Chronic pancreatitis is a debilitating disease presenting with pain, diabetes and steatorrhoea. Surgery offers better long‐term pain relief than other interventions, but there is still uncertainty about the optimal surgical procedure and approach and a lack of long‐term follow‐up data in patients with chronic calcific pancreatitis selected for laparoscopic surgical treatment.This was an observational cohort study of patients who underwent laparoscopic surgery for chronic calcific pancreatitis between January 2006 and April 2017, and had completed a minimum follow‐up of 1 year at a tertiary‐care teaching institute. Eligibility for the laparoscopic approach was main duct diameter greater than 7 mm, absence of extensive head calcification, size of head less than 3·5 cm, absence of local complications, and ASA grade I or II status. The primary outcome variable was a reduction in pain score by 1 year. Secondary outcomes were hospital stay, complications, pain score at 3 and 5 years, and the development or progression of exocrine and endocrine insufficiency.Some 57 patients were scheduled to undergo laparoscopic surgery for chronic pancreatitis: longitudinal pancreatojejunostomy (39), modified Frey's procedure (15) and pancreatoduodenectomy for suspicion of malignancy (3). The latter three patients were excluded from the analysis. Conversion to open surgery was needed in ten of the 57 patients (18 per cent). The mean(s.d.) age of the analysed cohort was 34·2(3·7) years and there was a predominance of men . Adequate pain relief was achieved in 91, 89 and 88 per cent of patients at 1, 3 and 5 years of follow‐up respectively.Laparoscopic surgical management of chronic calcific pancreatitis with longitudinal pancreatojejunostomy or modified Frey's procedure is feasible, safe and effective in selected patients for the relief of pain. Chronic calcific pancreatitis (CCP) is a debilitating disease characterized by recurrent abdominal pain, with gradual loss of gland function leading to exocrine and endocrine failure with steatorrhoea and diabetes. Traditionally, chronic pancreatitis is managed with dietary modifications, pancreatic supplements and analgesia. Invasive interventions are reserved for selected patients with intractable pain or those with local complications. Surgery provides better long‐term pain relief than endoscopic interventionsLaparoscopy in the surgical management of chronic pancreatitis is technically challenging. Anatomical landmarks may be difficult to identify as a result of recurrent episodes of inflammation. Tortuosity of the main pancreatic duct, potential for heavy bleeding, and an extended intracorporeal anastomosis can also pose difficulties.There is limited literature evaluating minimally invasive surgery for this disorder, with a lack of long‐term data regarding pain control and gland functionThis study reports a long‐term experience in the management of CCP using laparoscopic drainage procedures.This study involved a cohort of patients who underwent laparoscopic surgical interventions for unremitting abdominal pain related to CCP between January 2006 and April 2017. Patients whose operations were converted to open procedures were included, except those who underwent head resections for suspected malignant lesions.GEM Hospital and Research Centre is a tertiary‐care teaching hospital that serves a local population of 2·5 million, with additional referrals from nearby institutions. The annual volume of pancreatic surgeries ranges between 110 and 120 procedures. All operations were performed by two senior authors, with minimum experience of more than 50 laparoscopic pancreatic resections.Surgical decompression was reserved for patients with intractable pain requiring regular use of opiate analgesia or who had developed local complications. The laparoscopic approach was offered to those with a main duct diameter greater than 7 mm, absence of extensive head calcifications or mass formation within the head of the gland, and a head size of less than 3·5 cm (maximum head diameter in any direction) on contrast‐enhanced CT, and ASA grade I or II disease. The choice between longitudinal pancreatojejunostomy and a modified Frey's procedure was based on the extent of involvement of the pancreatic head. Patients thought to have predominantly head disease were selected for a modified Frey's operation. Until 2008, only longitudinal drainage was performed by laparoscopy, with the gradual introduction of laparoscopic modified Frey's procedure in selected patients after this date. The terminology and description of the modified Frey's procedure used here has been described previouslyThe records were obtained from a prospectively developed database for patients undergoing surgical treatment for chronic pancreatitis. Clinicopathological data, operative variables, postoperative morbidity and length of hospital stay were recorded. During follow‐up visits, pain scores, types of pain relief , and new onset of pancreatic exocrine and endocrine insufficiency were noted and analysed. After discharge, follow‐up visits were scheduled for 7 days, 3 months and 1 year after surgery, then annually. Personal visits were supplemented by telephone interviews.Pancreatic endocrine insufficiency was diagnosed when the fasting glucose level was above 7 mmol/l, requiring treatment for glycaemic control. Biochemical tests were not performed routinely to diagnose exocrine insufficiency, which was considered present if the patient had steatorrhoea requiring oral pancreatic enzyme supplementationFigs Figs All patients had bowel preparation the day before surgery. Details of laparoscopic longitudinal pancreatojejunostomy have been described previouslyPatients were monitored for a minimum of 24 h in a high dependency unit. Oral diet was allowed after the resumption of bowel sounds. On day 3 after surgery, the amylase level in the drain was measured and the drain removed on that day if there was no evidence of a pancreatic leak. Patients were discharged when tolerating solid diet after drain removal.All continuous variables are reported as mean(s.d.) values. Variables with a non‐normal distribution are reported as median (range) values. Dichotomous variables are expressed as frequencies. Statistical analyses were performed with Excel® (Office) for Windows® version 2007 .Between January 2006 and April 2017, 57 patients were offered laparoscopic surgery for CCP, of whom 39 had a longitudinal pancreatojejunostomy and 15 a laparoscopic modified Frey's procedure. Owing to suspicion of malignancy, the remaining three patients had a Whipple procedure and were thus excluded from the final analysis.2, and tropical pancreatitis was the predominant aetiology (56 per cent). All patients had pain, followed by weight loss (83 per cent), steatorrhoea (48 per cent) and diabetes (41 per cent) (Table The mean age of the 54 patients was 34·2(3·7) years, and the male to female ratio was 1·7 : 1. Most patients were undernourished, with a mean BMI of 24·12(0·67) kg/mTen of the initial 57 patients had conversion to open surgery .Table The mean duration of surgery for longitudinal pancreatojejunostomy was 220·6(32·0) min and that for the Frey's procedure was 271·0(18·8) min. Mean blood loss in the two groups was 184·5(16·4) and 290·0(34·5) ml respectively. Mean duct diameter was 9·7(1·4) mm. There was a single grade B pancreatic fistula and a single grade A postoperative haemorrhage in each group. Mean duration of hospital was 6·4(1·1) days for longitudinal pancreatojejunostomy and 7·8(1·8) days for the modified Frey's procedure (Table Mean follow‐up was 58·420·3) months in the longitudinal pancreatojejunostomy group and 46·4(16·8) months in the modified Frey's procedure group. At the end of 1 year, complete pain relief was observed in 49 of the 54 patients (91 per cent). Weight gain was seen in 43 patients (80 per cent). New‐onset endocrine and exocrine insufficiency were found in three of 35 (9 per cent) and two of 24 patients (8 per cent) respectively. After 3 years of follow‐up, complete pain relief was observed in 30 of 34 patients (88 per cent) after longitudinal pancreatojejunostomy and in nine of ten (90 per cent) after modified Frey's procedure. At 5 years of follow‐up, complete pain relief was seen in 21 of 24 patients (88 per cent) after longitudinal pancreatojejunostomy and in seven of eight (88 per cent) after modified Frey's procedure. By this time, new‐onset endocrine insufficiency had risen to 22 per cent (4 of 18) after longitudinal pancreatojejunostomy and 33 per cent (2 of 6) after modified Frey's procedure. New‐onset exocrine insufficiency was seen in 27 per cent (3 of 11) and 33 per cent (2 of 6) respectively at 5 years  with the two operations used. Slightly better pain relief was achieved in the Frey's procedure group at 1 and 3 years. The extent of head coring may influence pain relief, but modification of head coring can give comparable results to deep head coringNew‐onset endocrine insufficiency was observed in four of 18 patients at 5‐year follow‐up after longitudinal pancreatojejunostomy, and in two of six patients in the modified Frey's group, comparable to other studiesPatients in the present study were generally younger than those undergoing surgery for chronic pancreatitis in the West, with a larger main duct diameter, reflecting aetiology in southern IndiaThis study is not without limitation. A prospective cohort comprising highly selected individuals, undergoing advanced laparoscopic surgery at a high‐volume centre, with no open comparator arm, means these results should not be considered generalizable. Greater experience gained over the ten years of the study may also have influenced outcomes. Nevertheless, the present study has confirmed the feasibility of the laparoscopic approach with results comparable to those for open surgery, providing substantial pain relief and short hospital stays without compromising the principles of operation for CCP. Further insight into the role of surgery in patients with CCP is likely once the results of the ESCAPE trialThe authors declare no conflict of interest.


