Lumbar radiculopathy is one of the most common diseases of modern civilisation. Multimodal pain management (MPM) represents a central approach to avoiding surgery. Only few medium-term results have been published in the literature so far. This study compared subjective and objective as well as anamnestic and clinical parameters of 60 patients who had undergone inpatient MPM because of lumbar radiculopathy before and 1 year ±2 weeks after treatment. The majority of patients were very satisfied (35%) or satisfied (52%) with the treatment outcome. Merely 8 patients commented neutrally and none negatively. The finger-floor distance had decreased significantly (p < 0.01), and 30 patients (50%) had shown improved mobility of the spine after therapy. The need for painkillers had also been significantly reduced after 1 year. The arithmetical average of pain on a visual analogue scale was 7.21 before treatment, which had significantly decreased to 3.58 at follow-up (p < 0.01). MPM is an effective approach for treating lumbar radiculopathy by mechanical nerve root irritation. Therefore, in the absence of an absolute indication for surgery or an absolute contradiction for MPM, patients should first be treated with this minimally invasive therapy. In modern societies, lumbar radiculopathy and sciatica have become an increasing problem. Although all age groups are affected, elderly people are the largest population presenting with lumbar spine diseases. Lumbar radiculopathy may be caused by a herniated disc, disk protrusion or sciatica. Irritation or compression of the sciatic nerve often results in radicular pain along a specific dermatome and pseudoradicular pain. Such pain is often associated with claudicatio spinalis which decreases walking distances.Finding the right treatment is important to these patients, and surgery should only be considered as a last resort. On the other hand, long-term pain must also be avoided to prevent pain chronification. Most of the many conservative treatment options available are not standardised and thus difficult to compare. For lumbar radicular pain syndrome, injections are an important treatment modality for reducing the irritation of affected anatomical structures1451The study aimed at proving the positive mid-term effect of a multimodal inpatient therapeutic concept based on drug injections for patients with lumbar radiculopathy.This clinical study with a non-randomised unblinded prospective design included male and female patients with lumbar radiculopathy aged 29 to 79 years who had been treated according to a multimodal therapeutic concept at the Department of Orthopaedics of the University Medical Centre Regensburg between April 2009 and May 2010. Participation in the study was voluntary. Inclusion criterion was radicular pain arising from one specific nerve root diagnosed by the presence of either the Lasègue sign, pain radiating distal to the knee or clearly attributable motoric failure. In addition, patients had to have participated in at least five psychological sessions during therapy. A clear indication for MPM had to exist, and an absolute indication for surgery had to be excluded.Exclusion criteria were post-discectomy syndrome, rheumatic or inflammatory spinal disorders, tumours with spinal involvement and congenital spinal deformities. For ethical reasons, no control group was formed because such patients would have received placebo injections instead of the effective drugs. The study was approved by the Ethics Commission of the University of Regensburg  and carried out in accordance to approved guidelines of the Helsinki Declaration of 1975. A written informed consent was obtained from all subjects. The study is registered in the DRKS with number DRKS00010257 (WHO register).88 of initially 285 patients remained after evaluation of the patient files for exclusion criteria. After a telephone interview, further 28 patients were excluded, so that 60 volunteers remained in the study , Table 1The duration of the treatment was 8–12 days mean 10.8 days) for every patient. On average, each patient received two injections daily, one in the morning and one at noon. The injections are lumbar spinal nerve root analgesia (LSPA) of the affected nerve root in ‘freehand technique’39.8 days fPhysiotherapy and sports therapy as part of inpatient MPM includes group exercises and aqua training; accompanying measures consist of electrotherapy for muscle relaxation and thermotherapy. In addition, patients are instructed in progressive muscle relaxation according to Jacobsen and take part in coordination training. The most effective exercises are isometric exercises for strengthening the back muscles, which is further aided by medical training therapy with workout equipment. The main goal is recovery of the load-bearing capacity and reduction in pain-avoidance behaviour. The success of MPM depends on accurate patient information and consultation, continuous motivation, a systematic increase of load and permanent feedbackThe psychotherapeutic programme of multimodal pain management1415Data were recorded in standardised form at baseline and at the 1-year follow-up. The data obtained before and after treatment were compared to assess treatment success. The data provided information on the length and extent of the treatment success 1 year (±2 weeks) after hospitalisation. Physical and psychological factors were evaluated by means of the Oswestry Disability Index (ODI), the Short Form-36 (SF-36), the numerical rating scale of pain (NRS) and the Hospital Anxiety and Depression Scale (HADS-D). A detailed medical history and clinical examination of the patient completed the data for the assessment.Data were compared with the t-test for paired variables and the non-parametric Wilcoxon test. The level of significance was set at p < 0.05. Statistical analysis was done with the programme SPSS 19.0 by IBM®.In all patients, the diagnosis of lumbar radiculopathy was made by means of patient history and clinical symptoms prior to treatment. For 59 patients, an additional clinically relevant finding was detected in the MRI (VA herniation or protrusion). Only 1 patient had no radiological finding corresponding to the symptoms but still met the indication for MPM. As expected, L4/L5 was the most commonly affected site in our study population .The mean NRS value was 7.2 before treatment, 2.4 at discharge and 3.6 at follow-up, as shown in Dividing patients into age groups on average shows lower NRS values for younger patients at follow-up .Finger-floor distance had significantly improved from a mean of 20.92 cm (SD: 18.921) before treatment to 10.1 cm (SD: 12 097) at the 1-year follow-up (p < 0.05). Another spinal mobility measure is testing the motion directions to detect any mobility restrictions. At the initial examination, 37 patients showed mobility restriction in at least one direction. This figure was significantly reduced to 18 patients at follow-up (p < 0.05).Motor deficits in the sense of serious paresis such as foot drop were not included here because such deficits represent an indication for surgical treatment, which would have resulted in the withdrawal from the study. At the initial examination, 10 patients had motor deficits in terms of reduced strength (3/5 or 4/5) but none at follow-up. This difference is significant (p < 0.05). Sensory deficits such as hyposensitivity or paraesthesia were reduced from 25 to 17. 14 patients still experienced hyposensibility at different degrees, and 3 patients had paraesthesia. The number of complaint symptoms could also be reduced, and, according to the hypothesis, the difference was statistically significant in a one-sided test (p < 0.05). Thus, MPM reduced motor and sensory deficits as well as pain and accompanying symptoms.The Oswestry Disability Index (ODI) is used to measure everyday impairment. The mean value in our patients at the initial examination was 38.95% and 22.83% at follow-up, hence the reduction was significant (p < 0.05). In addition, the frequency of category ‘0% to 10%’ could be increased from 0 at baseline to 16 at follow-up. The Hospital Anxiety and Depression Scale (HADS-D) was additionally used to detect possible psychological impairment and to gain a comprehensive picture of a patient’s situation. No significant difference was found, only a slight decrease in the positive results. Nevertheless, 4 positive results were found at follow-up. Patients with a positive anxiety value often also showed a positive depression value. Thus, only a few patients had slightly elevated results in the HADS-D .The Short Form 36 (SF-36) was used in addition to the ODI and the HADS-D. The SF-36 and the ODI not only record physical impairment but – similar to the HADS-D − also issues of mental health. Thus, only the following 3 parameters were used when evaluating the SF-36: ‘subjectively experienced current state of health’, ‘current impairment’, which was categorized, and ‘health status compared to last year’. The information given on the perceived health status showed its development from the initial examination to follow-up. The median of this topic had significantly changed from ‘less well’ at baseline to ‘good’ at follow-up (p < 0.05). As already indicated by the ODI, even everyday impairment could be significantly reduced (p < 0.05). The majority of patients  rated their own health as improved, and only 8 patients considered their own health deteriorated over the previous year. However, some of these patients had developed other diseases and traumas such as a femoral neck fracture in addition to their back problems.At follow-up, patients were asked how satisfied they were with the success of their treatment and the treatment plan. 35% of patients (n = 21) were very satisfied, 52% (n = 31) were satisfied and 13% (n = 8) had an impartial attitude regarding the success and concept of the treatment. If required, most patients would repeat the therapy and recommend the treatment. Patients who did not reach the desired medium-term treatment outcome did still not view the treatment in a negative manner because the initial pain relief was perceived as very positive. In addition, patients had perceived the treatment and care within the MPM concept as very good and pleasant.et al.20Discogenic disorders mostly occur at certain levels of the spine. Segments L4/5 and L5/S1 and their respective nerve roots, for instance, are mostly stressed mechanically and therefore most commonly affectedAs conservative treatment options usually only single methods are compared. There are either only injectionsThere we see the big advantage of MPM. Patients get a lot of different conservative treatment methods in a very short time period. This leads to a quick pain relief and in combination with the psychological lessons avoids chronification.In contrast to former opinions, today pain management and physical activation are the centre of conservative treatment. The aim of the accompanying methods is to preserve or restore the full capacity of the spine-stabilizing muscles, to train coordination skills and to learn spine friendly behaviour. Risk factors that can lead to chronic pain must be eliminated. All methods serve to interrupt the vicious circle of “pain - stress - malposition- pain”.The injections help to reduce pain as fast as possible25So chronification can be avoided and when being back in daily life, the patient has new possibilities to avoid