental health”.Our results supported current knowledge concerning groups of CLBP patients in primary care. In particular, we identified a group that was most disabled and distressed, and which was mainly characterized by psychological variables. As shown in our study, pain-related coping strategies and resilience were low in these patients and might be addressed in differentiating treatment strategies. Future studies should focus on the identification of this group in order to achieve effective treatment allocation.DRKS00003123German Clinical Trial Register  Chronic pain syndromes, especially chronic low back pain (CLBP) is one of the most prevalent diseases in Western populations  and is oCurrent treatment recommendations emphasize a multidisciplinary approach for chronic lower back pain (CLBP) treatment . This thA possible solution could be considering whether every CLBP patient needs the multidisciplinary treatment. Considering the heterogeneous and multifactorial nature of chronic pain patients, it might be necessary to differentiate the main characteristics of patient groups and evaluate individual treatment approaches .Several attempts have been made to identify groups of pain patients. Studies are typically based on single dimensions such as traditional psychological measures  , pain exWe aimed to identify groups of patients with CLBP in the primary care setting. For group analyses, we considered pain characteristics, common psychological characteristics , and also included patient resources like resilience and coping strategies, which might contribute to future recommendations for CLBP patient counseling.Our data referred to the cross sectional baseline analysis of a 12-month cohort study that identified risk factors and protective factors of pain generalization in primary care CLBP patients. A detailed study protocol has been published elsewhere .This project is part of the research consortium LOGIN “Localized and Generalized Musculoskeletal Pain: Psychobiological Mechanisms and Implications for Treatment”, funded by the German Federal Ministry of Education and Research.During a 5-month period, fifty-eight general practitioners (evenly distributed in the northern region of Hessen in Germany) consecutively enrolled all eligible patients consulting for CLBP as a primary or secondary consulting reason (inclusion criteria). The symptom “chronic low back pain” was defined as back pain below the costal margin and above the inferior gluteal folds (with or without pain radiation), which had started at least three months prior and continued during most days  in the last three months. Patients under 18 years, pregnant women, and persons with an insufficient understanding of the German language or severe cognitive impairments  were excluded from the study.Patients who gave their informed consent were asked to complete a questionnaire directly after the consultation or at home. During the recruitment period, trained clinical monitors conducted two random quality control audits of the GPs’ performance.To explore descriptive characteristics, the questionnaire included the following physical and psychological parameters .To evaluate the number of different pain areas, we measured pain localization with the “body pain drawing model” proposed by Pfau et al. . Pain anWe used the three-item social support subscale from the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) to explore the partner’s reaction in response to patient’s pain  ,23.The severity of chronic pain was measured by the German translation of von Korff’s Graded Chronic Pain questionnaire (GCP) . SeveritUsing the Self-Administered Comorbidity Questionnaire (SACQ), we asked the patients about 14 common medical conditions: high blood pressure, heart disease, asthma, chronic obstructive pulmonary disease, ulcer/stomach disease, diabetes, high blood lipid level, kidney disease, osteoarthritis/degenerative arthritis, rheumatoid arthritis, osteoporosis, cancer disease, depression, other psychiatric diseases ,27.Psychosomatic symptoms were measured with the somatization subscale of the Symptom Checklist 90-Revised (SCL-90-R), a commonly used psychological status symptom inventory for psychopathology  .Screening for anxiety disorders and depression was done by the Hospital Anxiety and Depression Scale (HADS)  ,30.Fragebogen zu Bewältigungsressourcen bei Rückenschmerzen) questionnaire from Tamcam et al. [Coping resources for back pain were evaluated by the FBR  ,33.http://www.almo-statistik.de), which includes a k-means algorithm that is able to handle the different scalings of our variables and the large sample size. This program provides statistical measures to evaluate the appropriateness of a cluster solution  [We performed k-means cluster analyses generalized to all scales of measurement with squared euclidean distances . The k-me, eta2) .2 < 0.05. Accordingly, the following variables were excluded: gender, living with a partner, applied for pension, pain distribution, medication, WHYMPI – social support scale, education level, kind of job, time of pain. We attached special importance to certain individual variables  so that they were included irrespective of their eta2.Cluster analysis is an iterative process looking for the most relevant variables adding to an interpretable solution ,37. TherThe study was approved by the local ethics commission of Philipps University of Marburg, Germany  and is in accordance with the Declaration of Helsinki.Fifty-eight GPs with various practice characteristics  participated in the study. During the five-month recruitment period, they identified 746 eligible patients. Of these, 655 patients agreed to participate. A total of 647 subjects were analyzed; 8 patients were excluded because they did not report lower back pain in the pain drawing.On average, the participating CLBP patients were 56 years old . The majority was female, married, and living in a two-person household. Just over half (52.4%) reported having back pain for more than ten years. Half of the participants were employed; 74.6% of the unemployed participants were retired. Table max-value of 76.16 and an eta2 of 0.191, meaning that 19.1% of the variance can be explained by this partitioning and can be considered as a cluster solution with acceptable quality criteria [A three-cluster solution resulted in an Fcriteria ,37,38.2 values for the most important variables for cluster partitioning were found for employment status (eta2 = 0.44), days of sick leave (eta2 = 0.44), and age (eta2 = 0.40). In addition, having a hobby/enjoyment as a coping resource (eta2 = 0.41), depression (eta2 = 0.31), retirement status (eta2 = 0.35), and resilience (eta2 = 0.28) were also found to play an important role in cluster partitioning. All variables used in the cluster analysis are listed in Table The variables used for classification are depicted in Table Table  comprised mainly retired persons with an average age of 68.2 years . Patients in this cluster suffered from a medium pain severity. In most cases, they had musculoskeletal and other chronic cardiovascular/pulmonary/stomach diseases. In comparison to the other cluster groups, cluster 1 scored highest regarding perceived efficacy of coping resources and mental disorders. Furthermore, patients in cluster 1 were optimistic with regard to their pain prognoses. consisted of middle-aged patients  with only 44.2% employed. Most unemployed patients were pensioners due to disability (72.6%). Remaining unemployed patients were either keeping house (17.7%) or seeking work (8.8%). Patients from cluster 2 had the most pronounced pain (highest rate of high pain severity and number of pain areas) and a high rate of pain-related disability. In comparison to the other clusters, patients in this cluster had more psychological distress . Furthermore, they had the worst resilience and the least efficient coping resources. They were high health care utilizers regarding the number of consultations and operations. We called them “middle-aged patients with high mental distress and poor coping resources”. was also comprised of middle-aged , but mostly working (87.1%) patients. In comparison to the second cluster, they were less pain affected, had fewer comorbidities and showed a better mental health . Resilience was higher and coping resources were more pronounced than in patients belonging to cluster 2. In addition, they rarely required health care.Table We performed a k-means cluster analysis on a large data set of primary care patients with chronic low back pain. We found three clusters that can be characterized as “pensioners with age-associated pain caused by degenerative diseases”, “middle-aged patients with high mental distress and poor coping resources”, and “middle-aged patients who are less pain-affected and better positioned with regard to their mental health”.Several researchers have stated the need to identify patient groups that could serve as target groups for effective treatment strategies . Turk etShaw et al. identified four groups of patients with acute work-related back pain based on disability risk factors  . Group oBoersma et al. identified groups of acute and subacute spinal pain patients with regard to their risk for permanent pain or disability . Their gEven though the included variables and patient populations  of the aforementioned studies differ, they all have one aspect in common: All analyses revealed one patient group which seems most distressed and shows above average mental distress and high pain severity. In this way, mental health status seems to be a key differential factor.The primary care setting comprises a high prevalence of older, often multimorbid patients and many chronic diseases. Therefore, groups identified in different settings might not be relevant for general practice . Even thHill et al. developed the