The pain visual analog scale: is it linear or nonlinear?

Retrograde Drilling, Ossoscopy, and Autologous Bone Grafting: An Alternative Technique for Treatment of Osteochondral Lesion of the Talus Stage 2 and 3 in Adults

BACKGROUND

Symptomatic osteochondral lesions of the talus (OLTs) often require surgical intervention. There are various surgical methods. A generally valid, stage-dependent therapeutic algorithm does not exist. The aim of our study is to show long- term results of an alternative technique that combines retrograde drilling, debridement performed under arthroscopic visualization, and autologous bone grafting.

METHODS

The surgical technique was performed in 24 patients with medial or lateral OLTs, and the data were analyzed retrospectively. In our technique, the affected subchondral bone was overdrilled retrogradely and resected under arthroscopic visualization (ossoscopy) without violating the cartilage. The resulting defect was filled with autologous bone from the medial tibia metaphysis. Outcome parameters were the numeric rating scale (NRS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and range of motion (ROM). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed and a possible correlation with the clinical outcome scores was calculated. Data concerning complication rates were also collected.

RESULTS

The mean surface size of the OLTs was 0.9 ± 0.3 cm2. The mean follow-up was 89 months. The AOFAS score improved significantly from 57.7 points preoperatively to 88.8 points at the final follow-up (P < .0001). The pain value measured by the NRS decreased significantly from 8 to a pain level of 2. ROM improved in 37.5% of the patients for dorsiflexion and 29.2% for plantarflexion. There were no significant correlations between the MOCART score and the AOFAS score or the pain value on NRS.

CONCLUSION

Retrograde drilling, ossoscopy, and autologous bone grafting for OLTs is a promising technique with good long-term results. The patients' satisfaction rate, especially in OLT stages 2 and 3, was excellent.

LEVEL OF EVIDENCE

Level IV, case series.

'It's just a finger isn't it…': patients' perspectives of recovery following finger fractures and participation in surgical trials - a qualitative interview study

OBJECTIVES

To (1) generate detailed, person-centred data about the experience of finger injury and treatment and (2) understand the patients' perspectives of research involvement with a view to informing better designed future studies in hand injury.

DESIGN

Qualitative study using semistructured interviews and framework analysis.

PARTICIPANTS

19 participants who were part of the Cohort study of Patients' Outcomes for Finger Fractures and Joint Injuries study in a single secondary care centre in the UK.

RESULTS

The results of this study showed that although finger injuries are frequently seen as minor by patients and healthcare professionals, their effects on peoples' lives are possibly greater than first anticipated. The relative importance of hand functioning means that the experience of treatment and recovery varies and is shaped by an individual's age, job, lifestyle and hobbies. These factors will also inform an individual's perspective on and willingness to participate in, hand research. Interviewees showed reluctance to accept randomisation in surgical trials. Interviewees would be more likely to participate in a study testing two variants of the same treatment modality (eg, surgery vs surgery), rather than two different modalities, (eg, surgery vs splint). The Patient-Reported Outcome Measure questionnaires that were used in this study were seen as less relevant by these patients. Pain, hand function and cosmetic appearance were considered important, meaningful outcomes.

CONCLUSIONS

Patients with finger injuries need more support from healthcare professionals as they may experience more problems than first anticipated. Good communication by clinicians and empathy can help patients engage with the treatment pathway. Perceptions of an 'insignificant' injury and/or need for quick functional recovery will influence recruitment to future hand research (both positively and negatively). Accessible information about the functional and clinical consequences of a hand injury will be important in enabling participants to make fully informed decisions about participation.

Return-to-Work Following Occupational Rehabilitation for Long COVID: Descriptive Cohort Study

BACKGROUND

Emerging evidence suggests that worldwide, between 30% and 50% of those who are infected with COVID-19 experience long COVID (LC) symptoms. These symptoms create challenges with return-to-work (RTW) in a high proportion of individuals with LC. To tailor rehabilitation programs to LC sequelae and help improve RTW outcomes, more research on LC rehabilitation program outcomes is needed.

OBJECTIVE

This study describes the characteristics and outcomes of workers who participated in an LC occupational rehabilitation program.

METHODS

A cohort study was conducted. Descriptive variables included demographic and occupational factors as well as patient-reported outcome measures (PROMs, ie, the Fatigue Severity Scale [FSS], the Post-COVID Functional Scale [PCFS], the 36-item Short Form Health Survey [SF-36], the Pain Disability Index [PDI], the pain Visual Analogue Scale [VAS], the 9-item Patient Health Questionnaire [PHQ-9], the 7-item Generalized Anxiety Disorder Questionnaire [GAD-7], and the Diagnostic and Statistical Manual for Mental Disorders Fifth Edition [DSM-5] posttraumatic stress disorder [PTSD] checklist [PCL-5]). The main outcome variable was the RTW status at discharge. Descriptive statistics were calculated. Logistic regression examined predictors of RTW.

RESULTS

The sample consisted of 81 workers. Most workers were female (n=52, 64%) and from health-related occupations (n=43, 53%). Only 43 (53%) individuals returned to work at program discharge, with 40 (93%) of these returning to modified duties. Although there were statistically significant improvements on the pain VAS (mean 11.1, SD 25.6, t31=2.5, P=.02), the PDI (mean 9.4, SD 12.5, t32=4.3, P<.001), the FSS (mean 3.9, SD 8.7, t38=2.8, P=.01), the SF-36 PCS (mean 4.8, SD 8.7, t38=-3.5, P=.001), the PHQ-9 (mean 3.7, SD 4.0, t31=5.2, P<.001), and the GAD-7 (mean 1.8, SD 4.4, t22=1.8, P=.03), there were no significant improvements in the PCFS, the overall mental component score (MCS) of the SF-36, or on the PCL-5. The availability of modified duties (odds ratio [OR] 3.38, 95% CI 1.26-9.10) and shorter time between infection and admission for rehabilitation (OR 0.99, 95% CI 0.99-1.00) predicted RTW even when controlling for age and gender.

CONCLUSIONS

Workers undergoing LC rehabilitation reported significant but modest improvements on a variety of PROMs, but only 43 (53%) returned to work. Outcomes would likely improve with increased availability of modified duties and timelier rehabilitation. Additional research is needed, including larger observational cohorts as well as randomized controlled trials to evaluate the effectiveness of LC rehabilitation.

Simulated Forest Immersion Therapy: Methods Development

Shinrin-yoku, forest bathing, may provide relief from chronic and breakthrough pain in patients with axial spondyloarthritis and improve immune function through increasing NK cell numbers and activity and their downstream effectors, perforin and granulysin, after chemo- or radiation therapy in breast and prostate cancer patients. The aim of this paper is to describe the study protocol for a simulated forest immersion therapy using virtual reality and atomized phytoncides, volatile organic compounds found in forested areas designed to effect positive change for these two patient populations. The setting, including the room set up and samples with inclusion/exclusion specific to this type of intervention, is outlined. Measures and calibration procedures pertinent to determining the feasibility of simulated forest immersion therapy are presented and include: ambient and surface room temperatures and relative humidity in real time, ambient ultrafine particulate matter, ambient droplet measurement that coincides with volatile organic compounds, specific phytoncides, and virtual reality and atomization of phytoncide set up. Particular lessons learned while training and setting up the equipment are presented. Simulated forest immersion therapy is possible with attention to detail during this early phase when development of methods, equipment testing, and feasibility in deploying the intervention become operational. The expected outcome of the development of the methods for this study is the creation of a standardized approach to simulating forest therapy in a controlled laboratory space.

The Application of an Allogenic Bone Screw for Stabilization of a Modified Chevron Osteotomy: A Prospective Analysis

Background: Distal first metatarsal osteotomies are commonly performed operative procedures for hallux valgus deformity, and usually involve fixation with a metal screw. However, various bioabsorbable osteosynthesis materials have been in use for a number of years. One recent innovation is the Shark Screw®, a human cortical bone allograft. This study aimed to evaluate the efficacy and safety of this allogeneic screw in the stabilization of Reversed L-Shaped osteotomy, a modified Chevron osteotomy. Methods: In a prospective study, 15 patients underwent a Reversed L-Shaped osteotomy stabilized with the allogenic bone screw Radiological data on osteointegration of the screw and correction of the intermetatarsal angle were recorded. Furthermore, each follow-up examination included the collection of clinical data, the American Orthopedic Foot and Ankle Society (AOFAS) score, evaluation of pain level, and patient’s overall satisfaction. Results: Full osseous fusion of the osteotomy was seen in all patients. The bone screws were radiographically integrated after approximately 6.5 (±2.6) months. Neither nonunion nor failure occurred in any of our cases. Furthermore, we did not find any potential graft reaction. The AOFAS score improved significantly from 51.6 (±15.2) points to 90.9 (±10.3) (p < 0.001). The preoperative hallux valgus angle and intermetatarsal angle decreased significantly from 24.8 (±4.9) degrees to 7.2 (±4.4) degrees (p < 0.001) and 12.6 (±3.2) degrees to 4.8 (±1.3) degrees (p < 0.001), respectively. Conclusions: With this study, we demonstrated the efficiency of the allogenic bone screw (Shark Screw®) in regard to clinical and radiological short-term outcomes.

Immediate analgesic effect of two modes of transcutaneous electrical nerve stimulation on patients with chronic low back pain: a randomized controlled trial

Objective

To compare and assess the immediate analgesic effects of conventional and burst transcutaneous electrical nerve stimulation in patients with chronic low back pain.