falling back into the vicious circle of pain and has the positive feeling that there are always treatment options to reduce pain. For us this is the reason for the very good med-term effects of the MPM.The variety of pain scores used in the different treatment concepts makes a comparison with other studies difficult. Even comparisons within one and the same study are often not possible because answers are always subjective assessments, although items are objectified by pain scales. Thus, only comparisons are useful that include the scores before and after treatment and that are carried out for each individual patient. In the present study, a numerical pain scale was used, and its classification ranged from 1 to 10. The initial examination yielded values between 4 and 10 and an average value of 7.2. At discharge, the values ranged between 0 and 6, and the average value was significantly reduced to 2.4 (p < 0.05). All patients experienced at least temporary pain reduction. At the 1-year follow-up, values ranged between 0 to 10, and the average value was 3.6, which showed significant pain reduction (p < 0.05). Particularly younger patients had lower NRS values in the follow-up, thus benefited most from MPM. This finding is probably due to the fact that younger patients are not yet affected by degenerative changes, which are likely to contribute to pain symptoms.Ultimately, the pain symptoms of the patients in the present study could be reduced on average by 50%. However, because a ordinal scale was used in this study, it cannot be assumed that average pain intensity was halved. Spinal mobility was determined by means of finger-floor distance and movement restrictions according to active and passive mobility. However, not only restricted mobility of the lumbar spine may impede finger-floor distance but also shortened hamstrings and limited hip function. Nevertheless, a radiological study showed a valid connection between finger-floor distance and lumbar spinal mobilityPassive and active mobility provides more information on spinal mobility and possible spinal injury. Examinations test lateral flexion and rotation as well as restrictions in inclination and reclination angles which are often impeded in the presence of lumbar pain. At the initial examination, 62% of the patients in the current study had restricted mobility in at least one direction. Until follow-up, this figure could be reduced to 30% (p < 0.05). Thus, a significantly lower value (p < 0.05) was achieved in both mobility restriction and finger-floor distance.et al.The case-control study by Thomas et al.In addition to pain, patients are particularly affected by motor and sensory deficits. For this reason, attention should also be focussed on these complaints, although they are usually not a patient’s prime concern. Pain and its treatment are usually the most important issues for affected patients. At baseline, 10 patients of the present study had a motor deficit such as minor reduction in strength that did not indicate surgery. At follow-up, none of the patients had any motor skill problems. Thus, motor deficits could be reduced by 100%, which it is a significant result (p < 0.05). In addition, 25 patients had complained about sensitive deficits at baseline. At follow-up, this figure was reduced to 17. 14 patients still experienced hyposensibility at different degrees, and 3 patients had paraesthesia. However, these deficits were only intermittent. Of further significance is also the successful treatment of symptoms in 8 patients (p < 0.05). MPM resulted in significant pain relief (p < 0.05) as well as in decreased accompanying motor and sensory deficits. A similar development was also found by Madl The SF-36 questionnaire was used in addition to the ODI and the HADS-D because it measures both physical and psychological impairment. Therefore, only the following three parameters were used: ‘subjectively experienced current state of health’, ‘current impairment’, which was categorized, and ‘health compared to last year’. The patients’ current health status was documented in categories. The median had changed from ‘less good’ to ‘good’ from the first examination to the follow-up. Categorized impairment showed of course a similar pattern of that already provided by the ODI. Again, the number of patients with severe to very severe impairment had been reduced from 10 to 4. At the same time, the number of patients with little or no impairment had significantly increased from 3 to 26. Patients were also asked about the development regarding their general state of health. 63% of patients felt better 1 year after the therapy than at the beginning. Only 14% of patients reported deterioration in health. However, since this question included the development of general health and not just of back problems, the informative value of this parameter regarding therapeutic success is limited. For example, some patients had meanwhile been diagnosed with an internal disease or with a femoral neck fracture.Subjective patient satisfaction reflects very well how obtained results correspond with patient demands and expectations. So what do patients demand and expect from this treatment method? Demands and expectations may range from pain relief to slight improvement to maintaining the current health status. In the present study, 35% of patients were very pleased, 52% were pleased and 13% had an impartial attitude regarding the success and concept of the treatment. These figures may seem at first a bit surprising, as some patients still experience pain, partly also of higher intensity than before the treatment. Nevertheless, none of the patients commented negatively on the treatment which may be due to several reasons. As already mentioned, patient satisfaction crucially depends on patient expectation. Even small improvements of often short duration may already be perceived as positive, thus influencing patient satisfaction. Furthermore, the care provided, the detachment from the challenges of daily life and the related psychological relief may be perceived as positive by the patientsThe lack of a control group is a limiting factor of the study. But evaluating the overall concept of MPM and not just the sub-item of injections makes the implementation of a control group difficult. Moreover, study populations may show a trend towards chronic back problems because the admission requirement of inpatient multimodal therapy is the failure of outpatient unimodal therapy. Despite these limitations, this study yielded satisfactory results. Treating radicular pain by inpatient MPM based on injections still shows an average pain reduction by 3.6 points 1 year after therapy. The positive picture is completed by the subjective impression of the patients: 87% of the patients were satisfied or very satisfied with the treatment. 87% of the patients achieved medium-term pain relief. Finally, 12.98% of all treated patients had to be operated on during the observation period because of radicular and pseudoradicular complaint pathologies. In addition, no serious complications were observed.In summary, MPM based on injections is an effective and low-risk treatment option for lumbar radiculopathy. In the absence of an absolute indication for surgery or an absolute contraindication for MPM, patients with lumbar radiculopathy should be first treated with this minimally invasive intervention.The study was approved by the Ethics Commission of the University of Regensburg and carried out in accordance with the approved guidelines. Registration in DRKS number DRKS00010257.How to cite this article: Benditz, A. et al. Prospective medium-term results of multimodal pain management in patients with lumbar radiculopathy. Sci. Rep.6, 28187; doi: 10.1038/srep28187 (2016).


Obvious ACS”, LR 29) and at ruling out  ACS. In the “Strong suspicion of ACS” group, 60% of the patients did not have ACS. A positive TnT (LR 24.9) and an ischemic ECG (LR 8.3) were strong predictors of ACS and seemed superior to pain history for ruling in ACS. In patients with a normal TnT and non-ischemic ECG, chest pain history typical of AMI was not a significant predictor of AMI (LR 1.9) while pain history typical of unstable angina (UA) was a moderate predictor of UA (LR 4.7). Clinical gestalt was better than its components both at ruling in and at ruling out ACS, but overestimated the likelihood of ACS when cases were assessed as strong suspicion of ACS. Among the components of the gestalt, TnT and ECG were superior to the chest pain history for ruling in ACS, while pain history was superior for ruling out ACS.In the assessment of chest pain patients with suspected acute coronary syndrome (ACS) in the emergency department (ED), physicians rely on global diagnostic impressions . The aim of this study was to determine the diagnostic value of the ED physician’s overall assessment of ACS likelihood, and the values of the main diagnostic modalities underlying this assessment, namely the chest pain history, the ECG and the initial troponin result. 1,151 consecutive ED chest pain patients were prospectively included. The ED physician’s interpretation of the chest pain history, the ECG, and the global likelihood of ACS were recorded on special forms. The discharge diagnoses were retrieved from the medical records. A chart review was carried out to determine whether patients with a non-ACS diagnosis at the index visit had ACS or suffered cardiac death within 30 days. The gestalt was better than its components both at ruling in (“The online version of this article (doi:10.1186/s40064-015-0992-9) contains supplementary material, which is available to authorized users. Non-traumatic chest pain is a common presenting complaint among patients seeking care in the Emergency Department (ED). The management of these patients often hinges upon the perceived likelihood that an acute coronary syndrome (ACS) accounts for the patient’s chest pain. A substantial proportion of patients with chest pain are admitted for inpatient care in order to rule-out ACS, and many undergo stress testing, of which only a small proportion are abnormal and lead to a change in management  and coronary artery bypass surgery (CABG) are available 24 hours a day. Roughly 65,000 patients are assessed every year in the ED, of which about 5,500 present with non-traumatic chest pain. There is no dedicated chest pain observation unit. Patients with ST-elevation myocardial infarction (STEMI) who are identified via ambulance ECGs as a rule bypass the ED and are taken directly to the angiography suite.All patients aged over 18 years who presented with non-traumatic chest pain to the Lund ED during June 12th - October 8th 2009 were prospectively identified and enrolled in the study. Patients were excluded from the analysis if the history was unreliable due to e.g. alcohol intoxication or dementia, if they were transferred to another hospital, if they refused admission for inpatient evaluation, or if data were missing.All included patients were initially assessed by a triage team that measured vital signs, recorded an ECG and took routine blood tests including a troponin T (TnT). The patients were then assessed by a resident or a specialist in internal and/or emergency medicine. This physician took a history, performed a physical exam, and if necessary, reviewed the case with a senior colleague.After the patient encounter, the physician or one of the authors (MS) recorded