Patients with pressure ulcers (PUs) report that pain is their most distressing symptom, but there are few PU pain prevalence studies. We sought to estimate the prevalence of unattributed pressure area related pain (UPAR pain) which was defined as pain, soreness or discomfort reported by patients, on an “at risk” or PU skin site, reported at a patient level.We undertook pain prevalence surveys in 2 large UK teaching hospital NHS Trusts  and a district general hospital NHS Trust  during their routine annual PU prevalence audits. The hospitals provide secondary and tertiary care beds in acute and elective surgery, trauma and orthopaedics, burns, medicine, elderly medicine, oncology and rehabilitation. Anonymised individual patient data were recorded by the ward nurse and PU prevalence team. The analysis of this prevalence survey included data summaries; no inferential statistical testing was planned or undertaken. Percentages were calculated using the total number of patients from the relevant population as the denominator .A total of 3,397 patients in 9 acute hospitals were included in routine PU prevalence audits and, of these, 2010 (59.2%) patients participated in the pain prevalence study. UPAR pain prevalence was 16.3% (327/2010). 1769 patients had no PUs and of these 223 patients reported UPAR pain, a prevalence of 12.6%. Of the 241 people with pressure ulcers, 104 patients reported pain, a UPAR pain prevalence of 43.2% (104/241).One in six people in acute hospitals experience UPAR pain on ‘at risk’ or PU skin sites; one in every 8 people without PUs and, more than 2 out of every five people with PUs. The results provide a clear indication that all patients should be asked if they have pain at pressure areas even when they do not have a PU. A pressure ulcer (PU) is a “localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear” and they range in severity from skin redness Category 1) and superficial skin loss Category 2) to severe ulcers involving fat, muscle and bone  as defined by the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel [ and supe to severPain has been reported by patients to be a major symptom associated with PUs, with dressing changes being particularly painful times . PU painReviews of the literature carried out by Girouard et al., 2008, and Pieper et al. 2009 described how PU pain had been measured in a number of studies . They alGorecki et al., (2011) carried out a mixed methods systematic review  and idenHowever, the Gorecki et al., (2011) review was limited because they were unable to evaluate PU descriptors for Category 1 PUs  . A problIn order to describe pain in patient populations with and without PUs, we developed three definitions as follows:UPAR pain: Unattributed Pressure Area Related pain which is defined as pain, soreness or discomfort on any “at risk” or PU skin site, reported at a patient level.PAR pain: Pressure Area Related pain which is defined as pain, soreness or discomfort on any “at risk” skin site, reported at a skin site level (i.e. attributable).PU pain: Pressure Ulcer pain which is defined as pain, soreness or discomfort on any PU skin site, reported at a skin site level (i.e. attributable).PG-0407-10056) which aims to reduce the impact of PUs on patients through improved risk assessment and the development of measures to capture patient reported outcomes.The first in a series, this study sought to estimate the prevalence of unattributed pressure area related pain (UPAR pain) in hospital populations in a large representative sample in order to provide definitive estimates. This study is part of a suite of 6 studies which comprise the Pressure UlceR Programme of ReSEarch (PURPOSE), funded by the National Institute for Health Research  and 1 district general hospital NHS Trust  in England to establish UPAR pain point prevalence. Questions about pain were added to the routine annual PU prevalence audits undertaken in the participating NHS Trusts. In addition to the standard PU data recorded by ward and audit teams, patients were asked two questions relating to pain at pressure areas by a member of the Tissue Viability Team. These questions were1. At any time, do you get pain, soreness or discomfort at a pressure area 2. Do you think this is related to either; your pressure ulcer OR lying in bed for a long time OR sitting for a long time?The data were asked at a global patient level, and not by skin site, hence the pressure area related pain is not attributable to individual skin sites with or without PUs. These questions were adapted from the case screening questions used in a large postal survey of pain prevalence in the UK . Data weAs per standard PU prevalence audit methodology, the target population was “all inpatients of 18 years of age or older who were in hospital on the date of the participating Trust’s PU prevalence audit”. Patients in paediatric, obstetric and psychiatric care settings were excluded from the pain survey, as the prevalence of PU in these settings is very low, and hence the data collection to information burden ratio is unacceptably high in these settings. In addition to the standard PU audit data, the ward nurse was asked to consider whether each patient was able to report the presence or absence of pain.Patients were excluded from the pain prevalence study where it was considered ethically or clinically inappropriate by the ward nurse/clinical team, for example, those where death was considered to be imminent. Where patients were assessed as able to report pain these patients were eligible for inclusion in the pain prevalence. Where patients were assessed as not able to report pain this was recorded together with the reasons for ineligibility.Standard practice for the PU prevalence audit was used to assess and record data to ensure data capture for the total hospital population. Anonymised individual patient data was recorded by a designated ward nurse trained in the use of the data collection form and skin assessment as part of the preparation for the audit. Data recorded included ward speciality, date of birth, gender, height, weight, ethnicity, mobility, risk assessment scale  and skin classification by skin site using the European Pressure Ulcer Advisory Panel classification . The EPUThe analysis of this prevalence survey included data summaries and no inferential statistical testing was planned or undertaken. Percentages were calculated using the total number of patients from the relevant population as the denominator . All analyses were carried out using SAS software.The study was approved by the Leeds Central Research Ethics Committee (REC) prior to data collection. Ref No 09/H1313/14.Figure A total of 3,397 patients in 9 acute hospitals were included in the routine PU prevalence surveys and this constitutes our target hospital population. The mean age of patients was 65.8 SD 19.23), range 18-103 years. The numbers of men and women were similar: 48.7% male (1655/3397), and 50.9% female (1730/3397). The number of patients audited by place of assessment is presented in Table 9.23, ranOf the 3,397 participants included in the routine PU prevalence, 502 (14.8%) patients were reported to have 1066 PUs . The majority  of reported PUs were Grade 1, 22.2% (237/1066) were Grade 2 and less than 1 in 10  were severe PUs.Of the 3,397 hospital patients in the PU audit sample, 2010 (59.2%) were considered well enough to respond to the pain questions and hence were eligible for the pain prevalence. Of the 2010 patients in the pain prevalence population, 241/2010 (12.0%) had one or more PU. The PU profile of the categories observed from the total hospital population and pain prevalence population are detailed in Table Of the 2010 people asked the pain questions, 327 said yes to both questions, indicating they had pain on one or more skin sites with or without a PU, providing an overall UPAR pain prevalence of 16.3%. 1769 patients had no PU and of these 223 patients reported pain, an UPAR pain prevalence of 12.6%. Of the 241 people with PUs, 104 patients reported pain at one or more PU site, an UPAR pain prevalence of 43.2% (104/241).This study is the first to assess UPAR pain in a large representative hospital population including patients with and without PUs. The importance of inclusion of patients without PUs is underlined by the findings that 12.6% of patients without PUs reported pain on an ‘at risk’ skin site (one in eight people without obvious tissue damage). This group could be important because they are reporting pain over an ‘at risk’ skin site which they believed to be caused by pressure but they were not yet displaying damage clinically. There are no other published reports of this type of pain.In light of this finding, there could be gains from improving the recognition and treatment of pain in the ‘at risk’ population. The relationship between pressure area related pain and pressure injury is likely to be complex and this prevalence study was not designed to explain this relationship, rather it provides descriptive data to inform further study. As our pain prevalence study was cross-sectional we are not able to determine whether pain on an ‘at risk’ skin site is an early indicator of PU development; a prospective cohort study is currently underway addressing this research question.In relation to UPAR pain reported by patients with PUs, 43.2% of patients reported pain. It is important to note that the pain reported in this study is not necessarily PU pain, since the pain reports were not attributable to a particular PU, rather any “at risk” or PU skin site irrespective of damage. However, the pain prevalence is more than 3-fold the prevalence found in patients without PUs and the prevalence rate is comparable to the prevalence of pain in other chronic wounds in European populations ,16. FurtThere is a need to improve the assessment and treatment of pain for people with PUs as this will affect nearly half of the PU population based on our findings. There is also a need to provide pre-emptive treatment when pain due to pressure can be predicted. For example, in a study which investigated the pain associated with turning for pressure relief and other nursing procedures, turning was the most painful procedure compared to tracheal suction, wound drain removal, central line insertion and femoral sheath removal . It was The findings of this study underline the importance of assessing all patients for the presence/absence of pain and this should be a fundamental component of pressure area care. A key recommendation from Gorecki et al., 2011 was that we need to develop better methods of communicating about pain in relation to PU development . This stPoint prevalence rates provide evidence of the scale of a clinical problem and the general limitations of cross-sectional studies are acknowledged ,20-22. OThe results provide a clear indication for the implementation of monitoring pressure area related pain, and pain management in patients with and without PU. This is in an area which is a priority for patients and impacts upon the quality of life of nearly half of the population. More people with PUs reported UPAR pain than those without, however an important minority of patients without PUs reported UPAR pain. A prospective cohort study is currently underway to provide further insights into the relationship between pain and subsequent Category 2 PU development.This article presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG-0407-10056). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.The authors declare that they have no conflict of interest.MB contributed to the conception and design of the study, analysis and interpretation of the results and drafted the manuscript. MC contributed to the design of the study, performed the statistical analysis and provided revision to the draft manuscript. LW co-ordinated the data collection, contributed to the interpretation of the results and revising the manuscript. CR contributed to the design of the study and revising the manuscript. EMcG contributed to the conception and design of the study, the interpretation of the results and revising the manuscript. CD contributed to the conception, design of the study, the interpretation of the results and revising the manuscript. NS contributed to the conception and design of the study, the interpretation of the results and revising the manuscript. JB contributed to the concept and design of the study and interpretation of the results. SC co-ordinated the data collection, contributed to the interpretation of the results and revising the manuscript. RS contributed to the data collection, the interpretation of the results and revising the manuscript. EAN contributed to the conception, design of the study, interpretation of the results and revising the manuscript. JN conceived of the study, and participated in its design, was responsible for coordination and delivery of the study, interpretation of results and revising 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/1472-6955/12/19/prepub


Delirium after cardiac surgery is associated with a prolonged length of stay in the ICU, prolonged ventilation time and higher in-hospital mortality. Although the exact pathophysiology of delirium is unknown, both the use of analgesics and the experience of pain have been suggested to be associated with the occurrence of delirium. The aim of the study was to evaluate the association between delirium and analgesics and pain in the ICU.In a retrospective observational study, pain and delirium scores in patients admitted to the ICU after cardiac surgery via sternotomy during a 2-month period were analyzed. Delirium was scored using the Intensive Care Delirium Screening Checklist . Pain was scored on the Numeric Rating Scale . Morphine was administered according to a pain titration protocol.P < 0.01), without difference in pain scores between the groups . Delirious patients were older , and ventilation time and length of stay in the ICU were significantly longer . In-hospital mortality was significantly higher for this group .ICDSC ≥4 was recorded at least once for 32 (26%) of the 121 included patients. These patients received significantly less morphine than patients with all ICDSC scores <4 (mean dose 23 ± 8 mg/day vs. 29 ± 13 mg/day, While delirious patients received significantly less morphine than nondelirious patients, there was no significant relation between delirium and pain in patients following cardiac surgery in the ICU.


