Pain Research and Treatment The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Etiology and Use of the “Hanging Drop” Technique: A Review Tue, 15 Apr 2014 14:11:11 +0000 Background. The hanging drop (HD) technique presumably relies on the presence of subatmospheric epidural pressure. It is not clear whether this negative pressure is intrinsic or an artifact and how it is affected by body position. There are few data to indicate how often HD is currently being used. Methods. We identified studies that measured subatmospheric pressures and looked at the effect of the sitting position. We also looked at the technique used for cervical and thoracic epidural anesthesia in the last 10 years. Results. Intrinsic subatmospheric pressures were measured in the thoracic and cervical spine. Three trials studied the effect of body position, indicating a higher incidence of subatmospheric pressures when sitting. The results show lower epidural pressure (−10.7 mmHg) with the sitting position. 28.8% of trials of cervical and thoracic epidural anesthesia that documented the technique used, utilized the HD technique. When adjusting for possible bias, the rate of HD use can be as low as 11.7%. Conclusions. Intrinsic negative pressure might be present in the cervical and thoracic epidural space. This effect is more pronounced when sitting. This position might be preferable when using HD. Future studies are needed to compare it with the loss of resistance technique. Ludmil Todorov and Timothy VadeBoncouer Copyright © 2014 Ludmil Todorov and Timothy VadeBoncouer. All rights reserved. Morphine versus Nalbuphine for Open Gynaecological Surgery: A Randomized Controlled Double Blinded Trial Mon, 14 Apr 2014 16:46:50 +0000 Introduction. Pain is the commonest morbidity after open surgical procedures. The most effective treatment of postoperative pain is opioid therapy. Morphine, the commonly used opioid, is associated with many side effects including respiratory depression, sedation, postoperative nausea vomiting, and pruritus. Nalbuphine, on the other hand, is known to cause less respiratory depression. Thus this study was undertaken to compare the intraoperative and postoperative analgesic efficacy and side effect profile of the two drugs. Methodology. 60 patients undergoing open gynaecological surgery were randomized to receive either morphine (Group M) or nalbuphine (Group N) in the intraoperative and postoperative period. Intraoperative analgesic efficacy (measured by need for rescue analgesics), postoperative pain by visual analogue scale, and side effects like postoperative nausea, vomiting, sedation, respiratory depression, and pruritus were compared in both groups. Intraoperative and postoperative heart rate and blood pressure were also compared between the groups. Results. Need for intraoperative analgesia was significantly more in Group N (). Postoperative VAS scores were significantly different between the groups at various time points; however, none of the patients required any rescue analgesia. The incidence of various side effects was not significantly different between the groups. The haemodynamic profile of patients was comparable between the groups in both intraoperative and postoperative period. Conclusion. Nalbuphine provides less effective intraoperative analgesia than morphine in patients undergoing open gynaecological surgery under general anaesthesia. Both drugs, however, provided similar postoperative analgesia and had similar haemodynamic and side effect profile. Shiv Akshat, Rashmi Ramachandran, Vimi Rewari, Chandralekha, Anjan Trikha, and Renu Sinha Copyright © 2014 Shiv Akshat et al. All rights reserved. The Beliefs of Third-Level Healthcare Students towards Low-Back Pain Thu, 10 Apr 2014 07:01:27 +0000 Objectives. Beliefs held by healthcare providers are part of the complex recovery of a patient with low-back pain (LBP). The aim of this study was to investigate the attitudes and beliefs of Irish university healthcare students towards LBP. Methods. Physiotherapy (), medicine (), nursing, and midwifery () students completed the survey. Demographic data, LBP related beliefs [Back Beliefs Questionnaire (BBQ) and the Fear Avoidance Beliefs Questionnaire physical subsection (FABQ-PA)] were collected. Results. Two hundred and seventy-one students responded (response rate 29%). Student physiotherapists had significantly lower FABQ () scores than medical (95% CI [−5.492, −1.406]) and nursing students (95% CI [−7.718, −22.307]). Physiotherapy students had significantly higher BBQ scores () than medical (95% CI [1.490, 5.406]) and nursing students (95% CI [6.098, 11.283]). Beliefs of physiotherapy and medical students were significantly better among fourth-year year than first-year students () but were not significantly different for nursing students ( for FABQ and for BBQ). Conclusions. Physiotherapy students had more positive beliefs towards LBP than medical and nursing students. Physiotherapy and medical students’ beliefs towards LBP significantly improved over the course of their studies. Norelee Kennedy, John Healy, and Kieran O'Sullivan Copyright © 2014 Norelee Kennedy et al. All rights reserved. Is Hippocampus Susceptible to Antinociceptive Tolerance to NSAIDs Like the Periaqueductal Grey? Wed, 09 Apr 2014 08:47:00 +0000 Emotional distress is the most undesirable feature of painful experience. Numerous studies have demonstrated the important role of the limbic system in the affective-motivational component of pain. The purpose of this paper was to examine whether microinjection of nonsteroidal anti-inflammatory drugs (NSAIDs), Clodifen, Ketorolac, and Xefocam, into the dorsal hippocampus (DH) leads to the development of antinociceptive tolerance in male rats. We found that microinjection of these NSAIDs into the DH induces antinociception as revealed by a latency increase in the tail-flick (TF) and hot plate (HP) tests compared to controls treated with