STarT Back tool for the primary care setting . The tooOur study is subject to selection bias. GPs may have subconsciously preferred to recruit special cases , or forgotten to recruit patients due to high workload. Furthermore, some patients may have refused to participate in our study due to the long questionnaire, especially considering that our study population included a large proportion of older people with age-associated mental deficiencies. These factors might reduce the external validity of our results. In general, a limitation of cluster analysis is that the results depend on the input variables .Since the less pain-affected patients of cluster three (average age: 46.8 years) are younger than the more pain-affected patients of cluster two (average age: 57.8 years), it is possible that younger patients from the third cluster will move to the second cluster as they age. This is especially likely because increased age is a proven risk factor for increased pain outcomes  . We shouOur results supported current knowledge concerning groups of CLBP patients in primary care. This knowledge could be the starting point for developing a group-specific therapy for general practitioners.For the group “pensioners with age-associated pain caused by degenerative diseases”, a therapeutic orientation aligned with the guideline “pain of older people” ,47 wouldThe group “patients of an employable age with high mental distress and poor coping resources” should receive multimodal pain therapy with a particular focus on psychotherapy to improve coping resources and resilience. With regard to the fact that mental disorders, especially depression, are the most decisive cost factor of chronic pain , it is pFor the group “patients of an employable age who are less pain-affected and better positioned with regards to their mental conditions”, a general practitioner-based, time-contingent monitoring should be indicated. It should be planned independent of pain exacerbations and should be conducted according to the bio-psycho-social model of pain.Next step of our research will be to develop a therapy study which evaluates the efficacy of group-specific therapy approaches.Fragebogen zu Bewältigungsressourcen bei Rückenschmerzen (questionnaire for assessing coping resources for back pain); RS: Resilience.CLBP: Chronic low back pain; GP: General practitioner; WHYMPI: West haven-uyale multidimensional pain inventory; GCP: Graded chronic pain; SACQ: Self-administered comorbidity questionnaire; SCL-90-R: Symptom checklist 90-revised; HADS: Hospital anxiety and depression scale; FBR: Annika Viniol does not state any financial or non-financial conflicts of interest.Nikita Jegan does not state any financial or non-financial conflicts of interest.Oliver Hirsch does not state any financial or non-financial conflicts of interest.Corinna Leonhardt does not state any financial or non-financial conflicts of interest.Markus Brugger does not state any financial or non-financial conflicts of interest.Konstantin Strauch does not state any financial or non-financial conflicts of interest.Jürgen Barth does not state any financial or non-financial conflicts of interest.Erika Baum does not state any financial or non-financial conflicts of interest.Annette Becker was a consultant for Grünenthal GmbH, from whom she has also received a speaker’s fee.AV planned the study, collected and analyzed data and wrote the manuscript. NJ collected and analyzed data. OH analyzed data. MB and KS gave statistical support and planned the study. JB and EB planned and revised study design. CL and AB planned the study, discussed the results and revised the manuscript critically. All authors edited the drafted version of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/294/prepub


In therapeutic settings, patients with shoulder pain often exhibit deficient coordinative abilities in their trunk and lower extremities. The aim of the study was to investigate 1) if there is a connection between shoulder pain and deficits in balance ability and postural stability, 2) if pain intensity is related to balance ability and postural stability, and 3) if there is a connection between body mass index (BMI) and balance ability and postural stability.In this case–control study, patients (n = 40) with pathological shoulder pain (> 4 months) were matched with a healthy controls (n = 40) and were compared with regard to their balance ability and postural stability. Outcome parameters were postural stability, balance ability and symmetry index which were measured using the S3-Check system. In addition, the influence of shoulder pain intensity and BMI on the outcome parameters was analysed.Patients with shoulder pain showed significantly worse results in measurements of postural stability right/left (p < 0.01) and front/back (p < 0.01) as well as balance ability right/left (p = 0.01) and front/back (p < 0.01) compared to healthy controls. There