Physical therapists' perception of patients' pain and its effect on management

BACKGROUND AND PURPOSE: The purpose of this qualitative study was twofold: (1) to determine the factors that affected physical therapists' (PTs) perception of patients' pain and (2) to determine how this perception affected the management of patients. METHODS: Forty-six PTs with at least two years' experience practicing in pain management clinics, outpatient clinics or sports medicine clinics were interviewed. The data collected were transcribed, coded and analyzed for main themes. RESULTS: The most predominant factors found to affect PTs' perception of patients' pain were the therapist's personal and professional experience, area of practice and evaluative findings. CONCLUSIONS: In this sample there exists a common link between experience and evaluative findings: the longer PTs have been practicing the more proficient they become in performing and interpreting a thorough subjective and objective evaluation. PTs practicing in pain clinics were found to have a more holistic and multidisciplinary approach to patient care, whereas therapists practicing in outpatient and sports medicine facilities were more apt to focus on patients' physical symptoms and complaints. Four main themes of perceived patient pain and their corresponding management were developed: (1) patients presenting with legitimate/acute pain profiles render a slow, conservative approach by the PT; (2) patients presenting with debilitating/chronic pain were most often treated with an approach that stressed functional gains and patient independence; (3) the preferred treatment of patients characterized with a non-legitimate pain profile was an aggressive and multidisciplinary approach; (4) 'special cases' and their management were dependent upon the patient's functional level and pain tolerance.     

Anticoagulant effects of synthetic retinoids and activated vitamin D3

This study provided outcome data measuring variables of a psychoeducational group approach to self-management of 88 chronic pain patients and 25 controls. Most of the injuries were back injuries and work related. At the completion of the 16 group sessions, patients reported decreased depression, pain severity, interference, and affective distress and increased life control and general activity. At 1-year follow-up, there was continued increased return to work, lowered workers' compensation, fewer health care visits, and less prescribed pain medication than demographically similar controls. Results suggest that a group psychoeducational program involving learning of general coping skills primarily and pain coping skills secondarily produces an effective approach for the management of chronic pain.     

Idiopathic osteonecrosis of the medial femoral condyle. Classification and treatment

Idiopathic osteonecrosis of the medial femoral condyle is a well recognized cause of spontaneous, sudden onset of severe pain, usually at the anteromedial aspect of the knee joint. At the Department of Orthopaedic Surgery of the University of Ioannina, 105 knees in 101 patients were evaluated and treated for idiopathic osteonecrosis of the medial femoral condyle. The disease was found to follow a four-stage course, which consisted of a progression from no radiographic findings (Stage I), to a slight flattening of the medial condyle (Stage II), followed by the appearance of a radiolucent lesion (Stage III), and finally, articular cartilage collapse (Stage IV). Although Stages I and II potentially were reversible, Stages III and IV were associated with irreversible destruction of the subchondral bone and articular cartilage. Although bone scan is a nonspecific diagnostic modality, it was helpful in establishing diagnosis in the early stages of the disease. Conservative treatment was found appropriate for the first two stages, whereas surgical management was effective for patients with Stages III and IV. Specifically, osteotomy was useful for patients younger than 60 years of age with limited necrotic lesions, whereas unicompartmental arthroplasty was effective in older patients with more extensive lesions. Total knee arthroplasty can be reserved for cases where the disease has expanded to the lateral compartment.     

Unresectable pancreatic cancer: is a multi-modality approach a promising therapeutical alternative?

BACKGROUND/AIMS: The aim of this study was to evaluate the combination of immunochemotherapy and stop-flow upper abdominal chemotherapy in the prolongation of survival in patients with unresectable pancreatic cancer. METHODOLOGY: Thirty unresectable pancreatic cancer patients were treated with immuno-chemotherapy in combination with stop-flow upper abdominal chemotherapy, in an attempt to improve survival time. RESULTS: The results obtained in this study indicate that this kind of treatment is feasible, safe and effective for patients suffering from Stage III and IV pancreatic duct carcinoma. Twenty per cent of the patients within this group were able to undergo radical resection and remain alive and free of disease, with a mean survival rate of 16 months. CONCLUSION: The multi-modality approach used in this study achieved promising results for pancreatic cancer patients and is recommended as a promising therapeutic alternative.     