Methods

We conducted a three-arm single-blinded randomized controlled trial. A total of 105 patients with non-specific chronic low back pain aged between 18 and 85 years were randomly assigned into the following groups: Placebo Group (sham electrical stimulation), Conventional TENS Group (continuous stimulation at 100Hz for 100µs with sensory intensity), and Burst TENS Group (stimulation at 100Hz modulated at 2Hz for 100µs with motor-level intensity). All groups received a single application of transcutaneous electrical nerve stimulation for 30 minutes. The outcomes, namely, pain intensity, quality of pain, and pressure pain threshold were measured by the visual analog scale, McGill pain questionnaire, and algometry, respectively. The patients were evaluated before and immediately after the transcutaneous electrical nerve stimulation application.

Results

Pain intensity (visual analog scale score) and quality of pain (McGill pain questionnaire score) significantly decreased (p<0.05) in Intervention Groups (Conventional TENS Group and Burst TENS Group). A positive effect was observed in the interventions compared to the Placebo Group in all domains of the McGill pain questionnaire (p<0.05), excepting for the pain intensity. Pressure pain threshold significantly increased (p<0.05) immediately after the transcutaneous electrical nerve stimulation application in both Intervention Groups, but not in the Placebo Group. For significant difference was found during assessment when comparing both Intervetion Group.

Conclusion

Both transcutaneous electrical nerve stimulation modes were effective for pain modulation. Moreover, there was an increase in the pressure pain threshold. No significant results were found to indicate the best mode for the treatment of chronic low back pain.

Clinical Trial Registration: RBR-59YGRB.

Adipose Tissue-Derived Mesenchymal Stem Cells as a Potential Restorative Treatment for Cartilage Defects: A PRISMA Review and Meta-Analysis

Cartilage defects are a predisposing factor for osteoarthritis. Conventional therapies are mostly palliative and there is an interest in developing newer therapies that target the disease’s progression. Mesenchymal stem cells (MSCs) have been suggested as a promising therapy to restore hyaline cartilage to cartilage defects, though the optimal cell source has remained under investigation. A PRISMA systematic review was conducted utilising five databases (MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science) which identified nineteen human studies that used adipose tissue-derived MSC (AMSC)-based therapies, including culture-expanded AMSCs and stromal vascular fraction, to treat cartilage defects. Clinical, imaging and histological outcomes, as well as other relevant details pertaining to cartilage regeneration, were extracted from each study. Pooled analysis revealed a significant improvement in WOMAC scores (mean difference: −25.52; 95%CI (−30.93, −20.10); p < 0.001), VAS scores (mean difference: −3.30; 95%CI (−3.72, −2.89); p < 0.001), KOOS scores and end point MOCART score (mean: 68.12; 95%CI (62.18, 74.05)), thus showing improvement. The studies in this review demonstrate the safety and efficacy of AMSC-based therapies for cartilage defects. Establishing standardised methods for MSC extraction and delivery, and performing studies with long follow-up should enable future high-quality research to provide the evidence needed to bring AMSC-based therapies into the market.

Extracorporeal Shockwave Therapy for Patients with Chronic Achilles Tendinopathy in Long or Short Course

Methods

The data of 66 patients with CAT received ESWT was reviewed. According to the disease courses, those cases were allocated to short-term group (ST group, symptom duration 3-6 months) and long-term group (LT group, symptom duration >6 months). Propensity scores match (PSM) method was conducted to eliminate the confound factors in baseline features including gender, sport history, sides, type of CAT, BMI (body mass index), age, and scores evaluated by AOFAS (American Orthopedic Foot and Ankle Society) and VAS (Visual Analogue Scale) before ESWT. After balancing the features between ST and LT group, postinterventional VAS, AOFAS, and rate of Likert satisfaction scale at the 3rd month after first ESWT was statistically analyzed.

Results

Among the baseline features in ST and LT group, gender (female ratio, 44.4% vs 71.4%, p = 0.041) and BMI (23.26 ± 2.15 vs 24.63 ± 2.41, p = 0.024) were identified as confound factors. After elimination of biased features with PSM, 3 months after first ESWT, AOFAS and VAS in both groups are significantly improved, when compared with their scores at baseline (p < 0.01). Moreover, at postintervention month 3 (PIM3), AOFAS in ST group is significantly higher than LT group (85.08 ± 9.83 vs 76.76 ± 9.85, t = 76.76 ± 9.85, p = 0.019), and the rate of Likert satisfaction in ST group is better than LT group; although, it did not reach but close to significant level (70.6% vs 47.1%, χ ² = 1.943, p = 0.163). However, there is no statistical difference of VAS scores between two groups after ESWT (1.96 ± 0.98 vs 2.24 ± 1.29, t = 0.703, p = 0.487).

Conclusions

ESWT could effectively relieve pain and improve function of hind foot in patients with chronic Achilles tendinopathy, and especially, it could offer better benefit on functional improvement in patients with short duration of CAT symptom.

Comparing the efficiency of ultrasound, ketoprofen, and mucopolysaccharide polysulfate phonophoresis in the treatment of lateral epicondylitis: A randomized-controlled clinical study

Objectives

In this study, we aimed to compare the efficiency of ultrasound, mucopolysaccharide polysulfate phonophoresis, ketoprofen phonophoresis and exercise combinations in terms of pain, functionality, disability, and strength in patients with lateral epicondylitis (LE).

Patients and methods

This prospective, parallel-group, randomized-controlled clinical study included a total of 60 patients (42 males, 18 females; mean age 38.08 years; range, 21 to 50 years) with LE between April 2016 and October 2017. The patients were equally randomized into four groups based on the time of admission to the outpatient clinic. The Visual Analog Scale (VAS), painless weight lifting, the Patient- Rated Tennis Elbow Evaluation (PRTEE), and Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) were used to measure the outcomes. The measurements were performed at baseline, at the end of 10 daily sessions, and after a six-week follow-up period.

Results

The resting VAS scores in the ketoprofen phonophoresis group and lifted weights in the MPS and ketoprofen phonophoresis groups showed a significant improvement both after 10 days of treatment and at six-week follow-up visits (p<0.001). In the QuickDASH model, there was no significant improvement in the control group after 10 days of treatment (p>0.05); however, a significant improvement was observed after six weeks (p<0.001). Except for these variables, significant improvements were found in all groups for all variables at six-week follow-up (p<0.05). However, improvements were similar in all groups (p>0.05).

Conclusion

Based on our study results, for LE patients who are unable to adhere to exercise and splint use and are given a physical treatment plan, inclusion of ketoprofen and MPS phonophoresis in the treatment program may yield additional benefits in their daily living activities, functionality, and working life.

Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury

BACKGROUND

Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended. There is concern about the use of oral opioids for acute pain leading to dependence. This is an update of a Cochrane Review published in 2015.

OBJECTIVES

To assess the benefits or harms of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries.

SEARCH METHODS

We searched the CENTRAL, 2020 Issue 1, MEDLINE (from 1946), and Embase (from 1980) to January 2020; other databases were searched to February 2019.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain, or contusion of a joint, ligament, tendon, or muscle occurring within 48 hours of inclusion in the study), and comparing oral NSAIDs versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects, and early re-injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility, extracted data, and assessed risk of bias. We assessed the quality of the evidence using GRADE methodology.

MAIN RESULTS

We included 20 studies, with 3305 participants. Three studies included children only. The others included predominantly young adults; approximately 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, and five were at high risk of selective outcome reporting bias. Some evidence relating to pain relief was high certainty. Other evidence was either moderate, low or very low certainty, reflecting study limitations, indirectness, imprecision, or combinations of these. Thus, we are certain or moderately certain about some of the estimates, and uncertain or very uncertain of others. Eleven studies, involving 1853 participants compared NSAIDs with paracetamol. There were no differences between the two groups in pain at one to two hours (1178 participants, 6 studies; high-certainty evidence), at days one to three (1232 participants, 6 studies; high-certainty evidence), and at day seven or later (467 participants, 4 studies; low-certainty evidence). There was little difference between the groups in numbers of participants with minimal swelling at day seven or later (77 participants, 1 study; low-certainty evidence). Very low-certainty evidence from three studies (386 participants) means we are uncertain of the finding of little difference between the two groups in return to function at day seven or later. There was low-certainty evidence from 10 studies (1504 participants) that NSAIDs may slightly increase the risk of gastrointestinal adverse events compared with paracetamol. There was low-certainty evidence from nine studies (1679 participants) of little difference in neurological adverse events between the NSAID and paracetamol groups. Six studies, involving 1212 participants compared NSAIDs with opioids. There was moderate-certainty evidence of no difference between the groups in pain at one hour (1058 participants, 4 studies), and low-certainty evidence for no difference in pain at days four or seven (706 participants, 1 study). There was very low-certainty evidence of no important difference between the groups in swelling (84 participants, 1 study). Participants in the NSAIDs group were more likely to return to function in 7 to 10 days (542 participants, 2 studies; low-certainty evidence). There was moderate-certainty evidence (1143 participants, 5 studies) that NSAIDs were less likely to result in gastrointestinal or neurological adverse events compared with opioids. Four studies, involving 240 participants, compared NSAIDs with the combination of paracetamol and an opioid. The applicability of findings from these studies is in question because the dextropropoxyphene combination analgesic agents used are no longer in general use. Very low-certainty evidence means we are uncertain of the findings of no differences between the two interventions in the numbers with little or no pain at day one (51 participants, 1 study), day three (149 participants, 2 studies), or day seven (138 participants, 2 studies); swelling (230 participants, 3 studies); return to function at day seven (89 participants, 1 study); and the risk of gastrointestinal or neurological adverse events (141 participants, 3 studies). No studies reported re-injury rates. No studies compared NSAIDs with oral complementary and alternative medicines, AUTHORS' CONCLUSIONS: Compared with paracetamol, NSAIDs make no difference to pain at one to two hours and at two to three days, and may make no difference at day seven or beyond. NSAIDs may result in a small increase in gastrointestinal adverse events and may make no difference in neurological adverse events compared with paracetamol. Compared with opioids, NSAIDs probably make no difference to pain at one hour, and may make no difference at days four or seven. NSAIDs probably result in fewer gastrointestinal and neurological adverse effects compared with opioids. The very low-certainly evidence for all outcomes for the NSAIDs versus paracetamol with opioid combination analgesics means we are uncertain of the findings of no differences in pain or adverse effects. The current evidence should not be extrapolated to adults older than 65 years, as this group was not well represented in the studies.