saline into the DH. Subsequent tests on consecutive three days, however, showed that the antinociceptive effect of NSAIDs progressively decreased, suggesting tolerance developed to this effect of NSAIDs. Both pretreatment and posttreatment with the opioid antagonist naloxone into the DH significantly reduced the antinociceptive effect of NSAIDs in both pain models. Our data indicate that microinjection of NSAIDs into the DH induces antinociception which is mediated via the opioid system and exhibits tolerance. Nana Tsiklauri, Ivliane Nozadze, Gulnazi Gurtskaia, and Merab G. Tsagareli Copyright © 2014 Nana Tsiklauri et al. All rights reserved. Micronized Palmitoylethanolamide Reduces the Symptoms of Neuropathic Pain in Diabetic Patients Wed, 02 Apr 2014 12:46:34 +0000 The present study evaluated the effectiveness of micronized palmitoylethanolamide (PEA-m) treatment in reducing the painful symptoms experienced by diabetic patients with peripheral neuropathy. PEA-m, a fatty acid amide of the N-acylethanolamine family, was administered (300 mg twice daily) to 30 diabetic patients suffering from painful diabetic neuropathy. Before treatment start, after 30 and 60 days the following parameters were assessed: painful symptoms of diabetic peripheral neuropathy using the Michigan Neuropathy Screening instrument; intensity of symptoms characteristic of diabetic neuropathic pain by the Total Symptom Score; and intensity of different subcategories of neuropathic pain by the Neuropathic Pain Symptoms Inventory. Hematological and blood chemistry tests to evaluate metabolic control and safety were also performed. Statistical analysis (ANOVA) indicated a highly significant reduction in pain severity () and related symptoms () evaluated by Michigan Neuropathy Screening instrument, Total Symptom Score, and Neuropathic Pain Symptoms Inventory. Hematological and urine analyses did not reveal any alterations associated with PEA-m treatment, and no serious adverse events were reported. These results suggest that PEA-m could be considered as a promising and well-tolerated new treatment for symptomatology experienced by diabetic patients suffering from peripheral neuropathy. Chiara Schifilliti, Lelio Cucinotta, Viviana Fedele, Carmela Ingegnosi, Salvatore Luca, and Carmelo Leotta Copyright © 2014 Chiara Schifilliti et al. All rights reserved. Association between Neck/Shoulder Pain and Trapezius Muscle Tenderness in Office Workers Thu, 27 Mar 2014 11:21:50 +0000 Background. Neck/shoulder pain is a common musculoskeletal disorder among adults. The pain is often assumed to be related to muscular tenderness rather than serious chronic disease. Aim. To determine the association between neck/shoulder pain intensity and trapezius muscle tenderness in office workers. Methods. 653 employees from two large office workplaces in Copenhagen, Denmark, replied to a questionnaire on health and working conditions (mean: age 43 years, body mass index 24 kg·m−2, computer use 90% of work time, 73% women). Respondents rated intensity of neck/shoulder pain during the previous three months on a scale of 0–10 and palpable tenderness of the upper trapezius muscle on a scale of “no tenderness,” “some tenderness,” or “severe tenderness.” Odds ratios for tenderness as a function of neck/shoulder pain intensity were determined using cumulative logistic regression controlled for age, gender, and chronic disease. Results. The prevalence of “no,” “some,” and “severe” tenderness of the trapezius muscle was 18%, 59%, and 23% in women and 51%, 42%, and 7% in men, respectively (chi-square, P < 0.0001). Participants with “no,” “some,” and “severe” tenderness of the trapezius muscle, respectively, rated their neck/shoulder pain intensity to 1.5 (SD 1.6), 3.8 (SD 2.0), and 5.7 (SD 1.9) for women and 1.4 (SD 1.4), 3.1 (SD 2.2), and 5.1 (SD 1.7) for men. For every unit increase in neck/shoulder pain intensity, the OR for one unit increase in trapezius tenderness was 1.86 (95% confidence interval 1.70 to 2.04). Conclusion. In office workers, a strong association between perceived neck/shoulder pain intensity and trapezius muscle tenderness exists. The present study provides reference values of pain intensity among office workers with no, some, and severe tenderness of the trapezius muscle. Mikkel Brandt, Emil Sundstrup, Markus D. Jakobsen, Kenneth Jay, Juan C. Colado, Yuling Wang, Mette K. Zebis, and Lars L. Andersen Copyright © 2014 Mikkel Brandt et al. All rights reserved. Long-Term Persistency of Abnormal Heart Rate Variability following Long NICU Stay and Surgery at Birth Wed, 26 Feb 2014 09:54:55 +0000 Preterm birth is associated with painful procedures during the neonatal intensive care unit (NICU) stay. Full-term newborns can also experience pain, following surgery. These procedures can have long-lasting consequences. It has been shown that children born preterm show pain responses and cardiac alterations. This study aimed to explore the heart rate reactivity to pain in 107 subjects born either preterm or full-term who were between 7 and 25 years old at testing. We also evaluated the effect of pain experienced at birth, as represented by a longer NICU stay, time under ventilation, and surgery at birth. Participants were asked to immerse their right forearm in 10°C water for 2 minutes. Electrocardiograms were recorded at baseline and during the immersion procedure. Full-term subjects showed a stable increase in heart rate throughout the procedure, whereas preterm ones showed a strong increase at the beginning, which decreased over time. Also, preterm and full-term subjects who experienced pain at birth showed higher resting heart rate, stronger sympathetic activity, and lower cardiac vagal activity. Our study demonstrated a long-term impact of a long NICU stay and surgery at birth on cardiac autonomic activity. This could lead to impaired reactions to pain or stress in later life. Mélanie Morin, Serge Marchand, Louis