Tight glycaemic control prevents diabetic complications

About 70% of all patients with sickle cell disease suffer from pain crises. Pain crises are recurrent episodes of pain that range in severity from mild to severe, usually occur very abruptly and are often localized around joints. Pain crises are caused by vaso-occlusions in the vascular bed of the bone marrow, leading to necrosis, edema and increased pressure. For effective analgesia morphine or morphine analogues are often required. When treating a pain crisis the patient's complaints need to be taken seriously and analgesic therapy should be started promptly with analgesics in proportion to the severity of the patient's pain. With mild pain oral non-opioid analgesics are sufficient, in moderate pain they are given in combination with oral codeine. Severe pain requires IV morphine, also combined with a non-opioid analgesic. Intravenous morphine makes a thorough monitoring of ventilation and level of consciousness mandatory. Sickle cell patients do not become drug dependent if given morphine for adequate analgesia. While bone marrow transplantation has become an accepted treatment modality for sickle cell patients with severe pain crises, treatment with hydroxyurea to increase HbF levels and reduce incidence and severity of pain crises, however, is still experimental.     

Treatment of cancer-related pain: when orally administered medications fail

OBJECTIVE: To summarize the available pain-relieving interventions other than oral medications for cancer-related pain. DESIGN: The pertinent literature is reviewed, and the various options for treating pain in patients with cancer are discussed. MATERIAL AND METHODS: The appropriate situations for use of parenteral administration of opioids, spinal analgesia, neural blockade, and neurosurgical treatment are outlined, and the potential problems and complications associated with these techniques are described. RESULTS: The basic approach to the management of pain in patients with cancer is to begin treatment with less potent analgesic agents early and to progress toward use of more potent pharmaceutical agents, adjuvant drugs, and invasive procedures as needed for alleviation of pain. With parenteral administration of opioids, the dosage can be adjusted rapidly, and therapy can be continued even though a patient may have gastrointestinal dysfunction. A portable ambulatory infusion pump can be used in selected patients. The major advantage of spinal opioid analgesia is the intense analgesia provided with minimal side effects. The potential complications and the availability of treatment alternatives have limited the use of neurolytic blocks, which usually provide only temporary relief of pain. In carefully selected patients with pancreatic or other upper gastrointestinal neoplasms, however, neurolytic celiac plexus and splanchnic nerve blocks are effective. Patients who fail to respond to conservative interventions may be candidates for neurosurgical procedures, such as spinal cord, cortical, or brain-stem stimulation or neuroablative operations (most commonly, cordotomy). CONCLUSION: Cancer-related pain continues to be a major problem, and clinicians should be aware of the availability of effective treatment strategies and techniques. When orally administered medications fail to control pain or cause excessive side effects, patients should be referred to an appropriate specialist or medical center for consideration of other pain-relieving techniques.     

Ventilatory support following burns and smoke-inhalation injury

The first major improvement in the treatment of burn injury came with the recognition of the importance of fluid resuscitation to prevent shock and renal failure. Subsequently, the use of topical antibiotics to control burn-wound infection and prevent invasive burn-wound sepsis led to the next significant reduction in morbidity and mortality of burn patients. Although progress has been made in the treatment of inhalation injury, the pathophysiology of the injury is still incompletely defined. A better understanding of pathogenic mechanisms will lead to the development of therapeutic agents and treatment regimens that will modulate the cascades of humoral mediators of organ dysfunction and reduce the morbidity and mortality associated with inhalation injury. The recognition of ventilator-induced lung injury has led to adoption of alternative ventilatory techniques such as high-frequency percussive ventilation, which has been shown to substantially reduce the morbidity associated with inhalation injury.     