Postherpetic itch (PHI), or herpes zoster itch, is an intractable and poorly understood disease. We targeted 94 herpes zoster patients to investigate their pain and itch intensities at three separate stages of the condition . We used painDETECT questionnaire (PDQ) scores to investigate the correlation between PHI and neuropathic pain. Seventy-six patients were able to complete follow-up surveys. The prevalence of PHI was 47/76 (62%), 28/76 (37%), and 34/76 (45%) at the acute, subacute, and chronic stages, respectively. PHI manifestation times and patterns varied. We investigated the relationship of PHI with neuropathic pain using the visual analog scale (VAS), which is a measure of pain intensity, and the PDQ, which is a questionnaire used to evaluate the elements of neuropathic pain. The VAS and PDQ scores did not differ significantly between PHI-positive and PHI-negative patients. A large neuropathic component was not found for herpes zoster itch, suggesting that neuropathic pain treatments may not able to adequately control the itch. Accordingly, we suggest that a more PHI-focused therapy is required to address this condition. We have been investigating postherpetic pains focusing the nature of such pains , during PHI is an intractable condition for which no therapeutic approach has been established. Reports on PHI are limited to clinical experiences, and few case studies exist. PHI has not been resolved in many cases where therapy for neuropathic pain has been applied; such resolutions should have been achieved if PHI and neuropathic pain shared a similar pathology. PHI and neuropathic pain are considered to have different pathologies. Accordingly, we set out to investigate any neuropathic components using the painDETECT questionnaire (PDQ) , 5 and tThis study involved a survey of 94 patients receiving treatment for herpes zoster-related pain at our pain clinic on an outpatient basis between June 2013 and January 2015. They were studied beginning between 8 days and 1 month after the onset of herpes zoster. In this prospective study, the patients were surveyed using the PDQ and a visual analog scale (VAS) to evaluate pain intensity and an 11-point scale (0 to 10) to determine itch intensity. We used different scales to assess pain and itch. Pain was assessed by a VAS (100 mm), and itch was assessed by an 11-point numeric scale because, in our hospital, pain assessment is routinely performed using a 100 mm VAS. In addition, the 11-point itching scale was used for simplicity.Patients were asked to complete the PDQ at the start of treatment, and the VAS score and itch intensity were determined at the same time. The patients completed follow-up surveys over a subsequent 6-month period. Patients who did not attend the clinic for follow-up visits because their condition had resolved were surveyed by a telephone or through a postal questionnaire. For each follow-up survey, patients were categorized as being at one of these three stages: acute, subacute, or chronic. Their PDQ, itch intensity, and VAS scores were determined for each stage . The staA score of 1 point or greater on the itch intensity assessment scale was taken to indicate PHI, and PHI prevalence and manifestations were investigated for each stage of the illness.For each stage and PHI status, the results for age, sex, zoster site, total VAS score, and total PDQ score were evaluated. Itch severity was assessed as described by Oaklander et al., with a score on the itch-intensity assessment scale between 1 and 3 points representing a grade of “mild,” a score between 4 and 7 points representing a grade of “moderate,” and a score of 8 points or greater representing a grade of “severe” [We also investigated correlations between itch intensity and VAS and PDQ scores. Furthermore, chronic stage patients with a VAS score above 30 mm were regarded as having PHN, and we investigated the association between PHI status and PHN status.Statistical analyses were performed using SPSS Statistics 22.0 for Windows .Seventy-six of the 96 target patients were able to complete the follow-up surveys for 6 months. The prevalence of PHI tended to be high in patients with craniocervical herpes zoster and did not differ with age . TherapyThe prevalence of PHI (by stage) was 47/76 (62%) at the acute stage, 28/76 (37%) at the subacute stage, and 34/76 (45%) at the chronic stage . The medPHI patients showed varied itch manifestation times and patterns. Itching manifested across all stages beginning soon after the zoster onset . The proPHN was observed in 25/76 patients (33%); 11 of these patients were PHI positive (this subset accounted for 44% of PHN patients) . VAS andIn their study, Oaklander et al.  reportedItch intensity was assessed using an 11-point scale. Combined findings (for severity) of mild to moderate itching were greatest in the acute stage; patients with mild itching still accounted for the greatest proportion even after including patients with severe itching. The patients had presented at our clinic with concomitant pain from the acute stage. Accordingly, treatment for pain was started at an early stage after the zoster onset, with some patients receiving medication for neuropathic pain and nerve blockers. Patients also received medication for neuropathic pain in the subacute and chronic phases. We consider that this medication may have been effective, to a certain extent, against itching not associated with pain. Previous studies have shown that PHI responds well to treatment with an antihistamine agent and concomitant antiepileptic medication ; it has Oaklander et al. investigated patients experiencing PHN at least 1 month after zoster disappearance and found that 12.8% of patients still experienced severe itching . ConversPHI is reported to be more likely to occur in cases where herpes zoster affects the head, face, and neck rather than the truck and limbs, and its incidence is reportedly independent of age and sex . Similar+ neurons exhibited behaviors indicating only itching and no pain in response to capsaicin [We now turn to the relationship between pain and itching in herpes zoster. Oaklander et al. found a slight association between pain and itching . Howeverapsaicin . Anotherapsaicin . This reZoster-associated pain is considered to result from inflammation of the nerves and accompanying nerve damage and is mainly treated by addressing neuropathic pain. Conversely, PHI lacks an established therapeutic approach. It is frequently managed with neuropathic pain-focused therapies based on the thinking that pain and itch are similar, but some patients have not responded to these treatments. If pain and itch have different pathologies, then a therapeutic approach focusing on itch is required. In this study, we set out to investigate the nature of pain characteristically experienced by PHI patients and surveyed patients with a goal of establishing a therapeutic approach for PHI. As part of the study, we assessed pain using the PDQ, a questionnaire used in screening for neuropathic components; however, we could not demonstrate significantly high PDQ scores in PHI-positive patients. More specifically, our results do not show widespread pain of a neuropathic nature. Itch intensity showed an association with PDQ scores only in the acute stage, when a moderate, positive correlation was observed. However, no correlation was noted in the other stages. To elaborate, PHI patients do not necessarily have a neuropathic component to their condition, and neuropathic pain therapies may not be effective against PHI in some cases.We did not investigate synchronism for pain and itch in this study. Thus, we believe further investigation is needed. The occurrence of itch in pain-free intervals would seem to suggest that the neural pathways for pain and itch probably differ. At the very least, we believe that the nature of neuropathic pain is not a characteristic component of PHI and that pain and itch accordingly require different therapeutic approaches.We investigated the relationship between pain and itch in herpes zoster. We could not demonstrate a large neuropathic component for PHI in herpes zoster patients; pain and itch may have different mechanisms. Thus, PHI-focused therapies are needed, and we anticipate further research to establish such therapies for PHI.


Frailty is a term usually defined as a syndrome of physiological decline in late life, characterized by a state of increased vulnerability to stressors. It entails a high risk of adverse outcomes, such as functional deterioration, institutionalization, hospitalization and death. Pain is also likely to have a serious impact on older people who haveThe belief that ‘‘pain is just a part of getting older” is pervasive among patients and providers, and this notion might hinder effective treatment for the problem.With both conditions common among the elderly, particularly in hospitalized patients, the possibility of a correlation between frailty and pain has been raised. Elderly patients comprise a large proportion of admissions to Internal Medicine wards, therefore, both frailty and pain are frequently observed in this setting.In this letter, we report a small study which aimed to examine the correlation between frailty and pain in elderly patients admitted to an Internal Medicine ward. Consecutive patients, aged 65 or older, admitted during a 1-month period were recruited for the purposes of the study. All patients provided their written informed consent before their inclusion.We measured frailty using the Portuguese version of Tilburg Frailty Indicator (TFI)Of the 63 elderly patients admitted, 41 were included in the study. The mean age of participants was 79±6.0 years and 70.7% of the patients were women. A total of 58.5% patients were considered frail (TFI score ≥6). Mean TFI total score was 6.0±2.6 points. Mean physical domain score was 3.5±1.6, psychological domain score 2.0±1.2 and social domain score 0.4±0.5 points.Pain was reported in 80.5% of the patients, who had a mean score of 58.5±8.1 on the PIQ-6. There was a previous ambulatory prescription of pain medication in 9.8%. During admission, 56.1% had analgesic therapy . At discharge, 11.1% had an analgesic therapy prescription.Pain and frailty were higher in women and in the group aged >80 years, but this was not statistically significant (p=0.07).A higher PIQ-6 score was correlated with a higher total TFI, reaching statistical significance (r=0.442; p=0.004 - ,,In conclusion, higher levels of pain were correlated with higher levels of frailty. The concept of pain homeostenosis, where pain could diminish the physiological reserves needed to maintain homeostasis when faced with biological, psychological or social stressors, and therefore precipitate frailty, seems to be a well-supported hypothesis for this association.There are some limitations of this study. We recognize the multidimensional nature of frailty and pain, and that the lack of adjustment for depressive symptoms could be a bias in the study. Despite the small sample, our results emphasize the importance of early detection and interdisciplinary intervention for pain, especially in the elderly population, to help prevent vulnerability and reduce the incidence of complications. Hospitalization is an opportunity to intervene, but there is still much to be done in raising awareness of health professionals.