Couturier, Sophie Nadeau, and Sylvie Lafrenaye Copyright © 2014 Mélanie Morin et al. All rights reserved. Comparison of Postoperative Analgesic Effect of Intrathecal Clonidine and Fentanyl Added to Bupivacaine in Patients Undergoing Cesarean Section: A Prospective Randomized Double-Blind Study Tue, 04 Feb 2014 11:32:39 +0000 Objectives. To compare the analgesic efficacy of intrathecal clonidine and fentanyl added to bupivacaine after cesarean section. Methods. Ninety patients scheduled for cesarean section under spinal anesthesia were randomly allocated to one of the three following groups to receive bupivacaine 10 mg combined with 75 µg clonidine (group C), bupivacaine 10 mg combined with 0.5 mL fentanyl (group F), and bupivacaine 10 mg combined with 0.5 mL distilled water (group P), intrathecally. The time to first analgesic request, analgesic requirement in the first 24 hours after surgery, sensory and motor blockade onset time, duration of sensory and motor blockade, the incidence of hypotension, ephedrine requirements, bradycardia, and hypoxemia were recorded. Results. The duration of anesthesia in clonidine group () was longer compared to the placebo () and fentanyl () groups. This difference between group C versus F () and P groups () was significant. Similarly, the mean time to first analgesic request was also longer in group C () than in groups F () and P ( min). This difference between group C versus F () and P groups () was significant. Conclusion. Intrathecal clonidine 75 µg with bupivacaine prolonged the time to first analgesic request compared to fentanyl; however, the total analgesic consumption within the first 24 h postoperative was similar in fentanyl and clonidine groups following cesarean section. This trial is registered with ACTRN12611000909921 and NCT01425658. Marzieh Beigom Khezri, Meisam Rezaei, Morteza Delkhosh Reihany, and Ezzatalsadat Haji Seid Javadi Copyright © 2014 Marzieh Beigom Khezri et al. All rights reserved. Pain Symptoms in Fibromyalgia Patients with and without Provoked Vulvodynia Wed, 29 Jan 2014 00:00:00 +0000 Objective. The aim of the study was to compare the pain symptoms of fibromyalgia patients exhibiting (FMS+PVD) and not exhibiting (FMS) comorbidity with provoked vulvodynia. Study Design. The case control study was performed in 39 patients who had been diagnosed with FMS and accepted to undergo gynaecological examination and in 36 healthy women (C). All patients completed standardized questionnaires for pain intensity, pain area, and psychological functioning. The gynaecological examination included vulvar pain pressure reactivity (Q-tip), pelvic tone assessment (Kegel manoeuver), and a semistructured interview collecting detailed information about pelvic symptoms and sexual function. Results. FMS+PVD patients displayed a higher number of associated symptoms than FMS patients. The vulvar excitability was significantly higher in FMS+PVD than in FMS and in both groups than in Controls. Half of FMS+PVD patients were positive to Kegel manoeuver and displayed higher scores in widespread pain intensity, STAI-Y2, and CESD levels than Kegel negative patients. Conclusions. The study reveals that increased vulvar pain excitability may occur in FMS patients independently of the presence of coital pain. Results suggest that coital pain develops in patients with higher FMS symptoms severity due to the cooperative effects of peripheral and central sensitization mechanisms. Anna Ghizzani, Valentina Di Sabatino, Anna Lisa Suman, Giovanni Biasi, Enrica Laura Santarcangelo, and Giancarlo Carli Copyright © 2014 Anna Ghizzani et al. All rights reserved. Can Fluctuations in Vital Signs Be Used for Pain Assessment in Critically Ill Patients with a Traumatic Brain Injury? Wed, 22 Jan 2014 13:51:16 +0000 Background. Many critically ill patients with a traumatic brain injury (TBI) are unable to communicate. While observation of behaviors is recommended for pain assessment in nonverbal populations, they are undetectable in TBI patients who are under the effects of neuroblocking agents. Aim. This study aimed to validate the use of vital signs for pain detection in critically ill TBI patients. Methods. Using a repeated measure within subject design, participants () were observed for 1 minute before (baseline), during, and 15 minutes after two procedures: noninvasive blood pressure: NIBP (nonnociceptive) and turning (nociceptive). At each assessment, vital signs (e.g., systolic, diastolic, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), capillary saturation (SpO2), end-tidal CO2, and intracranial pressure (ICP)) were recorded. Results. Significant fluctuations () in diastolic (), HR (), SpO2 (), and ICP () were found across assessments, but they were similar during both procedures. In contrast, RR was found to increase exclusively during turning (; ) and was correlated to participants’ self-report. Conclusions. Findings from this study support previous ones that vital signs are not specific for pain detection. While RR could be a potential pain indicator in critical care, further research is warranted to support its validity in TBI patients with different LOC. Caroline Arbour, Manon Choinière, Jane Topolovec-Vranic, Carmen G. Loiselle, and Céline Gélinas Copyright © 2014 Caroline Arbour et al. All rights reserved. Perioperative Multimodal Anesthesia Using Regional Techniques in the Aging Surgical Patient Mon, 20 Jan 2014 13:10:59 +0000 Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit. Diana Nordquist and Thomas M. Halaszynski Copyright © 2014 Diana Nordquist and Thomas M. Halaszynski. All rights reserved. Pain Prevalence and Management in an Internal Medicine Setting in Italy Mon, 20 Jan 2014 11:58:51 +0000 Background. Since data on pain evaluation and management in patients admitted to internal medicine wards (IMWs) are limited, we aimed to evaluate these aspects in a cohort of internistic patients. Methods. We considered