The measurement of pain

Corrugator Muscle Activity Associated with Pressure Pain in Adults with Neck/Shoulder Pain

Background and Objectives: No studies have reported corrugator muscle activity associated with pain in people with pain. This study aimed to develop an objective pain assessment method using corrugator muscle activity with pressure pain stimulation to the skeletal muscle. Methods: Participants were 20 adults (a mean ± SD age of 22.0 ± 3.1 years) with chronic neck/shoulder pain. Surface electromyography (sEMG) of corrugator muscle activity at rest (baseline) and without and with pressure pain stimulation applied to the most painful tender point in the shoulder was recorded. Participants evaluated the intensity of the neck/shoulder pain and the sensory and affective components of pain with pressure stimulation using a visual analogue scale (VAS). The percentages of integrated sEMG (% corrugator activity) without and with pressure pain stimulation to the baseline integrated sEMG were compared, and the relationships between the % corrugator activity and the sensory and affective components of pain VAS scores were evaluated. Results: Without pressure stimulation, an increase in corrugator muscle activity due to chronic neck/shoulder pain was not observed. The % corrugator activity with pressure pain stimulation was significantly higher than that without stimulation (p < 0.01). A significant positive correlation between corrugator muscle activity and the affective components of pain VAS scores with pressure stimulation was found (ρ = 0.465, p = 0.039) and a tendency of positive correlation was found for the sensory component of pain VAS scores (ρ = 0.423, p = 0.063). Conclusions: The increase in corrugator muscle activity with pressure pain stimulation to the tender point in adults with chronic neck/shoulder pain was observed, although increased corrugator muscle activity resulting from the chronic neck/shoulder pain was not. These findings suggest that corrugator muscle activity with pressure pain stimulation can be a useful objective indication for tender point sensitivity assessment in the skeletal muscle with pain.

Application of cement-augmented pedicle screws in elderly patients with spinal tuberculosis and severe osteoporosis: a preliminary study

OBJECTIVE

Surgical management of elderly patients with spinal tuberculosis and severe osteoporosis is challenging. Cement-augmented pedicle screws (CAPS) have been specifically designed for elderly patients with osteoporotic spines. Herein, we investigated the feasibility of CAPS applied in elderly patients with spinal tuberculosis and severe osteoporosis.

METHODS

We retrospectively analyzed data of patients with spinal tuberculosis and severe osteoporosis between January 2017 and January 2021. Surgical data, including surgical duration and intraoperative blood loss, were recorded. Radiological parameters, such as correction of regional kyphotic angle and screw loosening, were also evaluated. Additionally, visual analog scores (VAS) and Oswestry disability index (ODI) were used to evaluate back pain and functional recovery, respectively. Erythrocyte sedimentation (ESR) and C-reactive protein (CRP) concentrations were detected to assess tuberculosis activity. The presence of complications and fusion rate was also assessed.

RESULTS

A total of 15 patients were included in this study. The surgical duration was 263.0 ± 56.2 min, with an average blood loss of 378.7 ± 237.0 ml. The correction of regional kyphotic angle was 12.4° ± 15.0°, and it was well maintained until the final follow-up. The mean VAS decreased from 6.0 ± 1.2 points to 0.5 ± 0.6 points, and ODI reduced from 37.8% ± 7.6% to 8.3% ± 2.8% (P < 0.01). At the final follow-up, ESR and CRP levels were within normal range. Bony fusion occurred in all patients, with an average fusion duration of 8.8 ± 1.5 months. No cases of pedicle screw pullout, screw loosening, or pseudoarthrosis occurred. Tuberculosis recurrence and dissemination were not observed during the follow-ups.

CONCLUSIONS

CAPS fixation is an effective and safe technique to achieve solid fixation and favorable clinical outcomes in elderly patients with spinal tuberculosis and severe osteoporosis.

Effect of acupuncture on the modulation of functional brain regions in migraine: A meta-analysis of fMRI studies

Background

Acupuncture, a traditional Chinese medicine therapy, is an effective migraine treatment, especially in improving pain. In recent years, many acupuncture brain imaging studies have found significant changes in brain function following acupuncture treatment of migraine, providing a new perspective to elucidate the mechanism of action of acupuncture.

Objective

To analyse and summarize the effects of acupuncture on the modulation of specific patterns of brain region activity changes in migraine patients, thus providing a mechanism for treating migraine by acupuncture.

Methods

Chinese and English articles published up to May 2022 were searched in three English databases (PubMed, Embase and Cochrane) and four Chinese databases (China national knowledge infrastructure, CNKI; Chinese Biomedical Literature database, CBM; the Chongqing VIP database, VIP; and the Wanfang database, WF). A neuroimaging meta-analysis on ALFF, ReHo was performed on the included studies using Seed-based d Mapping with Permutation of Subject Images (SDM-PSI) software. Subgroup analyses were used to compare differences in brain regions between acupuncture and other groups. Meta-regression was used to explore the effect of demographic information and migraine alterations on brain imaging outcomes. Linear models were drawn using MATLAB 2018a, and visual graphs for quality evaluation were produced using R and RStudio software.