The effect of local infiltration after breast surgery is controversial. This prospective double blind randomized study sought to document the analgesic effect of local anaesthetic infiltration after breast cancer surgery.-1 or isotonic saline. Pain was assessed on a visual analogue scale at H2, H4, H6, H12, H24, H72, and at 2 month, at rest and on mobilization of the arm. Patient'comfort was evaluated with numerical 0-3 scales for fatigue, quality of sleep, state of mood, social function and activity.Patients scheduled for mastectomy or tumorectomy and axillary nodes dissection had immediate postoperative infiltration of the surgical wound with 20 ml of ropivacaine 7.5 mg.mlTwenty-two and 24 patients were included in the ropivacaine and saline groups respectively. Postoperative pain was lower at rest and on mobilization at 2, 4 and 6 hour after surgery in the ropivacaine group. No other difference in pain intensity and patient 'comfort scoring was documented during the first 3 postoperative days. Patients did not differ at 2 month for pain and comfort scores.Single shot infiltration with ropivacaine transiently improves postoperative pain control after breast cancer surgery.NCT01404377 Surgical wound infiltration with a local anaesthetic solution is currently performed in many surgical procedures including, abdominal hysterectomy, caesarean section and inguinal hernia repair . Wound ith 2005, registration number 2277Comité Consultatif de Protection des Personnes dans la Recherche Biomédicale Paris- Cochin, president: Pr. Guerin C, approval on October 11) and written informed consent of the patients was obtained. ASA I - II patients, older than 18 years, scheduled for unilateral mastectomy or tumorectomy associated with axillary nodes dissection were included in the study. Patients receiving opioid or any other analgesic treatment for chronic pain before surgery, patients with known allergy to local anaesthetics, and patients with acquired or genetic haemostatic abnormality were excluded.This prospective, double-blind, randomized, single centre study was approved by an institutional ethical committee . Pain measurements were performed at 2, 4, 6, 12, 24, 48, and 72 hour after the end of surgery. The value of maximum abduction angle was noted for each patient.To evaluate quality of life patients were asked to score on a 4 points scale graded from 0 (the worst) to 3 (the best) the following items: sleep - fatigue - global activity - relationship with relatives - state of mood. A global score was attributed to each patient as the sum of categorical scores. Evaluation was performed at 24, 48 and 72 hour after the end of surgery.Patients left the hospital between the fourth and the sixth postoperative day. They were evaluated at two month, during the postoperative surgical consultation, for residual pain at rest and on movement using a visual analogue scale and for quality of life as previously defined.The sample size was based on an estimate of a 30% (SD 10%) decrease in pain intensity on mobilization on the day of surgery that was considered as the primary outcome. Given a type I error of 0.05 and a Type II error of 0.1, the required sample size was 22 patients per group; 25 patients were included in each group to take into account possible dropouts. Secondary outcomes were a decrease in pain score at rest, a decrease in rescue analgesic consumption and an improvement in the quality of life.Statistical analyses were performed with Stata v10.0 software .". Results are expressed as mean+/- standard deviation (SD). Normally distributed data  were analyzed using a two-way analysis of variance. Categorical data  were analyzed using Chi-2 test or Fisher's exact test. Mann-Whitney U-test was used for comparison of age, BMI, weight, and duration of surgery. P < 0.05 was considered significant.Three patients in the ropivacaine group and one in the control group were dropped out for surgical complication (one patient) and early discharge from hospital preventing from complete data collection 3 patients). Patients were comparable for demographics except for mean age which was statistically higher in the ropivacaine group table . Types o patientsTwo months after surgery VAS scores at rest were 4.4+/-10.7 and 9.1+/-15.2 in the control and the ropivacaine groups respectively (NS). Values of VAS scores on mobilization were 21.4+/-4.1 and 20.2+/-4.0 in the control and the ropivacaine groups respectively. Arm abduction angles were 147+/-23° and 139+/-29° in the control and the ropivacaine groups respectively. At this time, the quality of sleep was comparable in the two groups (2.9+/-.3 and 2.7+/-.6 in the control and the ropivacaine groups respectively) and the groups did not differ for global evaluation of quality of life (13.0+/-.2 and 12.3+/-.4 in the control and the ropivacaine groups respectively)This study documents significant but short duration benefit of wound infiltration after cancer breast surgery with axillary nodes clearance. Infiltration with ropivacaine solution was nevertheless effective for 6 hours after surgery but pain was controlled as well in patients without infiltration after this period of time. Since incomplete evaluation of pain and its consequences, were considered as flaws in previous studies, we carefully monitored pain, not only at rest but also on mobilization. We performed measurements of pain intensity soon after surgery, to evaluate the initial effect of infiltration. We assessed abduction of the upper limb knowing that it could be more painful after axillary incision, and we also evaluated patient's comfort. Nevertheless, local infiltration did not improve the ability to move the operated arm. Eventually, patient's comfort was equally effective when patients had been infiltrated or not.The duration of the effect of ropivacaine infiltration was in fact comparable to that reported by Baudry et al . and to We looked at parameters that could be impaired by pain in the postoperative period. The incidence of nausea was comparable and quite low in the two groups thanks to the preoperative administration of dexamethasone. In addition, dexamethasone could also have contributed to postoperative pain control as previously documented . Arm abdThe balance between advantages and drawbacks of local infiltration should consider the risk of adverse events. Although not reported in this series, the risk of inadvertent intravascular injection has to be kept in mind, prevented by careful aspiration before injection.Although it has been claimed that infiltration and regional block may have long lasting effect and may prevent the occurrence of late pain after surgery especially after breast surgery , the resSeveral other studies have also documented that regional anaesthesia using thoracic paravertebral block provided better pain control after unilateral breast surgery -17. MostOne can argue that preoperative infiltration, before skin incision would had provide better results in terms of postoperative pain control. Nevertheless, preoperative wound infiltration has not been documented to be superior to postoperative infiltration in the specific setting of breast surgery . This stIn patients scheduled for cancer breast surgery with axillary nodes dissection, wound infiltration with ropivacaine provides an effective pain control during a period of time limited to the first hours following surgery. No further benefit is documented then after.The authors declare that they have no competing interests.AV and FB designed the study-protocol; AV, AS, and JB included patients and checked for patients' files as investigators; RR and EB were referent surgeons and performed all the infiltrations; EM performed statitistics, FB wrote the manuscript, all authors reviewed and approved the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2253/11/23/prepub


Acupuncture is widely-used to treat patients with low back pain, despite insufficient evidence of the technique's efficacy for acute back pain. Motion style acupuncture treatment (MSAT) is a non-traditional acupuncture treatment requiring a patient to exercise while receiving acupuncture. In Korea, MSAT is used to reduce musculoskeletal pain and improve functional status. The study aims to evaluate the effect of MSAT on acute low back pain with severe disability.This study is a multicenter, randomized, active-controlled trial with two parallel arms. Participants with acute low back pain and severe functional disability, defined as an Oswestry Disability Index (ODI) value > 60%, will be randomly allocated to the acupuncture group and the nonsteroidal anti-inflammatory drug (NSAID) injection group. The acupuncture group will receive MSAT and the NSAID injection group will receive an intramuscular injection of diclofenac. All procedures will be limited to one session and the symptoms before and after treatment will be measured by assessors blinded to treatment allocation. The primary outcome will be measured at 30 minutes after treatment using the numerical rating scale (NRS) of low back pain while the patient is moving. Secondary outcomes will be measured at 30 minutes after treatment using the NRS of leg pain, ODI, patient global impression of change, range of motion (ROM) of the lumbar spine, and degrees of straight leg raising (SLR). Post-treatment follow-up will be performed to measure primary and secondary outcomes with the exception of ROM and SLR at 2, 4, and 24 weeks after treatment.The results of this trial will be discussed.NCT01315561ClinicalTrial.gov  Low back pain is a common symptom that greatly impacts individuals and societies and is experienced by 70-80% of adults at least once in their lives . ApproxiThe common treatment for low back pain is to prescribe painkillers, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), while encouraging patients to maintain their daily activities ,10. NSAIAcupuncture has been widely-used as a method for treating back pain, but there has been controversy about its effects. A systematic review of the literature concluded that acupuncture is effective for pain relief and functional improvement in chronic back pain in the short term, but that, for acute back pain, no evidence of the effectiveness of acupuncture was found . GuideliThis study is designed to examine the effects of MSAT on acute low back pain with severe disabilities.This study is a multicenter, randomized, active-controlled, assessor-blinded trial with two parallel arms. The trial will be conducted in the following two hospitals after obtaining permission from the Institutional Review Boards of the two institutions: Jaseng Hospital of Oriental Medicine in Seoul, Korea and Bucheon Jaseng Hospital of Oriental Medicine in Bucheon, Korea. The volunteers will be randomly divided into two groups 1:1 ratio). The experimental group will receive a single session of MSAT, and the control group will receive a single intramuscular injection of NSAIDs to treat acute low back pain. Thirty minutes after treatment, the subjects will be assessed to determine the outcome of the treatment. Post-treatment follow-up will be performed to measure primary and secondary outcomes at 2, 4, and 24 weeks after treatment  value ≥ 60%.