all patients consecutively admitted from June to December 2011 to our unit. Age, gender, and length-of-hospital-stay (LOS) were recorded. Comorbidities were arbitrarily defined, and pain severity was evaluated by Numeric Rating Scale (NRS) on admission and discharge. Results. The final sample consisted of 526 patients (mean age years; 308 women). Significant pain (NRS ≥ 3) was detected in 63% of cases, and severe (NRS ≥ 7) in 7.6%. Pain was successfully treated, and NRS decreased from 4.65 ± 2.05 to 0.89 ± 1.3 (). Compared with subjects with NRS < 3, those with significant pain were older (75.5 ± 13.9 versus 72.9 ± 14.5 years, ), and had a higher LOS (7.9 ± 6.1 versus 7.3 ± 6.8, ). Significant pain was independently associated with age (OR 0.984, ), cancer (OR 3.347, ), musculoskeletal disease (OR 3.054, ), biliary disease (OR 3.100, ), and bowel disease (OR 3.100, ). Conclusion. In an internal medicine setting, multiple diseases represent significant cause of pain. Prompt pain evaluation and management should be performed as soon as possible, in order to avoid patients’ suffering and reduce the need of hospital stay. Fabio Fabbian, Alfredo De Giorgi, Marco Pala, Alessandra Mallozzi Menegatti, Massimo Gallerani, and Roberto Manfredini Copyright © 2014 Fabio Fabbian et al. All rights reserved. Parental Catastrophizing Partially Mediates the Association between Parent-Reported Child Pain Behavior and Parental Protective Responses Mon, 20 Jan 2014 07:22:37 +0000 This study sought to model and test the role of parental catastrophizing in relationship to parent-reported child pain behavior and parental protective (solicitous) responses to child pain in a sample of children with Inflammatory Bowel Disease and their parents ( dyads). Parents completed measures designed to assess cognitions about and responses to their child’s abdominal pain. They also rated their child’s pain behavior. Mediation analyses were performed using regression-based techniques and bootstrapping. Results supported a model treating parent-reported child pain behavior as the predictor, parental catastrophizing as the mediator, and parental protective responses as the outcome. Parent-reported child pain behavior predicted parental protective responses and this association was mediated by parental catastrophizing about child pain: indirect effect (SE) = 2.08 (0.56); 95% CI = 1.09, 3.30. The proportion of the total effect mediated was 68%. Findings suggest that interventions designed to modify maladaptive parental responses to children’s pain behaviors should assess, as well as target, parental catastrophizing cognitions about their child’s pain. Shelby L. Langer, Joan M. Romano, Lloyd Mancl, and Rona L. Levy Copyright © 2014 Shelby L. Langer et al. All rights reserved. The Pain Frequency-Severity-Duration Scale as a Measure of Pain: Preliminary Validation in a Pediatric Chronic Pain Sample Mon, 20 Jan 2014 07:21:44 +0000 Typically, pain is measured by intensity and sensory characteristics. Although intensity is one of the most common dimensions of pain assessment, it has been suggested that measuring pain intensity in isolation is only capturing part of the pain experience and may not lead to an accurate measurement of how pain impacts a child’s daily functioning. The current study aimed to develop a measure that would capture pain intensity along with frequency and duration in a clinical sample of youth diagnosed with chronic pain. The pain-frequency-severity-duration (PFSD) scale was developed and data were collected from a multidisciplinary pain clinic at a large, midwestern children’s hospital. Validated measures of functional limitations and health related quality of life were also collected. Significant correlations were found between the PFSD composite score, functional limitations, and health related quality of life. Future research should continue to evaluate this questionnaire utilizing other validated pain measures and other areas potentially impacted by chronic pain and with more diverse samples. This initial finding suggests that the PFSD is a convenient self-reported measure and is strongly related to health related quality of life and functional disability. Katherine S. Salamon, W. Hobart Davies, Melissa R. Fuentes, Steven J. Weisman, and Keri R. Hainsworth Copyright © 2014 Katherine S. Salamon et al. All rights reserved. Effect of Platelet-Rich Plasma (PRP) versus Autologous Whole Blood on Pain and Function Improvement in Tennis Elbow: A Randomized Clinical Trial Mon, 20 Jan 2014 06:33:02 +0000 Background. Autologous whole blood and platelet-rich plasma (PRP) have been both suggested to treat chronic tennis elbow. The aim of the present study was to compare the effects of PRP versus autologous whole blood local injection in chronic tennis elbow. Methods. Forty patients with tennis elbow were randomly divided into 2 groups. Group 1 was treated with a single injection of 2 mL of autologous PRP and group 2 with 2 mL of autologous blood. Tennis elbow strap, stretching, and strengthening exercises were administered for both groups during a 2-month followup. Pain and functional improvements were assessed using visual analog scale (VAS), modified Mayo Clinic performance index for the elbow, and pressure pain threshold (PPT) at 0, 4, and 8 weeks. Results. All pain and functional variables including VAS, PPT, and Mayo scores improved significantly in both groups 4 weeks after injection. No statistically significant difference was noted between groups regarding pain scores in 4-week follow-up examination (). At 8-week reevaluations, VAS and Mayo scores improved only in PRP group (). Conclusion. PRP and autologous whole blood injections are both effective to treat chronic lateral epicondylitis. PRP might be slightly superior in 8-week followup. However, further studies are suggested to get definite conclusion. Seyed Ahmad Raeissadat, Leyla Sedighipour, Seyed Mansoor Rayegani, Mohammad Hasan