Chronic low back pain is a common public health problem all over the world. Conservative therapy is prescribed as the initial treatment strategy in chronic low back pain. The cornerstone of conservatism in back care is core muscle strengthening. However, exercises prescribed for the purpose are manifold and some are not easily done by patients in Asian countries. We developed an easy to adhere exercise protocol for core stabilization and tested its effectiveness in south Indian population.Prospective study of 73 patients with chronic low back pain (CLBP) who were subjected to Trivandrum Community-based Core Stabilisation protocol of treatment. The enrolled patients underwent initial Oswestry Disability Index (ODI) evaluation and Keele Start Back (KSB) questionnaire before starting the protocol. Back education was given, and the patient started on stratified exercise protocol. ODI assessment was done weekly. The trend in ODI changes and the factors determining them were assessed using ANOVA. The correlation of quantitative variables like age, initial ODI score, and KSB score with the rate of reduction of ODI was assessed using Pearson’s correlation. Cross-tabulations were done using the chi-square test. Parametric tests were used throughout the analysis as the quantitative study variables found to be linear. Multiple linear regression (for the quantitative outcome) and binary logistic regression (for the dichotomous outcome) were performed.p value < 0.001). The trend in reduction of ODI scores was significantly more in KSB score less than or equal to 3 compared to KSB more than 3 even after adjusting for the general trend of decreasing ODI score over time. The reduction in ODI scores appeared to be low for advancing age (p = 0.468) and higher KSB scores (p = 0.001).Mean (SD) of ODI score has reduced significantly from 43.4 (16.6) to 24.6 (17.1) over the period of 6 weeks (The TRICCS protocol is effective in a community-based approach in achieving satisfactory outcomes in CLBP in a period of 6 weeks. Patients with high KSB scores may require cognitive intervention also. Low back pain is a common musculoskeletal problem affecting the population both in developing and developed world. It is the major cause of work absenteeism and musculoskeletal disability . ChronicDysfunction of the motion segment of the spine . This group shows varying degrees of discal degeneration in MRI as demonstrated by Pfirrmann et al.  orNonspecific chronic low back pain which may not show significant degenerative changes in MRI.Chronic low back pain (CLBP) is defined to be back pain lasting more than 12 weeks. Chronic low back pain may be associated with true radicular symptoms in patients with canal or foraminal compromise or pseudoradicular leg pain where the pain does not fall into a particular dermatomal pattern. CLBP is generally assumed to be due to:The aim of the present study was to test the effectiveness of an exercise protocol (TRICCS protocol described later in the article) focused on core stabilization in patients with CLBP. The exercises should be easy to perform and culturally acceptable. The protocol should be easy to implement in communities with minimal resources.The study was approved by the Institutional Research and Ethics committee. Prior written consent was obtained from the patients.Patients with CLBP (low back pain of more than 3 months duration) between the age groups 18 and 70 years who come from suburban location around Government Medical College, Trivandrum, were included in this study. They should possess at least higher secondary education. This was deemed necessary as patients had to understand the philosophy behind conservative management. Their place of residence should be within 40 min travel distance to the clinic.Patients with other causes of back pain like fractures, tumors, high-grade spondylolisthesis, and infections.Patients with psychiatric illness.Patients who did not receive minimum higher secondary education. All the patients were referred to our clinic from general practitioners.During the first visit, a patient with low back pain was assessed by orthopedic spinal surgeon with radiographs and MRI. Those patients who were assigned as non specific CLBP formed part of the study.During the initial visit itself, these patients were counseled about the nature of the disease and were given a back education referring to the anatomy of the spine. Patients were encouraged to be interactive so that clear knowledge about the anatomy of the spine is acquired. They undergo the Oswestry Disability Index (ODI) assessment and Keeles Start Back (KSB) questionnaire by a nurse who is not involved in the treating group . In the Patients are reviewed every week, and depending on the ability to perform the basic exercises, they are graduated to do the intermediate exercises. The intermediate exercises were supine bridge exercises, prone bridge exercises, quadruped, and side bridge exercises Fig. . Twenty Those who were able to perform the intermediate set of exercises were trained to perform the above set of exercises lying on a physio ball. These form the advanced exercises Fig.  and helpThe KBS score and the weekly ODI scores were tabulated in excel sheets. Every week, patients received a phone call to remind them about the exercise that they have to do. Patients were followed up weekly in the clinic for a period of 6 weeks; thereafter, a telephonic interview was conducted at 3 months and 6 months.t test was used as the statistical test to compare the mean and standard deviation of quantitative variables with a dichotomous outcome . Cross-tabulations were done using the chi-square test. Parametric tests were used throughout the analysis as the quantitative study variables found to be linear. Multiple linear regression (for the quantitative outcome) and binary logistic regression (for the dichotomous outcome) were the multivariate analyses performed.The major outcome variables of the study are the trend in ODI scores measured repeatedly, reduction in ODI score as a percentage of the initial ODI score, and the final ODI score with a score 20 or less was taken as no or minimal disability. The trend in change of ODI score over the repeated observations and the factors contributing to the difference in the trend was assessed using repeated measure ANOVA. The correlation of quantitative variables like age, initial ODI score, and KSB score with the rate of reduction of ODI was assessed using Pearson’s correlation. Independent sample Eighty patients were enrolled; however, 7 patients did not complete the entire duration of the study. So there were 73 patients aged 13 to 65 years with a mean (SD) age of 39.81 (12.58) years who completed the study. Forty-four (60.3%) study participants were women. Fifty (68.5%) had a KSB score of 3 or less, 21 (28.8%) had a score of 4 to 6, and 2 (2.7%) had a KSB score more than 6. The initial ODI score (ODI 1) ranged from 14 to 82 with a mean (SD) 43.40 (16.56). Final ODI value (ODI 6) ranged from 2 to 70 with a mean (SD) of 25.20 (16.39). The reduction in ODI scores from ODI 1 to ODI 6 ranged from 0 to 92.86% of the initial ODI value with a mean (SD) of 46.64 (24). The proportion of people with an ODI value less than 20 at the end of follow-up was as high as 58.90%. The number (%) of participants who had an initial value 50 or more was reduced from 26 (39.4%) to 7 (10.6%). Eight participants (30.8%) out of the 26 patients with high ODI (above 50) scores received epidural injections.p value < 0.001, repeated measure ANOVA). KSB score was the only significant factor associated with the difference in the trend of ODI reduction. The trend in reduction of ODI scores was significantly more in KSB less than or equal to 3 compared to KSB more than 3 even adjusting for the general trend of decreasing ODI score over time  and KSB scores  were the two factors significantly correlated to the rate of reduction of ODI scores. The reduction in ODI scores appeared to be low for advancing age and higher KSB scores. However, the initial ODI score was not significantly correlated to the rate of reduction of ODI following the treatment protocol. The mean (SD) rate of reduction for men was slightly more than that of women [48.04 (21.16) % and 44.96 (24.63) % respectively]. But the difference was not statistically significant. The epidural injection was not significantly associated with the rate of reduction of ODI in patients with initial ODI scores 50 or above. Multiple linear regression analysis revealed that KSB score is the only factor significantly correlated to the rate of reduction of ODI score adjusting for initial ODI score and age (Table p < 0.001). The mean (SD) values of KSB scores for no disability and some disability were 2.39 (1.42) and 3.62 (1.50) respectively (p = 0.001). Logistic regression analysis also showed that these factors were significantly associated with a disability-free outcome even adjusting for the confounding  postural exercises, (b) aerobic exercises, (c) stretching exercises, and (d) core stabilization exercises. However, most clinicians will prescribe a combination of these exercises. Exercises prescribed for the western population are not suitable to most people in suburban India. It is generally observed that patients after starting the exercise may have an exacerbation of symptoms and they drop out of the exercise therapy. Hence, it is important to train patients in the correct way of performing the exercise. The exercises should be easy to be trained and performed. They should be taught with minimum resources. The population of suburban India is not fitness freaks. The Indian Council of Medical Research (ICMR) study  on physiTaking the above factors into consideration, our team analyzed various core exercises and zeroed them into three sets of exercises which we grouped into basic, intermediate, and advanced.Anatomically, the core is the musculature that surrounds the lumbopelvic region and includes the abdominals anteriorly, the paraspinal and gluteals posteriorly, the pelvic floor musculature inferiorly, the hip abductors and rotators laterally, and diaphragm superiorly. All these muscles have direct or indirect attachments to the extensive thoracolumbar fascia and spinal column, which connect the upper and lower limbs). The core muscles can be divided into two groups according to their functions and attributes. The first group of muscles is composed of the deep core muscles, which are also called local stabilizing muscles. These muscles primarily include the transversus abdominis, lumbar multifidus, internal oblique muscle, and quadratus lumborum , 6. The Passive system constitutes the vertebrae, intervertebral discs, zygoapophyseal joints, and ligaments.Active system constitutes the muscle and tendon surrounding and acting on the spinal columns.Neural system constitutes the nerves and CNS which directly controls the active system in providing dynamic stability .Core stability is influenced by the interaction between passive, active, and neutral control systems:The neutral zone is a region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column. Several studies—in vitro cadaveric, in vivo animal, and mathematical simulations—have shown that the neutral zone is a parameter that correlates well with other parameters indicative of instability of the spinal system. It has been found to increase with injury, and possibly with degeneration, to decrease with muscle force increase across the spanned level, and also to decrease with instrumented spinal fixation. In most of these studies, the change in the neutral zone was found to be more sensitive than the change in the corresponding range of motion. The spinal stabilizing system adjusts so that the neutral zone remains within certain physiological thresholds to avoid clinical instability .It is a widely used tool to assess disability following back pain. The score is calculated by the addition of the values assigned for each of the 10 individual questions and is used to categorize disability as