were no significant group differences with regard to symmetry index. However, there was a significant (p < 0.01) symmetry shift towards the affected side within the shoulder pain group. There was no correlation between pain intensity and measurements of balance ability or postural stability. Likewise, no correlation between BMI and deficiencies in balance ability and postural stability was established.Patients with pathological shoulder pain (> 4 months) have deficiencies in balance ability and postural stability; however the underlying mechanisms for this remain unclear. Neither pain intensity nor BMI influenced the outcome parameters. Patients with shoulder pain shift their weight to the affected side. Further research is needed to determine if balance training can improve rehabilitation results in patients with shoulder pathologies. Unrestricted shoulder function is largely dependent on the stability of the trunk, which in turn, is closely linked to the stability of the lower extremities and to balance control. The shoulder girdle has to compensate a loss of core stability and/or a deficient coordination of legs, torso or scapula by increasing movement speed and/or strength. For patients with shoulder pathologies, it is unclear whether the deficits in balance ability contribute to or is rather a consequence of the shoulder pathology.Current evidence shows that patients with shoulder pain often suffer from proprioceptive deficits in the shoulder, as wellTreede et. al suggest that pain processing may cause balance disorders. One expSimilarly, pain could have an effect on balance by disrupting neural speed processing. Research conducted by Luoto et. al showed that the speed of central information processing is decelerated when patients suffer from pain in the lumbar spine. It remaOther factors known to influence balance are cognitive process, such as attention,12 and cTo our knowledge, no studies have examined the influence of pathological shoulder pain on the balance system. The aim of this study was to investigate 1) if there is a connection between shoulder pain and deficits in balance ability and postural stability, 2) if pain intensity is related to balance ability and postural stability, and 3) if there is a connection between body mass index and balance ability and postural stability. Patients with pathological shoulder pain were compared to a healthy control group in regards to balance ability, postural stability  and body symmetry using the S3-Check system .Subjects were recruited from the ATOS-Clinic Heidelberg, Germany which specialises in shoulder surgery and an affiliated rehabilitation centre. Forty subjects with a mean age of 55.9 years, standard deviation SD ± 11.1) were enrolled in the patient group. The control group (n = 40) with a mean age (SD) of 56.7 (± 12.5) years, were primarily administrative staff from the ATOS-Clinic and the rehabilitation centre or were family members of patients. Written informed consent was obtained from all study participants. Inclusion criteria for the patient group were 1) pain originating in the shoulder, with a concurrent diagnosis by a physician specialised in shoulders, 2) musculoskeletal shoulder pain for more than 4 months with a pain intensity rating of at least 7 on a 15-point visual analogue scale (VAS) within the past 7 days of screening, 3) complaints of shoulder pain at rest during the screening examination. Exclusion criteria for both the patient group and the control group were 1) history of major surgery on the lower extremities (e.g. knee prosthesis or cruciate ligament plastics), 2) an injury of the lower extremities during the last six months which affected functional capabilities, 3) acute or chronic pain (including muscular pain) in the spine or lower extremities, 4) any kind of neurological complaint, 5) chronic headache, Morbus Mènière and diseases of the inner ear, 6) cardiovascular diseases which affect balance, 7) acute dizziness, 8) depression, 9) current intake of medication affecting the central nervous system (e.g. opiates), 10) cardiovascular medications which could cause balance issues, and 11) subjects who performed balance training (to avoid measurement bias). Patients (n = 734) who came to the clinic for a preliminary consultation with their treating physician regarding an upcoming shoulder surgery filled out an initial screening questionnaire. The questionnaires were reviewed and potential participants were evaluated by three trained examiners. Of those screened, 43 patients met the inclusion criteria and 33 were willing to participate. In addition, patients (n = 38) were recruited (same process as above) from the affiliated rehabilitation centre where they had an initial examination due to chronic shoulder pain. Eight met the inclusion criteria and 7 were willing to participate. From a total of 772 patients who were screened for participation, 51 met the inclusion criteria. Eleven