Bahrami, Masume Bayat, and Rosa Rahimi Copyright © 2014 Seyed Ahmad Raeissadat et al. All rights reserved. Fear of Severe Pain Mediates Sex Differences in Pain Sensitivity Responses to Thermal Stimuli Sun, 05 Jan 2014 10:55:21 +0000 The purpose of this paper was to examine the relationship of sex and pain-related fear in pain intensity reports to thermal stimuli and whether sex differences in reported pain intensity were mediated by pain-related fear. 177 participants, 124 female (23.5 ± 4.5 years old), filled out a demographic and fear of pain questionnaire (FPQ-III). Experimental pain testing was performed using thermal stimuli applied to the lower extremity. Participants rated the intensity of pain using the numerical pain rating scale (NPRS). Independent t-tests, Sobel’s test, and linear regression models were performed to examine the relationships between sex, fear of pain, and pain sensitivity. We found significant sex differences for thermal pain threshold temperatures () and suprathreshold pain ratings for 49°C () and 51°C (). FPQ-severe score mediated the effect of suprathreshold pain ratings of 49° (), 51° (), and pain threshold temperatures (). There are differences in the pain sensitivity between sexes, but this difference may be mediated by baseline psychosocial factors such as fear of pain. Maggie E. Horn, Meryl J. Alappattu, Charles W. Gay, and Mark Bishop Copyright © 2014 Maggie E. Horn et al. All rights reserved. Comparison of Postoperative Analgesic Effect of Dexamethasone and Fentanyl Added to Lidocaine through Axillary Block in Forearm Fracture Sun, 29 Dec 2013 19:28:18 +0000 Aim. Regional analgesia has been introduced as better analgesic technique compared to using systemic analgesic agents, and it may decrease the adverse effects of them and increase the degree of satisfaction. Several additives have been suggested to enhance analgesic effect of local anesthetic agents such as opioids and steroids. We designed this randomized double-blind controlled study to compare the analgesic efficacy of the dexamethasone and fentanyl added to lidocaine using axillary block in patients undergoing operation of forearm fracture. Materials and Methods. Seventy-eight patients 20–60 years old were recruited in a prospective, double-blinded, randomized way. Axillary block was performed in the three groups by using 40 mL lidocaine and 2 mL distilled water (L group), 40 mL lidocaine and 2 mL dexamethasone (LD group), and 40 mL lidocaine and 2 mL fentanyl (LF group). The onset time of sensory and motor block, duration of sensory and motor block, the total analgesic dose administered during 6 hours after the surgery, and hemodynamic variables were recorded. Results. The duration of sensory and motor block was significantly longer in LD group compared to other groups (). Similarly, the total analgesic consumption in LD group was smaller compared to other groups (). Comparison of hemodynamic consequences of axillary block and surgery failed to reveal any statistically significant differences between all groups. Conclusion. Addition of dexamethasone to lidocaine significantly prolonged the duration of analgesia compared with fentanyl/lidocaine mixture or lidocaine alone using axillary block in patients undergoing forearm fracture surgery. This trial is registered with IRCT2012120711687N1. Siamak Yaghoobi, Mahyar Seddighi, Zohreh Yazdi, Razieh Ghafouri, and Marzieh Beigom Khezri Copyright © 2013 Siamak Yaghoobi et al. All rights reserved. Phenotyping Chronic Pelvic Pain Based on Latent Class Modeling of Physical Examination Sun, 22 Dec 2013 10:04:47 +0000 Introduction. Defining clinical phenotypes based on physical examination is required for clarifying heterogeneous disorders such as chronic pelvic pain (CPP). The objective of this study was to determine the number of classes within 4 examinable regions and then establish threshold and optimal exam criteria for the classes discovered. Methods. A total of 476 patients meeting the criteria for CPP were examined using pain pressure threshold (PPT) algometry and standardized numeric scale (NRS) pain ratings at 30 distinct sites over 4 pelvic regions. Exploratory factor analysis, latent profile analysis, and ROC curves were then used to identify classes, optimal examination points, and threshold scores. Results. Latent profile analysis produced two classes for each region: high and low pain groups. The optimal examination sites (and high pain minimum thresholds) were for the abdominal wall region: the pair at the midabdomen (PPT threshold depression of > 2); vulvar vestibule region: 10:00 position (NRS > 2); pelvic floor region: puborectalis (combined NRS > 6); vaginal apex region: uterosacral ligaments (combined NRS > 8). Conclusion. Physical examination scores of patients with CPP are best categorized into two classes: high pain and low pain. Standardization of the physical examination in CPP provides both researchers and general gynecologists with a validated technique. B. W. Fenton, S. F. Grey, M. Reichenbach, M. McCarroll, and V. Von Gruenigen Copyright © 2013 B. W. Fenton et al. All rights reserved. The Effect of Platelet-Rich Plasma on Pain, Function, and Quality of Life of Patients with Knee Osteoarthritis Mon, 09 Dec 2013 16:23:01 +0000 Background. New studies in the management of knee osteoarthritis have focused on modern therapeutic methods stimulating cartilage healing process. In the present study, we evaluated the effects of 2 courses of leucocyte-rich PRP (LR-PRP) injections on patients’ QOL and functions and also the relationship between the PRP concentration and mentioned variables. Material and Methods. Sixty-five patients were evaluated. For each participant, WOMAC and the native (Farsi) edition of the SF-36 questionnaire were filled. Two courses of LR-PRP injections with 4-week interval were used. After 6 months, SF-36 and WOMAC questionnaires were filled again for each patient. Results. 