Treatment of proctalgia fugax with salbutamol inhalation

OBJECTIVES: Although no generally effective treatment for proctalgia fugax is known, inhalation of salbutamol has been reported to shorten pain attacks in isolated cases. METHODS: We conducted a randomized, double-blind, placebo-controlled, crossover trial of inhaled salbutamol in 18 patients with proctalgia fugax. The clinical effect was evaluated by recording the duration of severe pain and discomfort during acute attacks. In addition, anorectal motility recordings were analyzed for possible changes in anal resting tone, sphincter relaxation during rectal distension and in rectal compliance prior to and following administration of the two test substances. RESULTS: Sixteen patients completed all investigations. Compared to placebo, salbutamol inhalation shortened the duration of severe pain (p = 0.019). The effect was most marked in patients having prolonged attacks. In the asymptomatic state, neither salbutamol nor placebo led to a significant change in anal resting pressure, anal relaxation during rectal distension, or rectal compliance. Salbutamol also did not alter the threshold for rectal sensation. CONCLUSIONS: Salbutamol inhalation shortens attacks of severe pain in patients with proctalgia fugax. The mechanism of this effect remains unexplained.     

Breast cancer and benign breast disease patients evaluated in relation to oxidative stress

The 'WHO Analgesic Ladder' is a well validated approach for the selection of appropriate analgesic therapy for cancer pain as well as pain in AIDS. The mainstay of analgesic intervention for cancer and AIDS pain of moderate to severe intensity continues to be the appropriate use of opioid analgesics. There is, however, a growing appreciation for the role of adjuvant analgesics, such as antidepressants and other psychotropic medications, at each step of the WHO Analgesic Ladder, particularly in the treatment of neuropathic pain. Knowledge of the indications and usefulness of psychotropic analgesic drugs in cancer and AIDS pain populations will be most important to clinicians practicing in psycho-oncology/AIDS settings, particularly since these drugs are useful not only in the treatment of psychiatric complications of cancer and AIDS, but also as adjuvant analgesic agents in the management of pain. This paper reviews the literature on the use of antidepressants, psychostimulants, neuroleptics, anticonvulsants and other psychotropic analgesics in the management of cancer and AIDS pain. Mechanisms of analgesia, drug selection, and recommendations for clinical usage are discussed. The appropriate and timely use of psychotropic adjuvant analgesic drugs represents an opportunity for active psychiatric contribution to the multidisciplinary management of cancer and AIDS pain.     

Psychotherapy with the chronic pain patient using coping skills development: Outcome study.

This study provided outcome data measuring variables of a psychoeducational group approach to self-management of 88 chronic pain patients and 25 controls. Most of the injuries were back injuries and work related. At the completion of the 16 group sessions, patients reported decreased depression, pain severity, interference, and affective distress and increased life control and general activity. At 1-year follow-up, there was continued increased return to work, lowered workers' compensation, fewer health care visits, and less prescribed pain medication than demographically similar controls. Results suggest that a group psychoeducational program involving learning of general coping skills primarily and pain coping skills secondarily produces an effective approach for the management of chronic pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective study of long-term intrathecal morphine in the management of chronic nonmalignant pain

