Gender, age and ethnicity influence on pain levels and analgesic use in the acute whiplash injury

Gender-based differences in assessment and management of acute abdominal pain in the emergency department: A retrospective audit

BACKGROUND

Previous research has identified gender-based differences in acute pain management in the emergency department [ED]. The aim of this study was to compare pharmacological management of acute abdominal pain in the ED by gender.

METHODS

A retrospective chart audit was conducted at one private metropolitan ED including adult patients (18-80 years) who presented with acute abdominal pain in 2019. Exclusion criteria included: pregnancy, repeat presentation within the study period, pain-free at initial medical review or documented refusal of analgesia, and oligo-analgesia. Comparisons by gender included: (1) analgesia type and (2) time to analgesia. Bivariate analysis was undertaken using SPSS.

RESULTS

There were 192 participants: 61 (31.6 %) men and 131 (67.9 %) women. Men were more likely to get combined opioid and non-opioid medication as first line analgesia (men: 26.2 % n = 16; women: 14.5 % n = 19, p = .049). Median time from ED presentation to analgesia was 80 min for men (IQR: 60) versus 94 min for women (IQR: 58), (p = .119). Women (25.2 % n = 33) were more likely to receive their first analgesic after 90 min from ED presentation compared to men versus men (11.5 %, n = 7 p = .029). In addition, women waited longer before receiving second analgesia (women: 94, men: 30 min, p = .032).

CONCLUSION

Findings confirm there are differences in pharmacological management of acute abdominal pain in the ED. Larger studies are required to further explore differences observed in this study.

Nurses' Knowledge, Attitudes, and Barriers Toward Pain Assessment and Management in Assir Region, Saudi Arabia

Purpose:This study aims to assess nurses' knowledge and attitude towards pain assessment and management as an essential component of holistic nursing and patient care. Study Design: A cross-sectional descriptive design. Methods: A convenient sample of 282 nurses working in four health care institutions in the South region of Saudi Arabia was enrolled. The Knowledge and Attitudes Survey Regarding Pain tool was used to collect data from April-July 2021 through a web-based survey. Findings: The knowledge level and attitude of the nurses toward pain assessment and management was inadequate. The participants' correct mean score was (2.98). Forty percent achieved a passing score of 70%. Female nurses, postgraduate, working in medical-surgical units, had 5 to 10 years of work experience had higher knowledge and attitude levels. The barriers were categorized as patients, nurses, physicians, and system-related barriers. The most perceived barriers were nurses' shortage (76.2%); restricted opioids regulations (66.7%); and unavailable comfort measures as alternatives (59.9%). Conclusions: Inadequate nurses' knowledge and negative attitudes toward pain assessment and management is an alarming global concern. Healthcare administrators have to improve nurses' competencies through continuous education and training programs, adopt updated guidelines and eliminate barriers to achieve holistic patients' care including optimal pain control.