the physician’s assessment of the patient on a specific study form , nonspecific for ACS, or not suspicious of ACS. The form specified that central, pressure-type pain lasting over 15 minutes with or without radiation to the arm or shoulder is considered typical for AMI. Specifications for the other categories were not provided. Next, the physician noted the presence or absence of the following ECG changes: a) ST-elevation or depression ≥ 1 mm in at least two anatomically contiguous leads; b) left bundle branch block (LBBB); c) pathological Q-waves in at least two anatomically contiguous leads; d) T-wave inversions in at least two anatomically contiguous leads. In the present study, a non-ischemic ECG was defined as an ECG lacking all of the findings above.First, the physician categorized the chest pain history as Obvious ACS, typical symptoms and ST-elevation or LBBB not previously observed; Strong suspicion of ACS, a) typical symptoms or b) ST-T changes or LBBB not previously observed, or c) acute heart failure or hypotension regardless of ECG or d) ventricular tachycardia/fibrillation or AV-block III; Low suspicion of ACS, unclear symptoms and history, non-ischemic ECG; and No suspicion of ACS, a) no suspicion of ischemic heart disease, or b) stable angina pectoris. The physicians were free to disregard these definitions, but the definitions where non-controversial and reflected common clinical reasoning at the hospital during the study.Last, physicians recorded their composite assessment of the likelihood of ACS based on the chest pain history, ECG and the first TnT value, which in principle was always available at the time of assessment. In order to limit heterogeneity of the assessments, physicians had to choose among four ACS likelihood levels, with suggested definitions provided on the data form: The troponin assay used in this study was Elecsys troponin T, which has a 99th percentile cutoff of 0.01 μg/L, and with 0.03 μg/L reported as the lowest concentration with a coefficient of variation ≤ 10%. The first TnT test result was retrieved from the electronic patient records, with values ≥ 0.05 μg/L being considered indicative of ACS.Patients admitted after the ED assessment were cared for by ward physicians blinded to the data form. The discharge diagnosis (ICD 10) was obtained from the discharge summary, which was written by the ward physician and reviewed for quality and accuracy by a specialist in internal medicine and/or cardiology. For patients discharged from the ED, the discharge diagnosis (ICD 10) was retrieved from the ED patient record written by the responsible ED physician. Patients were considered to have ACS if they received the diagnosis in the Skåne University Hospital’s patient records, or suffered a cardiac death during the index visit or within 30 days of ED presentation. Those who received a non-ACS diagnosis at the index visit and were diagnosed with ACS within 30-days were categorized as missed ACS.typical of AMI” and “typical of UA”, where AMI and UA were used as the respective outcome measures. When a cell of a 2 x 2 table was 0, 0.5 was added to all cells before calculating likelihood ratios (LR)  were calculated with ACS as the outcome measure, except chest pain history assessed as “As shown in Figure As can be seen in Table The diagnostic performances of the assessments are described in Tables First, age < 40 years, chest pain history and overall gestalt not suspicious of ACS all practically ruled out ACS. Second, a positive initial TnT and an ischemic ECG were strong predictors of ACS and seemed superior to pain history for ruling in ACS. Third, in patients with a normal initial TnT and non-ischemic ECG, chest pain history typical of AMI was not a significant predictor of AMI while chest pain history typical of UA was a moderate predictor of UA.In this prospective study of patients with non-traumatic chest pain, we analyzed the diagnostic values of the overall clinical assessment of ACS likelihood, and the values of the main diagnostic modalities underlying this assessment, namely the chest pain history, the ECG and the initial troponin result. Our main findings were three: Obvious ACS”, LR 29) and at ruling out  ACS. None of the 441 patients with a “No Suspicion of ACS” gestalt had ACS within 30 days. In accordance with the results by Kline et al. No Suspicion” gestalt thus seems to rule out ACS in the ED, and to obviate the need for admission, serial troponins, and stress-testing for the exclusion of ACS. Miller et al. found that 2.8% of ED patients assessed as “noncardiac chest pain” had adverse cardiac events within 30 days . In addition, the patients were followed for 30 days after the ED visit. The discharge diagnoses reflected real life practice, and we believe that very few were inaccurate.In our review of the patient records at 30 days to determine whether an ACS diagnosis was missed or if the patient died, we may have missed a small number of patients presenting to other hospitals. However, such misclassifications were probably few and unlikely to significantly affect the results of this study.In the analysis, patients with or without ongoing chest pain were not separated. We have no data as to whether they were evaluated or treated differently.Suggested definitions of the different levels of ACS suspicion were present on the study forms, and although they left considerable room for judgment, other (or no) definitions may have led to somewhat different results. The definition of typical symptoms of MI might have been suboptimal as it is somewhat non-specific, but it is a definition commonly used in guidelines  and at ruling out (LR 0.01) ACS. The gestalt seemed to overestimate the likelihood of ACS when cases were assessed as strong suspicion of ACS. Among the components of the gestalt, the initial TnT and ECG were superior to the chest pain history for ruling in ACS, while pain history was superior for ruling out ACS. In patients with a non-ischemic ECG and a normal TnT, a chest pain history typical of AMI was not a significant predictor of AMI, but a pain typical of UA was still a moderately good predictor of UA.


Osteoarthritis (OA) is the most common chronic condition of the joints that takes place when the cartilage or a low friction surface between joints breaks down which leads to pain, stiffness and swelling. The purpose of the present study was to evaluate the therapeutic effect of intra-articular hyaluronic acid (HA) in comparison to corticosteroids (CS) for knee osteoarthritis.140 patients with knee osteoarthritis, who were followed for 3 months, were randomized to receive intra-articular injection of either hyaluronic acid or corticosteroid. By receiving one injection of drug during the enrollment in the study, the patients were treated. With the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), and the visual analog pain scale, an independent, blinded evaluator assessed the patients three times.The mean age of the patients in the corticosteroid group were 57 ± 1.9 years and in Hyaluronic acid group were 58.5 ± 8.3 years. WOMAC score represented that pain and stiffness did not improve in neither groups at any time points after intervention (P > 0.05). KOOS score suggested that symptoms improved after 3 months in both CS and HA groups. Besides, daily activity improved in both groups (P < 0.05).As a conclusion, it is argued that the most important difference between the two intervention groups is the duration of effectiveness. HA is suggested to be superior in the duration of pain relief when compared to CS. We can propose that HA can be administered every 3 months intra-articular for knee joint OA. Therefore, when CS has to be injected every 2 months, it will be more convenient to use HA. Osteoarthritis is a chronic progressive joint disease which often affects middle-age to the elderly  HA  or IA injections of 40 mg CS. The treatment consisted of one IA injections of HA or one injection of CS. And the follow-up visits were scheduled at 1, 2, and 3 months. Before inclusion, for fulfillment of the entry criteria, patients were evaluated. Moreover, qualified patients were informed about the aim and design of the study.http://www.randomization.com, which uses the pseudo-random number generator of Wichmann and Hill  grading scale , Function in Sport and Recreation (Sport/Rec), and Knee-related Quality of Life (QOL)  is an instrument regularly used to measure pain intensity based on a 0–10 cm . P value < 0.05 considered as significant level.In this study 69 patients at corticosteroid group with age of 57.0 ± 9.1 years and 71 in Hylan group with 58.5 ± 8.3 years were participated (P = 0.322). In corticosteroid group 17.4 % and in Hylan group 12.7 % were male (P = 0.435). Table As shown in Fig. Pain (P = 0.093) and stiffness P = 0.712) in corticosteroid group along with pain (P = 0.109) and stiffness (P = 0.112) in Hylan group were not statistically different before 3 months after intervention (Table  in cortiSymptoms improved after 3 months in both corticosteroid (P = 0.010) and Hylan groups (P = 0.003). Besides, daily activity improved in both corticosteroid (P = 0.026) and Hylan groups (P = 0.046). On the contrary, pain did not decrease 3 months after intervention in both corticosteroid (P = 0.099) and Hylan groups (P = 0.170).Osteoarthritis is a chronic disabling disease with morbidity and pain. Knee is a weight bearing joint frequently affected by degenerative processes which cause much disabilities. There are a few diseases modifying medical therapies for this disease condition. While primary treatment goals in knee OA include pain reduction improvement and improvement of joint mobility and function. Decreasing the progression of disease is an important secondary goal. Recent meta-analysis studies have argued that pharmacological interventions, to treat knee OA with oral NSAIDS, is inferior to intra-articular injections (Bannuru et al. Corticosteroids are other medications used as non-expensive pain modifying intra-articular injections (Bellamy et al. By using VAS, it was shown that both medications were equally effective in pain reduction in time points of first and second month after intervention. The effectiveness of pain reduction was more durable in HA group compared to CS. This was like what previous studies also provide Ray . At the WOMAC score represented that pain and stiffness did not improve in neither groups at any time points after intervention Table . HoweverConsequently, it is argued that the most important difference between the two interventions is the duration of effectiveness. Having compared to CS, HA is suggested to be superior in the duration of pain relief. We can propose that HA can be administered every 3 months intra-articular for knee joint OA. Therefore, it will be more convenient to use HA, when CS has to be injected every 2 months. It is probable that HA might be more cost-effective than CS although independent pharmacoeconomic studies are not sufficient. Our results present a more conservative treatment plan compared to the results of Abate et al. , who havThe superiority of our study on others is its double blind method. Furthermore, we did not focus only on pain score. This study has used several scales to clarify any differences between the two intra-articular injections. Future studies with more extensive follow-ups are demanding and will be taken into account by our research group.