60 patients were included in the final analysis. The mean platelet concentrations and white blood cell in PRP was 5-fold increase and 220 per microliter, respectively. The mean total WOMAC revealed significant change (). In SF-36, the mean changes of 2 major physical and mental domains were meaningful (). Discussion. In our study, 2 injections of PRP, with 4-week interval, improved the pain, stiffness, and functional capacity. Improvements in QOL (both PCS and MCS) were meaningful after injections. These changes were more significant in physical domains. PRP injection may be an alternative therapy in selective patients resistant to current nonsurgical treatments of knee osteoarthritis. Seyed Ahmad Raeissadat, Seyed Mansoor Rayegani, Marzieh Babaee, and Elham Ghorbani Copyright © 2013 Seyed Ahmad Raeissadat et al. All rights reserved. Hair-Normalized Cortisol Waking Response as a Novel Biomarker of Hypothalamic-Pituitary-Adrenal Axis Activity following Acute Trauma: A Proof-of-Concept Study with Pilot Results Tue, 03 Dec 2013 17:50:19 +0000 The mechanisms underlying the development of persistent posttraumatic pain and disability remain elusive. Recent evidence suggests that disordered stress-system pathway (hypothalamic-pituitary-adrenal axis) activity may be responsible for the genesis and maintenance of long-term sensory and emotional problems. However, confidence in current evidence is limited by the necessarily retrospective collection of data. Hair cortisol can serve as a calendar of HPA axis activity going back several months prior to injury. The purposes of this pilot study were to determine the feasibility of using hair cortisol and hair-normalized salivary cortisol as biomarkers of distress following traumatic injuries of whiplash or distal radius fracture. Ten subjects provided complete data within 3 weeks of injury. Hair cortisol, cortisol waking response (CWR), and mean daily cortisol (MDC) were captured at inception, as were self-report indicators of pain, disability, and pain catastrophizing. Pain and disability were also captured 3 months after injury. Results indicate that cortisol waking response may be a useful biomarker of current distress as measured using the pain catastrophizing scale, especially when normalized to 3-month hair cortisol ( raw, 0.93 normalized). Hair-normalized CWR may also have predictive capacity, correlating with 3-month self-reported disability at . While promising, the results must be viewed in light of the small sample. David M. Walton, Joy C. MacDermid, Evan Russell, Gideon Koren, and Stan Van Uum Copyright © 2013 David M. Walton et al. All rights reserved. Painful Diabetic Neuropathy in Japanese Diabetic Patients Is Common but Underrecognized Tue, 26 Nov 2013 14:55:40 +0000 Although chronic pain due to diabetic neuropathy, defined as painful diabetic neuropathy (PDN), is a debilitating and distressing complication of diabetes, epidemiological data on PDN has been scarce, especially in Asia. We evaluated the prevalence of Japanese PDN and its impact on their quality of life (QOL) and metnal state. In addition, we examined to which extent physicians are aware of patients’ PDN. A total of 298 patients with diabetes were found to be eligible for the study. We revealed that substantial percentage (22.1%) of Japanese diabetic patients had PDN and that PDN had negative effect on patients’ QOL and mental state. However, physicians were aware of PDN in only 36.4% of patients with the condition. To the best of our knowledge, this is the first report showing the extent of physicians’ awareness of patients’ PDN. In conclusion, physicians treating diabetes need to be more aware of patients’ PDN in everyday clinical practice to prevent the progression of PDN and improve the patients’ QOL and mental state. Mayumi Tsuji, Tetsuyuki Yasuda, Hideaki Kaneto, Taka-aki Matsuoka, Takahisa Hirose, Ryuzo Kawamori, Masako Iseki, Iichiro Shimomura, and Masahiko Shibata Copyright © 2013 Mayumi Tsuji et al. All rights reserved. Is There a Relation between Tension-Type Headache, Temporomandibular Disorders and Sleep? Wed, 20 Nov 2013 09:52:25 +0000 Introduction. Tension-Type Headache (TTH) is the most prevalent headache often associated with impaired function and quality of life. Temporomandibular Disorders (TMD) and TTH frequently coexist; characterized by pericranial tenderness and impact on daily life. We aim to apply a standardized questionnaire for TMD to characterize and analyse an eventual relation between sleep and oral health in TTH in a controlled design. Material and Methods. 58 consecutive TTH patients and 58 healthy controls were included. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) questionnaire, Oral Health Impact profile (OHIP) and questionnaires for sleep were applied. Results. TTH-patients had significantly higher pain scores (), decreased quality of life (), and higher total sleep scores () compared to controls. Conclusion. For the first time we have identified a clear relation between TTH and TMD symptoms, depression, anxiety, poor sleep, and impairments of oral function in carefully classified patients. These findings indicate a close, but incomplete, overlap between TTH and TMD. Their underlying pathophysiological mechanisms need further research. N. Caspersen, J. R. Hirsvang, L. Kroell, F. Jadidi, L. Baad-Hansen, P. Svensson, and R. Jensen Copyright © 2013 N. Caspersen et al. All rights reserved. The Immediate Effects of Orthoses on Pain in People with Lateral Epicondylalgia Tue, 19 Nov 2013 09:25:36 +0000 Objective. Tennis elbow is a common cause of upper limb dysfunction and a primary reason for pain at the lateral aspect of the elbow. The purpose of this study was to investigate the effects of three commonly used orthoses on pain severity. An elbow band, an elbow sleeve, and a wrist splint were assessed for their ability to reduce the level of reported pain. Method. A crossover randomized controlled trial was used. The orthoses were worn in a randomized order, and all participants were required to complete a control trial for which they wore a placebo orthosis. 