OBJECTIVE: To examine in a prospective manner the long-term safety and efficacy of chronic intrathecal morphine in patients with severe, nonmalignant pain refractory to less invasive modalities. METHODS: Forty patients with severe, chronic nonmalignant pain poorly managed by systemic medications were identified as candidates for intraspinal trial of morphine. Thirty participants reported successful pain relief during trial and were implanted with an intraspinal delivery system. Standardized measures of pain and functional status were assessed before treatment was begun and at defined intervals during the subsequent 24 months. Intrathecal opioid use and pharmacological and device-related complications were also monitored. RESULTS: The participants had a mean age of 58 +/- 13 years and a mean pain duration of 8 +/- 9 years. Fifty-three percent of the study participants were women. Pain type was characterized as mixed neuropathic-nociceptive (15 of 30 patients, 50%), peripheral neuropathic (10 of 30 patients, 33%), deafferentation (4 of 30 patients, 13%), or nociceptive (1 of 30 patients, 3%). Forty-seven percent of the patients were diagnosed with failed back surgery syndrome. Significant improvement over baseline levels of visual analog scale pain was measured at each follow-up examination after implant. Overall, 50% (11 of 22 patients) of the population reported at least a 25% reduction in visual analog scale pain after 24 months of treatment. In addition, the McGill Pain Questionnaire, visual analog scale measures of functional improvement and pain coping, and several subscales of the Chronic Illness Problem Inventory showed improvement throughout the follow-up period. Pharmacological side effects were managed medically by morphine dose reduction, addition of bupivacaine, or replacement of morphine with hydromorphone. Device-related complications requiring repeat operations were experienced by 20% of the patients. CONCLUSION: Continuous intrathecal morphine can be a safe, effective therapy for the management of severe, nonmalignant pain among a carefully selected patient population and can result in long-term improvement in several areas of daily function.     

Acute pain management clinical practice guideline: implications for nurse anesthetists

Millions of operative procedures are performed in the United States each year. One of the greatest concerns for the surgical patient is postoperative pain. Despite traditional efforts to alleviate this pain, clinical studies indicate that postoperative pain is not relieved in most patients. The federal Agency for Health Care Policy and Research (AHCPR) developed a clinical practice guideline, Acute Pain Management: Operative or Medical Procedures and Trauma to help clinicians, patients, and patient's families understand the assessment and treatment of postoperative acute pain in both adults and children. Certified registered nurse anesthetists (CRNAs) can use the guideline to improve acute pain management within their institutions. Effective pain management can be accomplished through a collaborative, interdisciplinary approach using an individualized proactive pain control plan. Frequent assessment and reassessment of pain, use of drug and nondrug therapies, and implementation of an institution-wide program using CQI/QA methods in necessary. Implications for CRNAs include providing patient and staff education, establishing standards of care for pain management, and adapting an aggressive "no pain, much gained" clinical practice.     

Wheat bran- but not oat bran-enriched diets increase the mucosal height of the cecum and colon of newly weaned and aged rats

BACKGROUND: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. METHODS: 1100 patients in the age group 5-88 years who underwent ambulatory surgery during a period of 6 months were asked to complete a questionnaire 48 h after the end of the operation. In the case of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature and severity of postoperative complications. RESULTS: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with management of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. CONCLUSION: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.     

Incidence of chronic pain following traumatic brain injury

OBJECTIVE: To index the frequency of reported chronic pain in patients with traumatic brain injury (TBI). DESIGN: A case series study was conducted on consecutive patients with TBI. SETTING: TBI patients were recruited from an adult tertiary care center brain injury clinic. PATIENTS: A consecutive sample of 132 patients who attended a brain injury rehabilitation center after TBI. The sample included 53 mild and 79 moderate/severe TBI patients. OUTCOME MEASURES: Patients were administered a protocol that indexed pain site, frequency, severity, and duration. RESULTS: Chronic pain was reported by 58% of mild TBI and 52% of moderate/severe TBI patients. Headaches were the most commonly reported pain problem. Chronic headaches were reported by 47% of mild TBI patients and 34% of moderate/ severe TBI patients. Neck/shoulder, back, upper limb, and lower limb pain were reported similarly by mild and moderate/severe TBI patients. CONCLUSIONS: Findings indicate that chronic pain is a significant problem in mild and moderate/severe TBI patients. More effective diagnosis of TBI patients with chronic pain may facilitate rehabilitation of these patients.     