mild or no disability (0 to 20%), moderate disability (21 to 40%), severe disability (41 to 60%), incapacity (61 to 80%), and restricted to bed (81 to 100%). The minimum clinically important difference in ODI was found to be 12.8 . In the The first step was to find the painless range of motion of the spine for a particular patient. Patients were encouraged to start the exercise regimen within this zone. We do not propose any new exercises that are not an already established core strengthening exercise. But we have picked few exercises that are easily doable for the Asian population and proposed a protocol which is effective in achieving improvement. As patients became accustomed to the exercise regimen, their pain-free range increased. Foundation set of exercises include abdominal tights, pelvic tilts, partial curls, and back extension. The intermediate set of exercises includes supine bridge, side bridge, prone bridge, and quadruped exercises. The advanced set includes doing the above exercises in an unstable platform like exercise ball and advanced quadruped exercises. When doing pelvic tilt exercises, patients were asked to concentrate on their deep core—transverse abdominis. They were asked to lie down in a supine position and asked to bring their hips together. This movement will contract their transverse abdominis. Patients were asked to do 20 repetitions of each exercise twice daily. Core stabilization exercises done over a physio ball has shown early and better achievement of core stability . Neural It is important to use a tool which stratifies patients with chronic low back pain. CLBP has an emotional component as well, and many patients need an assessment of their psychological profile as well.Keeles Start Back questionnaire is a simple tool to stratify patients based on their future risk of disability. Historically, anxiety, depression, fear avoidance practices, and inappropriate expectations have all been linked to chronicity of low back pain. Keele Start Back Tool helps in the stratification of CLBP patients into three groups—low risk who require no intervention other than education about back care, medium risk who will require physiotherapy, and high-risk group who will require behavioral adaptive interventions . UsefulnWhat is key to a successful TRICCS protocol is the patients’ adherence to the exercise regimen. Not only during the monitored physiotherapy schedule, but also the exercise adherence of the patient outside of the clinical setting is important. Mannion et al.  have shoOur study shows that TRICCS protocol of core strengthening is able to achieve a significant reduction in back pain-related disability in a self-help model based in a community setting. Adherence to the program is also high, and significant improvement can be expected in 6 weeks. Younger age, lesser ODI score, and lower KBS score guarantee a positive result. Patients with higher ODI score and high KBS score will require longer duration, and this can be informed to the patient at the start of treatment itself.Disability due to CLBP is a growing health care task all over the world. Hospital-based settings of treating CLBP are expensive models and are not reachable to the working population in the developing world. Hence, peripheral level models have to be developed to lessen the burden of this public health problem. In developing TRICCS protocol, our attempt was to make a simple and practical management algorithm which can be easily implemented in the community using the three-tier health system which is robust in the state of Kerala.Our results show that the TRICCS protocol is quite successful in treating chronic low back pain. What makes the protocol stand out is its simplicity which will help in community intervention for CLBP. Selected patients can be offered the service of behavioral therapists from the beginning itself so that the days of chronic pain and disability can be lessened.


Interventional techniques to manage cancer-related pain may be efficient treatment modalities in patients unresponsive or unable to tolerate systemic opioids. However, indication and selection of the right technique demand knowledge, which is still incipient among clinicians. The present article summarizes the current evidence regarding the five most essential groups of interventional techniques to treat cancer-related pain: Neuraxial analgesia, minimally invasive procedures for vertebral pain, sympathetic blocks for abdominal cancer pain, peripheral nerve blocks, and percutaneous cordotomy. Furthermore, indication, mechanism, drug agents, contraindications, and complications of the main techniques of each group are discussed. Nociception is the process by which information about actual or potential tissue damage is conveyed through the spinothalamic tract to the brain, where the information is processed and interpreted, and the descending pain modulatory system is activated . The intMost patients with cancer-related pain obtain satisfactory pain relief from medications that are referenced in the WHO analgesic ladder . HoweverA careful assessment of the patient is important to achieve satisfactory outcomes. This assessment includes patient characteristics, previous treatments, pain characteristics and mechanisms, patients’ preference, and skills and logistics to perform the selected invasive technique. Moreover, interventional techniques imply risks for complications. Therefore, potential benefits and harms should be considered for each patient .The present article aims at summarizing current evidence and improving specialist clinicians’ knowledge regarding the five most essential classes of interventional techniques to treat cancer-related pain: Neuraxial analgesia, minimally invasive procedures for vertebral pain, sympathetic blocks for abdominal cancer pain, peripheral nerve blocks, and percutaneous cordotomy. For each technique, we will briefly review indications, mechanisms, drug agents, current evidence, contraindications, and complications.When systemic analgesics are exhausted, the selection of patients for neuraxial therapy  is often based on location and mechanism of pain—especially when considering the benefits of adding local anesthetics ,6 or othA systematic review  analyzedContraindications to neuraxial therapy may exist in fragile patients, and complications of varying severity are described in the literature . They inPercutaneous vertebroplasty (PV), kyphoplasty (KP), radiofrequency ablation (RFA), and cryoablation (CA) are minimally invasive procedures indicated for the relief of vertebral bone pain in patients with metastatic lesions and/or compression fracture without neurologic sequelae. Despite the reported effectiveness and low risk associated with these interventions, availability of trained staff, lack of precise indications, and the high costs render the access to minimally invasive procedures sparse . Thus, tPV usually involves percutaneous injection of a cement, polymethylmethacrylate into the vertebral bodies, which can provide a mechanical stabilization of the lesion/compression fracture, increase bone strength and alleviate pain. KP is a variation of PV, which is performed by inflating a balloon in the vertebral body to make an empty space where the cement can be placed to correct vertebral height and kyphotic irregularities. In RFA, bone tumor or metastases are ablated using the heat generated from medium frequency alternating current. CA is an alternative to RFA in patients with metastatic bone disease and it is performed using cryoprobes, through which cooled, thermally conductive fluids are circulated. The area of tissue destruction created by this technique can be delimited more effectively by computed tomography than RFA. This is a potential advantage when treating tumors adjacent to critical anatomical structures. These techniques have gained worldwide application for back pain due to osteoporotic and malignant vertebral collapses refractory to conservative treatment . HoweverSeveral trials suggested a possible therapeutic role of these procedures, but existing data are often limited to series with a low number of patients, retrospective designs, or mixed populations. The low number of patients and the poor quality of data have not yet provided evidence for efficacy in cancer patients with vertebral tumors or metastases. Many factors confounded the interpretation of data and included a low accrual rate, patients with different types of fractures, unclear evaluation of fractures, other causes of pain, problematic sham designs, and lack of proper clinical examinations to determine the causes of pain . A systeContraindications for these invasive procedures are coagulopathy, neurological symptoms by vertebral compression or tumor encroachment on or within the spinal cord, complete collapse of the vertebra, presence of systemic or local infections, and certain types of lesions, such as osteoblastic metastasis ,19. CompThe neurolytic blockade of sympathetic pathways at different levels are indicated to patients with abdominal pain with a visceral mechanism, although abdominal pain often has concomitance of different pathophysiological mechanisms . The celCeliac plexus block (CPB) was claimed for the treatment of cancer-related pain originating from upper abdominal viscera, while the superior hypogastric plexus block (SHPB) is targeted for lower abdominal pain. These blocks interfere with neural conduction to abolish or reduce pain. Afferent and efferent conduction may be disrupted by injection of local anesthetics . DiffereA systematic review performed in 2014 investigated the evidence to support the treatment of adult patients with abdominal cancer-related pain with sympathetic blocks. The analysis included papers on sympathetic blocks compared with analgesic drugs/placebo and was conducted in adult patients with cancer-related pain. Twenty-seven studies were analyzed; 15 were RCTs, but only four were double-blind . It was The most appropriate timing for performing CPB is still controversial. It was suggested that CPB should be performed early, even in the presence of mild pain or in patients receiving low doses of opioids ,36,37,38Data regarding SHPB is sparse, as only one controlled clinical study has been produced . The oriGeneral contraindications for neurolytic blocks of sympathetic pathways include tumor invasion into the insertion site, coagulopathy, systemic or localized infection, complicated anatomy, and bowel obstruction ,48. RepoA logical approach for pain otherwise difficult to treat is to block peripheral nerves with local anesthetics and thereby block the signaling of nociceptive input to the central nervous system. The selection of which nerve block to apply is dependent on the source of pain. Therefore, the physicians involved in administering peripheral nerve blocks must have good knowledge of the innervation supplied from each nerve and the anatomical localization and access to the nerve. Peripheral blocks currently reported that are applied to cancer-related pain include paravertebral blocks, brachial plexus blocks, blocks of nerves in the head region, and intercostal nerves.The drugs used for nerve blocks are local anesthetics, which have to be applied continuously or intermittently because of a limited duration of action. Local anesthetic in use are lidocaine, bupivacaine, and ropivacaine, among others. The analgesic effect is similar, while toxicity may differ in relation to cardiac events and other local anesthetic toxic events. However, if the local anesthetic is given within the recommended dosages, the risk for toxicity is minimal. The duration of each local anesthetic action differs. Lidocaine is typically considered a local anesthetic of intermediate action (1.5–3 h), while bupivacaine and ropivacaine are long-action local anesthetics (4–18 h) . The durThe evidence for use of peripheral blocks is limited. A systematic review published in 2015 identified 16 papers, which reported a total of 79 cases . The nerIn summary, the evidence for use of peripheral