Background. Anxiety sensitivity (AS) and experiential avoidance (EA) have been shown to have an interactive effect on the response an individual has to chronic pain (CP) potentially resulting in long term negative outcomes. Objective. The current study attempted to (1) identify distinct CP subgroups based on their level of EA and AS and (2) compare the subgroups in terms of mood and disability. Methods. Individuals with CP were recruited from an academic pain clinic. Individuals were assessed for demographic, psychosocial, and personality measures at baseline and 1-year follow-up. A cluster analysis was conducted to identify distinct subgroups of patients based on their level of EA and AS. Differences in clinical outcomes were compared using the Repeated Measures MANOVA. Results. From a total of 229 participants, five clusters were formed. Subgroups with lower levels of AS but similar high levels of EA did not differ in outcomes. Mood impairment was significantly greater among those with high levels of EA compared to lower levels (p < 0.05). Significant improvement in disability (p < 0.05) was only seen among those with lower levels of EA and AS. Conclusions. This cluster analysis demonstrated that EA had a greater influence on mood impairment, while both EA and AS levels affected disability outcomes among individuals with CP.  Anxiety plays a significant role in a patient's response to pain. A key concept of anxiety is anxiety sensitivity (AS), which is defined as the fear of anxiety-related sensations; specifically, fear of bodily sensations due to beliefs that these sensations will have a negative somatic, cognitive, or social consequence . AS has Coping strategies are important and are often described in terms of adaptive and maladaptive styles. The role of adaptive coping styles is to promote a sense of self-control within the patient in response to negative thoughts, behaviours, and feelings . AS may The present study hypothesized that AS and EA play a highly influential role on mood and distress, pain disability, and pain intensity amongst patients with chronic pain. As such, this study sought to (1) divide individuals with chronic pain into subgroups according to their level of EA and AS and (2) identify which subgroups of patients with pain are most at risk to experience these comorbidities.Participants were recruited from an academic specialist pain outpatient clinic in London, ON. Participants had to meet the following inclusion criteria: be admitted to the outpatient pain clinic, have a diagnosis of chronic pain (≥3 months), and be between the ages of 18 and 65. Given that this study involved the completion of self-report questionnaires, patients with an inability to read and write in English were excluded.Patients who met the inclusion criteria were mailed a questionnaire booklet and consent form two weeks prior to their scheduled appointment at the pain clinic. Subsequently, the research assistant contacted the participants by telephone to answer any questions and instruct participants to complete the booklet prior to their appointment. The booklet consisted of background information related to the patient's demographic characteristics and the following questionnaires: Anxiety Sensitivity Index (ASI), Acceptance to Action Questionnaire (AAQ), average pain intensity, Depression Anxiety Stress Scales-Short Form (DASS-SF), and Pain Disability Index (PDI). The battery of questionnaires administered to patients was solely used for research purposes. The questionnaires were not seen by the treating physician and thus did not impact patients' treatment for chronic pain. Participants were asked to arrive half an hour before their appointment was scheduled to begin. Upon arrival at the clinic, the research assistant collected the questionnaire booklet and made sure to clarify with the participant that any answers left blank were purposely skipped. Subjects were mailed a follow-up questionnaire booklet 12 months following the in-person assessment, which included average pain intensity, DASS-SF, and PDI. Similar to the original protocol, contact was made with the participant via telephone to answer any questions and encourage timely completion. A self-addressed, stamped, return envelope was provided. Subjects who did not return their questionnaire booklet following three postcard reminders received a subsequent telephone reminder. All procedures were approved by the University of Western Ontario Health Sciences Review Board.The ASI  is a 16-The AAQ  is a 9-iIndividuals were asked to rate their average pain over the past two weeks on an 11-point numeric rating scale, ranging from 0 to 10, with 0 being no pain and 10 being worst pain. This composite pain intensity score has been shown to be a very reliable measure of pain intensity in chronic pain patients and has been used in recent research .The DASS-SF  is a 21-The PDI  is a 7-ik-means analyses) provides the maximum flexibility in determining the appropriate number of clusters. This hierarchical approach identifies the optimal number of clusters that maximizes differences between clusters while minimizing within-group differences on the dependent variables [k-means nonhierarchical procedure then confirms the number of clusters identified. This method of clustering provides a robust identification of clusters and capitalizes on the strengths of both methods while compensating for weaknesses [A two-step cluster analysis was performed to organize observations into two or more mutually exclusive groups, where members of the group share properties in common. The two-step cluster analysis procedure  according to cluster membership to compare patient scores at baseline and one-year follow-up. Post hoc analyses were conducted with a Tukey correction to compare mood, pain intensity, and pain disability between cluster differences. All tests were performed using SPSS version 23.0  and were two-tailed. The significance level was set at 0.05.Two clustering variables were used in the analysis: AS and EA measured by the ASI and AAQ, respectively. The log-likelihood distance measure was used, with subjects assigned to the cluster leading to the largest likelihood. The number of clusters was not predetermined. The Bayesian information criterion was used to judge adequacy of the final solution. Differences in sample demographic characteristics were compared according to cluster membership using univariate analysis of variance for continuous variables and In total 383 patients were eligible to participate during the study period, 229 agreed to participate in the study and completed study questionnaires. The study population had an average age of 45.6 years (SD = 11.5) and comprised predominantly females (64.2%). The majority of individuals were married or in a serious relationship (73.1%) and had experienced chronic pain for less than 10 years (84.8%).p < 0.001). n = 38) had the highest levels of both EA and AS; these individuals constitute patients with the highest levels of both AS and EA. Participants in Cluster 2 (n = 26) scored the second highest for AS but the second lowest for EA; these individuals could be characterized as those that were functional copers with high anxiety sensitivity. AS scores continually decreased in Clusters 3 (n = 59), 4 (n = 63), and 5 (n = 43), respectively. The EA scores for Clusters 3, 4, and 5 followed a similar pattern; however, Cluster 3 scored above the mean EA scores while Clusters 4 and 5 scored below the mean  = 9.52, p < 0.006). However, no significant main effect for time (within-subject) was found on mood  or disability (PDI) scores from baseline to follow-up. Additionally, no significant interactions between time and clusters on average pain intensity  = 0.74, p = 0.056), depression  = 0.96, p = 0.43), anxiety  = 1.05, p = 0.38), stress  = 18.02, p = 0.26), or disability  = 3.35, p = 0.11) were found based on the repeated measures MANOVA.Repeated measures analysis with Tukey correction resulted in an overall improvement of average pain intensity scores within the full sample of patients when comparing baseline to follow-up scores, representing a main effect of time on average pain intensity  = 11.81, p < 0.001), DASS-SF depression  = 10.76, p < 0.001), DASS-SF anxiety  = 10.62, p < 0.001), DASS-SF stress  = 12.28, p < 0.001), and PDI scores  = 4.83, p < 0.001). No significant main effect (between subject) of cluster was seen in average pain intensity  = 1.45, p = 0.22).As seen in p < 0.05). Cluster 3 also scored significantly higher than Clusters 4 and 5 on DASS-SF total, DASS-SF depression, DASS-SF anxiety, and DASS-SF stress and scored significantly higher on pain disability compared to Cluster 5 . Cluster 2 did not significantly differ from any of the other clusters.Post hoc analysis resulted in a number of significant differences among clusters on mood and pain disability scores . ClusterTo our knowledge the current study is the first to subdivide individuals with a diagnosis of chronic pain based on their levels of EA and AS and compare the subgroups on outcomes of pain intensity, mood, and disability over time. Five clusters emerged within our sample when patients were grouped based on levels of EA and AS. Overall, average pain intensity decreased from baseline to one year follow-up, while no significant difference in pain intensity was seen between clusters. Hence, it can be assumed that the changes in distress and disability are not necessarily related to a differential in pain intensity among the different subclusters.No significant difference in mood and disability was seen overall between scores at baseline and follow-up; however, when participants were subdivided into five subgroups based on their level of EA and AS, significant differences were found among the clusters for mood and disability after one year. Consistent with our hypothesis, Cluster 1, individuals with the highest levels of EA and AS, experienced greater levels of distressed mood and disability compared to those in Cluster 5 who reported low levels of EA and AS. A previous cross-sectional study by Esteve and Ramírez-Maestre  also fouIndividuals in Cluster 2 who reported moderate levels of both EA and AS did not differ from those in Cluster 3, 4, or 5 who had lower levels of mood and disability. However, the individuals in Cluster 2 had significantly lower levels of distress and disability compared to Cluster 1 (highest levels of EA and AS). This finding may indicate that there is a threshold of EA and AS levels required for perceiving greater disability and distress. Those with moderate levels of EA and AS appear to cope as well as the patients in Clusters 3, 4, and 5, which reported the lowest EA and AS levels. This suggests that experiencing a moderate amount of inflexibility and need for control may not substantially reduce the coping capability of patients with chronic pain.Surprisingly, individuals from both Clusters 1 and 3 significantly differed from Cluster 5 on their reports of pain disability. Individuals in these two subgroups had similarly high levels of EA; however, those in Cluster 3 were almost 2 standard deviations below Cluster 1 in AS scores and were only 1 standard deviation above Cluster 5 scores. This finding suggests that pain disability may be independently influenced by levels of EA, rather than AS, among individuals with chronic pain. This is further strengthened by the finding that although Cluster 2 included individuals with higher AS levels than those in Cluster 3 (1 standard deviation above), their moderate levels of EA did not result in significant differences in mood and disability compared to Cluster 5. Esteve et al.  examinedConsistent with other studies examining levels of AS among individuals with chronic pain, the current study found that patients reported significantly greater levels of AS than the general population. Overall, the current study population had ASI scores 1 standard deviation above the general population mean based on normative data  collected by Pollard . IndividThe current study had several limitations. First, our population consisted of patients treated at a specialist pain clinic. Previous studies have shown that these individuals may have longer histories of pain, have undergone more interventions, and consume the highest amounts of pain medications . Hence, Assessment of EA and AS was conducted only at baseline; however, it may be beneficial to assess if there is an effect of time on both measures in future studies. Evaluating the stability of these trait-like constructs over time among individuals with chronic pain may be of importance. Rosellini et al.  found thDespite these limitations, the current study has important research and clinical implications. This study has expanded our understanding of the effect of AS and EA on mood and disability among individuals with chronic pain. Further, it has demonstrated that individuals with high levels of EA and AS are at risk for experiencing negative mood and greater disability. The study found that EA, rather than AS, may be related to disability among those with chronic pain. Identification of these individuals may help clinicians develop multimodal management plans resulting in more optimal outcomes. Use of acceptance based strategies and cognitive behavioural therapy which help individuals improve their willingness to experience unwanted events and improve their cognitive flexibility may be recommended adjunct therapies for this population.