The use of acupuncture reflexotherapy in treating patients with rheumatoid arthritis

Efficiency was studied of multi-modality treatment of rheumatoid arthritis (RA) involving acupuncture (A). Indices were assessed for the number of the inflamed joints, the joint index, duration of the morning rigidity and visual scale of pain. Combined treatment of RA using A was found to more effectively lower the values for the joint index and visual scale of pain. A conclusion was reached to the effect that A may improve results of drug treatment.     

Outcomes of varicocele ligation done for pain

PURPOSE: Surgical ligation is an option in the management of patients with painful varicocele. Little objective data exist addressing the effectiveness of this treatment. We reviewed records from 58 patients who underwent varicocele ligation at our institution from January 1985 to May 1996 to establish success of surgical ligation of the painful varicocele. MATERIALS AND METHODS: ICD-9 billing codes were used to identify all patients who had undergone varicocele ligation for pain since 1985. We documented patient age, grade and location of varicocele, duration and quality of pain, response to conservative therapy and surgical approach to ligation. Telephone interviews and chart reviews were conducted to determine resolution of pain, complications of the procedure and if the patient would choose surgery again. RESULTS: We obtained followup on 35 of the 58 painful varicocele patients (60%). Average patient age was 25.7 years (range 15 to 65). The varicocele was on the left side in 30 men and bilateral in 5. Of the patients 31 described the pain as a dull throbbing ache, 2 as sharp and 2 as a pulling sensation. Initial conservative therapy failed in all 35 men. Varicocele was grade III in 18 cases, grade II in 16 and grade I in 1. The inguinal or subinguinal approach was used in 24 patients, high ligation in 10 and laparoscopic repair in 1. In 30 patients there was (86%) complete resolution of pain postoperatively and 1 had partial resolution. Only 4 patients (11%) had persistent or worse symptoms. CONCLUSIONS: This retrospective review supports the conclusion that varicocele ligation is an effective treatment for painful varicocele in properly selected patients.     

Pharmacologic pain. Management for cancer patients at home

Pain management is one of the most important responsibilities of the home care nurse serving cancer patients. Patients and caregivers often fear uncontrolled pain, and need frequent reassurance that effective pain control can be achieved. This article discusses the etiology and types of cancer pain, pain assessment, pharmacologic pain management interventions, and evaluation of pain management for home care patients.     

Long-term effects of pentobarbital anesthesia on the atrial natriuretic peptide system in rats

The midline fascial splitting approach is a modified midline approach to the iliac crest for bone graft that takes advantage of the anatomic planes between layers of the dorsal lumbar fascia. Two hundred consecutive grafts were taken by this technique with one superficial infection, two cases of serous hematoma, and three patients with significant postoperative pain at the harvest site, for an overall complication rate of 3%. In comparison, bone grafts were harvested from 200 consecutive patients by the midline subcutaneous approach to the iliac crest with 2 deep infections, 1 cluneal nerve injury, 15 patients with severe and disabling pain at the harvest site, and 12 patients with a serous hematoma, for an overall complication rate of 15%. The midline fascial splitting approach significantly reduced the incidence of postoperative serous hematoma (P < 0.007) as well as the incidence of significant and disabling pain (P < 0.001). In addition, the approach is simple, straightforward, anatomic, and decreases trauma to soft tissues.     

Ischemic therapy in thrombocytopenia from hypersplenism

Percutaneous transfemoral arterial balloon occlusion or gelatin sponge embolization of the splenic artery or both were carried out in three high-risk patients with hepatic cirrhosis to reduce splenic hyperfunction and improve severe thrombocytopenia. Although this maneuver raised peripheral platelet counts in each patient, in one patient left upper quadrant pain with splinting of the lower chest cage led to hypostatic lower lobe pneumonia, while in another septic splentitis with gas-forming organisms necessitated splecectomy. Transfemoral occlusion of the splenic artery, although an effective, noninvasive approach to control splenic hyperfunction, has at the same time potential dangers that should be viewed with extreme caution in therapeutic application.