• Patients who are 20 - 60 years of age.• Patients who are able to receive a lumbar magnetic resonance imaging (MRI) scan and agree to the procedure.• Patients who agree to voluntarily participate in this study and sign informed consent.• Patients who have been diagnosed with a serious disease that can cause low back pain .• Patients with a chronic disease that could interfere with the effect of the treatment or the interpretation of treatment results .• Patients with progressive neurological deficit or severe neurological symptoms.• Patients for whom acupuncture would be inappropriate or unsafe • Patients currently taking corticosteroids, immunosuppressant drugs, psychiatric medicine, or any other medication that may influence the results.• Patients who had experienced gastrointestinal side effects after taking NSAIDs or are currently being treated for gastrointestinal disease.• Patients who are currently pregnant or planning to become pregnant.• Patients who are judged to be inappropriate for the clinical study by the researchers.d) > 0.5.The sample size for this clinical study was estimated using the mean difference in numerical rating scale (NRS) for low back pain between the experimental and control groups. We used the NRS as a scale measuring the pain intensity of low back pain. As MSAT is more effective than NSAID injection in previous clinical experience, we set the effect size , and a block size of 6 is used to allocate the two groups (1:1 ratio). The numbers will be kept by a researcher who has no direct contact with the study participants. The randomized numbers will be kept in sealed envelopes, and random allocation will be conducted by opening an envelope as the researcher is informed of a participant's registration at each clinical trial center. In the case of events deemed necessary to code break halfway during trial such as serious adverse events, the researcher will be contacted.Before the randomization allocation, participants will be informed that they will be assigned to one of the two groups. Random allocation will be performed if a participant is eligible and signs the informed consent form. The subject identification codes will be recorded on case report forms (CRFs) and the randomization table.This study is designed as a randomized, controlled, assessor-blinded trial. As the experimental group receives acupuncture treatment, namely MSAT, and the control group receives NSAID injection, we are unable to blind both physician and subject to the modality of treatment. Still, assessor-blinding will be achieved by blinding the assessor performing outcome assessment and CRF data entry to the random allocation and treatment of subjects. Statistical analysis will be performed by an independent statistician who is blinded to the identification of each treatment group.The acupuncture group and the NSAID injection group will each receive a single treatment session.The acupuncture treatment will be conducted by oriental medicine doctors who have more than 5 years of clinical experience. These doctors will be required to complete three workshop sessions prior to participating in this study to ensure that the acupuncture is performed as stated in the protocol  and on both sides of Haenggan (LR2) and Gokji (LI11). These acupuncture points were selected according to traditional Chinese medicine theory and previous clinical experiences. When being inserted into GV16 and both sides of LR2, the needles are positioned perpendicular to the body surface. For LI11, the needle is positioned 30 degrees to the body surface. No specific manipulative interventions will be employed in this process. Disposable sterile needles  will be used. Each acupuncture point will be decided on using guidelines based on the World Health Organization Standard Acupuncture Point Locations in the Western Pacific Region . While tIf a subject refuses the treatment due to intolerably severe pain during the procedure, the procedure is stopped immediately and the degree of increase in pain and any abnormal reactions are carefully observed and recorded. The total number of subjects who terminate the treatment is recorded.Subjects who are assigned to the control group will receive an intramuscular injection of diclofenac sodium  in an area of the buttocks where there is no pain. The presence of gastrointestinal side effects or any other side effects will be carefully observed and recorded. In addition, the number of subjects who receive the treatment will be recorded.When the patients are screened, they will complete questionnaires about their sex, age, height, weight, blood pressure, medical history, and other factors. To determine whether the subjects qualify for the study, their ODI will be calculated through a questionnaire. Their history of back pain, pain intensity, functional status, and other factors will be surveyed. They will also receive a physical examination, X-ray, and lumbar MRI. Evaluations of the patients' back pain will be conducted at baseline and 30 minutes after treatment Table , becausePrimary outcome refers to the intensity of low back pain, and it will be evaluated using the NRS. Although the NRS is considered a subjective evaluation indicator, it is widely used due to its simplicity. With NRS, a patient chooses one number, ranging from 0 to 10, that best expresses their current level of pain (0 being no pain and 10 being the most excruciating pain the subject has ever experienced) ,20. BecaThe patients' functional status will be evaluated using the ODI questionnaire. It is a 10-item questionnaire developed to evaluate the degrees of disability for lower back pain . Each caTo complete a comprehensive evaluation of improvement in back pain and the movement limited by back pain, we will determine the patient global impression of change (PGIC) ,23. PGICBecause this study will be conducted with patients who have limited movement due to severe pain, we will check their ROM and degree of SLR to assess the improvement of their movement at baseline and 30 minutes after treatment. The measurement of ROM is reliable (r = 0.94) and valid (r = 0.97) , but it The ROM is checked by measuring the angle between the lumbar spine and a vertical straight line at the patient's full extension and flexion capability. If the measurement is impossible because of pain, the angle is recorded as 0 degrees. To measure degrees of SLR, we will check the leg angle from the patient in a supine position who will then lift each leg up passively with their legs extended. We will measure the angle from the elevated leg to the surface of the floor.Patients with low back pain may or may not have accompanying leg pain. When leg pain is reported, to assess any improvement in symptoms, the degree of pain is measured for the left and right sides separately by using the NRS. The degree of leg pain might also differ at rest and during activity. Therefore, when the NRS is being evaluated, patients will be asked to answer the question, "Please indicate the intensity of pain you feel now as you are try to move" to minimize errors. The NRS for leg pain will also be checked at baseline and 30 minutes and at 2, 4, and 24 weeks after treatment.d) with 95% confidence interval. If there are any differences in age, gender and body mass index between the two groups and the differences are thought to have any influences on the outcome variables, the independent variables will be considered to be covariates and the analysis of covariance (ANCOVA) will be performed. The results will be considered to be statistically significant when P < 0.05.All statistical analyses will be performed in the principle of intention-to-treat analysis using the SAS version 9.1.3 statistical program. For descriptive statistics, normally distributed variables will be expressed as mean and standard deviation. Variables with a skewed distribution or non-parametric variables will be expressed as median and range. For the comparison of the NRS, ODI, ROM and SLR between the two groups, independent t-test will be used, followed by the calculation of effect size  will be included in the safety monitoring reports.The trial will stop if the principle investigator believes there is an unacceptable risk of serious adverse events in the groups.NSAID: nonsteroidal anti-inflammatory drug; MSAT: motion style acupuncture treatment; ODI: Oswestry Disability Index; MRI: magnetic resonance imaging; NRS: numerical rating scale; CRF: case report form; ROM: range of motion; SLR: straight leg raising; PGIC: patient global impression of change.Drs. Joonshik Shin, In-Hyuk Ha, Tae-Gyu Lee, Youngkwon Choi, Byoung-Yoon Park, and Me-riong Kim are employees of Jaseng Hospital of Oriental Medicine during the period of the study. Otherwise, the authors declare that they have no other competing interests.JSS, IHH, and TGL drafted the protocol and JSS wrote the final manuscript. MSL, YKC, BYP, and MRK contributed to the research design and made critical revisions. JSS is the representative of Jaseng Hospital of Oriental Medicine and participated in the trial design as study director. All of the authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6882/11/127/prepubDetailed explanation of method of MSAT. A text file describing the method, origin, purpose and applications of MSAT.Click here for fileMovie file of method of MSAT. A movie file illustrating the method of MSAT through a demonstration with an actual patient.Click here for file