52 participants with lateral epicondylalgia were recruited, and the level of pain at their elbow was recorded using the visual analogue scale (VAS). Results. The reported pain for all orthoses was lower than that of the placebo (). Pain reduction was significantly greater with a counterforce elbow band or a counterforce elbow sleeve compared to a wrist splint (). There was no significant difference between a counterforce elbow band and a counterforce elbow sleeve (). Conclusion. All the types of orthoses studied showed an immediate improvement on pain severity in people with lateral epicondylalgia. The counterforce elbow orthoses (elbow band and elbow sleeve) presented the greatest improvement, suggesting that either of them can be used as a first treatment choice to alleviate the pain in people with tennis elbow. Ebrahim Sadeghi-Demneh and Fahimehsadat Jafarian Copyright © 2013 Ebrahim Sadeghi-Demneh and Fahimehsadat Jafarian. All rights reserved. Intravenous Paracetamol Reduces Postoperative Opioid Consumption after Orthopedic Surgery: A Systematic Review of Clinical Trials Wed, 06 Nov 2013 09:01:38 +0000 Postoperative pain management is one of the most challenging jobs in orthopedic surgical population as it comprises of patients from extremes of ages and with multiple comorbidities. Though effective, opioids may contribute to serious adverse effects particularly in old age patients. Intravenous paracetamol is widely used in the postoperative period with the hope that it may reduce opioid consumption and produce better pain relief. A brief review of human clinical trials where intravenous paracetamol was compared with placebo or no treatment in postoperative period in orthopedic surgical population has been done here. We found that four clinical trials reported that there is a significant reduction in postoperative opioid consumption. When patients received an IV injection of 2 g propacetamol, reduction of morphine consumption up to 46% has been reported. However, one study did not find any reduction of opioid requirement after spinal surgery in children and adolescent. Four clinical trials reported better pain scores when paracetamol has been used, but other three trials denied. We conclude that postoperative intravenous paracetamol is a safe and effective adjunct to opioid after orthopedic surgery, but at present there is no data to decide whether paracetamol reduces opioid related adverse effects or not. Bright Jebaraj, Souvik Maitra, Dalim Kumar Baidya, and Puneet Khanna Copyright © 2013 Bright Jebaraj et al. All rights reserved. Plasma Amino Acids Changes in Complex Regional Pain Syndrome Mon, 04 Nov 2013 15:06:55 +0000 Complex regional pain syndrome (CRPS) is a severe chronic pain condition that most often develops following trauma. Blood samples were collected from 220 individuals, 160 CRPS subjects, and 60 healthy pain-free controls. Plasma amino acid levels were compared and contrasted between groups. L-Aspartate, L-glutamate, and L-ornithine were significantly increased, whereas L-tryptophan and L-arginine were significantly decreased in CRPS subjects as compared to controls. In addition, the L-kynurenine to L-tryptophan ratio demonstrated a significant increase, whereas the global arginine bioavailability ratio (GABR) was significantly decreased in the CRPS subjects. The CRPS subjects demonstrated a significant correlation between overall pain and the plasma levels of L-glutamate and the L-kynurenine to L-tryptophan ratio. CRPS subjects also showed a correlation between the decrease in plasma L-tryptophan and disease duration. This study shows that CRPS subjects exhibit significant changes in plasma levels of amino acids involved in glutamate receptor activation and in amino acids associated with immune function as compared to healthy pain-free controls. A better understanding of the role plasma amino acids play in the pathophysiology of CRPS may lead to novel treatments for this crippling condition. Guillermo M. Alexander, Erin Reichenberger, B. Lee Peterlin, Marielle J. Perreault, John R. Grothusen, and Robert J. Schwartzman Copyright © 2013 Guillermo M. Alexander et al. All rights reserved. Validation and Clinical Application of a Biopsychosocial Model of Pain Intensity and Functional Disability in Patients with a Pediatric Chronic Pain Condition Referred to a Subspecialty Clinic Tue, 22 Oct 2013 09:48:54 +0000 Background. Pediatric chronic pain is considered to be a multidimensional construct that includes biological, psychological, and social components. Methods. The 99 enrolled study patients (mean age 13.2 years, 71% female, 81% Caucasian) and an accompanying parent completed a series of health-related questionnaires at the time of their initial appointment in a pediatric chronic pain medicine clinic. Results. Significant correlations (, ) were observed between pediatric chronic pain intensity and patient anxiety, patient depression, patient pain coping, parent chronic pain intensity, and parent functional disability. Pediatric chronic pain intensity was significantly associated with patient anxiety (). Significant correlations (, ) were observed between pediatric functional disability and patient chronic pain intensity, patient anxiety, patient depression, patient pain coping, parent chronic pain intensity, parent functional disability, parent anxiety, parent depression, and parent stress. Pediatric functional disability was significantly associated with patient chronic pain intensity (), patient anxiety (), patient pain coping (), and parent functional disability (). Conclusions. These findings provide empirical support of a multidimensional Biobehavioral Model of Pediatric Pain. However, the practical clinical application of the present findings and much of the similar previously published