While many studies have addressed various issues with regards to pain management, there is limited knowledge about how nurses assess pain in surgical wards. This study aimed to describe Thai nurses’ experiences of pain assessment in a surgical ward.A cross-sectional explorative study was conducted. Participants were selected through theoretical sampling. Data was collected through interviews with twelve registered nurses working in surgical wards. Qualitative content analysis guided the analysis of the data.Nurses use a double/triple check system, communicated to the healthcare team via records and protocols, and they used their skills and experiences in pain assessment. The results showed that nurses missed the opportunity to include the patients’ self-reported pain in their accounts. Though much evidence of pain was collected, this did not seem to benefit the patients. Furthermore, the nurses were not using instruments to measure pain, which illustrates the potential unreliability of professionals who have differing opinions concerning the patients’ pain.Thai nurses worked based on a ‘patient-evidence’ paradigm when assessing patients in pain; this should be shifted to an evidence-based paradigm. Furthermore, by including the patients’ self-reported pain in their assessment, nurses would both improve the quality of the pain assessment and empower patients in their pain management. Pain management practices in Thailand should be improved through education, training, supportive innovation, and collegial competence development in order to improve the quality of care in the post-operative field. Nurses play a key role in pain assessment and in advising on the standards of pain management in post-operative recovery on surgical wards. Nurses are the main providers of professional care within the post-operative care setting –3. ZoëgaThere are many barriers that can interfere with the process of pain management. According to Shoqirat , many ofPrevious studies conducted in Egypt and England have illustrated that higher quality pain assessment and management can be achieved with good patient observation charts and pain assessment documentation. However, these studies have also recommended that nurses should improve their knowledge and skills in pain assessment and management , 10. To Earlier studies have revealed that nurses need to improve their communication with patients, as this is necessary to determine cultural sensitivities and to provide nursing care based on the individual’s distinct values, beliefs, and traditions in a healthcare setting , 9. In TA systematic literature search for Thai articles regarding pain management, published between 1990 and 2009 , resulteAn explorative cross-sectional study with qualitative approach was conducted, which used in-depth interviews as a method of data collection . QualitaThe study was conducted in a surgical ward of a public hospital in Bangkok, Thailand; the surgical ward had a capacity of 50 beds. The selected surgical ward provided pre- and post-operative care to patients that had undergone abdominal surgery.The data collection took place during September 2013. To recruit the potential participants, the surgical wards of the hospital were contacted and, upon acceptance by the head nurses, nurses were contacted and given information about the study. All nurses who were contacted agreed to participate in the study. Data was collected by theoretical sampling based on Benner’s nursing theory , and theThe interviews were conducted in Thai, which was the mother tongue of the interviewer and the interviewees, in a quiet room within the hospital where the participants worked. The interviews lasted approximately 45–60 min, and all interviewees were given enough time to express themselves. The interviews were recorded with a digital voice recorder, with the participants’ permission, and were later transcribed verbatim. The contact information of the interviewers was provided to the interviewees, in case they wished to share additional reflections at a later date. The first author (MC) and second author (AN) discussed the qualitative interviews in terms of sufficiency and richness of the contents . RecruitHow do you know when the patients are in pain?How do you measure the patients’ pain and what do you utilize in measuring the pain? And please, could you tell me how you assess pain in your daily practice?If the patient’s pain is not relieved by painkillers, how do you assess their pain afterwards?When someone has been expressing a high level of pain and/or differences exist between individuals, how do you assess their pain?Do you have a way of sharing strategies with the other team members or other nurses in the pain assessment practice in order to manage the pain of the patients?Probes for each question were as follows: Could you describe more about that? Could you give me an example of that? What does that mean to you?Prior to the interviews, a semi-structured set of interview guidelines was designed and contained the following questions:The data analysis was conducted manually, according to qualitative content analysis . First, To ensure the rigor of the study, the principles of trustworthiness in qualitative research  were folThis study was approved by the Hospital Research Ethics Committee of Thailand (Code: 16/2555), and the Ethical Review of Research Involving Humans, Sweden (Code: 2012/383). All data were treated confidentially. The participants were fully informed of all aspects of the study and their rights, and signed a written consent.n = 9) and all participants had at least a Bachelor’s degree in Nursing Sciences . Most of the nurses were female  double/triple check system, (ii) communication via records and protocols, and (iii) using skills and experience The nurses described the procedure they used when assessing patients’ pain; this procedure is a double/triple check system, a multi-method approach to pain assessment involving the following: (i) using a verbal scale to assess pain, (ii) judging patients’ pain based on appearance and mobility, and (iii) consulting the patients’ documentation. The nurses and nurses’ aides used face scales and a numeric scale as tools in their routine practice. Nursing aides recorded pain scores every 4 h, and the nurses would re-assess all those patients with pains scores higher than five according to the hospital’s protocol of pain management in the hospital. Below is an excerpt of an interview with one of the participants:I always ask the patients, ’Are you in pain?’ Em…I have noticed one in three of the patients is in pain. He had told me he had mild pain level, estimated as two or three (out of ten). But he changed his habits, becoming agitated and complaining of discomfort, like colicky pain, and he became a bit aggressive. And he was moving around in his bed…he expressed it as being quite painful. I then have to judge whether to give him pain medication or not. (Beginner 2)The nurses must reassess a patients’ pain if they have a pain score higher than five (out of ten) or if the patient has requested pain medication. The nurses mentioned that it was difficult to correctly assess and manage the patients’ pain level, and to decide when to give pain medication. An example of this is seen in the following excerpt:I have examined his wound and investigated his lower-left or right abdomen as to whether or not there was distension. Perhaps the patient had a full bladder that feels painful. I asked if the patient has any post-operative pain on the second day of recovery. Then, I observed how he walked by himself, to see if he felt pain after physical activity. (Advanced 3)The nurses also judged patients’ pain based on their appearance and mobility, and investigated any potential complications by conducting physical examinations. The nurses often rechecked the pain levels in order to clarify and ensure that the recorded pain levels corresponded to the causes of the pain and suffering. Nurse’s conducted physical examinations through abdominal examination and noted any abdominal distention, the presence or absence of pain, any bleeding from the wound, whether the bladder was full and so on, in order to determine if the patients were still in pain and if their pain scores had reduced. After completing the examination, the nurses notified the physician. Below is an example excerpt describing this examination:‘consulting the patients’ documentation’ when conducting the pain assessment, as is illustrated in the following excerpt:I just look at the pain record as plot graphs in the graphic sheets. The physicians usually check the patients' progress as well as pain management levels by looking at the recorded vital signs on the graphic sheets… This is the information they use…to make judgments and decisions about administering pain medication. Some patients might need to decrease medication if the level of pain has been decreasing according to the graphs. (Competent 1)The documentation was recorded six times per day (in 4-h cycles) for all patients, in accordance with the hospital’s protocol for pain management. The nurses also referred to occasionally assessing a patient’s post-operative pain by relying on his or her own experiences or by asking the relatives about the patient.Moreover, as the following excerpt illustrates, the nurses often referred to This category illustrates how records and documentation of pain assessment were used for communication among the members of the team, in order to provide some continuity of care in the treatment of pain. The pain assessment process relied on routines and structure; for example, pain was evaluated and recorded as a number score every 4 h, which was plotted in the graphic sheet every 4 h and given to the physician, who then selected appropriate pain medication. It became clear that despite these protocols, this communication was particularly vulnerable to the recording of inaccurate pain levels. There was frequently an incompatibility of patients’ expressions with the nurses’ documentation, and the physicians mainly prescribed medication according to the patients’ expressions and not necessarily with regard to the nurses’ documented pain assessment.We have plotted pain scores in the graphic sheet every 4 h. I guess that it could be an accurate representation of the patients’ pain…after giving pain medication. If the pain scores of the patients do not