Objectives. To investigate the effect of 8 weeks of NMES + Ex  on pain and functional improvement in patients with knee osteoarthritis (OA) compared to exercise (Ex) alone. Design. Randomized controlled trial. Setting. A specialty outpatient clinic. Participants. Patients  with knee OA. Interventions. Participants were randomly assigned to NMES + Ex or Ex group. Outcome Measures. Numerical Rating Scale 0 to 10 (NRS) and the Timed Up and Go (TUG) test were the primary outcomes. The secondary outcomes used were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results. Following the interventions, a statistically significant improvement in both groups was observed in all outcomes assessed. For the comparison between the groups, no statistically significant difference was found between the NMES + Ex and the Ex groups in NRS (P = 0.52), TUG test (P = 0.12), and aspects of WOMAC: pain (P = 0.26), function (P = 0.23), and stiffness (P = 0.63). Conclusion. The addition of NMES to exercise did not improve the outcomes assessed in knee OA patients. This study was registered at the Australian Clinical Trials Registry (ACTRN012607000357459). Osteoarthritis (OA) is the most common form of arthritis. It affects one-third of adults and tends to increase with age . Knee OAThe synovium is infiltrated with inflammatory cells and secretes excess synovial fluid, leading to capsular swelling . ThroughNeuromuscular electrical stimulation (NMES) is defined as the application of electrical stimulation using surface electrodes placed over skeletal muscles to produce visible muscle contraction through the activation of intramuscular nerve branches . This teThus, the objective of this study was to conduct a randomized clinical trial following methodological criteria, including allocation concealment, blinding of the examiner, and application of intention-to-treat analysis to assess the role of NMES in improving pain and physical function in patients with knee OA. It is important to study interventions with the potential to improve functional status in this patient population . The study was conducted at the Interlagos Specialty Outpatient Clinic, São Paulo, Brazil. Patients were referred from the Rheumatology Department according to the inclusion and exclusion criteria and randomly allocated into groups using a computer-generated randomization chart. The allocation codes were sealed in opaque envelopes by a third person not involved in the study to avoid selection bias. Written informed consent was obtained from all participants. The study was approved by the Research Ethics Committee of the Universidade Federal de São Paulo (UNIFESP), Brazil, no. 0141/07, and registered with the Australian Clinical Trials Registry, no. ACTRN012607000357459.t-test and analysis of covariance (ANCOVA) were used for comparisons between groups; the covariant was obtained from a previous study [Setting the significance level at 5% and the power of the sample at 80%, a sample size of 40 patients per group was estimated to be necessary to detect a difference of at least 1 minute ± 3 seconds in the Timed Up and Go (TUG) test, which was considered to be the minimum clinically significant difference for the present trial . Paired us study .One hundred patients were recruited according to inclusion and exclusion criteria. Eligibility criteria were age 50 to 75 years, OA grade 2 or greater according to the radiographic classification of OA proposed by Kellgren and Lawrence , and diaPatients were divided into two groups of 50 each: (1) the NMES combined with exercises (NMES + Ex) group and (2) exercise (Ex) group. Patient medication was standardized and not modified during the study period. Paracetamol was prescribed for pain, and diacerein and chloroquine for OA control.Interventions were delivered for both groups by the same physical therapist, twice a week, for 8 weeks, with each session lasting about 40 minutes. All patients received a manual including guidelines on how not to overload the knee during daily activities and instructions on the use of ice packs in case of pain and inflammation and warm compresses in case of pain without inflammation as follows. Manual for Patients with Osteoarthritis of the Knee. The purpose of this manual is to explain osteoarthritis and to teach how you can adjust yourself to your daily activities, according to the knee symptoms. Try to seriously follow our orientations for your own benefit!The Knee. The knee joint is composed of 3 bones—the femur (thigh bone), the patella (kneecap) and the tibia (leg bone). It has muscles, capsule, ligaments, meniscus, and the cartilage that lines the bones and protects them from the impact. The knee joint supports nearly the whole weight of our body. What Is Osteoarthritis? It is a disease caused by the breakdown of cartilage in the joints. The layers in the cartilage become damaged and with time they lose the function of smoothing the contact between the bone surface and the joints. The pain is a result of the attrition of one bone against the other in the absence or decreased cartilage in the joints.What Are the Signs and Symptoms? Patients with osteoarthritis may have some pain mainly when starting a movement, as in morning stiffness or after immobilization. With time, the pain might be intensified and be permanent. The presence of crepitation when moving the knees is often.What Kind of Difficulties Might I Have in My Daily Life? Difficulties found in daily live vary according to the patients' symptoms. In general, however, the patient has pain and difficulty when supporting the body weight using the affected knee, going up and down the stairs, or when walking.What Should I Do When It Is Painful? A doctor can prescribe the treatment for osteoarthritis. However, a simple form of improving the pain is to use warm to hot water bottle over the knee joint  with the aid of an elastic band, and loaded quadriceps strengthening exercises combined with NMES. The strengthening exercise with NMES was performed in the sitting position with the knee and hip flexed to 90 degrees; patients contracted their quadriceps at each NMES stimulus. μs, contraction time 10 s, rest time 30 s every 20 minutes; current intensity was the maximum tolerated by each patient [NMES was applied using an electrical stimulator  with two 7.5 × 13 cm self-adhesive electrodes  placed over the region of the quadriceps muscle . NMES parameters were as follows: pulsed current, biphasic, asymmetrical, rectangular waveform, frequency 50 Hz, pulse duration 250  patient . Patients in the Ex group performed the same exercise program as those in the NMES group but without NMES. The exercise protocol included 10 minutes of warm-up on a stationary bicycle ergometer, stretching of hamstrings muscles with the aid of an elastic band, and knee extension exercises performed for 3 sets of 15 repetitions with rest intervals of 30–45 seconds between sets. For both groups, the training load for the strengthening exercises was established based on 50–60% of the 10-repetition maximum (RM) instead of 1 RM to avoid injury by excessive muscle contraction .Patients were evaluated before and after intervention by a physical therapist blinded to group assignment. The primary outcomes were the TUG test results  and paint-test was performed to compare pre- and postintervention values at a significance level of 0.05 (P < 0.05). Statistical analysis was performed on an intent-to-treat (ITT) basis and included all patients who were randomized to treatment. Mixed model analysis of variance with repeated measures was used with occasion measures as within-group factors and intervention as between-group factor. Paired Student's d [Relations between the observations were analyzed using an unstructured covariance matrix. Missing-data imputation was not performed to evaluate pre- and postintervention differences between the two groups, because Chakraborty and GU  showed td . The anad .The demographic and clinical characteristics of patients, including age, sex, side treated, and body mass index (BMI), as well as TUG test values, NRS pain scores, and WOMAC scores on the pain, physical function, and stiffness subscales, are shown in P < 0.0001; TUG test, P < 0.0001) and Ex group . The primary outcomes are listed in No significant differences between groups were found in NRS pain scores and TUG test time on ITT analysis. A significant decrease in pain intensity (NRS scores) and TUG test time was observed after intervention compared with baseline in the NMES + Ex group  and in the Ex group . The secondary outcomes are listed in No significant differences between groups were found on the pain, physical function, and stiffness subscales of the WOMAC index on ITT analysis. There was a significant improvement in all WOMAC subscales in the NMES + Ex group  treated with either NMES alone or exercises alone or exercises combined with NMES. The authors reported a significant improvement on the WOMAC pain subscale in the three groups, but no significant differences in WOMAC scores were found between groups [In this randomized clinical trial, the NMES combined with exercise did improve pain and physical function, but there was no evidence that it did better than exercise alone. Our results are in agreement with the findings of Rosemffet et al.  who condn groups . The lack of difference in treatment outcome between groups in the present study might be attributed to the fact that the participants had no clinically significant muscle or functional impairment. A finding substantiating this hypothesis is that the mean TUG test values in the two groups were similar to those found in the study of Steffen et al., for elderly patients with no physical limitations categorized under the same mean age group . The TUGGiven that the greater the muscle impairment, the greater the NMES effect, patients with a more advanced stage of OA might obtain greater benefit from NMES –27. WithA limitation of this study is that the current intensity used for electrical stimulation was not recorded. However, the maximum current intensity tolerated by each patient was applied as in previous studies , 24, 30.The questionnaires used in this study have been translated into Brazilian Portuguese, cross-culturally adapted, and validated in previous studies , 31, 32.Statistical analysis was performed on an intent-to-treat basis to minimize the impact of protocol violations (which may occur after randomization) on the results and conclusions and to avoid an overestimation of the treatment effect. This randomized clinical trial conforms to the Consort Statement  , whose aOur results revealed that the application of NMES combined with a conventional exercise program was as effective as the exercise program alone in reducing pain and improving physical function in patients with knee OA, and therefore no therapeutic benefit was observed with the use of NMES. Moderate exercises, including warm-up and muscle stretching and strengthening exercises—combined or not with NMES—are recommended to reduce pain and improve physical function and quality of life in patients with knee OA.