Surgical Management of Monoarticular Rheumatoid Arthritis of the Fifth Metatarsophalangeal Joint

OBJECTIVE

To investigate the clinical and radiological outcomes in patients with monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint after Weil osteotomy.

METHODS

From July 2011 to September 2015, 18 feet of 16 rheumatoid arthritis patients who underwent Weil osteotomy of the fifth metatarsal toe with a mean age at the time of surgery of 48.8 ± 7.4 years were reviewed retrospectively. The mean disease duration was 44.6 ± 6.8 months, and the follow-up period was 36 months. Clinical outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), 10-item SF-36 physical functioning and 2-item SF-36 bodily pain, Visual Analogue Scale (VAS), and satisfaction scores. In the radiologic evaluation, fifth metatarsophalangeal angle (MTP-5), lateral deviation angle (LDA), and longitudinal axes of the fifth metatarsal were measured on anterior-posterior (AP) weight-bearing radiographs preoperative and at the last follow-up.

RESULTS

Clinical assessment showed that the total average of AOFAS was significantly increased from preoperative 53.6 ± 9.0 to 98.7 ± 2.0 points, and the VAS score was significantly decreased from preoperative 4.1 ± 1.5 to 1.1 ± 0.8 points at the last follow-up (P < 0.001). The total averages of SF-36 physical functioning and SF-36 bodily pain were significantly increased from preoperative 48.9 ± 9.0 to 99. ± 2.1 and from 61.4 ± 12.1 to 99.4 ± 2.4 points, respectively, at the last follow-up (P < 0.001). Subjectively, the excellent outcome of the surgery results were rated by 13 patients (81.3%) that underwent surgery and three patients (18.7%) were rated as good. Regarding radiographic parameters, the mean MTP-5 significantly decreased from 21.5° ± 1.2° preoperatively to 10.2° ± 1.2°, the mean LDA significantly decreased from 7.1° ± 1.2° preoperatively to -2.4° ± 1.0°, and the mean length of the fifth metatarsal was significantly shortened from 71.5 ± 1.4 preoperatively to 67.8 ± 1.5 mm at the final follow-up visit (P < 0.001). No malunion, nonunion, necrosis, pseudoarthrosis, or fracture of the fifth metatarsal was found. No exuberant bone growth, perforation of the screw, subluxation, or dislocation was observed. No indications of modification, revision or repeat surgery, or delayed wound healing were observed during follow-up period.

CONCLUSION

Surgical management of the monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint can achieve good clinical and radiological outcomes, with pain relief and dislocation reduction, as well as high satisfaction and improvement without recurrence or progression during the follow-up period.

Infiltration of bupivacaine into the preperitoneal space and trocar incisions of patients undergoing laparoscopic totally extraperitoneal repair of unilateral inguinal hernia: a prospective randomized controlled observational study

Introduction

Although laparoscopic repair of inguinal hernia is associated with reduced postoperative pain, it is not entirely painless. In addition to reducing the need for analgesic medication, postoperative complications, and hospitalization, postoperative pain control enables early return to normal activity.

Aim

To evaluate the efficacy of bupivacaine instilled into the pre-peritoneal space and trocar incisions of patients undergoing laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia.

Material and methods

Bupivacaine was instilled into the pre-peritoneal space and trocar incisions of the patients in group I (n = 23), whereas it was infiltrated only into the trocar incisions of the patients in group II (n = 21). No local anesthetic was administered to the patients in group III (n = 21). Postoperative pain was assessed using the Visual Analog Scale (VAS) at 4 and 24 h, and the dosage of analgesic medication was noted.

Results

No significant difference regarding age, gender, body mass index, ASA class, history of abdominal surgery, or smoking was noted between the three groups (p > 0.05). VAS score at 4 h was significantly higher in group III than in groups I and II (p < 0.05). The dosage of analgesic medication was significantly higher in group III than in groups I and II (p < 0.05), with no significant difference between groups I and II (p > 0.05).

Conclusions

Infiltration of long-acting local anesthetic into the pre-peritoneal space and trocar incisions of patients undergoing laparoscopic TEP repair of inguinal hernia reduces the need for analgesic medication by reducing early postoperative pain.

Introduction the revolving scarf osteotomy for treating severe hallux valgus with an increased distal metatarsal articular angle: a retrospective cohort study

BACKGROUND

Hallux valgus(HV) with an increased distal metatarsal articular angle (DMAA) is one of the most common foot deformities among adults. Double metatarsal osteotomy (DMO) is effective in treating severe HV deformity with an increased DMAA. However, this technique presents the risk of avascular necrosis (AVN) of the metatarsal head and transfer metatarsalgia due to shortening of the first metatarsal. The aim of this study was to introduce a surgical procedure defined as revolving scarf osteotomy (RSO) and compare the clinical and radiological results of RSO and DMO performed for treating severe HV with an increased DMAA.

METHODS

First metatarsal osteotomies and Akin osteotomy were performed in 56 patients (62 ft) with severe HV with an increased DMAA in Honghui Hospital from January 2015 to December 2017. RSO was performed in 32 ft and DMO was performed in 30 ft. The Akin osteotomy was performed in both groups. The American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, the hallux valgus angle (HVA), intermetatarsal angle (IMA), DMAA, and first metatarsal length (FML) and the rates of complications were compared preoperatively and postoperatively in the two groups.

RESULTS

The mean AOFAS score, VAS score, HVA, IMA, and DMAA showed significant improvements in both groups after surgery, but with no significant differences between the two groups. The postoperative FML was significantly larger in the RSO group than in the DMO group (p < 0.001). One of the 30 ft (3.3%) in the DMO group exhibited transfer metatarsalgia at 12 months postoperatively, while another foot (3.3%) in same group had avascular necrosis of the metatarsal head. One of the 30 ft (3.1%) in the RSO group had hallux varus.

CONCLUSIONS

No differences in the clinical and radiographic results were observed between the two groups with severe HV and an increased DMAA. However, RSO does not cause shortening of the metatarsal and AVN of the metatarsal head. A long-term, randomized, controlled prospective study with a larger sample would provide higher-level evidence for confirming the clinical efficacy and safety of RSO.

Scarf Osteotomy for Correction of Hallux Valgus Deformity in Adolescents

Objective

To report the radiological and clinical outcomes of the modified scarf osteotomy for the treatment of hallux valgus deformity in adolescents.

Methods

This retrospective study analyzed 21 patients (31 feet) who underwent a modified scarf osteotomy for correcting juvenile hallux valgus deformity between March 2015 and January 2017. There were 3 male (3 feet) and 18 female (28 feet) patients. The average age at the time of surgery was 28.6 years (range, 20–35). Patients were postoperatively followed up in the outpatient department for 12–18 months. Clinical and radiological assessments were performed preoperatively and postoperatively at 1 year. Moreover, postoperative complications were recorded. Statistical analyses for differences between preoperative and postoperative values were performed.

Results

All the 21 patients were postoperatively followed up for 12–18 months, with an average of 13.2 ± 2.5 months. Clinical assessment showed that the American Orthopaedic Foot and Ankle Society score was increased from preoperative 58.0 ± 5.8 to postoperative 94.2 ± 6.6 points, respectively, and the visual analog scale score was remarkably decreased from preoperative 6.0 ± 2.0 to postoperative 1.5 ± 2.0 points at 1 year follow‐up. Further radiological assessment showed that the hallux valgus angle was 37.5° ± 9.2°, 14.1° ± 6.5°, and 14.5° ± 6.5° before surgery, half a year after surgery, and 1 year after surgery, respectively; the intermetatarsal angle was 14.1° ± 4.4°, 4.8° ± 3.2°, and 5.5° ± 4.9°, respectively; and the distal metatarsal articular angle was 31.0° ± 3.5°, 7.2° ± 2.3°, and 7.5° ± 2.1°, respectively. They were significantly improved at half a year after surgery and 1 year after surgery compared to those before surgery. Complications occurred in two patients (9.5%) who had numbness on the skin of the edge of the medial incision, and the symptoms were relieved after 10 months. There was no clinical recurrence in all patients. One of the 31 feet had hallux varus, which was corrected in a second operation. Notably, a postoperative radiograph of a typical case whose both feet had hallux valgus deformity and underwent modified scarf osteotomy and additional Akin osteotomy showed adequate correction of the hallux valgus angle (HVA, 11°), intermetatarsal angle (IMA, 6°), and distal metatarsal articular angle (DMAA, 8°) on left foot compared to preoperative HVA (28°), IMA (13°), and DMAA (35°).

Conclusion

The modified scarf osteotomy can effectively correct the adolescent hallux valgus deformity, which is worth popularizing.

Extractable synovial fluid in inflammatory and non-inflammatory arthritis of the knee

INTRODUCTION/OBJECTIVES

We hypothesized that mechanical compression of the knee in rheumatoid arthritis (RA) would mobilize occult extractable fluid and improve arthrocentesis success.

METHODS

Sixty-seven consecutive knees with RA and 186 knees with OA and were included. Conventional arthrocentesis was performed and success and volume (milliliters) determined; the needle was left intraarticularly, and mechanical compression was applied with an elastomeric knee brace. Arthrocentesis was then resumed until fluid return ceased. Fluid was characterized as to volume and cell counts.