patients declined due to lack of time, leaving 40 subjects (aged 35–80) that consented and were enrolled in the patient group for the study  and sex.Anthropometric data- age, sex, body height, body weight- and pain parameters were collected during the screening process Table . BMI was• the stability index right/left using the postural stability scale,• the stability index front/back using the postural stability scale,• the sensorimotor index right/left using the balance ability scale,• the sensorimotor index front/back using the balance ability scale,• the symmetry index right/left using the symmetry scale,• the symmetry index right/left using the symmetry scale.The S3-Check  is a testing system for determining the balance ability and postural stability as well as the sensorimotor regulation ability. A sensor which collects the data using specialised computer software  is integrated into a uniaxial balance plate. The plaThe testing was performed in a calm environment. Study subjects were instructed to remove their shoes and position their feet in a bipedal stance on the balance plate. Tests were performed with arms crossed in front of the body to eliminate compensatory arm movements during the tests and to minimize the influence of shoulder dysfunction Figure . During • “front/back”• “right/left”The subject had to hold the balance plate in a horizontal position without receiving visual feedback from a monitor. There was a 30-second break in between both testing directions. The best test from the two series of the respective testing direction was used for further analysis.An evaluation of the interrater-reliability of the SThe statistical power was calculated using G Power 3.1.2 . Statistical analysis was performed by SPSS version 19 .Statistical significance level was set at the p < 0.05. Normal distribution was examined using the Kolmogorov-Smirnov-Test. Univariate analysis of an association between shoulder pain, shoulder pathology, pain intensity, balance ability and postural stability was performed using Spearman’s rho correlation. To detect differences of parameters within each group of patients the Wilcoxon signed rank sum test and to detect differences of parameters between both groups the Mann–Whitney-U-Test was used. The chi-square-test measured the relative frequency which shows if there is a shift tendency of symmetry to or away from the pathological shoulder.There were no significant differences between the control group (n = 40) and the subject group (n = 40) regarding age  and sex (40% women). The study subjects’ average pain intensity was 9.6 (± 2.0), assessed by a 15-point VAS with the majority of the subjects (n = 33) reporting pain levels ranging from 7-11/15 VAS. The number of patients whose pain duration was stated as > 4 months or > 6 months was 8 and 32, respectively. The BMI of the patient group was significantly higher  than the BMI of the control group  Table . The posThere was no correlation between stability index and pain intensity, and also no correlation between sensorimotor index and pain intensity Table .Neither the shoulder pain group nor control group showed a correlation between BMI and the balance measurements: stability index, sensorimotor index and symmetry index Tables  and6. TThe study demonstrated that painful shoulder pathologies can disturb body stability, even when the influence of arm movement is restricted. Our findings showed no evidence of a correlation between pain intensity and deficits in balance ability and postural stability, and no evidence of a correlation between BMI and balance ability and postural stability.One explanation for the disturbances in balance observed in our patients might be related to pain processing. Both pain processing and balance control circuits partly rely on the same central nervous system pathways,21. ShouThe unproven relationship between pain intensity and disturbed body stability might indicate that pain could be responsible for balance issues in general.This assumption is supported by results from Ruhe et al.,23 with This is in contrast to the research of Jones et al.. They exSo far no study has confirmed these results for shoulder pain patients.Our study showed no correlation between BMI and disturbances of balance ability and postural stability. While some research supports our findings, inconsistencies throughout the literature remain,23,26-28Due to the narrowly defined inclusion criteria and comprehensive exclusion criteria of participant selection, as well as the fact that the patient group and control group were well-matched according to age and sex, some potential confounding factors were mitigated at the start of the study.Although our study showed that, in contrast to healthy controls, patients with painful shoulder pathologies do exhibit problems in balance ability, it does not clarify the underlying mechanisms for these problems. In addition, factors such as