Migraine is considered a unilateral headache though several patients exhibit bilateral pain. Previous studies suggest the presence of bilateral pressure pain sensitivity in temporalis region in unilateral migraine patients. No data exists concerning pressure sensitivity maps of the head in this population.To determine differences in pressure pain sensitivity maps of the head in patients with unilateral or bilateral migraine.Ten patients with strictly unilateral migraine on left side, 10 on the right and 10 with bilateral migraine, all of them episodic. Pressure pain thresholds were measured in 21 points distributed over the scalp. Locations of those points were based on normalized positions for electroencephalogram recordings. Pressure pain sensitivity topographical maps were constructed. All patients were headache-free when evaluated.No differences existed among the 3 groups in age, time from onset of migraine and days with pain during previous month. Cartographic maps of the head did not reveal significant differences between patients with predominantly unilateral migraine (either left or right side dominant) and bilateral migraine . Pressure sensitivity maps of the head revealed that the temporal part of the head  were more sensitive  than the remaining parts of the head.Our results suggest that pressure pain sensitivity map of the head is independent of the presence of bilateral or unilateral pain in migraine. Further, it seems that the temporal scalp may be the most sensitized part of the head in these patients, accordingly to previous studies.No conflict of interest.


Estimating pain in patients of intensive care unit (ICU) is essential, but because of their special situation, verbal scales cannot be used. Therefore, to estimate the level of pain, behavioral pain scale was developed by Payen in 2001.The aim of this study was to investigate the validity and reliability of behavioral pain scale in patients with low level of consciousness due to head trauma hospitalized in ICU.This descriptive prospective study was performed in Yazd in 2013. In this study, fifty patients, including thirteen women and thirty seven men, were involved. To collect the data a questionnaire including demographic and Glasgow coma scale (GCS) information as well as a list of behavioral pain scale (BPS) were used. SPSS software (version 18) was used to analyze the data.There was no significant difference in reliability proving of average score of BPS recorded by two day and night assessors (P > 5). Cronbach’s alpha was 85 for painful procedures and 76 for non-painful procedures. In addition, known groups’ technique (painful and non-painful procedures) was used to assess validity. The average scores were 7.75 during painful procedures and 3.28 during non-painful procedures (P = 0.001). The results stated that BPS scores during these two procedures were significantly different.BPS in patients with low level of consciousness due to head trauma has strong reliability and validity. Therefore, this scale can be used for patients hospitalized in ICU to assess the level of pain. Intensive Care Unit (ICU) is designed for taking care of patients with complicated and life threatening conditions , 2. PatiThe study by Puntillo showed that while 29% of patients cannot remember their pain, 71% of them report the experience of pain five days after discharging from ICU . AccordiTo relieve pain, the first stage is assessing pain which is an important goal in taking care of patients . It is iAssessment of pain in critical patients, especially those who cannot speak, is a big problem for clinical personnel and researchers . TherefoThe pain management in these patients is often careless and in non-experimental methods . On the Therefore, in 2001, a scale was developed by Payen to help nurses assess patients and critical patients' pain, which was named behavioral pain scale. The validity and reliability of this scale have been confirmed, but more studies are needed to guarantee this scale in making clinical decisions to use painkillers in intensive care unit. Behavioral pain scale concludes three behavioral expressions:Facial expressionUpper limbsCompliance with ventilation This scale is not accepted to be used for public population . In addiThis descriptive prospective study was conducted to determine the validity and reliability of behavioral pain scale in patients with low level of consciousness due to head trauma hospitalized in ICU in Rahnemoon Training Hospital in Yazd in 2012.Patients eligible for the study, were included based on purposive sampling method. Using previous studies and consulting with a statistical adviser, the number of samples was found to be 50 . The population included patients over sixteen years old, patients on ventilators with endotracheal tube, and patients with GCS = 5-8. Quadriplegic patients and those who were receiving neuromuscular blockade drugs were excluded from the study. The researcher made no interventions in the course of treatment. Information about behavioral pain scale was only observed and recorded during the current procedures, so informed consent was not needed. On the other hand, the patient was assigned a code of confidentiality recorded in the questionnaire and checklist. The authoritiess in Yazd Shahid Rahnemoun Training Hospital were asked for permission to use samples.To collect information a questionnaire including age, sex and GCS, as well as a checklist of behavioral pain scale criteria were used. Behavioral pain scale is made of these three parts:Facial expressionUpper limbsCompliance with ventilationEach of these stages is scored from 1 to 4. The minimum score of behavioral pain scale is 3 meaning that there is no pain and the maximum is 12, which indicates the highest level of pain. Two current procedures in each ward were considered for each patient including painful procedures  and non-painful procedure . Checklist was completed for each patient by the main researcher and a nurse simultaneously. Two methods were used to assess the validity. Known groups’ technique is an approach for structural validation. Two painful and non-painful procedures were selected as different groups. Then the scores of behavioral pain scale were measured in both groups and compared. The other approach was based on the fact that if behavioral pain-scale measures the level of pain, BPS score must be increased during painful procedures and must not be increased during non-painful procedures. Reliability was assessed in three aspects:Stability. The score of level of pain was measured day and nightInternal cohesion. It was assessed by a Cronbach's testEquilibrium. Behavioral pain scale was applied by two assessors simultaneouslyCollected data were coded and then analyzed by SPSS software (version 18) using t-test, Cronbach's alpha method, Wilcoxon test and Man-Whitney test. The significance level in this study was considered as P < 0.05.Fifty patients, including 13 women and 37 men, were assessed in this study according to the inclusion criteria. During the study no patients were excluded. The average age of patients was 38.98 years, with the lowest age of 17 and the highest of 82. There were 9 patients with GCS = 8, 13 with GCS = 7, 8 with GCS = 6, and 20 with GCS = 5. The results of this investigation confirmed the reliability in three aspects.The average score during painful procedures was 7.79 in the morning and 7.71 at night (P = 0.135). The average score during non-painful procedures was 3.30 in the morning and 3.26 at night (P = 0.569). These results showed that the score of behavioral pain scale during procedures in the morning and at night were not significantly different. Therefore, the reliability of this aspect of the scale was verified.Cronbach's alpha was 0.85 for painful procedures and 0.76 for non-painful procedures showing that this scale has the highest level of reliability.The results showed that the levels of pain reported by the researcher and nurse were not significantly different. The score average of behavioral pain scale in low level consciousness was assessed according to sex.Mann–Whitney test indicated no significant difference regarding the level of pain before and during painful and non-painful procedures in morning and at night, in men and women (P > 0.05). There were no associations between pain and sex. Based on the methods used to verify the validity of structural validation technique, it is concluded that the average score was 7.75 during painful procedures and 3.28 during non-painful procedures (P = 0.001). These results showed that the scores of behavioral pain scale during painful and non-painful procedures were significantly different so this aspect of validity of behavioral pain scale was verified.In the other method, the scores were recorded before and during each procedure. The results stated that the average score was 3.01 before painful procedures and 7.75 during painful procedures (P < 0.001), which means that the scores of BPS before and during painful procedures were significantly different. Furthermore, the average score was 3.01 before non-painful procedures and 3.28 during non-painful procedures (P < 0.001), which showed that the scores of behavioral pain scale before and during painful procedures were significantly different.In this study, the reliability of this scale was verified from the stability point of view. The results of this study are in compliance with Payen's in 2001 in France, which studied and assessed the pain in sedate critical patients (receiving sedative drugs) using behavioral pain scale. They found no difference in the scores of behavioral pain scale in the morning, evening, and night. Reliability was assessed and verified from the internal cohesion point of view. Aissaoui's study  is in agIn this study, reliability was also assessed and verified from the equilibrium point of view. In 2005, Aissaoui assessed patients by three teams to investigate the equilibrium and stability of the scale. The results showed no significant difference between the assessments of three teams . TherefoIn Ahler’s et al., AissaouThe results of some other studies are in agreement with this study. For instance, Young's showed a significant difference in increasing the score of behavioral pain scale during painful procedures (patient's movement). To verify the validity logically, the patient got higher score in behavioral pain scale during painful procedures . In addi


Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are major orthopedic surgery models, addressing mainly ageing populations with multiple comorbidities and treatments, ASA II–IV, which may complicate the perioperative period. Therefore effective management of postoperative pain should allow rapid mobilization of the patient with shortening of hospitalization and social reintegration. In our review we propose an evaluation of the main analgesics models used today in the postoperative period. Their comparative analysis shows the benefits and side effects of each of these methods and guides us to how to use evidence-based medicine in our daily practice. Primary total arthroplasty of the hip or knee is a common surgery today with an increasing incidence related to age. The mean age at surgery for TKA is 70 years, but there is a tendency worldwide to increase the proportion of younger patients  –3. To alBesides increasing the number and the age of patients receiving prosthetic joint, a number of comorbidities are associated with increasing age. According to a national cohort report from 2009, 32,6% of the patients with TKA had three comorbidities or more and the most common ones are hypertension 67,8%), diabetes (20%), and obesity  [%, diabetEffective treatment of postoperative pain continues to be a challenge because it influences the surgical outcome  and for Relationship between analgesic technique and the immediate and remote postoperative outcome and success of surgery is not new, and postoperative pain assessment using visual analogue scale (VAS) and opioid requirements is the primary outcome variable in most studies.http://www.americanpainsociety.org/uploads/pdfs/npc/section_2.pdf).That is why, since 1996, the pain was declared the fifth vital sign by the American Pain Society   and has been the gold-standard for a long time in postoperative pain control in THA.Regarding TKA, Mahoney et al. administered bupivacaine and morphine continuously on epidural catheter and reported good-to-excellent analgesia but with a high incidence of adverse effects related to epidural catheter and opioids . The necMoiniche et al. study the effect of pain relief with balanced analgesia on postoperative convalescence parameters in 20 patients scheduled for TKA . At 48 hOpioid dose reduction is one of the important goals of postoperative analgesia, to reduce both side effects  and consecutive sedation, leading to a delay in patient mobilization. In addition to careful monitoring, symptomatic management is required for each type of secondary reaction that occurred, leading to a higher consumption of drugs and therefore higher costs of hospitalization.Understanding the mechanisms involved in nociceptive acute pain, identifying the effect of opioid-induced hyperalgesia and persistent postsurgical pain by regional anesthesia, directs the development of new drugs or different analgesia regimens for improving postprosthetic outcome .Therefore, epidural technique has quickly gained popularity compared to intravenous opioid analgesia. Several studies have shown that epidural analgesia may reduce the risk of myocardial ischemia and tachyarrhythmia in coronary high-risk patients proposed for elective noncardiac surgery  and evenBesides the protective effect in high-risk cardiac patient, epidural analgesia has a beneficial effect on lung function with decreased incidence of postoperative pulmonary morbidity as shown by meta-analysis of Ballantyne et al. . All theCochrane data of evidence-based medicine led a study in 2003, trying to answer the question, “Is the lumbar epidural analgesia more efficient than the systemic analgesia or spinal analgesia for pain relief after elective primary hip or knee arthroplasty?” . Their cIn the same year, a study compared the analgesic effectiveness and side effects of intrathecal morphine sulphate in small doses, between 0.0 and 0.3 mg, on 40 patients with THA and 40 patients with TKA . The conPeripheral nerves blocks (PNB) offer advantages over epidural analgesia for the TKA patients. Ganapathy as well as Capdevilla used a modified 3-in-1 Winnie continuous femoral block , 23 withSome of these better results may be due to the new mixture used by Capdevilla with the femoral catheter: lidocaine 1% and clonidine plus morphine. The usefulness of these adjuvants in brachial plexus block had been demonstrated by Singelyn et al.  and BernContinuous administration using a femoral catheter is more useful than single shot but with minimal impact on hospital length of stay and long-term functional recovery .Among local anesthetics, lidocaine 1% performs a better motor block than bupivacaine 0.25% and seems to be more efficient in alleviating quadriceps muscle spasm ; this spFowler's meta-analysis from 2008 undertook a systematic review of all randomized trials comparing epidural analgesia with peripheral PNB for TKA. There was an evaluation on 464 patients of morphine consumption, epidural and PNB side effects, and the patient satisfaction . The conAdvantageous for femoral nerve block (FNB) is pain reduction related to significant reduction of quadriceps spasm, secondary after TKA and therefore it improves toleration of passive motion . The FNBIlfeld et al.'s study in 2010 introduces the concept of continuous ambulatory FNB for 4 days after a TKA discharge . BeaupreRegarding the quadriceps weakness secondary to FNB, Wasserstein concluded that single-shot FNB did not increase the fall's risk. Advanced age, obesity, and continuous femoral nerve blockade are independent risk factors for inpatient falls after primary total knee arthroplasty .The evidence-based data regarding FNB are as follows: continuous FNB provides better pain relief than that attained with single-injection FNB and information was insufficient for review authors to conclude on the comparison of FNB with local infiltration analgesia or oral analgesia or on the safety of the various analgesic techniques .A modern and easy identification method of the femoral nerve is the ultrasound. For experienced hands, the femoral nerve block under the echographic guidance has a fast installation with a high success rate . The useThe sciatic nerve block contribution is still controversial. Pros are Cappelleri et al. who concluded that continuous sciatic nerve block improves analgesia, decreases morphine request, and improves early rehabilitation compared with single-injection sciatic nerve block , in contThe knee innervation is mainly covered by the femoral, sciatic, and obturatorius nerves, excepting few areas of the classical incision that are innervated by the lateral cutaneous femoral nerve. The injection of the femoral nerve catheter even on a large volume of local anesthetic or the distribution of the solution more cranially does not cover the obturatorius nerve in terms of analgesia , 51, 52.Adductor canal block is a sensory blockade that provides analgesia in the territory of obturatorius nerve and saphenous nerve. There are only two studies related to the efficiency of adductor canal block analgesia compared with other established techniques in TKA, FNB. Adductor canal block preserved quadriceps muscle strength better than FNB and therefore promotes early ambulation, without a significant difference in postoperative pain , 56.The psoas block analgesia should be theoretically superior to that of the femoral nerve block in TKA. Paradoxically, Morin found that the analgesia via femoral/sciatic nerves blocks combination is superior to the psoas block with decreased need for opioid .Decreasing opioid consumption can be achieved by using a combination of analgesics belonging to different pharmacological classes. The multimodal analgesia is actually a balanced analgesia through a multimodal approach to postoperative pain, with synergistic effect of various analgesics and consecutive reduction of side effects associated with them by lowering doses .α-2 adrenergic agonists or (3) subarachnoid or epidural administration of local anesthetics, opioids, and α-2 adrenergic agonists or (4) combinations thereof.This synergistic analgesic effect can be achieved by the following: (1) peripheral techniques using local anesthetics, nonsteroidal anti-inflammatory agents, opioids, and other analgesics or (2) peripheral nerves blocks with the use of local anesthetics and In a systematic review of analgesics and anesthetics interventions dedicated to optimal pain influencing primary hip arthroplasty, Fischer et al. use in their analysis the Cochrane protocol and evidence-based recommendations are the following: PROSPECT group recommended for postoperative analgesia general anesthesia combined with peripheral nerve block or intrathecal administration of local anesthetic and opioid . MoreoveThere is evidence of multimodal approach to pain, suggesting that that the use of analgesics in different pharmacological classes improves postoperative pain control in patients with arthroplasty.Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors added systemic route have a synergistic effect with local anesthetic in most cases and a safety profile regarding side effects . RegardiSeveral studies are dedicated to the adding of gabapentin to the multimodal analgesia in arthroplasty. Mathiesen starts from the evidence that gabapentin is effective in reducing postoperative pain and opioid consumption . He studClarke et al. study the effect of a single dose of pregabalin 600 mg administered preoperatively or postoperatively with spinal regional anesthesia and multimodal analgesia in THA. Multimodal regimen includes preoperative administration of acetaminophen p.o., celecoxib p.o., and dexamethasone i.v. The study concludes that gabapentin added to a multimodal regimen does not reduce acute pain, opioid consumption, or chronic pain after total hip arthroplasty .Over the last decade, technological progress of the types of prostheses and minimally invasive surgical approaches have resulted in a faster recovery, decreased length of stay and lower costs. Parallel analgesic techniques migrate from the central  to periphery .Soon, the concept of intra-articular local infiltration of the wound developed by Kerr and Kohan is picked up by a lot of clinics and schools, especially Scandinavia, UK, and Australia. Kerr and Kohan have developed the type of technique “local infiltration analgesia (LIA)” for pain control after total knee and hip arthroplasty. This requires systematic infiltration of a mixture of ropivacaine, ketorolac, and adrenaline in the tissues surrounding the surgical wound to achieve satisfactory analgesia with minimal discomfort .The technique is revolutionary because it allows virtually immediate mobilization; most of the 325 patients included in the study can walk with assistance in 5-6 hours after surgery and regain independent mobility in 13 to 22 hours of surgery. Pain score was satisfactory, between 0 and 3 on the VAS, and side effects were infrequent; 71% of the patients were directly discharged home after one night spent in the hospital. The study's conclusion was that “LIA is simple, practical, safe and effective pain control after THA/TKA.”Study of Andersen et al. in 2007 starts from preliminary experience using intra-articular ropivacaine in the shoulder surgery by Gottschalk and Horn , 62 and Thorsell et al.'s study, also a prospective randomized trial, found no clinically important effect of LIA on the catheter compared to peridural analgesia, although patients with LIA were mobilized faster and had a higher degree of satisfaction, but there was no reduction in the consumption of morphine .In the same way the prospective randomized study of Specht finds no statistically significant analgesic differences between LIA administered on catheter and placebo administered into intra-articular space in THA .The prospective, randomized Lunn et al.'s study on a larger number of patients, 120, compares the analgesic efficiency between LIA with large volumes, 150 mL, and placebo in the presence of a multimodal analgesia system composed of acetaminophen, celecoxib, and gabapentin preoperatively and analyzes the first variable pain to walk from a distance of 5 m 8 hours after the surgery. The study concludes that the administration of high-volume LIA does not reduce acute pain compared to placebo in the presence of a multimodal system that combines the three drugs in total hip prosthesis .The administration of local anesthetic in the surgical wound is a reasonable approach to reduce nociceptive transmission from the source . DevelopThe Swedish National Arthroplasty Registry data show for THA a steady increase in the number of replacements under the LIA in fast-track mode, as well as for TKA, the percentage being 75%. None of the studies published till 2011 could reproduce the short duration of hospitalization reported by Kerr and Kohan original study, but the average time of hospitalization decreased from 6–10 days to 3–5 days .Kehlet and Andersen create a review of randomized clinical trials on the basis of existing data at the level of the year 2011 related to efficiency of LIA with large volumes in the THA and TKA. At that time, there was little evidence to recommend in both intraoperative and postoperative THA technique of letting the catheter in the wound when given nonopioid oral multimodal analgesia; regarding TKA, evidence supported the intraoperative analgesic effectiveness of LIA but not the use of the catheter for postoperative analgesia .Moreover, for TKA there are sufficient data to sustain that the compressive bandage may prolong analgesia after administration of high-volume LIA intraoperative . As withAnother recent study dedicated to the effectiveness of LIA in the THA is Solovyova et al.'s study who come into contradiction with Andersen: LIA “per se” or followed by continuous administration of ropivacaine as part of multimodal analgesia with acetaminophen, celecoxib, and pregabalin does not bring additional benefit or reduction of the opioid consumption compared to placebo .If THA has not demonstrated the effectiveness of LIA in managing conditions of multimodal analgesia, for TKA there are multiple studies that compare LIA with different analgesic techniques that demonstrate the superiority of LIA on evidence-based grounds.Thus, Toftdahl et al. by comparing the intraoperative and perioperative analgesia of LIA with continuous femoral nerve block in TKA show a superiority of the LIA and early mobilization, without influencing the duration of hospitalization .Essving et al. found the same positive analgesic LIA effect and a reduction of the postoperative morphine consumption, comparing the intraoperative versus postoperative administration only, with a high degree of patient satisfaction .Spreng et al. compare epidural analgesia with large volumes LIA and local adjuvants combined such as ketorolac and morphine . The study concludes that the LIA with local adjuvants reduces opioid consumption, allow a faster mobilization and a reduction in length of stay; ketorolac and morphine were more effective locally than systemically administered .Dillon's study starts from the Kerr and Kohan technique and presents in a review several changes related to evidence-based data that they use in patients proposed for joint replacement: add dexamethasone to the initial mixture and use minimally invasive surgical approaches, give up the use of intraoperative tourniquet limiting edema and allowing reducing of pain associated with edema, and use bandage from toe to thigh also involved in improving analgesia associated with LIA .Their experience shows that LIA is well tolerated by patients allowing early walking on the day of surgery for both THA and TKA with a good pain control and decreasing the duration of hospitalization .Perlas retrospective study of 298 patients analyzed analgesia and recovery at 48 hours in patients with TKA and LIA versus continuous femoral nerve block or LIA plus adductor canal block. LIA was associated with improved early analgesia and walking in the first postoperative day; the adding of the adductor canal block allowed a faster gait with the increased incidence of discharge to home .Fowler explores in a recent review the LIA with large volume in THA/TKA versus peripheral nerves blocks in terms of functional outcome, persistent postoperative pain, costs, and the revision rate. Despite the growing popularity and good postoperative analgesia the role of LIA in the context of a recovery program, the persistent postoperative pain, or efficiency compared with peripheral nerves blocks is not clear .The most recent review is from 2014, analyzing 27 randomized controlled studies including 756 patients operated on with THA and 888 patients with TKA. Andersen and Kehlet explore the effectiveness of LIA in early treatment of postoperative pain, the analgesic efficiency of the surgical wound catheter in postoperative period, and if there is any impact on the duration of hospitalization. As shown earlier, LIA has similar analgesic effectiveness with administration of intrathecal morphine and epidural analgesia in THA. For TKA, most trials provide a reduction of pain with LIA and also a reduction in the amount of opioids compared to placebo. LIA is similar to continuous femoral nerve, intrathecal morphine analgesia, or epidural analgesia for early postoperative period, with a high risk of error due to different systemic analgesia between groups. Using the wound catheters for postoperative analgesia does not bring additional benefits; length of hospital stay is not related to analgesic effectiveness .THA and TKA are surgical procedures for removal of pain and restoration of mobility to patients with gonarthrosis and coxarthrosis, which are associated with moderate to severe postoperative pain. If former analgesic approaches addressed first the postoperative pain, appearance of new operative techniques, like minimally invasive surgical approaches, has led to an adaptation of postoperative analgesia methods with the aim of more early mobilization, even on the day of surgery, and a shorter hospital stay with home discharge directly without the need for an intermediary rehabilitation center. Each of these new models has its adepts and the choice of one or another belongs to the anesthetic-surgical team according to the surgeon technique and has a single aim: a better prognosis for the patient.


Background. To differentiate acute coronary syndrome (ACS)from other causes in patients presenting with chest pain at the emergency department(ED) is crucial and can be performed by the nurse triage. We evaluated the effectivenessof the ED nurse triage for ACS of the tertiary care hospital. Methods. We retrospectivelyenrolled consecutive patients who were identified as ACS at risk patients by the ED nurse triage.Patients were categorized as ACS and non-ACS group by the final diagnosis.Multivariate logistic analysis was used to predict factors associated with ACS.An online model predictive of ACS for the ED nurse triage was constructed. Results. There were175 patients who met the study criteria. Of those, 28 patients (16.0%) were diagnosed with ACS.Patients with diabetes, patients with previous history of CAD, and those who had at least one characterof ACS chest pain were independently associated with having ACS by multivariate logistic regression. The adjusted odds ratios were 4.220 , 3.333 , and 12.539 , respectively.Conclusions. The effectiveness of the ED nurse triage for ACS was 16%. The online tool is available for the ED triage nurse to evaluate risk of ACS in individuals. Chest pain is the second common presentation at the emergency department (ED) . There aCoronary artery disease (CAD) is the leading cause of death in Thailand and worldwide , 3. At tRamathibodi Hospital is a tertiary and university hospital located in Bangkok, Thailand. Nursing triage at the ED for ACS has been established and aims to correctly identify ACS patients. Patients presenting with chest pain are firstly evaluated by the ED nurses. Those patients who are at risk for ACS were evaluated by the triage nurse; ACS fast track will be activated. The effectiveness of the nurse triage at the ED has never been evaluated. We aimed to study the correlation of nurse triage for ACS and final diagnosis of each patient and what factors are suggestive for ACS and create an online tool for nurse triage at the ED to identify patients with ACS.Consecutive patients who were identified as ACS suspected by nursing triage at the ED, Ramathibodi Hospital, Mahidol University, Thailand, were enrolled. The study period was between December 1, 2006, and June 30, 2007. The final diagnosis of each patient was made by an attending physician at discharge.Charts of all patients enrolled by ACS nursing triage at the ED were retrospectively reviewed. The study variables included baseline characteristics, comorbid diseases, characters of chest pain, risk factors for CAD, and laboratory results. Chest pain characters of ACS or angina chest pain was one of these following features: chest tightness, squeeze pain in the chest, pain referred to shoulder, arm, or mandible, difficulty in breathing, tachypnea, dull aching pain at epigastrium, presence of sweating, or unexplained fatigue, palpitation, syncope, or pain not relieved by sublingual nitroglycerin. Risk factors for CAD were older age, obesity, dyslipidemia, smoking, hypertension, diabetes, male gender, family history of premature CAD in first-degree relatives with male age less than 45 years or female age less than 55 years.Study variables were defined as follows: hypertension: resting systolic blood pressure more than 140 mmHg, diastolic blood pressure more than 90 mmHg under standard procedures for blood pressure measurement, currently taking antihypertensive agents, or diagnosed as hypertension by physicians ; diabeteDiagnosis of AMI was classified as ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (Non-STEMI) according to the criteria provided by the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) . UnstablP value less than 0.20 by univariate logistic regression or clinically significant variables such as age or gender were included in the subsequent multiple logistic regression analysis. The best model by multiple logistic regression analysis was the model with the highest adjusted R square. An online model predictive of ACS for nursing triage at the ED was produced from the best model by multiple logistic regression analysis. The online tool was available at http://chestpain-rama.webs.com/. The probability of having ACS ranged between 0 and 1.The rate of ACS was calculated to evaluate the effectiveness of the nursing triage. Descriptive statistics were used to identify the differences between both groups. Variables with a There were 175 patients who were identified by the nursing triage at the ED to be ACS at risk. Of those, 28 patients (16.0%) were diagnosed with ACS. The other 147 patients (84.0%) were diagnosed as non-ACS.Clinical variables between ACS and non-ACS group were shown in Patients with diabetes and previous history of CAD or who had ACS chest pain were independently associated with having ACS by multivariate logistic regression . The adjhttp://chestpain-rama.webs.com/. The probability of having ACS was calculated based on the final model of multivariate logistic regression. The probability equals 1/[1 + ex−]; X = −5.85 − [0.96 × gender] + [0.04 × age] + [1.20 × cad] + [1.44 × dm] + [2.53 × chest pain]; gender: female = 0 and male = 1; age: years; CAD: previous history of coronary artery disease; DM: no diabetes = 0 and diabetes = 1; chest pain: having one character of angina pain as mentioned in Methods.The online formula to predict risk of having ACS in patients presenting with chest pain at the ED was posted at http://chestpain-rama.webs.com/).A crowded ED has been shown to be associated with poor cardiovascular outcomes in patients with chest pain at the ED . High waThe present study showed that having diabetes mellitus and previous CAD and having characters of angina chest pain were significantly associated with having ACS in patients with chest pain at the ED . These fFactors in the tools are practical and are comprised of only clinical factors. Recently, some technology such as stress myocardial perfusion imaging or multislice computed tomography coronary angiography was used in the triage for chest pain patients to correctly diagnose ACS and also reduce hospitalization –14. ThesThe Ramathibodi ACS nursing triage correctly identified ACS lower than that identified in a previous study from Spain (16.0% versus 21.7%) . In SpaiP value (Gender was included in the final model due to potential risk for ACS, but it did not declare the significant P value . A previP value . This fiThere are some limitations in this study. Due to retrospective study design, some risk factors for ACS were missing such as history of smoking or family history of sudden death. The total numbers of screened patients were also unable to be retrieved because the registration system recorded only final diagnosis. Data used in the study were obtained from the file of ACS nursing triage at the ED. Further studies should be performed to evaluate the validity of the triage online tool.In conclusion, the effectiveness of the ED nurse triage for ACS was 16%. The online tool is available for the ED triage nurse to evaluate risk of ACS in individuals.