blocks for cancer-related pain is still anecdotal. Still, the published cases illustrate the potential benefit from use of peripheral blocks. New techniques such as ultrasound identification of nerves, now routinely applied for use of local anesthesia during surgical procedures, will ease the placement of catheters for administration of local anesthetics. Moreover, techniques to ensure that catheters do not dislodge can be improved. Thus, physicians involved in treatment of cancer-related pain could benefit from collaboration with anesthesiologist involved in orthopedic surgery . At the Local anesthetics have adverse effects related to the potential drug toxicity, to the effects from the nerve block in itself or as a complication to the procedure. Toxicity is not a clinical issue given that the local anesthetic is administered at recommended doses and not inadvertently injected intravascularly. However, because of a low, but still present risk of acute toxicity (cardiac toxicity and seizures) due to an intravascular injection, physicians administering nerve blocks should have the knowledge and equipment available to handle such incidents. Complications related to the effect from local anesthetic is not a major clinical issue. If, for instance, a plexus nerve block is given in a dose that paralyses the arm, the local anesthetic dose can simply be reduced, or the infusion discontinued, and motor function will resolve. Also, complications related to the procedure of insertion is not reported for patients with cancer-related pain. There may be a risk for nerve injury resulting in neuropathic pain but given that the procedure is performed by skilled personnel using adequate techniques, this risk is small. Moreover, peripheral block is not associated with risk such as meningitis, epidural abscesses or hematomas feared by central blocks. Neurolytic peripheral blocks, on the other hand, will result in permanent disability if wrongly performed, and may—if correctly performed—after some time, result in neuropathic pain caused by reinnervation. Therefore, neurolytic blocks should not be the first-choice treatment. It should be used rarely and only in patients with expected short survival time (<3 months).Percutaneous cordotomy by radiofrequency has become a viable choice due to advances on fluoroscopic equipment and the possibility of performing the procedure under sedation instead of general anesthesia , which represents an advantage to fragile patients with advanced cancer. However, this intervention causes an irreversible disruption of the nervous conduction and, therefore, risks and consequences should be examined carefully. The selection of patients with cancer for this procedure is based on presence of malignant unilateral pain refractory to systemic treatment and other nondestructive interventions, life expectancy of few years or less considering the possibility of pain recurrence , and anatomic location of the intervention that permits a safe procedure ,57. It iPercutaneous cordotomy is a thermal lesion caused by radiofrequency electric current in spinothalamic tract contralateral to the side of the pain, interrupting conduction fibers and selectively eliminating pain and temperature sensation from the affected half of the body. Its mechanism is unclear, but alteration on descending impulse or dorsal horn modulation, damage of C fibers and immunomodulatory effect may all play a role on pain transmission . In convRetrospective and uncontrolled studies suggested that percutaneous cordotomy is effective in reducing pain, and decreasing or discontinuing opioid use ,60,61. HThe side effects of this procedure include numbness and dysesthesias below the level of the lesion. Contraindications are abnormal coagulation, infection, severe respiratory dysfunction, and advanced disease that hinders positioning the patient correctly during the procedure . BilaterThe present review is not exhaustive regarding interventional techniques to the management of refractory cancer-related pain. However, other invasive techniques, e.g., midline myelotomy and stereotactic cingulotomy, are otherwise promising based on very few up-to-date small size series ,68. Desp


We aimed to evaluate the prevalence, characteristics and impact of breakthrough pain (BTP) in patients with cancer attending the main specialties involved in the diagnosis and management of BTP in Spain using a multicenter, observational, cross-sectional, multidisciplinary study. Investigators had to record all patients seen at the clinic during 1 month, determine whether the patients had cancer pain, and apply the Davies algorithm to ascertain whether the patients were suffering from BTP. Of the 3,765 patients with cancer, 1,117 (30%) had cancer-related pain, and of these patients, 539 had BTP . The highest prevalence was found in patients from palliative care , and the lowest was found in those from hematology . Prevalence varied also according to sex and type of tumor. According to the Alberta Breakthrough Pain Assessment Tool duration, timing, frequency, location, severity, quality, causes, and predictability of the BTP varied greatly among these patients. BTP was moderate (Brief Pain Inventory [BPI]-severity median score = 5.3), and pain interference was moderate (BPI-interference median score = 6.1) with a greater interference with normal work, general activity, and enjoyment of life. Patients with BTP showed a mean ± standard deviation score of 28.5 ± 8.0 and 36.9 ± 9.5 in the physical and mental component, respectively, of the SF-12 questionnaire. In conclusion, prevalence of BTP among patients exhibiting cancer-related pain is high. Clinical presentation is heterogeneous, and therefore, BTP cannot be considered as a single entity. However, uniformly BTP has an important impact on a patient’s functionality, which supports the need for early detection and treatment. A Spanish consensus on BTP in patients with cancer considers that treatment with opioids is a requirement for its diagnosis2. However, this condition is far from a uniform clinical entity, and even experts in this area consider that transient exacerbation of pain can occur without background pain or when background pain is uncontrolled or regardless of opioid treatment4.Breakthrough pain (BTP) has been defined as a “transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger despite relatively stable and adequately controlled background pain”5. It should be noted that there are several definitions and methods of classifying BTP as well as several tools for screening and/or diagnosing this condition6. Deandrea et al.7 in a systematic review of 19 studies, found the lowest prevalence (40%) of BTP in studies conducted in outpatients and the highest prevalence in those conducted in a hospice setting (≈80%); they estimated an overall pooled prevalence of 59%.Breakthrough pain (BTP) is a common problem encountered in clinical practice in patients with cancer, has a heterogeneous clinical presentation, and is associated with an important impact on the patient, family, caregivers and society. The prevalence of BTP varies greatly depending on the study, especially on the definition and the setting8. In that study, the median number of episodes of BTP ranged from 1/month to 24/day, the median time to peak intensity ranged from less than 1 minute to 240 minutes, and the pain intensity was moderate in 34% of patients and severe in 62% of patients8. Similar heterogeneous presentation of BTP has been reported in surveys conducted in Canada9 and Norway10, and the clinical picture appears very similar on both sides of the Atlantic11. Age, type of cancer, performance status, background pain intensity, and mechanism are among the factors affecting the clinical presentation of BTP12. Breakthrough cancer pain has an important impact on the individual in terms of the impairment of daily life activities and quality of life. Most patients with BTP report that pain stops them from doing something8. In patients with advanced cancer, those exhibiting BTP had greater impairment in most dimensions of quality of life than those without BTP13. BTP not only interferes with general activities but also has a negative impact on pain management; in a study conducted on 258 patients who had received opioids, the presence of BTP was associated with a lower likelihood of achieving personalized pain goals14. Finally, BTP is responsible for a substantial economic burden due to the increased utilization of healthcare services, including hospitalization15.The clinical picture of BTP varies greatly from patient to patient. In a European study conducted in 1,000 patients with cancer, 44% had incident pain, 41.5% had spontaneous pain and 14.5% had a combination of both forms of presentationet al. recently reported a prevalence of BTP of 39% and great variability in the type of presentation using a retrospective evaluation with the Davies algorithm16. Very recently, Camps et al. reported the results of a survey conducted by 108 medical oncologists throughout Spain and found that 493 (91%) of the 540 patients evaluated exhibited BTP also using the Davies algorithm; more importantly, over 40% of the cases of BTP had not been previously detected by the medical oncologist17.Information on the prevalence and clinical characteristics of BTP in Spain is very limited. In a study conducted on a sample of patients with advanced cancer attending the palliative care outpatient clinic of a university hospital in Lleida, Canal-Sotelo The primary objective of this study was to evaluate the prevalence of BTP in patients with cancer attending the main specialties involved in the diagnosis and management of BTP in Spain . Secondary objectives included evaluating the 1-month cumulative incidence of BTP, describing the clinical characteristics of patients with undiagnosed BTP, and evaluating the impacts on daily activities and quality of life.This was a multicenter, observational, cross-sectional, multidisciplinary study conducted in outpatients of the medical oncology, radiation oncology and hematology departments as well as in those attending pain and palliative care units from November 2016 to April 2018. The study was approved by the Ethics Committee of the Hospital La Princesa  and conducted following the principles of the Helsinki Declaration.1, the patient had to exhibit pain for ≥12 hours/day during the previous week, or pain had to be present if not taking analgesia; the background pain had to be rated as none or mild but not moderate or severe for ≥12 hours/day during the previous week; and the patient had to present transient exacerbations of pain. Patients were excluded if they had a severe mental disorder or had a medical condition or other situation that in the investigator’s judgment greatly interfered with data collection.The study was undertaken in two steps. In the first step, to evaluate the prevalence of BTP, participant investigators had to record all patients seen at the clinic during 1 month, determine whether the patients had cancer pain, and apply the Davies algorithm to ascertain whether the patients were suffering from BTP. In addition, investigators recorded information on age, sex, Karnofsky performance status, type of tumor and stage. In the second step, to analyze the characteristics of patients with cancer and BTP, participant investigators had to recruit the first two patients of each day who met the selection criteria up to a maximum of 10 patients. To be included in this second step, patients had to be 18 years or older, present oncologic pain adequately controlled with opioids, meet the criteria of BTP according to the Davies algorithm, not be under treatment for BTP, and give written informed consent. To meet Davies’ criteria18, the Alberta Breakthrough Pain Assessment Tool20, the Karnofsky scale21, and the SF-12 questionnaire23. The participant investigators did not received any training on the hetero-administered evaluation tools.In patients who met the selection criteria, we recorded information on