RESULTS

In the RA, knee mechanical compression decreased failed diagnostic arthrocentesis from 56.7% (38/67) to 26.9% (18/67) (- 47.4%, p = 0.003) and increased absolute arthrocentesis yield from 4.7 ± 10.3 ml to 9.8 ± 9.8 ml (108% increase, 95% CI - 8.5 < - 5.1 < - 1.7 p = 0.0038). Total extractable fluid yield was 96% greater in RA (9.8 ± 9.8 ml) than OA (5.0 ± 9.4 ml, p = 0.0008), and occult extractable fluid was 77% greater in RA than OA (RA 5.3 ± 8.7 ml, OA 3.0 ± 5.5 ml, p = 0.046). Large effusions versus small effusions in RA demonstrated increased neutrophils in synovial fluid (p = 0.04) but no difference in radiologic arthritis grade (p = 0.87). In contrast, large effusions versus small effusions in OA demonstrated no difference in neutrophils in synovial fluid (p = 0.87) but significant different radiologic arthritis grade (p = 0.04).

CONCLUSION

Mechanical compression improves the success of diagnostic and therapeutic knee arthrocentesis in both RA and OA. Large effusions in RA are associated with increased neutrophil counts but not arthritis grade; in contrast, large effusions in OA are associated with more severe arthritis grades but not increased neutrophil counts. Key points• Mechanical compression of the painful knee improves arthrocentesis success and fluid yield in both rheumatoid arthritis and osteoarthritis.• The painful rheumatoid knee contains approximately 100% more fluid than the osteoarthritic knee.• Large effusions in the osteoarthritic knee are characterized by higher grades of mechanical destruction but not increased neutrophil counts.• In contrast, large effusions in the rheumatoid knee are characterized by higher synovial fluid neutrophil counts but not the grade of mechanical destruction, indicating different mechanisms of effusion formation in rheumatoid arthritis versus osteoarthritis.

The Visual Analogue Scale for Rating, Ranking and Paired-Comparison (VAS-RRP): A new technique for psychological measurement

Traditionally, the visual analogue scale (VAS) has been proposed to overcome the limitations of ordinal measures from Likert-type scales. However, the function of VASs to overcome the limitations of response styles to Likert-type scales has not yet been addressed. Previous research using ranking and paired comparisons to compensate for the response styles of Likert-type scales has suffered from limitations, such as that the total score of ipsative measures is a constant that cannot be analyzed by means of many common statistical techniques. In this study we propose a new scale, called the Visual Analogue Scale for Rating, Ranking, and Paired-Comparison (VAS-RRP), which can be used to collect rating, ranking, and paired-comparison data simultaneously, while avoiding the limitations of each of these data collection methods. The characteristics, use, and analytic method of VAS-RRPs, as well as how they overcome the disadvantages of Likert-type scales, ranking, and VASs, are discussed. On the basis of analyses of simulated and empirical data, this study showed that VAS-RRPs improved reliability, response style bias, and parameter recovery. Finally, we have also designed a VAS-RRP Generator for researchers’ construction and administration of their own VAS-RRPs.

Interrelationships among endometriosis-related pain symptoms and their effects on health-related quality of life: a sectional observational study

Objective

To assess the correlation between different pain symptoms and different domains of women's health-related quality of life (HRQoL).

Methods

Seventy-seven women with deep infiltrating endometriosis were successively enrolled between June 2011 and August 2013 while being prepared to undergo laparoscopy due to pain and/or infertility. We quantified the intensities of dysmenorrhea, deep dyspareunia, chronic pelvic pain, and dyschezia (menstrual and non-menstrual) using a 11-point visual analog scale (VAS: 0-10) and the validated full versions of the Short Form 36 (SF36) and Endometriosis Health Profile (EHP30) questionnaires to assess HRQoL. The pain symptoms were considered simultaneously in a hierarchical agglomerative clustering method (exploratory multivariate approach) and the associations among scores were tested by bivariate correlation.

Results

Dysmenorrhea showed the lowest similarity on to the multivariate cluster analysis and no statistically significant correlation with the other pain symptoms: deep dyspareunia (P=0.244), chronic pelvic pain (P=0.108), menstrual dyschezia (P=0.238), and non-menstrual dyschezia (P=0.380). Dysmenorrhea and chronic pelvic pain were the main symptoms correlated with all domains of the SF36 and the EHP30 (core instrument) questionnaires (P<0.05).

Conclusion

Dysmenorrhea and chronic pelvic pain were independent factors associated with HRQoL.

Different predictors of pain severity across age and gender of a Chinese rural population: a cross-sectional survey

OBJECTIVES

To investigate a 4-week period of pain prevalence and the risk factors of experiencing pain among a rural Chinese population sample. To explore the psychosocial and health condition predictors of pain severity and the interactions of age and gender with these factors in real-life situations among the general adult population in China.

METHODS

Data were collected from a random multistage sample of 2052 participants (response rate=95%) in the rural areas of Liuyang, China. Visual analogue scale was used to assess participants' pain experienced and a series of internationally validated instruments to assess their sociodemographic characteristics, self-reported health status, depression symptoms, anxiety symptoms, sleep quality, self-efficacy and perceived stress.

RESULTS

The pain prevalence over the 4-week period in rural China was 66.18% (62.84% for men and 68.82% for women). A logistic regression model revealed that being female (adjusted OR=1.58, 95% CI 1.24 to 2.02), age (adjusted OR=1.03, 95% CI 1.02 to 1.05), depressive symptoms (adjusted OR=1.07, 95% CI 1.02 to 1.13) and medium-quality sleep (adjusted OR=2.14, 95% CI 1.26 to 3.64) were significant risk factors for experiencing pain. General linear model analyses revealed that (1) pain severity of rural Chinese was related to self-rated physical health and social health; (2) the interactions of age, gender with employment status, depression symptoms, perceived stress and physical health were significant. Simple effect testing revealed that in different age groups, gender interacted with employment status, depression symptoms, perceived stress and physical health differently.

CONCLUSIONS

Improving physical and social health could be effective in reducing the severity of pain and the treatment of pain should be designed specifically for different ages and genders among the general population.

Comparative Evaluation between Single Noncompression Miniplate and Two Noncompression Miniplates in the Treatment of Mandibular Angle Fractures

This study was conducted to compare the outcome of single noncompression miniplate versus two noncompression miniplates in the treatment of mandibular angle fracture. A total of 40 patients were divided into two groups: Group I ( n  = 20), patients were treated by single miniplate at superior border of mandible by intraoral approach; Group II ( n  = 20), patients were treated by one miniplate at superior border of mandible, intraorally, and another at the lateral aspect of angle, transbuccally by trocar and cannula. Comparative evaluation was done at 1, 2, 4, 6, and 12 weeks and 6 months. The findings of this study suggest that there was no significant difference in postoperative complications (malocclusion, pain, swelling, infection, facial nerve injury, wound dehiscence, plate exposure) and bite force between the two groups.

Comparison of the incidence of postoperative pain after using a continuous rotary system, a reciprocating system, and a Self-Adjusting File system in single-visit endodontics: A prospective randomized clinical trial

Aim:

The aim of this study is to compare the incidence of postoperative pain using the ProTaper Next (PTN), WaveOne Gold (WOG), and Self-Adjusting File (SAF) systems.

Materials and Methods:

Two hundred and fourteen patients with irreversible pulpitis were selected for single-visit endodontics. The teeth were blindly assigned to three groups based on the instrumentation system used: Group A (PTN), Group B (WOG), and Group C (SAF). Participants were asked to note the incidence of the pre- and postoperative pain on a visual analog scale at different time intervals. Paired t-test and one-way ANOVA were used along with post hoc Tukey's test.

Results:

The greatest mean pain in Group A (PTN) and Group B (WOG) was found to be maximum in the first 24 h with a significant reduction in pain at the subsequent observation time points of 48 h, 72 h, and 7 days. Group C (SAF) showed minimum pain followed by Group B followed by Group A which showed comparatively higher pain scores even at the end of 7 days.

Conclusions:

In single-visit endodontics, SAF system may prove to be a better system compared with PTN and WOG as it produces minimal postoperative pain, thus improving the overall acceptance of endodontic treatment.

Improvement in diagnostic and therapeutic arthrocentesis via constant compression

We hypothesized that constant compression of the knee would mobilize residual synovial fluid and promote successful arthrocentesis. Two hundred and ten knees with grade II-III osteoarthritis were included in this paired design study: (1) conventional arthrocentesis was performed with manual compression and success and volume (milliliters) determined; and (2) the intra-articular needle was left in place, and a circumferential elastomeric brace was tightened on the knee to provide constant compression. Arthrocentesis was attempted again and additional fluid volume was determined. Diagnostic procedural cost-effectiveness was determined using 2017 US Medicare costs. No serious adverse events were noted in 210 subjects. In the 158 noneffusive (dry) knees, sufficient synovial fluid for diagnostic purposes (≥ 2 ml) was obtained in 5.0% (8/158) without compression and 22.8% (36/158) with compression (p = 0.0001, z for 95% CI = 1.96), and the absolute volume of arthrocentesis fluid obtained without compression was 0.28 ± 0.79 versus 1.10 ± 1.81 ml with compression (293% increase, p = 0.0001). In the 52 effusive knees, diagnostic synovial fluid (≥ 2 ml) was obtained in 75% (39/52) without compression and 100% (52/52) with compression (p = 0.0001, z for 95% CI = 1.96), and the absolute volume of arthrocentesis without compression was 14.7 ± 13.8 versus 25.3 ± 15.5 ml with compression (72.1% increase, p = 0.0002). Diagnostic procedural cost-effectiveness was $655/sample without compression and $387/sample with compression. The new technique of constant compression via circumferential mechanical compression mobilizes residual synovial fluid beyond manual compression improving the success, cost-effectiveness, and yield of diagnostic and therapeutic arthrocentesis in both the effusive and noneffusive knee.