decrease, then I will notify the doctor or discuss with the team members as to what to do to relieve the pain of the patient. (Novice 2)In the excerpt below, a nurse mentions the importance of the communication document showing the graphs of pains scores and vital signs over time, as it is used by team members to manage patients’ pain:A patient had not told me about his pain yet, so I have to observe the patient to follow the process of completing the vital signs records. I just ask the nursing aide for the patients’ pain score, because it is their responsibility to ask the patient about their pain scores while the nurse is checking the vital signs of the patients (every 4 h). (Advanced 3)The nurses expressed as an incompatibility of the patients’ expressions and nurses’ documentation, which they felt was due to individual staff not completing the documentation records according to protocol. During the assessment certain information should be recorded, such as the morphine or pethidine dose administered, pain score, and vital signs, as well as the nurses’ notes used for recording the patient’s progress and response to treatment. Occasionally, this documentation was incomplete when the attending staff simply forgot to fill out the relevant sheets:The nurses mentioned that according to policies and guidelines, they should manage all documentation. However, the nurses had a heavy workload of caring for patients; as the documentation process was also very time-consuming, the records were sometimes not completed. The nurses mainly completed the documentation of pain assessment as a matter of routine and not with the primary intention of detecting patients’ pain and helping to alleviate it.The quality of a pain assessment depends heavily on the individual nurses’ experience, as well as their level of knowledge and competence. The following two issues were found to affect the outcome of the pain assessment: (i) variation in pain assessment skills, and (ii) differences in the interpretation of patients in pain. From one nurse it became clear that the nurses' aides have a limited amount of knowledge when compared to nurses.Perhaps I just have to look at pain scores on the vital sign recording sheet; however, these may be inconsistent with my assessment of the pain scores regarding that patients’ pain. (Novice 3)The nurses’ routine assessments were performed every 4 h, checking the vital signs and recording the patient’s self-reported pain score. The nurses then decided if the pain level was tolerable or required intervention; if they felt medication was needed, they would inform the physician who would then assess the patient and prescribe medication as appropriate. However, much variation was found in the nurses’ abilities to predict a patient’s pain tolerance when evaluating an individual patient’s history and their signs of pain. The level of competency in pain assessment is important, and experienced nurses generally have more comprehensive skills than novice nurses and nurses’ aides. This is important in managing pain effectively:I guess that we have too little time for sharing information, advising each patient, and providing routine care for patients in pain. Some of the staff don’t assess pain scores and also don’t reassess after administering to their patients. I am always assessing the patients’ pain scores that were inconsistent between nurse aides and me … by asking the patients questions like, ‘Do you feel pain?” Also, I spend more time conversing with the patients in order to understand and investigate their problems. I thought that is what nursing staff should do when caring for their patients… (Advanced 5)The nurses mentioned concerns about the difference in skill levels when interpreting pain assessments; for example, considerably different levels of experience are found between the experienced nurses and the novices or nurses’ aides. Accurate pain assessments are needed for more effective pain management; the accuracy of these assessments depends heavily on the nurses’ skills and expertise in the field of post-operative care, as well as their biases and previous experiences. In practice, these differences can affect the time needed to provide pain medication to the patients. One experienced nurse described this process in the following quote:The nurses’ abilities to measure pain varied between novice and expert nurses with regards to the accuracy of the pain assessment and their decision-making. All of the nurses expressed a well-intentioned effort to assist the patients in communicating their pain level. However, in order to prevent delay in the treatment of the patients’ pain, novice nurses remain under the supervision by an advanced beginner or competent level and/or expert nurse.“Patient evidence” paradigm. Thai nurses’ pain assessment did not involve having the patient declare their pain level, although the patients’ self-reported pain should be considered the gold standard of pain assessment. Thai nurses tried to verify patients’ statements in various ways, including verbal numeric scales, and judging patients’ appearance and mobility. Although the patients’ direct voice and statement was the starting point of the pain assessment, the Thai nurses in this study did not include patients’ verbal expressions and complaints of pain in their assessment and documentations, but rather tried to evaluate patients’ pain through objective measurements. The nurses tended to rely heavily on routines and structures and regarded competence as an individual concern, meaning that they did not share their knowledge and experiences with one another. This approach did not foster collegial competence development, which is an important component of an evidence-based paradigm and is considered as best practice according to literature. The Thai nurses should strive to follow an evidence-based paradigm, grounded on research-based strategies, person-centered approaches, and collegial competence development.This study explored Thai nurses’ experiences of pain assessment in a surgical ward and showed that pain assessment carried out by the Thai nurses’ stems from what we decided to name a The surgical nurses that participated in this study accumulated a lot of evidence, yet missed the point of evidence-based practice; namely, expert nurses should relay information to each other in order to make appropriate care decisions based on the information they have. The nurses often assessed pain as a routine task, during which the nurses were task-focused rather than patient-focused. Insufficient pain management is, to a large extent, due to inadequate pain assessments , 10, 14,The nurses in our study did not show any considerable differences in their pain assessment with regards to their level of expertise; rather it seemed that the beginners were taught by the expert surgical nurses to follow the patient-evidence paradigm. This distinctly intuitive knowledge can been described through Benner's theoretical approach , in whic‘Evidence-based paradigm’, which is best practice according to the literature. The nurses collected evidence through verbal numeric and face scales, and judged pain levels based on their own previous experiences of similar situation. Communication with patients and with other team members (physicians and nurses/nursing aides) did not result in the best outcome for patients. The management of the patients’ pain, whether acute or chronic, is multi-faceted because pain is presented to the nurses or physicians in many different ways [Ambiguity surrounding pain assessment can further challenge nurses’ skills and competency in assessing and managing pain, as well as the effectiveness of pain management , 23. Ourent ways , 24. Likent ways  that fouIn addition, the impact of the nurses’ professional role in pain assessment seemed to be of interest in terms of the miscommunication that arises between the nurses and the patients. There are concerns about the relationship between the healthcare professionals and the patients involving the pre-existing culture and traditional contexts . The natIt seems as though the nurses wanted to accurately determine what the patient claims were and to record pain in other ways than just the patients’ complaints. Although a lot of evidence of pain was collected, they were not put into use for the patients’ benefit. It is important to reflect on the pain management guidelines and policy in the hospital, as this may improve staff attitudes towards sufficiency of pain management for the patient. If following an evidence-based practice paradigm, Leach  proposedThe results of the study indicate that the participants used a patient-evidence approach to assess pain. Nurses play a pivotal role in assessing and monitoring pain, and the multi-method approach they used illustrated their nursing skills and ability to collect patient information and then rationally integrate this information with their own pre-existing beliefs, which are derived from their own experiences in pain assessment. Nursing care should follow an evidence-based paradigm that helps narrow the gaps between research and clinical practice.Future research should further examine these pain assessment procedures, focusing on ways to improve pain assessment methods and possibly develop a set of pain management guidelines, which could ultimately improve the communication of pain assessment between the nurses and the physicians in post-operative care.The results of this study clearly indicate that pain assessment by the Thai nurse in this study follows a patient-evidence paradigm, as opposed to the evidence-based paradigm that should become the norm. The nurses should gain their knowledge through research-based strategies, person-centered approaches and collegial competence development, and actualize improved quality of the routines and incident reports. We propose that improving the communication between the health care providers and the patients would lead to improved pain management outcomes. It would also be appropriate to empower the patients, such that they might contribute to their pain assessment with self-recorded data. Nevertheless, nurses should receive further education and training in pain assessment, and work in environments that are supportive to innovation and collegial competence; such developments would lead to improvements in the quality of care in the post-operative field.