Sexual dimorphism of the posterior cervical spine muscle attachments

Cervical spinal injury and neck pain are common disorders with wide physical implications. Neck pain and disability are reported to occur in females more often than in males, and chronic or persistent neck pain after whiplash is twice as common in females. Female athletes also sustain a higher percentage of concussions compared to male athletes. Still, while sexual differences in clinical presentation and outcome are well-established, the underlying etiology for the disparity remains less clear. It is well-established that the origin and insertion landmarks of posterior neck muscles are highly variable, but we do not know if these interindividual differences are associated with sex. Expanding our knowledge on sexual dimorphism in the anatomy of the cervical muscles is essential to our understanding of the possible biomechanical differences between the sexes and hence improves our understanding as to why females suffer from cervical pain more than males. It is also of paramount importance for accurate planning of posterior cervical spine surgery, which cuts through the posterior cervical musculature. Therefore, our main objective is to characterize the anatomy of posterior neck musculature and to explore possible sexual differences in the location of their attachment points. Meticulous posterior neck dissection was performed on 35 cadavers, 19 females, and 16 males. In each specimen, 8 muscle groups were examined bilaterally at 45 osseous anatomical landmarks. Muscles and their attachment sites were evaluated manually then photographed and recorded using Microscribe Digitizer technology built into 3D models. A comparison of attachment landmarks between males and females for each muscle was conducted. Out of the eight muscles that were measured, only two muscles demonstrated significant sex-related anatomical differences-Spinotranversales (splenius capitis and cervicis) and Multifidus. Male Spinotransversales muscle has more attachment points than female. It showed more cranial insertion points in the upper cervical attachments (superior nuchal line, C1 posterior tubercle, and mastoid process) and more caudal insertion points in the spinous processes and transverse processes of the lower cervical and upper thoracic vertebrae. Thus, the male subjects in this study exhibited a greater coverage of the posterior neck both cranially and caudally. Female Multifidus has more attachment points on the spinous processes and articular processes at middle and lower cervical vertebrae and at the transverse processes of the upper thoracic vertebrae. All remaining muscles exhibited no sexual differences. Our findings highlight, for the first time, a sexual dimorphism in attachment points of posterior cervical musculature. It reinforces the notion that the female neck is not a scaled version of the male neck. These differences in muscle attachment could partially explain differences in muscle torque production and range of motion and thus biomechanical differences in cervical spine stabilization between sexes. It sheds a much-needed light on the reason for higher whiplash rates, concussion, and chronic cervical pain among females. Surgeons should take these sexual morphological differences into consideration when deliberating the best surgical approach for posterior cervical surgery.

Can measuring passive neck muscle stiffness in whiplash injury patients help detect false whiplash claims?

BACKGROUND

Whiplash injury of the cervical spine is the most common injury after a car accident and in 25% of patients it progresses into chronic neck pain.

AIM OF THE STUDY

To investigate the difference in neck muscle stiffness using shear wave ultrasound elastography between subjects who suffered an uncomplicated whiplash injury and a control group. Possible recognition of patients who insist on physical therapy in order to support their false whiplash injury claims.

METHODS

This study included 75 whiplash injury patients and 75 control subjects. Trapezius, splenius capitis and sternocleidomastoid muscles were examined by ultrasound shear wave elastography.

RESULTS

Increased muscle stiffness was noticed in trapezius muscle bilaterally in the whiplash group when compared to the control group (p < 0.001; right 57.47 ± 13.82 kPa vs. 87.84 ± 23.23 kPa; left 54.4 ± 12.68 kPa vs. 87.21 ± 26.47 kPa). Muscle stiffness in splenius capitis and sternocleidomastoid muscles was not suitable for analysis because of asymmetrical data distribution. Patients with less than 76 kPa of muscle stiffness in trapezius muscle are unlikely to belong in whiplash injury group (sensitivity 90% for right and 97% for left trapezius muscle, specificity 72% and 73%, respectively).

CONCLUSION

Patients measuring below 76 kPa of muscle stiffness in the trapezius muscle might have no whiplash injury. Further follow-up of the patients measuring higher than cut-off value might be beneficial for detecting patients with prolonged neck muscle spasm that can lead to chronic cervical pain syndrome.

Recovery despite everyday pain: Women's experiences of living with whiplash-associated disorder

INTRODUCTION

Living with whiplash-associated disorders (WAD) means living every day under the influence of pain and limitations. As the incidence of WAD and the related intensity of pain are somewhat higher among women than men, the aim of the present study was to describe women's experiences of living with WAD.

METHODS

A purposive sample of seven women participated in individual in-depth qualitative interviews, the transcripts of which were subjected to qualitative content analysis.

RESULTS

The results of the analysis suggested six themes of women's experiences with WAD: living with unpredictable pain; trying to manage the pain; living with limitations; being unable to work as before; needing support and understanding; and learning to live with limitations. The findings showed that unpredictable pain limited women's strength to engage in activities of daily life and be as active as before. Support and understanding were important for their ability to manage changes in their daily lives.