A Pilot Study of Perceived Mouth Dryness, Perceived Swallowing Effort, and Saliva Substitute Effects in Healthy Adults Across the Age Range

Xerostomia, or perceived mouth dryness, increases with advancing age, but its influence on swallowing effort is unknown. This study: (1) quantified relationships among age, perceived sense of swallowing effort, and ratings of perceived mouth dryness, and (2) examined changes in swallowing effort following application of a gel-based saliva substitute in healthy participants. This was a cross-sectional observational study and data were collected from attendees of a community healthy aging fair. Forty-two healthy participants (mean age = 65 years; 20 female) were enrolled. Each participant rated perceived effort with swallowing and perceived mouth dryness on a 10-cm horizontal, undifferentiated line. After participants applied a gel-based saliva substitute (Biotene^® Oral Balance) to their tongue and oral mucosa, they rated perceived effort with swallowing again. Age was associated with greater perceived mouth dryness (r = 0.37, p < 0.03) but not with perceived swallowing effort (r = 0.16, p = 0.32). Perceived mouth dryness was associated with greater perceived swallowing effort (r = 0.62, p < 0.001). Perceived swallowing effort declined following application of the salivary substitute (mean difference = 9.39 mm, p < 0.002). Age was found to be a significant predictor of perceived mouth dryness (p < .02); and perceived mouth dryness was found to significantly predict perceived swallow effort (p < .001). Perceived mouth dryness increased with advancing age, but perceived swallowing effort did not. Regardless of age, participants with higher levels of perceived mouth dryness also reported more perceived effort with swallowing suggesting a role for adequate oral lubrication in this perception. Even in healthy participants, use of a gel-based saliva substitute lowered perceived swallowing effort.

Effect of Standardised Scoring Conventions on Inter-rater Reliability in the Endoscopic Evaluation of Crohn's Disease

BACKGROUND AND AIMS

The Crohn's Disease Endoscopic Index of Severity [CDEIS] and Simplified Endoscopic Score for Crohn's Disease [SES-CD] demonstrate consistent overall intra- and inter-rater reliability. However, the reliability of some index items is relatively poor. We evaluated scoring conventions to improve the reliability of these items.

METHODS

Five gastroenterologists with no previous experience scoring the CDEIS or SES-CD were trained on their use. A total of 65 video recordings of colonoscopies were scored blindly by each gastroenterologist before and after additional training on index scoring conventions. Intra-class correlation coefficients [ICCs] assessed the effect of application of these conventions on the reliability of the CDEIS, SES-CD, and a Global Evaluation of Lesion Severity [GELS] score.

RESULTS

Following training on scoring conventions, inter-rater ICCs (95% confidence interval [CI]) for the total SES-CD score increased from 0.78 [0.71, 0.85] to 0.85 [0.79, 0.89]. The ICCs for the total CDEIS and GELS scores were not affected: corresponding inter-rater ICCs were 0.74 [0.65, 0.81] and 0.49, [0.38, 0.61] before and 0.73 [0.65, 0.81] and 0.53 [0.42, 0.64] following application of scoring conventions. Estimations of ulcer depth, surface area, anatomical location, and stenosis were important sources of variability.

CONCLUSIONS

Use of scoring conventions previously developed by expert central readers enhanced the reliability of the SES-CD but did not similarly affect the CDEIS or GELS. As the SES-CD is more likely to be reliable than the CDEIS and can be optimised with targeted training, it is the preferred instrument for use in clinical trials.

Using Visual Analogue Scales in eHealth: Non-Response Effects in a Lifestyle Intervention

Background

Visual analogue scales (VASs) have been shown to be valid measurement instruments and a better alternative to Likert-type scales in Internet-based research, both empirically and theoretically [1,2]. Upsides include more differentiated responses, better measurement level, and less error. Their feasibility and properties in the context of eHealth, however, have not been examined so far.

Objective

The present study examined VASs in the context of a lifestyle study conducted online, measuring the impact of VASs on distributional properties and non-response.

Method

A sample of 446 participants with a mean age of 52.4 years (standard deviation (SD) = 12.1) took part in the study. The study was carried out as a randomized controlled trial, aimed at supporting participants over 8 weeks with an additional follow-up measurement. In addition to the randomized questionnaire, participants were further randomly assigned to either a Likert-type or VAS response scale version of the measures.

Results

Results showed that SDs were lower for items answered via VASs, 2P (Y ≥ 47 | n=55, P=.5) < .001. Means did not differ across versions. Participants in the VAS version showed lower dropout rates than participants in the Likert version, odds ratio = 0.75, 90% CI (0.58-0.98), P=.04. Number of missing values did not differ between questionnaire versions.

Conclusions

The VAS is shown to be a valid instrument in the eHealth context, offering advantages over Likert-type scales. The results of the study provide further support for the use of VASs in Internet-based research, extending the scope to senior samples in the health context.

Trial Registration

Clinicaltrials.gov NCT01909349; https://clinicaltrials.gov/ct2/show/NCT01909349 (Archived by WebCite at http://www.webcitation.org/6h88sLw2Y)

A comparative evaluation of the effect of diclofenac sodium with and without per-orally administered methylprednisolone on the sequelae of impacted mandibular third molar removal: A cohort randomized double-blind clinical trial

Aim and Objectives:

This study evaluated the efficacy of oral methylprednisolone and diclofenac sodium on post-operative sequelae after third molar surgery.

Settings and Design:

A randomized double-blind clinical trial was conducted (with institutional and university approval for dissertation) to evaluate the effect of methylprednisolone with diclofenac sodium (group A) as compared with diclofenac sodium and placebo (group B) on three variables: Pain, swelling and trismus, after third molar surgery.

Materials and Methods:

Thirty consecutive consenting patients for surgical removal of mandibular impacted third molar were randomly placed into two groups of 15 each (groups A and B). Pain, swelling and trismus were observed by visual analog scale, facial measurements and inter-incisal opening. Scores were recorded after 24 and 72 h and on the seventh post-operative day. Results were subjected to the Chi-square test and independent sample t-test (P = 0.05).

Results:

Mean difference in pain experienced between the two groups was statistically significant at 24 h (P = 0.015) and 72 h (P = 0.001) and on the seventh day (P = 0.005). Difference in inter-incisal distance was insignificant (P = 0.239) pre-operatively, but significant after 24 h (P = 0.014) and 72 h (P = 0.001) and on the seventh post-operative day (P = 0.001). Mean difference in swelling was highly significant after 24 h (P = 0.001) and 72 h (P = 0.0001) and on the seventh post-operative day (P = 0.047).

Conclusions:

The combination of oral dose of methylprednisolone (a corticosteroid) diclofenac sodium (a non-steroidal anti-inflammatory drug) was found to be more effective than diclofenac sodium alone on the sequelae of surgical removal of impacted mandibular third molar.

Methylsulfonylmethane and boswellic acids versus glucosamine sulfate in the treatment of knee arthritis: Randomized trial

Until now glucosamine sulfate (GS) has been the most widely used supplement and has been shown to be efficacious in the treatment of osteoarthritis (OA). Methylsulfonylmethane (MSM) and boswellic acids (BA) are new effective supplements for the management of inflammation and joint degeneration, according to previous experimental studies. The aim of our study is to test the effectiveness of association of MSM and BA in comparison with GS in knee arthritis.In this prospective randomized clinical trial, MEBAGA (Methylsulfonylmethane and Boswellic Acids versus Glucosamine sulfate in the treatment of knee Arthritis), 120 participants affected by arthritis of the knee were randomly assigned to an experimental group (MB group) or a control group (GS group) treated for 60 days with 5 g of MSM and 7.2 mg of BA or with 1500 mg of GS daily, respectively. At the 2-month (T1) and 6-months (T2) follow-up , the efficacy of these two nutraceuticals was assessed using the visual analog pain scale (VAS) and the Lequesne Index (LI) for joint function, along with the use of anti-inflammatory drugs (non-steroidal anti-inflammatory drugs and anti-cyclooxygenase-2).The repeated measures ANOVA analysis shows that for VAS, LI, and the use of anti-inflammatory drugs scores there are improvements due to the time in the two groups (respectively, F=26.0; P<0.0001; F=4.15; P=0.02; F=3.38; P=0.04), with a tendency to better values for the MB group at T2.On the basis of these preliminary data, we could support the efficacy of the MSM in association with BA in the treatment of OA. These results are consistent with the anti-inflammatory and chondroprotective effects previously occurred in experimental studies. This new combination of integration (MSM and BS) has presented good results and satisfactory in comparison with GS, until now the cornerstone of the treatment of arthritis in according to guidelines.

Anterolateral Portal Is Less Painful than Superolateral Portal in Knee Intra-Articular Injection

Purpose

Intra-articular knee injections are commonly performed in clinical practice for treating various knee joint disorders such as osteoarthritis and rheumatoid arthritis. When selecting the portal for injection, not only intra-articular needle accuracy but also procedural pain should be taken into consideration. The purpose of this study was to determine whether injection through anterolateral portal provokes less pain and provides better pain relief compared to superolateral portal.

Materials and Methods

A total of 60 patients with primary osteoarthritis of the knee receiving intra-articular injections were randomized into 2 groups according to the type of portal approach; anterolateral or superolateral. All patients received hyaluronic acid (20 mg) and triamcinolone (40 mg) as the first injection followed by second and third injections of hyaluronic acid on a weekly basis. Underlying knee pain, procedural pain, and knee pain at 4 weeks were evaluated using visual analogue scale (VAS).

Results

Injection through anterolateral portal provoked less pain (VAS, 1.5±1.3) than the superolateral portal (VAS, 1.5 vs. 2.7; p=0.004). No differences were found in the degree of pain relief at weeks between the two groups (p=0.517).