With increasing human longevity there is increasing prevalence of osteoporosis and of osteoporotic vertebral fractures. Most vertebral fractures do not require medical therapy for pain, but a minority are associated with severe pain and disability.Vertebroplasty has been used increasingly for painful acute osteoporotic fractures. The best available evidence for vertebroplasty is provided by two placebo controlled trials which showed no significant clinical benefit of vertebroplasty over placebo. These were not acute fracture trials with the majority of fractures in both trials being well beyond the acute time frame of 6 weeks. There is evidence from an open label randomized controlled trial of vertebroplasty versus conservative therapy in acute fractures suggesting clinical efficacy in acute vertebral fractures.This is a blinded trial of Vertebroplasty for Acute Painful Osteoporotic fractURes - the VAPOUR trial. Patients greater than 60 years in age with new severe onset of back pain and osteoporotic vertebral fractures of less than 6 weeks duration will be enrolled. They will be randomized to receive either vertebroplasty or a placebo procedure. Data regarding pain, disability, and quality of life will be collected over a 6-month period. The enrolled patients and the outcome assessors will remain blinded for the duration of the trial.The VAPOUR trial will apply similar methodology to the previous blinded trials but in a patient group with exclusively acute fractures and the most severe pain.NCT01482793 registered on 28 November 2011.ClinicalTrials.gov trial identifier:  With increasing human longevity there is increasing prevalence of osteoporosis. Vertebral body fractures are among the most common osteoporotic fractures. Whilst most cause minimal symptoms, a subset can cause severe acute fracture pain. Vertebroplasty has become a commonly used procedure for the management of painful osteoporotic vertebral fractures.There is conflict in the best published evidence for vertebroplasty. There are two blinded randomized controlled trials (RCTs) published together in 2009 ,2 which The largest open label RCT of vertebroplasty  limited A debate developed regarding the apparent discrepancy in findings between the blinded and the open label trials. Proponents of vertebroplasty argued that patient selection and procedural technique explained the negative findings in the blinded trials ,6. The VA meta-analysis  of the tThere is clearly a requirement for a resolution of the conflicting clinical evidence for vertebroplasty in the acute fracture setting. This requires a blinded RCT of vertebroplasty for acute vertebral fractures (defined as less than 6 weeks duration) with new onset of severe back pain (defined as pain score greater than 7/10). We are conducting such a trial: Vertebroplasty for Acute Painful Osteoporotic vertebral fractURes .The mechanics of vertebroplasty underpin the treatment’s application and patient selection, and these principles need be clarified as they affect study design. We hypothesize that vertebroplasty is only effective when applied in the acute fracture setting in patients with severe pain. It can then potentially provide internal fixation and ameliorate the acute pain generated by fracture fragment motion. To achieve adequate internal fixation in a collapsing bone, we believe that the volume of injected cement is important to outcome and this volume will be measured. We also hypothesize that fractures in different parts of the spine are subject to different biomechanical forces which affect fracture behaviour. These segments may therefore respond differently to vertebroplasty. We will analyze the sub-groups of thoracic T4-T10), thoraco-lumbar (T11-L2) and lumbar L3-L5) as categorized in previous RCTs of spinal augmentation  and also through the National Ethics Application Form by Northern Sydney Local Health District Human Research Ethics Committee [HREC/11/HAWKE/228]. Local approval was obtained from South Eastern Sydney local health district governance for St George Public Hospital [SSA/12/STG/30] and for Sutherland Hospital [SSA/12/STG/60]. Local approval was obtained for Liverpool Hospital from South Western Sydney local health district governance [SSA/12/LPOOL/45-12/027]. Local approval was obtained for Royal North Shore Hospital from North Sydney local health district governance [1301–009 M].Although the majority of osteoporotic fractures cause minimal morbidity, there is a sub-group of patients that experience severe pain or immobility. This can be a turning point in the life of an elderly patient and can be the difference between independence and institutionalized care. This patient group may develop complications from conservative therapy. Such complications could include narcotic-induced delirium, narcotic-induced constipation, loss of confidence in mobilizing after prolonged bed rest and swelling in the lower legs due to prolonged sitting with the legs not elevated. The principle of acute intervention is to break this downward spiral and allow early mobilization, earlier rehabilitation and recovery of independence.There are several difficulties in conducting a randomized controlled procedural trial in an elderly population with acute pain. The primary end point of this trial is the numeric rated pain score at 2 weeks. Patient-rated pain score is subjective and can be affected by other factors, particularly the use of narcotic analgesics. For this reason, the trial includes two office visits . These visits allow for the collection of a properly performed visual analogue pain score to supplement and compare with the numeric pain score. The office visits do make the trial more difficult to conduct as elderly patients with osteoporotic fractures often have difficulty arranging transportation and require family members, often at their inconvenience, to accompany them.The Roland Morris Disability score will provide important data as it comprises 24 yes/no questions relating to low back pain and disability. This measure is regarded by the authors as of equal importance to the pain measures. The disability caused by painful spinal fractures is of just as much clinical importance as the pain itself and the 24 yes/no questions are perhaps less subjective than the simple nomination of a pain score. Analgesic use and duration of hospitalization will also provide objective although indirect measures related to pain and disability.The inability to provide informed consent may preclude a significant number of otherwise eligible patients from the trial. Elderly patients hospitalized with acute fracture pain are usually treated with narcotic analgesics which can induce delirium and lack of clarity in short-term memory. Patients with chronic back pain are also to be excluded. These patients may derive a clinical benefit from vertebroplasty, but this would less likely translate to a statistically significant change in pain score if the baseline pain score is chronically elevated.Although the trial sites had existing vertebroplasty programs, we decided at all trial sites to stop offering vertebroplasty outside of the trial. As the best available evidence does not support routine use of vertebroplasty, this was an ethical decision. Patients referred for vertebroplasty now have the choice between enrolment in the trial or conservative therapy. The only means of obtaining a vertebroplasty is via enrolment in the trial. This facilitates enrolment into the trial and links the trial directly to real clinical practice.There is no crossover in this trial. The larger of the published blinded RCTs  allowed At the time of writing (5 September 2014) 112 patients had been enrolled into the trial. At current rates of enrolment we would anticipate concluding enrolment in December 2014.


Postero-lateral thoracotomies are routinely performed in thoracic surgery. Post-operatively, the pain can be incapacitating due to many factors including intercostal nerve injury. Therefore neurovascular bundle (NVB) protection may be a key element in improving pain control. Two methods of chest closure are used in our unit; traditional pericostal closure and intracostal closure.To investigate whether intracostal suture placement reduces acute postoperative thoracotomy pain and length of stay.A retrospective cohort study involving 1031 patients who underwent primary postero-lateral thoracotomies in the past 3 years was conducted at our regional cardiothoracic centre.5 different surgeons, 4 using pericostal sutures and 1 intracostal sutures placement performed the surgeries. Patient's primary method of analgesia was per anaesthetists' preference.After completion of the appropriate procedure, patients had one or two soft chest tubes placed as per surgeon's preference.In the pericostal group, Vicryl 2.0 sutures were placed around their ribs in the standard pericostal fashion.The intracostal group had their thoracotomies closed by drilling approximately four evenly spaced holes using a 5-mm attachment to a pneumatic drill. Vicryl 2.0 sutures were placed through the hole and just over the top of the rib aboveChest tubes were removed as per surgeons' preference. A visual analogue scale objectified pain at post op day 0, 1, 2 and 3. Pain scores and length of admission were outcomes measured.There were 744 patients in the pericostal group and 287 patients in the intracostal group. Patients in the intracostal group were younger , but all other parameters were similar. The mean pain score for the pericostal group on post op day 3 and length of stay was significantly higher.Intracostal suture placement reduces pain on post op day 3 and length of stay.