The intensity analysis of rest pain, pain during coughing and pain in deep breathing, showed that visual analogue scale (VAS) scores were significantly lower in RIPC group compared to the control group: p = 0.0087, 0.0119, and 0.0015, respectively. There were no differences between groups in the analysis of presence or absence of mechanical hyperalgesia (p = 0.0704) and in the serum levels of IL-6 dosage over time (p < 0.0001). This clinical model of remote ischemic preconditioning promoted satisfactory analgesia in patients undergoing conventional cholecystectomy, without changing serum levels of IL-6.This study aims to evaluate the viability of a clinical model of remote ischemic preconditioning (RIPC) and its analgesic effects. It is a prospective study with twenty (20) patients randomly divided into two groups: control group and RIPC group. The opioid analgesics consumption in the postoperative period, the presence of secondary mechanical hyperalgesia, the scores of postoperative pain by visual analog scale, and the plasma levels interleukins (IL-6) were evaluated. The tourniquet applying after spinal anesthetic block was safe, producing no pain for all patients in the tourniquet group. The total dose of morphine consumption in 24 hours was significantly lower in RIPC group than in the control group ( Ischemic preconditioning (IPC) is defined as brief periods of ischemia, interspersed with reperfusion, prior to a sustained period of ischemia. This procedure is performed in order to prepare and protect the cell to the damage caused by a long period of ischemia . It is aMany surgical and nonsurgical cardioprotective strategies have been developed to reduce the levels of ischemic injury, some more successful than others. In addition to its protective effects in ischemia-reperfusion injury, there is a considerable amount of evidence indicating the effects of IPC in inflammatory conditions of nonischemic nature, probably through a systemic action .β levels after limb ischemia in pigs [The effects of inflammatory cytokines have been demonstrated in relation to TNF-alpha, which has been identified as the major mediator involved in the development of tolerance to induced IPC . A reduc in pigs  and incr in pigs , 8. Isch in pigs .The remote ischemic preconditioning (RIPC) is achieved by a series of short nonlethal ischemic periods, interspersed with periods of reperfusion in distant tissues, that results in a target organ protection in late ischemic events –13. KosiPostoperative pain has inflammatory and nociceptive nature. It results from the interaction between tissue damage and nociceptive sensory receptor stimulation through inflammatory mediators. Thus, considering that the mediators of inflammation are closely related to the reduction of the excitability threshold of the nociceptive primary afferent, and the release of factors related to the inflammatory response can be changed by RIPC, the hypothesis is reasonable that this simple procedure could affect the pain response, producing postoperative analgesia.This study aims to evaluate the analgesic activity of a clinical model of ischemic preconditioning on postoperative pain resulting from subcostal incision, as well as the influence of this technique in the cytokines levels in the postoperative period.The study was approved by Walter Cantídio University Hospital's Scientific Ethical Committee, which is regularly affiliated to National Research Ethics Commission (CONEP) registered with number 015.03.12. The research was conducted in accordance with the Helsinki Declaration and the principles of Good Clinical Practice. The approval was ratified by the Department of Studies of Santa Casa de Misericordia Hospital in Fortaleza.A randomized controlled trial, partially blind , with prospective and quantitative nature was developed at Santa Casa de Misericordia Hospital from June 2013 to June 2014. After applying informed consent form, the patients were randomized utilizing sequentially numbered opaque sealed envelopes to one of two groups (ratio 1 : 1) by the study coordinator. The same anesthetic-surgical medical team did all procedures. All included patients were females, between the ages of 20 and 55 years, with cholelithiasis, physical status, ASA I or II ). The exclusion criteria were patients under 20 or above 55 years old, those with signs or symptoms suggestive of acute cholecystitis or choledocholithiasis, and subjects with more than one comorbidity or with one comorbidity clinically uncontrolled or poorly defined. We also excluded those subjects who did not properly understood the methods assessment of postoperative pain, those who did not sign the informed consent form, and patients who presented hemodynamic changes or other serious intraoperative complications, as well as those who had an inappropriate spinal block.The choice of the experimental design was a challenge. There are no clinical studies using remote preconditioning for abdominal surgery. Thus, this model was based on previous studies using the technique in orthopedic surgery –4. HowevPain control in the postoperative period was indirectly assessed by measuring the intravenous morphine consumption during 24 hours. All patients received a predetermined and fixed analgesia with intravenous metamizole (1 g) every 6 hours. The visual analogue scale (VAS) was applied once 24 hours after surgery, asking about pain intensity in three situations: at rest, during deep inspiration, and during cough induction. Two independent investigators, blinded to the study group where the patient was allocated, performed all the postoperative VAS measurements.The presence of hyperalgesia produced by mechanical stimulation of the area surrounding the incision previously marked was observed 24 hours after the end of the procedure . This evT0 (before ischemic preconditioning), T1 , T2 , and T3 (24 hours after the surgery).In order to assess the role of IL-6 in the RIPC effects on acute postoperative pain and hyperalgesia, 5 mL of blood samples was collected in four different moments: The surgical technique was similar in all patients, performed by the same surgical team and based on classical technique performed for conventional surgery: right subcostal incision. Only three anesthesiologists, experienced in performing spinal blocks, participated in the implementation of standardized anesthesia with a spinal block in L2-L3 space using a needle gauge in the range 26-27, heavy bupivacaine 0.5%, for a total of 15 mg–20 mg (3-4 mL), and 5 micrograms of sufentanil.t-test (parametric data) and the Mann-Whitney test or Kruskal-Wallis (nonparametric variables). Qualitative variables were compared using the Fisher exact test [α) (level of significance) was set at 0.05 (5%) considering as statistically significant p value less than 0.05. The GraphPad PRISM® software version 5.00 for Windows  was used for both implementation of statistical procedures as for the preparation of graphics.Quantitative variables were initially analyzed by the Kolmogorov-Smirnov test to check the normality of distribution. For descriptive statistics, the mean and standard error of the continuous variables were calculated. Intergroup comparisons at each time point were performed by using the unpaired act test . In all There were no significant differences in the analysis of the variables: age, weight, duration of surgery, and ASA physical status between the two groups, as shown in Tables The overall total morphine consumption in 24 hours was significantly less in tourniquet group compared to the control group which can be shown in Analysis of the evaluation of the intensity of pain at rest and in deep breathing and coughing showed significantly lower VAS scores at Garrote group compared to the control group, as shown in Figures p < 0.0001). There was a growing increase in the concentration of IL-6 with no difference statistically significant between the groups control and tourniquet in the times of each sample.There were significant differences in IL-6 between the two dosage groupsin the course of time as shown in The data presented in this study demonstrate a significant reduction in postoperative pain in patients undergoing conventional cholecystectomy who were submitted to remote preconditioning ischemic before the surgical procedure. It demonstrates an unprecedented way, the effect of remote ischemic preconditioning over abdominal surgery pain, since in previous publications, the pneumatic cuff was applied directly to the operated member –4.During the past two decades, multiple variations on the theme of RIPC have been investigated, encompassing both in vitro and in vivo models. The cardioprotective effect has been the main focus; however RIPC protects the myocardium, but also other parenchymal organs and, notably, the vasculature . Sousa FStudies where peripheral limb ischemia is the RPIC stimulus have mostly employed 3 or 4 episodes of 5 min arm and/or leg ischemia interspersed with 5 min reperfusion periods. However, these are empiric choices, the optimal algorithm has not been identified, and it has been postulated that “hyperconditioning”  may be deleterious . Thus thThe laparoscopic cholecystectomy is considered the gold standard for the surgical treatment of gallstones and is replacing the conventional technique in most services . HoweverThis study presents a clinical model of PCIR as a strategy that can be associated with other in the multimodal analgesia resulting in adequate pain control postoperatively  and meetThe higher reduction in morphine consumption postoperatively in RIPC group also needs to be presented as a very relevant finding, facing the possibility of reducing the complications arising from the adverse effects of opioids that increase postoperative morbidity .An important question to be answered is how could PCIR act to produce analgesia? It has been demonstrated that circulating monocytes play a key role in ischemia/reperfusion injury RIPC downregulating the expression of a broad portfolio of proinflammatory genes in circulating monocytes  and reduDetails of the mechanisms for local release of the protective signal at the remote site and the contributions of neuronal and humoral pathways to the RPCI are not yet clear; however several extracellular signalling molecules, such as adenosine, bradykinin, and opioids, have been identified as mediators and effectors  supportiBesides that, it seems that in most cases the common final step of the molecular mechanisms involved in preconditioning is the opening of potasium-ATP channels . Recent In conclusion, this model of remote ischemic preconditioning is feasible to reproduce in clinical setting, improved pain control, and reduced morphine use in postoperative patients undergoing cholecystectomy conventional with nonlaparoscopic technique. The analgesic effect is not related to the inhibition of inflammatory mediator, interleukin 6 production.