Conclusions

We recommend the use of anterolateral portal for intra-articular knee injection as it provokes less pain and comparably short-term pain relief than the superolateral portal.

A Randomized Double Blinded Comparison of Epidural Infusion of Bupivacaine, Ropivacaine, Bupivacaine-Fentanyl, Ropivacaine-Fentanyl for Postoperative Pain Relief in Lower Limb Surgeries

BACKGROUND

Continuous epidural infusion of Bupivacaine and Ropivacaine with or without the addition of Fentanyl has been evaluated by various researchers for effective postoperative pain relief. Studies however, depict significant variability in their results with regard to analgesic efficacy and adverse effects like hypotension, motor blockade etc.

AIM

To comparatively evaluate postoperative analgesic efficacy, motor sparing effect, postoperative haemodynamic variations and total postoperative analgesic consumption in first 24 hours.

MATERIALS AND METHODS

A randomised double blind study was conducted on 100 adult, ASA grade I and II patients, of either sex who had undergone elective lower limb surgery under spinal anaesthesia. According to the group allocated, patients were started on epidural infusion after completion of surgery. Group I (0.2% Ropivacaine), Group II (0.1% Ropivacaine + 2μg/ml Fentanyl), Group III (0.2% Bupivacaine), Group IV (0.1% Bupivacaine + 2μg/ml Fentanyl) at the rate of 6 ml/hour. VAS scores, epidural consumption, supplemental epidural boluses, rescue analgesics, haemodynamics, motor block, sensory block regression, sedation, nausea and pruritis were recorded by a blinded observer for 24 hours.

RESULTS

The haemodynamic parameters were stable in all the groups. Side effects including the motor block were negligible and comparable in all groups. Group I patients had significantly lower VAS scores, mean total epidural consumption, supplemental epidural bolus requirement and rescue analgesic requirement among all groups.

CONCLUSION

It can be concluded that epidural analgesia using Ropivacaine 0.2% infusion is more effective than other study groups when used for postoperative pain relief in lower limb surgeries.

The effects of music listening on pain and stress in the daily life of patients with fibromyalgia syndrome

Music listening is associated with both pain- and stress-reducing effects. However, the effects of music listening in daily life remain understudied, and the psycho-biological mechanisms underlying the health-beneficial effect of music listening remain unknown. We examined the effects of music listening on pain and stress in daily life in a sample of women with fibromyalgia syndrome (FMS; i.e., a condition characterized by chronic pain) and investigated whether a potentially pain-reducing effect of music listening was mediated by biological stress-responsive systems. Thirty women (mean age: 50.7 ± 9.9 years) with FMS were examined using an ecological momentary assessment design. Participants rated their current pain intensity, perceived control over pain, perceived stress level, and music listening behavior five times per day for 14 consecutive days. At each assessment, participants provided a saliva sample for the later analysis of cortisol and alpha-amylase as biomarkers of stress-responsive systems. Hierarchical linear modeling revealed that music listening increased perceived control over pain, especially when the music was positive in valence and when it was listened to for the reason of 'activation' or 'relaxation'. In contrast, no effects on perceived pain intensity were observed. The effects of music listening on perceived control over pain were not mediated by biomarkers of stress-responsive systems. Music listening in daily life improved perceived control over pain in female FMS patients. Clinicians using music therapy should become aware of the potential adjuvant role of music listening in daily life, which has the potential to improve symptom control in chronic pain patients. In order to study the role of underlying biological mechanisms, it might be necessary to use more intensive engagement with music (i.e., collective singing or music-making) rather than mere music listening.

Reliability and responsiveness of algometry for measuring pressure pain threshold in patients with knee osteoarthritis

[Purpose] This study aimed to establish the intrarater reliability and responsiveness of a clinically available algometer in patients with knee osteoarthritis as well as to determine the minimum-detectable-change and standard error of measurement of testing to facilitate clinical interpretation of temporal changes. [Subjects] Seventy-three patients with knee osteoarthritis were included. [Methods] Pressure pain threshold measured by algometry was evaluated 3 times at 2-min intervals over 2 clinically relevant sites—mediolateral to the medial femoral tubercle (distal) and lateral to the medial malleolus (local)—on the same day. Intrarater reliability was estimated by intraclass correlation coefficients. The minimum-detectable-change and standard error of measurement were calculated. As a measure of responsiveness, the effect size was calculated for the results at baseline and after treatment. [Results] The intrarater reliability was almost perfect (intraclass correlation coefficient = 0.93–0.97). The standard error of measurement and minimum-detectable-change were 0.70–0.66 and 1.62–1.53, respectively. The pressure pain threshold over the distal site was inadequately responsive in knee osteoarthritis, but the local site was responsive. The effect size was 0.70. [Conclusion] Algometry is reliable and responsive to assess measures of pressure pain threshold for evaluating pain patients with knee osteoarthritis.

A study of promethazine hydrochloride and pentazocine intramuscular sedation along with 2 % lidocaine hydrochloride and adrenaline and comparison to placebo along with 2 % lidocaine hydrochloride and adrenaline for surgical extraction of mandibular third molar

BACKGROUND AND OBJECTIVES

The main objective is to study and compare the sedative and analgesic effects of intramuscular injection fortwin-phenergan along with local anesthetic and normal saline placebo along with local anesthetics in mandibular third molar surgery. We also assessed and compared the postoperative experience of the patient in relation to the pain intensity, time to first analgesic taken and total number of analgesics consumed over a period of 48 h in the two groups.

MATERIALS AND METHODS

Patients who came to the Department of Oral and Maxillofacial Surgery, The Regional Dental College; with complaints regarding mandibular third molar were chosen for the treatment. Patients were evaluated using Corah Dental Anxiety Scale (CDAS) and those patients having a score of CDAS 13 and above were selected. Sixty patients were selected out of which 30 patients formed group 1 and another 30 patients group 2. The patients were randomly divided with flip method into group 1 (study group) and or group 2 (controlled group).

RESULTS

Our study results showed that the operating conditions for both the groups at the end of surgery were similar without significant difference. Most of the surgical procedures were graded as excellent and good in both the groups except that difficulty was encountered in two patients from group 1 and one from group 2.

CONCLUSION

It could be concluded that particular drugs do not have much influence on the surgical procedure in our study, but it was found that patients from group 1 were more cooperative as compared to group 2 when difficulty was encountered during the surgical procedure.

Barriers to Chronic Pain Measurement: A Qualitative Study of Patient Perspectives

OBJECTIVE

Preliminary evidence suggests that chronic pain patients complete pain intensity measures using idiosyncratic methods. Our objective was to understand these methods and how they might impact the psychometric properties of the instruments.

DESIGN

A qualitative focus-group based study.

SETTING

An academic center in New York City.

SUBJECTS

Outpatients (n = 36) with chronic low back pain, or neuropathic pain due to diabetes or HIV.

METHODS

Participants were divided into three focus groups based on their pain condition, and asked to discuss pain intensity measures (visual analog and numeric rating scales for average pain over 24 hours; Brief Pain Inventory; and McGill Pain Questionnaire). Audio-recordings were transcribed and analyzed using an inductive thematic method.

RESULTS

We discovered four main themes, and five sub-themes: 1) doubt that pain can be accurately measured (subthemes: pain measurement is influenced by things other than pain, the numbers used to rate pain do not have an absolute meaning, and preference for pain intensity ratings "in the middle" of the scale); 2) confusion regarding the definition of pain; 3) what experiences to use as referents (subthemes: appropriate comparator experiences and the interpretation of the anchors of the scale); and 4) difficulty averaging pain.

CONCLUSIONS

The themes discovered suggest that patients include sensations and experiences other than pain intensity in their ratings, experience the rating of pain as a comparative task, and do not use the scale in a linear manner. These themes are relevant to understanding the validity and scale properties of commonly used pain intensity measures.

Is the pain visual analogue scale linear and responsive to change? An exploration using Rasch analysis

Objectives

Pain visual analogue scales (VAS) are commonly used in clinical trials and are often treated as an interval level scale without evidence that this is appropriate. This paper examines the internal construct validity and responsiveness of the pain VAS using Rasch analysis.

Methods

Patients (n = 221, mean age 67, 58% female) with chronic stable joint pain (hip 40% or knee 60%) of mechanical origin waiting for joint replacement were included. Pain was scored on seven daily VASs. Rasch analysis was used to examine fit to the Rasch model. Responsiveness (Standardized Response Means, SRM) was examined on the raw ordinal data and the interval data generated from the Rasch analysis.

Results

Baseline pain VAS scores fitted the Rasch model, although 15 aberrant cases impacted on unidimensionality. There was some local dependency between items but this did not significantly affect the person estimates of pain. Daily pain (item difficulty) was stable, suggesting that single measures can be used. Overall, the SRMs derived from ordinal data overestimated the true responsiveness by 59%. Changes over time at the lower and higher end of the scale were represented by large jumps in interval equivalent data points; in the middle of the scale the reverse was seen.

Conclusions

The pain VAS is a valid tool for measuring pain at one point in time. However, the pain VAS does not behave linearly and SRMs vary along the trait of pain. Consequently, Minimum Clinically Important Differences using raw data, or change scores in general, are invalid as these will either under- or overestimate true change; raw pain VAS data should not be used as a primary outcome measure or to inform parametric-based Randomised Controlled Trial power calculations in research studies; and Rasch analysis should be used to convert ordinal data to interval data prior to data interpretation.

Same-day discharge after minimally invasive transforaminal lumbar interbody fusion: a series of 808 cases

BACKGROUND

The versatility of transforaminal lumbar interbody fusion (TLIF) allows fusion at any level along with any necessary canal decompression. Unilateral TLIF with a single interbody device and unilateral pedicle fixation has proven effective, and minimally invasive techniques have shortened hospital stays. Reasonable questions have been raised, though, about whether same-day discharge is feasible and safe after TLIF surgery.