age, sex, type of cancer and tumor stage at the time of diagnosis, previous treatment with surgery, chemotherapy and/or radiotherapy, current tumor stage and treatment, and the presence of the following signs or symptoms: mucositis, nausea/vomiting, constipation, bone fractures, xerostomia, peripheral neuropathy or other. The presence of comorbidities was evaluated using a checklist including the following entities: ischemic heart disease, heart failure, peripheral arterial disease, cerebrovascular disease, dementia, Parkinson’s disease, hemiplegia, chronic respiratory disease, connective tissue disease, gastroduodenal ulcers, mild chronic hepatic disease, moderate/severe chronic hepatic disease, diabetes, diabetes with target organ damage, moderate/severe chronic renal disease, AIDS, and second neoplasia. The following characteristics of the BTP were evaluated: iatrogenic origin, the mechanism , triggers , location and type. According to the intensity and duration and based on the anamnesis, pain had to be classified as type I (pain with a short duration and high intensity that begins and ends suddenly), type II , type III  or type IV . Finally, the following evaluation tools were applied: the Brief Pain Inventory (BPI)20.The Alberta Breakthrough Pain Assessment Tool (ABPAT) consists of a patient self-reporting section (15 questions) that assesses the relationship of pain flares to background pain, further probes for details about sources of relief, and enquires about the timing, frequency, location, severity, quality, causes, and predictability of the BTP; the last four items of the tool were not included since they are related to the treatment of BTP. The ABPAT also has two questions to be answered by the physician or the nurse concerning the etiology and pathophysiology of pain. The ABPAT has been validated in patients with cancer pain who present with BTPWith a precision of ±1%, a confidence level of 95%, and an expected frequency of 50% of patients presenting with BTP , a minimum sample of 13,200 patients seen at the investigators’ clinics was needed.Quantitative variables are described with the mean and the standard deviation (SD) or, if needed, with the median and the interquartile range (IQR). Qualitative variables are described with absolute and relative frequencies.To calculate the prevalence of BTP, we included the number of patients with BTP as defined with Davies’ criteria in the numerator and the number of patients with oncologic pain adequately controlled with opioids in the denominator; the corresponding 95% confidence interval was also calculated. The prevalence of BTP is also presented by age, sex, specialty, type of tumor, tumor stage, and performance status. The cumulative 1-month incidence of undiagnosed BTP was calculated in the same way but using new cases of BTP  in the numerator. A subgroup analysis according to age (<70 and ≥70 years) was also performed.All analyses were performed using IBM SPSS Statistics version 22.The study was approved by the Ethics Committee of the Hospital La Princesa .Written informed consent was obtained from every subject.A total of 3,765 patients were seen at 32 sites by 43 specialists from pain units (n = 15), radiotherapeutic oncology (n = 9), medical oncology (n = 7), hematology (n = 6) and palliative care (n = 6). Patients were predominantly male , aged below 70 years  and with a performance status of 80 or below in 1,841 (49%) of the 3,751 patients with available information. The most frequent types of tumors were multiple myeloma  and breast cancer , and most patients had stage III/IV tumors .Of the 3,765 patients with cancer, 1,117 (30%) had cancer-related pain, and of these patients, 539 had BTP  Fig. . The higOf the 539 patients with BTP, we recruited 207 consecutive patients who were not receiving treatment for BTP, mostly from pain units (36%), radiotherapeutic oncology (22%) and medical oncology 17%)  patients and incidental in 118/206 (57%). Among patients with incidental pain who were further categorized depending on the trigger (n = 117), BTP was volitional in 78 (67%), nonvolitional in 29 (25%) and procedural in 10 (9%). Depending on the intensity and duration  and interference (median score of 7.9) as well as the worst quality of life ; the mean Karnofsky score was significantly lower in patients with type III BTP (58 in type III BTP vs. 65–69 in the remaining types of BTP).In a This study across several specialties dealing with cancer shows that breakthrough pain is present in almost half of the patients with cancer-related pain and is more common in patients with nonhematologic tumors, especially those with pancreatic or colorectal cancer. The characteristics of treatment-naïve breakthrough pain are heterogeneous, although in a majority of patients it is nociceptive, severe and associated with a relevant impairment of daily life.16. However, other studies conducted in Spain have found higher prevalence rates. Thus, in a recent study conducted by 108 medical oncologists, Camps et al. reported a prevalence of 91% of BTP using the Davies algorithm17. We think that the selection of patients in that study could explain, at least in part, this high prevalence of BTP; these authors selected patients who, before the start of the study, had been treated by the participant oncologists as patients suffering some kind of cancer-related pain17. In contrast, we based our selection on all patients with cancer seen at the participant sites, except for patients seen at pain units, regardless of whether they had cancer-related pain. The authors of the validation of BPI in cancer patients in Spain also found a higher prevalence of BTP (70%)18. However, they also selected patients who already had cancer-related pain and diagnosis of BTP was not based on the Davies algorithm but on the physician evaluation18. Overall, we think that, bearing in mind the patient selection process, the figures reported by Canal-Sotelo et al.16 in their unicenter study and our figures probably better reflect the quantitative dimension of the problem in Spain. Our results are also consistent with those reported by Greco et al.24 in Italy, who found a prevalence of BTP of 52% using the Edmonton Staging System in patients with cancer and pain. They are also consistent with those of a European survey that, similar to us, was conducted by several specialists dealing with cancer-related pain  and found that 289 (42%) out of the 682 patients with cancer pain had BTP using the definition of BTP included in the ABPAT13. Finally, our prevalence figures are within the range reported by Andrea et al. in their systematic review of the literature7.We found that 48% of patients with cancer-related pain had BTP. This figure is consistent with the results of a retrospective study recently conducted in a single center in Spain, which, using the Davies algorithm in outpatients from the palliative care department, found a prevalence of BTP of 39%12, but we are not aware of similar studies reporting the prevalence of BTP according to the type of tumor, and therefore, our results could not be put into perspective in this regard. Consistent with the lowest prevalence among patients with hematologic malignancies, the prevalence of BTP was much lower in hematology (25%) than in other specialties involved in our study, especially among patients treated in the palliative care department (61%). Greco et al.24 in a study conducted in Italy also found a higher prevalence in patients from palliative care, pain units and hospices compared to those treated in oncology departments/centers.According to our results, the prevalence of BTP varies depending on the type of tumor, with the highest prevalence being in patients with pancreatic pain and colorectal cancer and the lowest in patients with hematological malignancies. The type of tumor may influence some clinical characteristics of BTPet al.7 also found that the prevalence of BTP is higher in patients from palliative care and those managed in a hospice. This latter study also identified several other factors affecting the prevalence of BTP; thus, prevalence was higher in older patients, males, and those with advanced disease7. Our results are somewhat consistent with this pattern, although there were only slight differences in prevalence rates between males and females and between patients aged ≥70 years and those <70 years. The prevalence of BTP also varies with performance status and tumor stage, but regardless of these characteristics, the prevalence is high in every subgroup. All these data support that, as recommended by the experts4, all patients with cancer-related pain, regardless of tumor stage or functional status, should be screened for the presence of BTP.In a systematic review of the literature, Deandrea et al. in 13 European countries8, and the results from Europe do not seem to greatly differ from those from Canada11. Consistent with previous studies26, we found an important variability regarding time to peak intensity and pain duration. More uniform are the results regarding the underlying mechanism of BTP and the peak intensity; our results and the literature consistently show that most patients exhibit nociceptive pain with severe intensity and that BTP was triggered by some kind of movement26. According to our results and those from other authors26, in a substantial proportion of patients −37% in our study and over 50% in other studies- BTP is fairly unpredictable. When categorized by its intensity and duration (types I to IV), we found a relevant proportion of patients in each category ranging from 15% of patients exhibiting type III BTP to 33% of those exhibiting type I BTP. Regardless of the characteristics of BTP, it has an important impact on the individual in terms of interferences with work and daily activities; our results using the BPI overlap those of Davies’ in the European survey8. We also found an important impairment of the quality of life as evaluated with the SF-12 questionnaire; however, although we know that BTP contributes to the deterioration of the quality of life in patients with cancer13, unfortunately, we are not able to evaluate the contribution of BTP to this impairment. Interestingly, the characteristics of BTP seem to be associated with a differential impact on quality of life; thus, we found that type III BTP  was associated with greater intensity and interference with daily activities and worst quality of life. These results suggest that the categorization of pain according to intensity and duration may be useful for detecting patients suffering from a greater impact of pain and could provide some orientation for pain management. However, our cross-sectional design does not allow us to establish a causal relationship for this association, and further research is needed in this regard.The type of pain according to its relation to trigger events  was evenly distributed among patients with BTP. Almost overlapping results were found in the study conducted by Davies 27. We think that the apparently low prevalence of cancer pain in our study could be explained in part because in our study patients were recruited from several sources, some of them not commonly included in previous prevalence studies ; other potential explanations are that we excluded patients with pain not secondary to the disease, and that a substantial number of recruited patients had hematological malignancies. Another limitation is that although we intend to include patients with disease-related pain, it is possible that participant investigators have included some patients with iatrogenic pain (e.g. chemotherapy- or radiotherapy-induced neuropathic pain). We think that the need of being stabilized under treatment with opiods –a treatment uncommonly used for these conditions- limits the possibility of these erroneous inclusions. Our categorization of pain according to pain duration and severity was based on ad-hoc evaluation tool and thus requires further replication and validation. Finally, this study was sponsored by a pharmaceutical company and this could have introduced a bias.Study limitations include the already mentioned cross-sectional design for some evaluations and the sample size, which was far below the one estimated in our sample size calculation. This latter issue should be considered in the interpretation of the prevalence results of the several subgroups analyzed due to the lack of precision of the estimates. Overall, the prevalence of cancer-related pain in our study (i.e. 33%) could be considered low. A systematic review of 122 studies found that the prevalence of pain in patients with cancer ranges from 39% to 66% depending on the cancer treatment status17 and undertreated28, and our results indicate that over 40% of patients are able to foretell the occurrence of BTP episodes.In conclusion, our study confirms in the Spanish setting the high prevalence of breakthrough pain among patients exhibiting cancer-related pain. Although the prevalence of breakthrough pain varies according to several factors, including type of cancer, tumor stage and performance status, regardless of these characteristics, it is present in a substantial proportion of patients, indicating that this problem should be investigated in every patient with cancer pain. Clinical presentation is heterogeneous, and therefore, breakthrough pain cannot be considered as a single entity. However, uniform breakthrough pain has an important impact on a patient’s functionality, which supports the need for early detection and treatment, especially considering that some surveys indicate that breakthrough pain is frequently undetected