Stimulation of the primary motor cortex (M1) has been shown to reduce the pain of neuropathy in multiple studies. There are several methods of stimulation both invasive and non-invasive. Recent work by this laboratory has seen that 40% of a sample of chronic neuropathic pain patients responded positively to non-invasive repetitive transcranial magnetic stimulation (rTMS) to the motor cortex with a reduction in pain levels by at least 20%. The effect however is short lived and multiple return visits are necessary to maintain this response. Transcranial direct current stimulation (tDCS) offers a more mobile method of motor cortex stimulation and is similarly non-invasive. The protocol described is designed to assess the analgesic effect of a home-based tDCS treatment device on chronic neuropathic pain in both responders and non-responders to previous TMS treatment.n = 24) will receive anodal, cathodal and sham tDCS over M1. All patients will have previously completed a study of rTMS of the motor cortex and have been designated as responders or non-responders to this modality.This article reports the protocol for a randomised, sham-controlled, double-blinded crossover study in which patients with chronic neuropathic pain ], self reported health status  and anxiety/depression . A linear mixed model with fixed effects will analyse changes in pain scores from pre- to post- interventions. Analysis will be carried out on an intention-to-treat basis. A proportion analysis will also be carried out with patients separated into either responders or non-responders to previous TMS.Safety will be assessed throughout the study by monitoring of adverse events.The result of this trial will assess the efficacy of self-administered tDCS of the motor cortex in the treatment of chronic neuropathic pain and also provide insight into whether a potential differential effect is seen in patients that have previously been shown to be either responsive or non-responsive to rTMS over the same area.ISRCTN56839387 date 27 January 2014. First patient randomised to trial 30 October 2012. Stimulation of the primary motor cortex M1) of the brain was first shown to reduce central pain in patients by Tsubokawa et al.  of the b.Previous research in our laboratory has shown that approximately 40% of chronic pain patients obtained at least 20% improvement in pain scores following high-frequency rTMS of the M1 motor cortex  lasting tDCS involves the application of a low-amplitude constant electric current to the scalp, a proportion of which enters the skull to affect cortical activity in the brain. It does not directly induce action potentials in neurons but rather alters the membrane potential and thus influences the excitability of these cells ,7. TypicIt has been shown to be effective in the treatment of various conditions including motor function recovery following stroke, reduced epileptiform discharges in epilepsy, mood elevation in depression and improvement of motor function in Parkinson’s disease -12.Several studies have also shown it reduces the perception of acute pain ,14 and etDCS of the motor cortex also influences the activity of areas distant to the site of stimulation and this is probably achieved through inter-neuronal connections between these sites . This isThe main aim of this study will be to determine the efficacy of home-based tDCS treatment in two chronic neuropathic pain patient populations: responders and non-responders to rTMS. The hypothesis is that those patients who have previously responded to rTMS will also respond to tDCS while non-responders may not. To test this hypothesis TMS responders will be subjected to three different types of tDCS: anodal, cathodal and sham tDCS. In addition, there remains a possibility that tDCS may show efficacy even in those patients who previously have not responded to rTMS. Therefore, non-responders will be subjected to the same three modes of stimulation as responders.Ethical approval for this study was granted from the National Research Ethics Committee REC reference 12/EE/0315.Patients will be selected based on response to previous treatment with rTMS for chronic pain, i.e., all subjects, both responders and non-responders from previous rTMS studies, will be invited to participate. All subjects shall be informed of the purpose of the experiment and written consent to enter the study will be obtained prior to entering the study by the principal investigator.Inclusion criteria include (1) age between 18–85 years; (2) stable analgesic medication for the prior month; (3) mean pain levels ≥4 out 10 on VAS for pain during the 1-week run-in phase, based on patient diary; (4) willingness to take part; (5) ability to consent; (6) previously had a minimum of five sessions of TMS for pain, and can be named as a “responder” or “non-responder” where the responder reports a weekly average pain reduction of 20% on an NRS of 0–10, following five rTMS sessions.Exclusion criteria are (1) severe pain of other origin, e.g. musculoskeletal pain that in the opinion of the investigator may interfere with the reporting of the neuropathic pain being targeted; (2) metal implants/coils/electronic devices; (3) drug or alcohol abuse; (4) pregnancy; (5) psychiatric or psychological disorders; (6) epilepsy; (7) inability to understand instructions or operate equipment; (8) high-dose opioids; (9) uncontrolled medical conditions .  Patients were diagnosed with neuropathic pain, according to the new classification . Two speThis study will be a randomised, double-blind, double cross-over, sham-controlled trial. Three stimulation modes will be compared: anodal, cathodal and sham stimulation.Twelve responders and 12 non-responders to rTMS will be randomly assigned to receive anodal, cathodal or sham stimulation as their first treatment session.Randomisation will be done by a research clerk not otherwise involved in the study. Computer-generated numbers will be used to create the participant numbers and order lists. The latter will be placed in a numbered opaque envelope and sealed. The copy of the order lists and participant numbers is kept by the research clerk.The initial and follow-up assessments will include a record of (1) handedness (not in follow-up assessments); (2) NRS for pain, including measurements for overall daily pain severity, unpleasantness of pain and severity of paroxysmal pain attacks if present. Pain diaries will be filled out daily for 1 week at baseline and for 14 days beginning at each stimulation period . (3) HeaThe stimulation site will be the same as used during previous TMS treatments. In practice, this will mean placing the anodal/cathodal electrode over the primary motor or premotor cortex contralateral to the pain. All patients have previously had an MRI of the brain and their localisation on the scalp of the previous TMS treatment can be easily obtained using the brain navigation system associated with the PRI TMS device . In the few cases where this is not possible, the location will be based on bony landmarks as advised by Fregni et al. . In thos2 electrode.  All subjects are asked to remain non-active during this time and engage in either light reading/watching television or listening to the radio.Direct current will be delivered from a battery-driven, constant current stimulator  using saline-soaked surface sponge electrodes (5 × 5 cm) placed over the previously identified area to target the motor cortex (M1) and over the contralateral supraorbital area. The device will be worn for 20 min each day for 5 days consecutively beginning on the first day of their visit. During active treatment the current delivered will be 1.4 mA with a size 25 cmFor sham stimulation, the electrodes are placed in the same positions as for anodal M1 stimulation; however, a constant current of 1.4 mA is only delivered for 30 s (10-s ramp on). During active tDCS treatment, subjects typically report tingling sensations under the electrodes, which rapidly fade . Our shaA research assistant (not otherwise connected with the study) will set the stimulation characteristics as indicated by the information in a sealed envelope opened at the patient visit . This will be repeated at the two subsequent visits. The mode of stimulation is not revealed to the patient or investigators.At the first visit subjects are measured up for individually fitted headband locators for electrode placement. Headbands are measured and marked relative to ear tragi, the nose and midline of scalp. A separate occipital band ensures the locator headband cannot slip from its position. Anodal and cathodal electrodes are differently coloured (red and black) and the patient is shown which way around they should be placed. Once fitted, subjects are shown how to position the headbands reproducibly and instructed on how to position the band markers relative to the anatomical landmarks described. Patients are then asked to demonstrate this to the investigator and feedback given until electrodes are correctly and reproducibly positioned. Photographs and measurements are taken in case of the need for reference at home and all instructions are given to the patient in writing also. In this patient information leaflet subjects are informed of potential side effects such as tingling, burning sensation, dizziness, headache, nausea and phosphenes while switching the device on or off abruptly. Electrode placement is re-checked at the beginning of each treatment block.Programming of devices requires a dedicated programmer with security code access. Overriding or manual reprogramming is not available to patients.The study will have five phases. At baseline , the patient is given a short presentation of how the tDCS device is used with one of the investigators being the substitute patient. The patient will then receive the Patient Information Sheet and Pain diary. If they wish to join the study they will contact the Research Clerk after having read the information after a minimum of 24 h. The Research Clerk will provide the appointment for visit 1, advising the patient to fill in the pain diary over a minimum of 7 days. At visit 1, eligibility will be determined (as per inclusion and exclusion criteria). Provided they are eligible patients will be recruited and consented. The patient and carer/partner will then be shown how to apply the tDCS device, and the patient will then try it on themselves, with the help of the carer/partner if necessary. The first trial stimulation will be carried out according to the randomisation order by the research assistant. The investigators will then confirm that the patient and carer/partner have understood all details of the stimulation. Following instructions regarding the daily use of the device, a further pain diary is supplied and a subsequent visit agreed in 2 weeks’ time. At this visit (visit 2), the patient will return the pain diary and will surrender the tDCS device. The third visit (3) will be arranged for a further 4 weeks’ time (wash-out period); during the interim a daily pain diary will be kept. At visit 3, the tDCS device will be returned to the patient, and a new stimulation mode will be selected by the research assistant as per the randomisation order. After 2 weeks (visit 4), the tDCS device will again be surrendered to the investigators and the second wash-out period of 4 weeks with diary keeping started. At visits 5 and 6, tDCS device will be received and later surrendered by the patient as during previous treatment arms. The final visit (7) will happen in a further 2 week’s time.In the case of patients who wish to continue, the tDCS device will be given him/her for regular daily use and visits agreed at 1 month, 3 months, 6 months and 12 months. Before each visit, they are asked to keep a 1-week pain diary to assess their mean pain level.The primary outcome measure will be the mean daily pain intensity during each mode of tDCS. Secondary outcome measures will be change in hospital anxiety and depression scale (HADS), mini mental state examination and the general health survey (SF 36). Monitoring of device usage will also be recorded, along with patient experience of using the device. At the end of each treatment the device will be returned and interrogated to record actual date, time, duration and number of stimulations delivered and if stimulations were successful.p = 0.036 (two-tailed Fisher’s exact test). Other results would yield important data for future studies (see below).As this is a pilot study, it is based on an opportune sample of 24 patients who have previously undergone rTMS and expressed willingness to take part in the study. No formal power calculations have therefore been carried out. If, however, 8/12 responders receiving anodal tDCS report a beneficial effect [weekly mean reduction of 30% or 2 units on NRS (0–10) from tDCS] and just 2/12 of non-responders do the same, this itself would give a statistical significance of Stata Statistical Software, College Station, TX: StataCorp LP). A proportion analysis will also be carried out with patients separated into responders and non-responders and their response rated as positive  and negative (pain relief less) and analysis carried out separately for the three different tDCS treatments.A linear mixed model will be formed with fixed effects of mode of tDCS, treatment sequence, responder group and treatment period, and the random effect as patient (nested in sequence); the model will be first fitted with the pain intensity data. All patients will be included and all pairwise comparisons will be made with the estimated contrast from this model. Secondary continuous outcome measures will be analysed in the same way as the primary endpoint. Baseline covariates will be incorporated as standard fixed effects but the sensitivity of the results to other ways of incorporating baseline information will be assessed . This inWith the effectiveness of non-invasive M1 stimulation recently demonstrated there has been a call from patients to facilitate more convenient forms of this therapy. It has been in direct response to this patient lead call that the present exploration of home-based non-invasive tDCS of M1 has been devised. Self-administration of tDCS obviously has both advantages and disadvantages. While it may not confer the same accuracy and consistency as clinic-based, professionally administered stimulation sessions, it does reflect the necessity for patients to be able to administer this type of therapy in the convenience of their own home. It is recognised that there will be limitations on the ability to control timing of stimulus applications and there may be some variability in technique. However, all subjects will be thoroughly briefed in the correct positioning of electrode placement and measurements will be made against previously taken MRI scans and navigated TMS data. These measurements are transferred on to securely locating headbands that are fitted individually to each patient. Each subject is observed while placing the electrodes on a number of occasions to ensure correct technique. The study described is very much a real-world test of both the effectiveness and practicality of using tDCS in this patient population, with a method of delivery that is based on other portable home-use devices such as transcutaneous electrical nerve stimulation, which has been in use for several years, albeit with varying success. If a positive effect is demonstrated it may represent an important cost-efficient option for non-invasive motor cortex stimulation in the treatment of chronic pain.This trial is on-going and actively enrolling.