QUESTIONS/PURPOSES

We determined, in a high-volume spine practice, what proportion of patients having one- or two-level minimally invasive unilateral TLIF go home on the day of surgery or stay longer and compared the two groups in terms of outcome scores (VAS scores for back and leg pain, Waddell-Main Disability Index), complications, and hospital readmissions.

METHODS

We retrospectively studied all 1005 patients who underwent 1114 minimally invasive unilateral TLIF procedures by one surgeon between March 18, 2003, and April 12, 2013. For the first 43 months, Medicare patients (65 years or older) were not offered same-day discharge. All other patients were offered the chance to be discharged home on the same day if they felt well enough. Followup data were for 3 months. VAS scores for back and leg pain and Waddell-Main Disability Index were recorded in a prospectively maintained database and readmissions were ascertained by chart review. Data were available on 100% of discharges, 95% of preoperative outcome scores, and 81% of outcome scores out to 3 months.

RESULTS

Of the 1114 procedures, 808 went home the day of surgery, resulting in a 73% same-day discharge rate. Mean differences in outcome scores from preoperatively to 3 months were similar between groups, except for a difference in VAS lower leg pain in hospital stay patients, which was of borderline statistical and unlikely clinical significance (3.3 versus 2.7, p = 0.05). The only important differences between groups were slightly more medical complications and readmissions for patients 65 years and older who stayed in hospital overnight (3.9% versus 0%, p < 0.01); however, some self-selection bias toward staying overnight among patients with higher self-rated disability and pain scores likely accounted for this difference.

CONCLUSIONS

Surgeons experienced in minimally invasive spine surgery can consider same-day discharge for patients having minimally invasive unilateral TLIF procedures.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

CHELT therapy in the treatment of chronic insertional Achilles tendinopathy

The application of laser therapy on soft tissue is used for pain relief, anti-inflammation action and biostimulation. The efficiency of High Energy Laser Therapy has not yet been studied on Achilles tendinopathy. The aim of the study is to evaluate the effectiveness of a flow of Cold air and High Energy Laser Therapy (CHELT) versus Extracorporeal Shock Waves Therapy (ESWT) in the treatment of Achilles tendinopathy. In this prospective, clinical trial, 60 subjects affected by insertional Achilles tendinopathy were enrolled and randomized to CHELT (30 subjects) or to ESWT (30 subjects). In CHELT group the patients received ten daily sessions of 1,200 J and 12 W of laser therapy (wavelength of 1,084, 810 and 980 nm) added to a flow of cold air at -30 °C. In the ESWT group, the patients received three sessions at 3- to 4-day intervals of 1,600 impulses with an energy flux density (EFD) of 0.05-0.07 mJ/mm(2). Both groups of participants performed stretching and eccentric exercises over a 2-month period. The visual analogue scale (VAS), the Ankle-Hindfoot Scale, and the Roles and Maudsley Score were measured before treatment (T0), and at end of the treatment session (T1) and 2 (T2) and 6 months (T3) after treatment during the follow-up examinations. In both groups, we found a statistically significant improvement of the VAS at T1, T2 and T3 (p < 0.01). The difference between the two groups was statistically significant in favour of the CHELT group (p < 0.001). At 2 months, the CHELT group was statistically better for Ankle-Hindfoot Scale and the Roles and Maudsley Score (p < 0.05) and at 6 months only for the Roles and Maudsley Score (p < 0.001). High Energy Laser Therapy gave quicker and better pain relief. It also gave the patient a full functional recovery and greater satisfaction.

Preemptive analgesia in third molar impaction surgery

INTRODUCTION

We have evaluated efficacy of diclofenac sodium as pre-emptive analgesia agent in a prospective triple blind placebo controlled randomized clinical trial in a patients undergoing third molar impaction surgery.

MATERIALS AND METHODS

Randomization of groups was done by randomization software and two groups were constituted one group receiving placebo pre operatively and then the drug for next five days while the other group was given diclofenac sodium pre operatively and then for five days.

RESULTS

Results were achieved with help of measurement of outcome variables like postoperative tenderness, swelling and trismus on a visual analogous scale (VAS) and other personalized scale. Collected data shows that there is a significant reduction in the score of postop tenderness in experimental group (P = 0.00), while there is a minimal difference between score of postoperative swelling and tenderness (P > 0.04).

CONCLUSION

So, we can conclude that use of diclofenac sodium as a preemptive analgesic agent is beneficial for better pain control in third molar impaction surgery.

Muscle sympathetic response to arousal predicts neurovascular reactivity during mental stress

Mental stress often begins with a sudden sensory (or internal) stimulus causing a brief arousal reaction, and is followed by a more long lasting stress phase. Both arousal and stress regularly induce blood pressure (BP) increases whereas effects on muscle sympathetic nerve activity (MSNA) are variable. Here we have compared responses of MSNA and BP during arousal induced by an electrical skin stimulus and mental stress evoked by a 3 min paced auditory serial arithmetic test (PASAT) in 30 healthy males aged 33 ± 10 years. In addition, recordings were made of ECG, respiratory movements, electrodermal activity and perceived stress. We also monitored corresponding effects of a cold test (CT: 2 min immersion of a hand in ice water). The arousal stimulus evoked significant inhibition of one or two MSNA bursts in 16 subjects, who were classified as responders; the remaining 14 subjects were non-responders. During mental stress responders showed a significant decrease of MSNA and a lesser BP increase compared to non-responders. In non-responders MSNA was unchanged or increased. Perceived stress was higher in non-responders (P = 0.056), but other measures were similar in the two groups. In non-responders mental stress and the cold test induced increases of BP that lasted throughout the subsequent rest period. During the cold test MSNA and BP increased equally in responders and non-responders. In the whole group of subjects, there was a significant correlation (r = 0.80, P < 0.001) between MSNA responses induced by arousal and by mental stress but not between responses evoked by arousal and the cold test (r < 0.1, P > 0.6). Additionally arousal-induced MSNA change was positively correlated with blood pressure changes during MS (systolic BP: r = 0.48; P < 0.01; diastolic BP: r = 0.42; P < 0.05) but not with blood pressure changes during CT. We conclude that in males the MSNA response to arousal predicts the MSNA and BP responses to mental stress.

A randomized, double-blind, placebo-controlled trial of preemptive analgesia with bupivacaine in patients undergoing mastectomy for carcinoma of the breast

Background

In this prospective, randomized, placebo-controlled, double-blinded clinical trial we tested the hypothesis that preemptive analgesia with bupivacaine applied in the area of the surgical incision in patients undergoing mastectomy for breast cancer would reduce post-operative acute pain and would reduce the amount of analgesics used during surgery and in the post-operative period.

Material/Methods

Participants were assigned into 1 of 2 groups – with bupivacaine applied in the area of surgical incision or with placebo. We assessed the intraoperative consumption of fentanyl, the postoperative consumption of morphine delivered using a PCA method, and the subjective pain intensity according to VAS score reported by patients in the early post-operative period.

Results

Out of 121 consecutive cases qualified for mastectomy, 112 women were allocated randomly to 1 of 2 groups – group A (bupivacaine) and group B (placebo). The final study group comprised 106 breast cancer cases. Between the groups, a statistically significant difference was observed with respect to: lower fentanyl consumption during surgery (p=0.011), lower morphine (delivered by means of a PCA) consumption between the 4–12^th postoperative hours (p=0.02) and significantly lower pain intensity assessed according to VAS score at the 4^th and 12^th hours after surgery (p=0.004 and p=0.02 respectively) for the group A patients.

Conclusions

Preemptive analgesia application in the form of infiltration of the area of planned surgical incisions with bupivacaine in breast cancer patients undergoing mastectomy decreases post-operative pain sensation, limits the amount of fentanyl used during surgery, and reduces the demand for opiates in the hours soon after surgery.

Calcitonin for treating acute and chronic pain of recent and remote osteoporotic vertebral compression fractures: a systematic review and meta-analysis

Vertebral collapse is a common fracture associated with osteoporosis. Subsequent pain may be severe and often requires medications and bed rest. Several studies have suggested the use of calcitonin for the treatment of fracture pain. We sought to determine the analgesic efficacy of calcitonin for acute and chronic pain of osteoporotic vertebral compression fractures (OVCF). We searched for randomized, placebo, and controlled trials that evaluated the analgesic efficacy of calcitonin for pain attributable to OVCFs. We performed meta-analyses to calculate standardized mean differences (SMDs) using a fixed or random effects model. The combined results from 13 trials (n = 589) determined that calcitonin significantly reduced the severity of acute pain in recent OVCFs. Pain at rest was reduced by week 1 [mean difference (MD) = -3.39, 95% confidence interval (CI) = -4.02 to -2.76), with continued improvement through 4 weeks. At week 4, the difference in pain scores with mobility was even greater (SMD = -5.99, 95% CI = -6.78 to -5.19). For patients with chronic pain, there was no statistical difference between groups while at rest; there was a small, statistically significant difference between groups while mobile at 6 months (SMD = 0.49, 95% CI = -0.85 to -0.13, p = 0.008). Side effects were mild, with enteric disturbances and flushing reported most frequently. Although calcitonin has proven efficacy in the management of acute back pain associated with a recent OVCF, there is no convincing evidence to support the use of calcitonin for chronic pain associated with older fractures of the same origin.

Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial

BACKGROUND

Shoulder pain is a common musculoskeletal problem that is often chronic or recurrent. Myofascial trigger points (MTrPs) cause shoulder pain and are prevalent in patients with shoulder pain. However, few studies have focused on MTrP therapy. The aim of this study was to assess the effectiveness of multimodal treatment of MTrPs in patients with chronic shoulder pain.