cognitive alterations were not explored as part of this study. Because we only included patients with pain scores greater than 7/15 VAS, our findings cannot be applied to patients with pathological shoulder pain with reported pain scores of less than 7/15 VAS. Likewise, we do not know how pain duration may affect the balance system – as one would expect in neuro-physiological changes – since Another limitation was the fact that conclusions could not be drawn according to shoulder pathology sub-group, due to the small sample size and varying numbers of subjects per sub-group. Considerably more subjects suffered from medium strong pain (n = 33) than from strong pain (n = 7) . However, the quality criteria for the S-3 Check were calculated on the basis of another system of balance testing. Thus, these results cannot be compared with those from other testing systems since the demands for the sensorimotor system are different for each testing system.Current practice for shoulder rehabilitation focuses on improving joint mobility, muscle strength, muscle endurance and muscle balance. Although some authors,4 postulThe study shows that moderate to severely-rated painful shoulder pathologies are accompanied by deficits in balance ability and postural stability. However, it can neither show a relationship between pain intensity and balance issues nor clarify the underlying mechanism. Our study could not show a correlation between BMI and balance ability or postural stability.Further research is necessary to clarify whether an association exists between pain intensity and balance problems in patients with shoulder problems, as well as between BMI and balance problems. Futhermore, there is a need to determine other factors which influence balance ability in persons with shoulder pathologies. Exploring the link between pain treatments, such as early pain therapy, and balance issues could also contribute to finding solutions for patients with balance deficits. In addition, further research is needed to determine if balance training can improve rehabilitation results in patients with shoulder pathologies.The authors declare that they have no competing interests.TB planned the study, examined the patients and was the main author of the paper. PM did the statistical analysis of the study and was responsible for the statistical methods used in the study as well as for data interpretation. HL and TK were involved in planning the study and methodological considerations, CP participated in the content, the design and helped draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/282/prepub


One of the most important complications in cesarean surgery is postoperative pain, and different ways have been proposed to control it.The purpose of this study was to determine the efficacy of Diclofenac and Paracetamol combination in comparison with Meperidine on postoperative pain after cesarean surgery.One hundred and twenty women candidates for elective cesarean section under spinal anesthesia categorized as ASA class I were selected and randomly assigned to receive either Diclofenac suppository at the end of the operation and thereafter 1 gram infused bolus of Paracetamol (group A), or 20 mg bolus of Meperidine after transition to recovery room (group B) to control postoperative pain.Postoperative pain was present in recovery in 38.3% and 23.3% in groups B and A, respectively (P = 0.009). Postoperative pain was seen after six hours of operation in 38.7% and 16.7% in groups B and A, respectively (P = 0.010). Postoperative pain was present after 12 hours of operation in 38.3% and 15% in groups B and A, respectively (P = 0.002). The additive Meperidine use was the same between the two groups in recovery (P > 0.05). The additive Meperidine use was seen after six hours of operation in 26.7% and 6.7% in groups B and A, respectively (P = 0.013). The additive Meperidine use was seen after 12 hours of operation in 16.7% and none of the patients in groups B and A, respectively (P = 0.004). The frequency of drug adverse effects was the same between the two groups (P > 0.05).Totally, according to the obtained results it may be concluded that Paracetamol and Diclofenac combination would have a better efficacy in postoperative pain control and need reduction to additive analgesia compared to Meperidine. Cesarean section is one of the main surgeries performed in obstetric/gynecologic departments which its rate is increasing due to various causes including rise in marital age, legal issues in the obstetric/gynecologic department, socioeconomic status of the community, and etc. . TherefoOne of the main complications of cesarean surgery is postoperative pain which patients are faced with . PostopeSeveral methods including pharmacological and anesthesiological approaches are available for pain relief after cesarean section -10. EachTherefore, in this study, the efficacy of nonopioid drugs such as nonsteroidal