CONCLUSIONS

Pain considerably affects the daily lives of women with WAD, particularly by limiting their ability to perform activities and to enjoy their professional and social lives. As women with WAD need support with managing their daily lives, nurses and other healthcare personnel should adopt a person-centred approach, in order to support such women according to their individual needs and circumstances.

Sex-related differences in symptoms of temporomandibular disorders and structural changes in the lateral pterygoid muscle after whiplash injury

Whiplash injury is an initiating or aggravating factor of temporomandibular disorder (TMD). Although there are sex-related differences in the mechanism of pain perception and pain control, there is a lack of research on differences in TMD after whiplash injury. We aimed to evaluate sex-related differences in the clinical symptoms and magnetic resonance imaging (MRI) findings of patients with TMD attributed to whiplash injury. This retrospective, cross-sectional study included 100 patients (50 women; 50 men; mean age, 37.60 years) who visited our oro-facial pain clinic with symptoms of TMD after whiplash injury. All patients underwent detailed evaluations for history of trauma, and their clinical and MRI findings were comprehensively assessed. Women with TMD after whiplash injury perceived more pain and presented more tenderness upon palpation than did men with TMD. In addition, women showed higher volume (58% vs 26%) and signal changes (54% vs 20%) in the lateral pterygoid muscle (LPM) and more anterior disc displacement without reduction (ADDWoR) (40% vs 20%) than did men. The presence of ADDWoR (odds ratio, 10.58; P = 0.007) and condylar degeneration (odds ratio, 9.30; P = 0.015) predicted LPM volume; stressful conditions (beta = 1.34; P = 0.011) correlated with increased visual analogue scale scores, and sleep problem was associated with an increased palpation index (PI) (beta = 0.42; P < 0.001) and neck PI (beta = 0.49; P < 0.001) scores only in women. Our results showed sex-specific differences in pain intensity, distribution of clinical and abnormal MRI findings, and their relationships, and these differences should be considered when treating patients with TMD.

Nurses' Knowledge, Attitudes, and Barriers Toward Pain Management Among Postoperative Patients in Jordan

PURPOSE

The purpose of this study was to measure nurses' knowledge, attitudes, and barriers regarding pain management (PM) of postoperative patients in Jordan.

DESIGN

A descriptive survey research design was used.

METHODS

This descriptive study adopted a modified version of the "Knowledge and Attitudes Survey Regarding Pain" tool, administered to 120 nurses working in surgical wards.

FINDINGS

Nurses had inadequate knowledge of PM, with a mean knowledge score of 63.9%. Knowledge of PM and attitudes toward PM were associated positively with the age of the participant (P = .001), years of experience in the surgical area (P = .026), and academic degree of participants (P = .026).

CONCLUSIONS

Surgical nurses in this study had low knowledge levels and poor attitudes regarding PM in postoperative patients. Unless identified barriers to PM are seriously addressed, this vital aspect of holistic care will continue to be marginalized.

Factors associated with high pain intensity during wound care procedures: A model

The most common wound care procedures (WPCs) performed on open wounds are dressing changes and wound cleansing. Dressing changes cause moderate to severe pain in 74% of patients, nearly half (36%) of whom experience severe pain (rated as 8-10 on a 10-point numeric rating scale). The purpose of this paper is to propose a model of clinically accessible factors that can be tested in order to develop a clinical tool to identify which patients are likely to experience high intensity pain during nonoperative WCPs, such as dressing changes. Although multiple factors are known to be associated with pain, the factors selected for this model were limited to those that (1) are supported based on evidence and/or pain mechanisms and (2) are readily accessible to clinicians/practitioners and can be tested as a prediction tool to be used prior to WCPs. This model may be helpful to identify those likely to experience high intensity pain during WCPs. In this way, use of aggressive pain management strategies, including specialty dressings, pharmacologic analgesics, and/or non-pharmacological strategies, such as high intensity transcutaneous electrical stimulation.