Chronic pain, regional or widespread, is a frequent and multidimensional symptom in arthritis. There is still limited information on chronic pain in spondyloarthritis, which is important to recognize for adequate diagnosis and treatment. Our objective was to study differences in prevalence of chronic widespread pain in two spondyloarthritis subgroups: ankylosing spondylitis (AS) and undifferentiated spondyloarthritis (USpA).A population-based postal survey involving questions on the duration, distribution, and intensity of pain was answered by 940 patients with AS (ICD-10 M45.9) or USpA . The patients were categorized as having chronic widespread pain, chronic regional pain, or no chronic pain, and prevalence estimates for the pain groups were calculated, including age- and sex-adjusted prevalence.p = 0.033). More women than men reported having chronic widespread pain , while the sex distribution for chronic regional pain was equal. Reports of pain intensity were equal in AS and USpA, with no significant difference in pain intensity between women and men who had chronic regional pain or chronic widespread pain. In the multiple logistic regression analysis, chronic widespread pain was associated to female sex, being an ever-smoker, and having a higher body mass index, controlled for SpA subgroup and disease duration.The prevalence of chronic widespread pain was 45.3% in AS vs. 49.3% in USpA, and that of chronic regional pain was 17.7% vs. 21.9% (The prevalence of chronic widespread pain in patients with AS and USpA is high, and with a female predominance, but with no difference in pain intensity between women and men. Chronic pain can complicate the clinical evaluation in patients with SpA, and highlights the need for a thorough clinical examination, including evaluation of inflammation and an accurate pain analysis, to individualize non-pharmacological and pharmacological treatment decisions. Pain is a frequent and multidimensional symptom in patients with arthritis , 2. AparSpA is a group of chronic rheumatic diseases with similar clinical features such as back pain, asymmetrical peripheral arthritis, enthesitis, and extra-articular manifestations, and includes―among others―AS and undifferentiated spondyloarthritis (USpA) . In SwedThere is an increased attention regarding difficulties of managing chronic pain in SpA in the clinic. But as to date, the few studies exploring chronic pain in SpA have mainly concentrated on patients with AS and pain corresponding to the more complex fibromyalgia (FM) syndrome , with prThe aim of the study was to assess differences in prevalence of self-reported CWP in a population-based cohort of patients diagnosed with AS or USpA, including differences between women and men.The county of Skåne is the most southerly region of Sweden. All healthcare visits, for both inpatients, and outpatients, are registered in the Skåne Health Care Register (SHCR) using unique personal identification numbers. About one-eighth of the Swedish population is covered in the SHCR. Information on the healthcare provider, on the date of visit, and on ICD-10 diagnoses is included in the SHCR. More details of this register are given elsewhere , 31.n = 3711), which was identified through the SHCR during the period 2003–2007. For inclusion in the cohort, a diagnosis of SpA (with ICD-10 codes), was required to be registered, either by a rheumatologist or an internist on one occasion, or twice by any other physician in primary or secondary care on two separate occasions. A validation of the accuracy of the SpA diagnosis in the SHCR has previously been performed, with a valid diagnosis in 98% of the cases [This cross-sectional study made use of the population–based SpAScania cohort , 940 with a diagnosis of AS  or USpA  were included in the study. All patients with a diagnosis corresponding to psoriatic arthritis, IBD-related arthritis, or reactive arthritis were excluded. An analysis of non-responders within the large SpAScania cohort has previously been published . This sh.The questionnaire consisted of several validated patient-reported outcome measures as described elsewhere . Data onFor assessing pain intensity, a numerical rating scale (NRS) was used, ranging from 0 (meaning no pain) to 10 (meaning worst possible pain). For pain to be considered chronic, it had to be persistent or recurrent for more than 3 months during the previous 12 months . The ovePrevalence estimates for self-reported pain in AS and USpA, including age- and sex-adjusted prevalence, were calculated and differences in mean values were analysed with Student’s t-test. Differences in proportions were analysed with chi-square test. Multivariate logistic regression analysis was used to study the associations with (i) chronic pain (CRP and CWP) vs. NCP, (ii) and CWP vs. NCP/CRP, as dependent variables. Age, sex, SpA subgroup, smoking status, and BMI were all included in the analyses as independent variables, and thereby controlled for each other in the analyses. The multivariate logistic regression analyses were done with simple contrast to a reference group for each of the variables. Age- and sex- adjusted prevalence rates were adjusted by the direct method using the Swedish census population of 2009 as a standard population, to adjust for the differences in age and sex distribution in the AS and USpA groups. Analyses were performed using SPSS software version 20 for Windows .The study is reported according to the STROBE  guidelines .n = 570) were older, with a mean age of 54.2 (SD 13.9) years vs. 49.1 (13.6) years, were more often men (65.6% vs. 41.6%), and had a mean disease duration that was twice as long (20.3 (SD 13.5) years vs. 10.3 (9.5) years) as that of patients with USpA (n = 370). There was no significant difference in pain intensity between AS and USpA, but patients with USpA reported having a higher number of pain regions than patients with AS (mean 5.3 (SD 4.9) vs. 4.5 (4.5), p = 0.019) (Table p ≤ 0.001) and a higher number of pain regions than men (mean 5.7 (SD 4.8) vs. 4.1 (4.6), p ≤ 0.001). Differences between women and men in the AS and USpA subgroups are presented in Table p = 0.005). In addition, self-reported use of sDMARDs and bDMARDs were similar between patients in the three pain groups , but more patients with CWP reported using corticosteroids compared to patients belonging to NCP or CRP .Patients with AS ( 54.2 SD 3.9 yearsp = 0.137), and were more often men (62.3%). In addition, 64.2% of the non-responders had AS.Five per cent (53/940) of the patients could not be categorized into any of the pain groups  due to missing responses on the chronic pain question and the pain mannequin, leaving 536 patients with AS and 351 patients with USpA. The patients not responding to the chronic pain questions had a mean age of 55.5 (SD 12.9) years (AS 57.5 (SD 12.8) vs. USpA 52.0 (SD 12.7), p = 0.033). CWP was also more common in women than in men, with a prevalence for the total SpA group of 54.1% vs. 41.2% (p ≤ 0.001), while there was an equal sex distribution regarding CRP , and that of CWP 46.9%. CWP was significantly more common in USpA than in AS  or in those reporting CWP (5.1 (2.3) vs. 5.0 (2.2), p = 0.622).Pain intensity was not significantly different between women and men in patients reporting CRP (mean (SD) 4.0 (2.3) vs. 3.5 (2.0), n = 940) of 44.9% (95% Cl 39.1–50.7), being higher for women  than for men . For patients with AS, the minimum age- and sex-adjusted prevalence of CWP was 42.7% (95% Cl 34.4–51.0) as compared to 47.8% (95% Cl 37.4–58.2) in patients with USpA, and this was mainly explained by the higher prevalence of CWP in women with USpA  than in women with AS .Assuming that those who did not answer the pain duration and distribution questions had NCP, this would give a minimum age- and sex-adjusted prevalence of CWP for the total group  1.78), and with CWP vs. NCP/CRP (OR 1.70), controlled for age, SpA subgroup (AS or USpA), smoking status, BMI, and disease duration. A higher BMI was associated with chronic pain (OR 1.05), and CWP (OR 1.05), while being an ever-smoker was associated with CWP only OR 1.44). Belonging to a specific subgroup (AS vs. USpA), or experiencing a longer disease duration was not associated with either chronic pain, or CWP, when controlling for all other variables  and disease duration were not. These findings can complicate the evaluation of disease activity and response to treatment in patients with AS and USpA, and emphasise the need of an early and thorough clinical examination, including not only evaluation of inflammation, but also an accurate and careful pain analysis.The results from the present study are difficult to compare in relation to previous research on SpA, since to our knowledge, there have been no studies on the prevalence of CWP in AS and USpA without limiting it to FM. However, the prevalence of CWP in AS and USpA was clearly higher than in the general population , 8, and Previous research has found that it is important to consider that the evaluation and diagnosis of SpA, particularly in women, can be delayed  and compThe women in our study had a higher prevalence of CWP, and CWP was associated with female sex in the logistic regression analysis. These findings are in accordance with the results of previous studies that have investigated FM in SpA –29, 36, In agreement with earlier studies in the general population , 43, CWPWe found no association between SpA disease duration and chronic pain in this study. One reason for this may be that personal or other factors are more important than disease duration when it comes to developing chronic pain, and especially CWP.Strengths of the present study were that patients from both primary and specialist health care were included, and the relatively large sample size. Another strength was that the instruments represent different dimensions of pain , and are commonly used and validated , 46, 47.We found a high prevalence of concomitant CWP in patients with AS or USpA, with an even higher prevalence in women, but with no difference in the intensity of pain in women and men who experienced CWP. The results highlight the importance of a thorough pain analysis included in the clinical examination, to identify patients with high and/or increasing pain levels and multiple pain regions. It may also guide appropriate and individualized treatment decisions, including non-pharmacological and pharmacological treatment options.