METHODS

A single-assessor, blinded, randomized, controlled trial was conducted. The intervention group received comprehensive treatment once weekly consisting of manual compression of the MTrPs, manual stretching of the muscles and intermittent cold application with stretching. Patients were instructed to perform muscle-stretching and relaxation exercises at home and received ergonomic recommendations and advice to assume and maintain good posture. The control group remained on the waiting list for 3 months. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score (primary outcome), Visual Analogue Scale for Pain (VAS-P), Global Perceived Effect (GPE) scale and the number of muscles with MTrPs were assessed at 6 and 12 weeks in the intervention group and compared with those of a control group.

RESULTS

Compared with the control group, the intervention group showed significant improvement (P < 0.05) on the DASH after 12 weeks (mean difference, 7.7; 95% confidence interval (95% CI), 1.2 to 14.2), on the VAS-P1 for current pain (mean difference, 13.8; 95% CI, 2.6 to 25.0), on the VAS-P2 for pain in the past 7 days (mean difference, 10.2; 95% CI, 0.7 to 19.7) and VAS-P3 most severe pain in the past 7 days (mean difference, 13.8; 95% CI, 0.8 to 28.4). After 12 weeks, 55% of the patients in the intervention group reported improvement (from slightly improved to completely recovered) versus 14% in the control group. The mean number of muscles with active MTrPs decreased in the intervention group compared with the control group (mean difference, 2.7; 95% CI, 1.2 to 4.2).

CONCLUSIONS

The results of this study show that 12-week comprehensive treatment of MTrPs in shoulder muscles reduces the number of muscles with active MTrPs and is effective in reducing symptoms and improving shoulder function in patients with chronic shoulder pain.

TRIAL REGISTRATION NUMBER

ISRCTN: ISRCTN75722066.

A Randomized Controlled Trial of the Cost-Effectiveness of Ultrasound-Guided Intraarticular Injection of Inflammatory Arthritis

Objective.

We studied whether sonographic needle guidance affected the outcomes of intraarticular (IA) injection for inflammatory arthritis.

Methods.

Joints with inflammatory arthritis (n = 244; 76% rheumatoid arthritis, 3% small joints, 51% intermediate, and 46% large) were randomized to injection by conventional palpation-guided anatomic injection (120 joints) or sonographic image-guided injection enhanced with a 1-handed reciprocating procedure device mechanical syringe (124 joints). A 1-needle, 2-syringe technique was used. After IA placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and triamcinolone acetonide was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined.

Results.

Relative to conventional palpation-guided methods, sonographic guidance for injection of inflammatory arthritis resulted in an 81% reduction in injection pain (p < 0.001), 35% reduction in pain scores at outcome (p < 0.02), 38% increase in the responder rate (p < 0.003), 34% reduction in the non-responder rate (p < 0.003), 32% increase in therapeutic duration (p = 0.01), 8% reduction ($7) in cost/patient/year, and a 33% ($64) reduction in cost/responder/year for a hospital outpatient (p < 0.001).

Conclusion.

Sonographic needle guidance improves the performance, clinical outcomes, and cost-effectiveness of IA injections for inflammatory arthritis. (Clinical Trial Identifier NCT00651625)

Opioids for the treatment of chronic non-cancer pain in older people

Chronic pain occurs in 45-85% of the geriatric population and the need to treat chronic pain is growing substantially. Unfortunately, treatment for chronic pain is not always correctly targeted, which leads to a reduced quality of life, with decreased socialization, depression, sleep disturbances, cognitive impairment, disability and malnutrition. Considering these consequences, healthcare professionals should aim at improving the diagnosis and treatment of chronic pain in older persons. One of the most important limitations in achieving successful pain management is that older people are not aware that pain management options exist or medications for pain, such as opioids, have associated benefits and adverse effects. Importantly, opioids do not induce any organ failure and if adequately used at the right dosage may only present some predictable and preventable adverse effects. Treating and controlling chronic pain is essential in elderly patients in order to maintain a good quality of life and an active role in both the family and society. To date there are only a few randomized clinical trials testing opioid therapy in elderly patients, and the aim of the present review is to highlight the efficacy and tolerability of opioid use through a literature search strategy in elderly people with chronic non-cancer pain.

Interpretation of response categories in patient-reported rating scales: a controlled study among people with Parkinson's disease

BACKGROUND

Unambiguous interpretation of ordered rating scale response categories requires distinct meanings of category labels. Also, summation of item responses into total scores assumes equal intervals between categories. While studies have identified problems with rating scale response category functioning there is a paucity of empirical studies regarding how respondents interpret response categories. We investigated the interpretation of commonly used rating scale response categories and attempted to identify distinct and roughly equally spaced response categories for patient-reported rating scales in Parkinson's disease (PD) and age-matched control subjects.

METHODS

Twenty-one rating scale response categories representing frequency, intensity and level of agreement were presented in random order to 51 people with PD (36 men; mean age, 66 years) and 36 age-matched controls (14 men; mean age, 66). Respondents indicated their interpretation of each category on 100-mm visual analog scales (VAS) anchored by Never--Always, Not at all--Extremely, and Totally disagree--Completely agree. VAS values were compared between groups, and response categories with mean values and non-overlapping 95% CIs corresponding to equally spaced locations on the VAS line were sought to identify the best options for three-, four-, five-, and six-category scales.

RESULTS

VAS values did not differ between the PD and control samples (P = 0.286) or according to educational level (P = 0.220), age (P = 0.220), self-reported physical functioning (P = 0.501) and mental health (P = 0.238), or (for the PD sample) PD duration (P = 0.213) or presence of dyskinesias (P = 0.212). Attempts to identify roughly equally spaced response categories for three-, four-, five-, and six-category scales were unsuccessful, as the 95% CIs of one or several of the identified response categories failed to include the criterion values for equal distances.

CONCLUSIONS

This study offers an evidence base for selecting more interpretable patient-reported rating scale response categories. However, problems associated with raw rating scale data, primarily related to their ordinal structure also became apparent. This argues for the application of methodologies such as Rasch measurement. Rating scale response categories need to be treated with rigour in the construction and analysis of rating scales.

The differential effects of core stabilization exercise regime and conventional physiotherapy regime on postural control parameters during perturbation in patients with movement and control impairment chronic low back pain

BACKGROUND

The purpose of the present study was to examine the differential effect of core stability exercise training and conventional physiotherapy regime on altered postural control parameters in patients with chronic low back pain (CLBP). As heterogeneity in CLBP population moderates the effect of intervention on outcomes, in this study, interventions approaches were used based on sub-groups of CLBP.

METHODS

This was an allocation concealed, blinded, sequential and pragmatic control trial. Three groups of participants were investigated during postural perturbations: 1) CLBP patients with movement impairment (n = 15, MI group) randomized to conventional physiotherapy regime 2) fifteen CLBP patients with control impairment randomized to core stability group (CI group) and 3) fifteen healthy controls (HC).

RESULTS

The MI group did not show any significant changes in postural control parameters after the intervention period however they improved significantly in disability scores and fear avoidance belief questionnaire work score (P < 0.05). The CI group showed significant improvements in Fx, Fz, and My variables (p < 0.013, p < 0.006, and p < 0.002 respectively with larger effect sizes: Hedges's g > 0.8) after 8 weeks of core stability exercises for the adjusted p values. Postural control parameters of HC group were analyzed independently with pre and post postural control parameters of CI and MI group. This revealed the significant improvements in postural control parameters in CI group compared to MI group indicating the specific adaptation to the core stability exercises in CI group. Though the disability scores were reduced significantly in CI and MI groups (p < 0.001), the post intervention scores between groups were not found significant (p < 0.288). Twenty percentage absolute risk reduction in flare-up rates during intervention was found in CI group (95% CI: 0.69-0.98).

CONCLUSIONS

In this study core stability exercise group demonstrated significant improvements after intervention in ground reaction forces (Fz, Mz; g > 0.8) indicating changes in load transfer patterns during perturbation similar to HC group.

TRIAL REGISTRATION

UTRN095032158-06012009423714.

Comparative efficacy of topical tetraVisc versus lidocaine gel in cataract surgery

Background

To compare the clinical efficacy of lidocaine 2% with tetracaine 0.5% for cataract surgery.

Methods

In a randomized, multi-surgeon, controlled clinical trial,122 consecutive cataract cases eligible for topical anesthesia, were randomly assigned to receive lidocaine 2% gel (1 ml) or tetracaine solution 0.5% (TetraVisc, 0.5 ml) before clear corneal phacoemulsification. Main outcome measure was visual analog scale (0 to 10), which was used to measure intra-operative pain. Secondary outcome measures included patients' discomfort due to tissue manipulation and surgeon graded patients' cooperation. Duration of surgery and intra-operative complications were also recorded.

Results

The mean age in TetraVisc (TV) group was 70.4 years and in the lidocaine gel group (LG) it was 70.6 years (p = 0.89). Patient reported mean intra-operative pain scores by visual analog scale were 0.70 ± 0.31 in TV group and 1.8 ± 0.4 in LG group (P < 0.001). Mean patient cooperation was also marginally better in the TV group (8.3 ± 0.3) compared to LG group (8.4 ± 0.6) (P = 0.25). 96% of patients in TV group showed intra-operative corneal clarity compared to 91% in LG group. TV group had less (1 out of 61 patients, 1.6%) intra-operative complications than LG group (3 out of 61 patients, 4.8%). No anesthesia related complications were noted in either group

Conclusion

Topical TetraVisc solution was superior to lidocaine 2% gel for pain control in patients undergoing clear corneal phacoemulsification. Lidocaine 2% gel is similar to TetraVisc in patient comfort and surgeon satisfaction.

Trial Registration

Clinical trials number: ISRCTN78374774