Suprascapular Nerve Block Versus Interscalene Block as Analgesia After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Noninferiority Trial

PURPOSE

To compare the efficacy of suprascapular nerve block (SSB) and interscalene block (ISB) as postoperative analgesia within the first 24 hours after arthroscopic supraspinatus and/or infraspinatus tendon repair.

METHODS

A single-blind, randomized controlled study was performed between 2013 and 2014. The inclusion criteria were arthroscopic supraspinatus and/or infraspinatus tendon repair confirmed intraoperatively, with or without associated procedures, and informed consent. The exclusion criteria were a previously operated shoulder, repair of the subscapularis tendon, and an allergy to local anesthetics. ISB was performed under ultrasound guidance by an anesthesiologist, whereas SSB was performed based on specific anatomic landmarks by a surgeon. The primary evaluation criterion was mean shoulder pain score during the first postoperative 24 hours assessed on a visual analog scale by the patient. The secondary criteria were complications of locoregional anesthesia, the use of analgesics in the recovery room (the first 2 hours) until postoperative day 7, and pain (visual analog scale) during the first week. Forty-four patients were needed for this noninferiority study. An institutional review board approved the study.

RESULTS

Seventy-four patients were randomized, and 59 met the intraoperative inclusion criteria. Six patients were excluded (1 for pneumothorax after ISB, 1 for unsuccessful SSB, and 4 for incomplete questionnaires). None of the patients were lost to follow-up. There was no significant difference between the SSB and ISB groups in mean pain score for the first 24 hours (P = .92) or the first 7 days (P = .05). However, there was significantly less pain in the ISB group in the recovery room (P = .01). Consumption of analgesics was comparable between the groups, but the SSB group took significantly more morphine in the recovery room.

CONCLUSIONS

In this prospective, randomized controlled study, SSB was as effective as ISB for mean pain control within the first 24 hours but ISB was more effective in relieving pain in the recovery room after arthroscopic supraspinatus and/or infraspinatus tendon repair.

LEVEL OF EVIDENCE

Level I, therapeutic, randomized controlled study.

Decrease of morbidity in road traffic accidents in a high income country - an analysis of 24,405 accidents in a 21 year period

BACKGROUND

The WHO initiated the "Decade of Action for Road Safety" because the fatality on road traffic accidents could become the fifth leading cause of death in 2030. On the contrary, fatalities continue to decrease in high income countries. The aim of the study was to find evidence for changes in injury severity of passenger car occupants after road traffic accidents in Germany over time, and to find contributing factors.

METHODS

Data from the German In Depth Accident Study (GIDAS), representative for Germany, was used. A total of 24.405 accidents, reported from 1991 until 2011. 44.503 adult passenger car occupants were examined. A multivariable logistic regression model was developed to find reasons for observed trends over time.

RESULTS

The relative decrease in mortality was 68.8% from 1991 until 2011. Between 2006 and 2011, the percentage of severely injured traffic victims was less than half, both in terms of the whole body and individual body regions. For injuries with an Abbreviated Injury Scale (AIS) ≥ 2, the percentage of persons with lower leg injuries declined by 72.5%, followed by the percentage of persons with pelvic injuries (61.5%), upper extremity injuries (57.7%), head injuries (54.3%), thorax injuries (50.0%), and abdomen injuries (40.0%). The multivariable regression model found 13 independent variables associated with injury prevention (e.g. seat belt use: OR 0.41, CI 95% 0.32-0.49; airbag: OR 0.86, CI 95% 0.75-0.99). The implementation of protective factors increased over time while accident constellations with a high probability for severe injury decreased over time.

CONCLUSION

The decrease of severe injuries after road traffic accidents can be only attributed to a comprehensive approach including the enforcement of road safety policies and innovations in car engineering and emergency medicine. Traffic related measures and alcohol level control, and seat belt usage enforcement next to other technical advances are considered especially important.