The purpose of this study was to evaluate the correlation between pain associated with retrobulbar block and anxiety levels before the injection.  This prospective observational, noninterventional study included consecutive patients who received a retrobulbar block by a single surgeon prior to undergoing 25G PPV at the Department of Ophthalmology, Rambam Health Care Campus, between April 2016 and August 2017. Patients plotted their anxiety levels  using the visual analogue scale for anxiety (VASA), and immediately after receiving the injection, they plotted their experienced level of pain  using the visual analogue scale for pain (VAS), with scores ≥7 defined as severe. r = 0.43, p=0.002) with no other preprocedural parameters demonstrating a significant association with the VAS score. In multivariate analysis, the VASA score was the only factor that was significant (p=0.01), and a patient with a severe VASA score was 20 times more likely of experiencing severe pain (p=0.006). The ROC curve analysis revealed an area under the curve of 0.89 (p < 0.001), and a VASA score >4 demonstrated a sensitivity of 83.3% and a specificity of 73.8% in predicting severe pain.  Overall, 48 eyes of 48 patients aged 68.4 ± 10.3 years were included, of which 62.5% were of male gender. Severe anxiety and pain were experienced by 10.4% and 12.5%, respectively. There was a significant correlation between VASA and VAS scores . Pars plana vitrectomy (PPV) is considered the definitive treatment of choice for vitreous hemorrhage , rhegmatRetrobulbar block carries its own potential complications including dreaded ones, both local (ocular perforation)  and systThe main purpose of this study was to evaluate the correlation between pain associated with retrobulbar block and anxiety levels before the injection. In addition, we evaluated the relationship between demographic characteristics such as age, gender, and prior injections with preprocedural anxiety and procedure-related pain. Finally, we attempted to characterize patients at high risk for severe pain during retrobulbar block.The study was carried out with approval from the Rambam Health Care Campus Ethics Board. The study adhered to the tenets set forth in the Declaration of Helsinki. Signed informed consents were collected from all of the recruited patients.All patients included in this prospective consecutive observational, noninterventional study received a retrobulbar block prior to undergoing 25G PPV at the Department of Ophthalmology, Rambam Health Care Campus, between April 1, 2016, and August 31, 2017. All patients were 18 years or older and were referred to PPV by retina specialists in our institution. Indications for injection included vitreous hemorrhage, rhegmatogenous retinal detachment, macular hole, and epiretinal membrane. Exclusion criteria were anterior segment conditions that could affect pain sensation, such as conjunctival irritation, active conjunctivitis, or keratitis or bullous keratopathy or a history of herpetic ocular infection.Variables recorded were the patient's age, gender, whether or not the patient was a native of the country, level of education , indication for PPV, whether or not the patient was retired, whether or not the patient had undergone previous PPV, whether or not the patient had undergone previous ocular surgery, and history of use of psychiatric medications . Any use of preprocedural anxiolytic was recorded.Patients were asked during the routine presurgical intake to plot their anxiety levels using the visual analogue scale for anxiety (VASA) on a scale from 0 to 10 with “no anxiety or fear” scored as 0 and “unbearable anxiety or fear” scored as 10. The visual analogue scales are well-documented and validated tools for reliable assessment of anxiety , pain 1, and othAll patients underwent the following retrobulbar injection in a single eye by an experienced surgeon (Y. B.) in the surgery room: after topical instillation of oxybuprocaine hydrochloride 0.4%, skin sterilization was performed with an alcohol pad, and afterwards, a 5 ml mixture of 1 : 1 bupivacaine 0.5% and lidocaine 2% was injected with an Atkinson 23G retrobulbar needle through the inferior lid and into the retrobulbar space.N (%). We compared preinjection characteristics of patients, by using Student's t-test for normally distributed variables or Kruskal–Wallis test for nonparametric variables. We used chi-Square or Fisher's exact test as indicated for analysis of categorical variables. One-way analysis of variance (ANOVA) was used for comparison of multiple group averages. Spearman or Pearson's correlation was used to analyze the relationship between preoperative variables and VAS scores wherever appropriate. Stepwise backward multivariate logistic regression analysis was done to determine the baseline variables that enabled to predict VAS scores. For this purpose, we introduced as independent variables those variables that reached a significant level less than 0.30 in univariate analysis. Receiver-operating characteristic (ROC) curve analysis was then performed to identify the optimal VASA score (Youden's index) predicting severe pain (VAS score ≥ 7). A p value less than 0.05 was considered statistically significant.All data collected in this study were recorded using Microsoft Excel 2013 (Microsoft Corporation). Statistical analyses were performed using Minitab software, version 17 . Results were expressed as mean ± SD, median (range), or Overall, 48 eyes of 48 patients aged 68.4 ± 10.3 years (range 48–88 years) were included in this study, of which 62.5% were of male gender. The VASA scores were 3.0 ± 2.5 (range 0–9.0) with the majority of patients experiencing mild (60.4%) to moderate (29.1%) anxiety and the rest (10.4%) experiencing severe anxiety .r = 0.43, p=0.002) and no significant correlation between age and VAS score . The results of the univariate correlational analyses between VAS scores and preprocedural parameters are depicted in p=0.10), no other parameters were significantly associated with VAS scores.There were a statistically significant correlation between preprocedural VASA and VAS scores . The association between ranges of the VASA score and the odds of a severe VAS score is further detailed in p=0.006), while a patient with a mild VASA score was 10 times less likely of experiencing severe pain (p=0.02). The ROC curve analysis is presented in p < 0.001). In brief, a VASA score >4 demonstrated a sensitivity of 83.3% and a specificity of 73.8% in predicting severe pain , with no other parameters significantly associated with the VAS score including multivariate analysis. In addition, patients with a severe VASA score were 20 times more likely to experience severe pain. This finding is supported by Segal et al. who reported a significant correlation between anxiety prior to intravitreal injections and pain during intravitreal injections [In the current study, there was a statistically significant correlation between preprocedural VASA and VAS scores (jections . Interesjections . They poIn recent years, there has been a trend towards PPV being performed in ambulatory surgery centers under retrobulbar block. In addition to no longer exposing the patient to the potential systemic complications of general anesthesia, this option also avoids unnecessary hospitalization, enables, in some countries, surgery to be performed without the presence of an anesthesiologist, and reduces surgical times, allowing for more patients to receive treatment . This emEnsuring patient cooperation during a retrobulbar block is of interest in order to maintain safety. As such, some surgeons routinely prescribe sedation such as propofol prior to retrobulbar blocks , 30; howA limitation of this study is that though a clear correlation between anxiety and pain during retrobulbar blocks was demonstrated, it is unclear whether reducing the anxiety would indeed reduce pain. As such, future studies should evaluate whether anxiolytics and premedication benefit patients undergoing retrobulbar block, particularly those with moderate to severe anxiety.