data may be tenuous. Thomas R. Vetter, Gerald McGwin Jr., Cynthia L. Bridgewater, Avi Madan-Swain, and Lee I. Ascherman Copyright © 2013 Thomas R. Vetter et al. All rights reserved. Effects of Mild and Severe Knee Joint Pain on Various Activities of Daily Living in the Female Elderly Wed, 02 Oct 2013 10:32:59 +0000 This study aimed to examine the differences in the ability to perform various activities of daily living (ADLs) among groups with various knee problems. The participants consisted of 328 elderly females (age 60–94; mean age 76.1 years; standard deviation 6.2). The subjects were classified into three groups: those without knee pain, those with mild knee pain, and those with severe knee pain. ADLs with markedly higher (>97%) and lower (<38%) achievement rates in the group without knee pain were not significantly different among the three groups. Achievement rates of 40%–97% for ADLs were significantly lower in the group with severe knee pain than in the group without knee pain. In addition, the groups with mild and severe knee pain demonstrated significantly lower achievement rates of ascending and descending stairs and sitting up than the group without knee pain. In conclusion, regardless of the presence of absence of mild or severe knee pain, some ADLs are difficult to achieve, while others are easy. The elderly with severe knee pain find it difficult to achieve many ADLs. In addition, it is difficult for the elderly with mild and severe knee pain to ascend and descend stairs and to sit up. Hiroki Sugiura and Shinichi Demura Copyright © 2013 Hiroki Sugiura and Shinichi Demura. All rights reserved. Role of Botulinum Toxin Type-A (BTX-A) in the Management of Trigeminal Neuralgia Tue, 01 Oct 2013 09:38:40 +0000 Trigeminal neuralgia (TN) is a clinical condition characterized by paroxysmal attacks of severe and electric shock-like pain along the distribution of one or more branches of the trigeminal nerve. Various medicinal or surgical modalities have been employed in the past with variable success. Newer methods were tried in search of permanent cure or long-lasting pain relief. The purpose of this paper is to present the review of the literature regarding the use of botulinum toxin type-A (BTX-A) in the management of trigeminal neuralgia. Gaurav Verma Copyright © 2013 Gaurav Verma. All rights reserved. Randomized Controlled Trial of Etodolac versus Combination of Etodolac and Eperisone in Patients of Knee Osteoarthritis Mon, 30 Sep 2013 10:01:22 +0000 Objective. To compare the efficacy and tolerability of etodolac versus etodolac in combination with eperisone in patients of Osteoarthritis knee. Patients and Methods. A prospective, randomized, open label, parallel group, comparative study was conducted in 60 patients of knee OA over a period of 2 months. Thirty patients received etodolac 600 mg once daily and 30 patients received eperisone 50 mg thrice daily in addition to etodolac 600 mg once daily for 8 weeks. Efficacy assessment was done on the basis of improvement in mean scores of spontaneous pain on Visual analog scale (VAS), pain on movement, functional capacity, joint tenderness, swelling, erythema on Likert scale, and patient's overall arthritic condition on a five-point investigator scale at the end of study period as compared with the baseline scores. Assessment of tolerability was done by recording the occurrence of adverse events. Data was analyzed using Chi square test and students t-test. Results. All the enrolled patients completed the study and were compliant to the treatment regimens that they were allocated to. Both the treatment groups showed a statistically significant improvement in all the efficacy parameters at the end of 8 weeks as compared to baseline () with no statistically significant difference between the groups. Adverse events were few and mild in nature. Conclusion. Combination of etodolac and eperisone is as effective as etodolac alone in patients of OA knee. Thus, it is concluded that additional use of muscle relaxant has no adjuvant value in patients of OA knee and is not recommended. The study is registered with the Clinical Trial Registry of India vide registration number CTRI/2013/03/003442. Navjot Kaur, Harinder Singh, and Avinash Chander Gupta Copyright © 2013 Navjot Kaur et al. All rights reserved. Opioid Therapy Pharmacogenomics for Noncancer Pain: Efficacy, Adverse Events, and Costs Wed, 18 Sep 2013 16:29:39 +0000 Chronic non-cancer pain is a debilitating condition associated with high individual and societal costs. While opioid treatment for pain has been available for centuries, it is associated with high variability in outcome, and a considerable proportion of patients is unable to attain relief from symptoms while suffering adverse events and developing medication dependence. We performed a review of the efficacy of pharmacogenomic markers and their abilities to predict adverse events, dependence, and associated economic costs, focusing on two genes: OPRM1 and CYP2D6. Data sources were articles indexed by PubMed on or before August 6, 2013. Articles were first selected after review of their titles and abstracts, and full papers were read to confirm eligibility. Initially, fifty-two articles were identified. Of these, 17 were relevant to biological actions of pharmacogenomic markers and their effect on therapeutic efficacy, 16 to adverse events, 15 to opioid dependence, and eight to economic costs. In conclusion, increasing costs of opioid therapy have made the advances in pharmacogenomics an attractive solution to personalize care with unclear repercussions related to the impact on costs, morbidity, and outcomes. This intersection of pharmacoeconomics and pharmacogenomics presents a unique platform to further examine current advances in clinical medicine and their utility in cost-effective treatment of chronic pain. Yan Xu and Ana Johnson Copyright © 2013 Yan Xu and Ana Johnson. All rights reserved.