anti-inflammatory drug (Diclofenac) and Acetaminophen were compared with narcotics (Meperidine). So if its effectiveness would be approved in controlling postoperative pain, narcotic medication side effects such as dyspnea, nausea and vomiting, itching and urinary retention could be avoided in postoperative pain management.One hundred and twenty women with anesthesia class of ASA-I were selected among those undergoing elective cesarean section under spinal anesthesia at Amiralmomenin hospital, Tehran, Iran between 2011 and 2012, and randomly divided into two groups (N = 60). Exclusion criteria were general anesthesia during cesarean section for any reason, complications during cesarean section, and allergic reactions to medications. This study was approved by the Ethical Committee of Islamic Azad University, Tehran Medical Branch, and the Helsinki Declaration was respected all over the study course.All cases received 10 ml of ringer-lactate serum through appropriate IV line. After monitoring blood pressure, heart rate, heart rhythm, oxygen saturation, getting 5-6 liter per minute of oxygen by mask, and sitting in preparation for spinal anesthesia in L4-L5 intervertebral space, 2-2.5 milliliter of Marcaine 0.5% (Bupivacaine) was injected to L3-L4 space through a 26 gauge needle. In case of blood pressure reduction, ringer-lactate and ephedrine were administered. For postoperative pain control in group A, two rectal suppositories of Diclofenac were used after completion of cesarean section and on the operating table. One gram bolus of Paracetamol  was infused within 15 minutes while transferring to the recovery room. The patients then received the above mentioned dose repeatedly every four hours for the next 12 hours. On the other hand, if group A patients had moderate pain they received 10 mg of Meperidine intravenously.A bolus of 20 mg of Meperidine was infused immediately after transferring to recovery room in group B patients and received a repeated dose of 20 mg every four hours for the next 12 hours. More than four (moderate and severe pain) patients received an extra dose of 10-20 mg of Meperidine due to severe pain between Meperidine injections based on visual analogue scale (VAS). The variables were age, duration of surgery, side effects and pain according to VAS. The results were analyzed using SPSS version 13.0, and pain intensity and Meperidine consumption were compared between the two groups. For qualitative variables, frequency and percentage frequency and for quantitative variables mean and standard deviation were reported. The T-test was used for evaluation of differences between the two groups with a statistically significant difference at 0.05.The mean age and duration of operation were alike between the two groups . PostopeAdditive Meperidine use was the same between the two groups in recovery (P > 0.05). Additive Meperidine use was seen after six hours of operation in 26.7% and 6.7% in Meperidine group and Diclofenac/Paracetamol group, respectively (P = 0.013). Additive Meperidine use was seen after 12 hours of operation in 16.7% and none of the patients in Meperidine group and Diclofenac/Paracetamol group, respectively (P = 0.004). The frequency of drug adverse effects was the same between the two groups . Cesarean section constitutes a public health priority , 11 becaIn a study conducted by Gleeson and colleagues in England it was declared that Meperidine use caused analgesia in 87% of patients at postoperative phase , but in In a study conducted by Kilicaslan and colleagues in Turkey it was declared that Paracetamol increases analgesia and reduces the need to Tramadol  which isIn Wilder-Smith and associates study the effect of Diclofenac and Tramadol use in pain reduction after cesarean surgery was evaluated in 120 cases, and it was found that the effect of the two intramuscular drugs including Diclofenac 75 mg and Tramadol 100 mg simultaneously was significantly over the effects of each one alone in reducing pain after cesarean , which iIn a study in Sweden conducted by Legeby and colleagues on 50 women undergoing mastectomy, it was found that using Diclofenac suppositories with a dose of 100 mg reduced narcotic drugs consumption significantly up to 34% compared to placebo , which oIn a study by Sylaidis and colleagues conducted on twenty patients in England it was stated that a single 100 mg rectal dose of Diclofenac had a good effect on reduction of postoperative pain and the need to use other narcotic analgesics  which coTotally, according to the results of this study and comparison with other studies performed in this field of health, it may be concluded that combination of Diclofenac and Paracetamol effectiveness is far better at reducing pain after cesarean section and the amount of required analgesics compared to Meperidine. However further studies are required to confirm and validate the findings obtained in the current study.