Results

A total of 7 studies comprising 236 patients in the treatment group and 173 in the control group were included in the meta-analysis. The results suggest that acupuncture treatment helps to improve pain symptoms in patients with migraine. The left angular gyrus is hyperactivation, and the left superior frontal gyrus and the right superior frontal gyrus are hypoactivated. The migraine group showed hyperactivation in the corpus callosum compared to healthy controls.

Conclusion

Acupuncture can significantly regulate changes in brain regions in migraine patients. However, due to the experimental design of neuroimaging standards are not uniform, the results also have some bias. Therefore, to better understand the potential mechanism of acupuncture on migraine, a large sample, multicenter controlled trial is needed for further study. In addition, the application of machine learning methods in neuroimaging studies could help predict the efficacy of acupuncture and screen migraine patients suitable for acupuncture treatment.

Combining Electrodermal Activity With the Peak-Pain Time to Quantify Three Temporal Regions of Pain Experience

Background

Self-reported pain levels, while easily measured, are often not reliable for quantifying pain. More objective methods are needed that supplement self-report without adding undue burden or cost to a study. Methods that integrate multiple measures, such as combining self-report with physiology in a structured and specific-to-pain protocol may improve measures.

Method

We propose and study a novel measure that combines the timing of the peak pain measured by an electronic visual-analog-scale (eVAS) with continuously-measured changes in electrodermal activity (EDA), a physiological measure quantifying sympathetic nervous system activity that is easily recorded with a skin-surface sensor. The new pain measure isolates and specifically quantifies three temporal regions of dynamic pain experience: I. Anticipation preceding the onset of a pain stimulus, II. Response rising to the level of peak pain, and III. Recovery from the peak pain level. We evaluate the measure across two pain models (cold pressor, capsaicin), and four types of treatments (none, A=pregabalin, B=oxycodone, C=placebo). Each of 24 patients made four visits within 8 weeks, for 96 visits total: A training visit (TV), followed by three visits double-blind presenting A, B, or C (randomized order). Within each visit, a participant experienced the cold pressor, followed by an hour of rest during which one of the four treatments was provided, followed by a repeat of the cold pressor, followed by capsaicin.

Results

The novel method successfully discriminates the pain reduction effects of the four treatments across both pain models, confirming maximal pain for no-treatment, mild pain reduction for placebo, and the most pain reduction with analgesics. The new measure maintains significant discrimination across the test conditions both within a single-day's visit (for relative pain relief within a visit) and across repeated visits spanning weeks, reducing different-day-physiology affects, and providing better discriminability than using self-reported eVAS.

Conclusion

The new method combines the subjectively-identified time of peak pain with capturing continuous physiological data to quantify the sympathetic nervous system response during a dynamic pain experience. The method accurately discriminates, for both pain models, the reduction of pain with clinically effective analgesics.

Evaluation of Pressure Pain Sensitivity in the Forefoot of Healthy Individuals

BACKGROUND

The evaluation of musculoskeletal pain in podiatric medical practice is mainly based on anamnesis and manual examination. However, when manual palpation is performed, the digital pressure necessary to adequately explore the different structures of the foot is unknown. We evaluated the pressure pain threshold in forefoot structures to determine the intensity and duration of the stimulus as clinically relevant and representative.

METHODS

In a transversal analytical study of 15 healthy individuals, 16 forefoot points were explored with a handheld pressure palpometer calibrated to exert maximum pressing force of 1.0 or 2.0 kilogram-force (kgf) applied during 5 or 10 sec. The combinations of the different pressures and intervals were selected randomly. Participants had to self-rate the pressure pain sensitivity of each stimuli on a 100-mm horizontal line (0-100 numeric rating scale), setting the pain threshold to 50 (100 being pain as bad as it could be). Likewise, aftersensation and referred pain patterns were recorded.

RESULTS

All participants indicated painful stimuli at some of the 16 forefoot points studied in the experimental protocol when pressure was applied with the 2.0-kgf palpometer; 53.3% showed evidence of pain at any forefoot point when the 1.0-kgf palpometer was used. The odds of evoking a painful sensation are 9.8 times higher when using a 2.0-kgf palpometer versus a 1.0-kgf palpometer. In addition, referred sensations were observed with a significantly higher frequency when applying the 2.0-kgf palpometer.

CONCLUSIONS

Bone and soft structures show differences in pressure sensitivity, increasing significantly when applying higher pressure force. Soft structures, specifically intermetatarsal spaces, showed the lowest pain pressure thresholds. More research is needed to better understand pressure pain response.

Assessment and Management of Pain in Patients Sustaining Burns at Emergency Department Kenyatta National Hospital, Kenya: A Descriptive Study

Background: Poorly managed burn pain affects the victim by delayed healing, psychological disturbances, and chronic pain. Burn injuries are the fourth leading cause of injuries worldwide. The incidence of thermal burns in Kenya is 3%. Pain assessment and control are integral parts of management that a burn victim should be offered. We lack data on pain management in burn patients during setup. Methods: A descriptive study was carried out at the emergency department (ED) of Kenyatta National Hospital. We enrolled patients who sustained thermal burns until a sample 138 patients was reached. Enrollment of patients was done from February to August 2015. The pain level was assessed using a visual analogue scale, and the Lund and Browder chart was used to record the depth and extent of the burn. Data on the type of analgesia prescribed and its route of administration was collected. Data was analyzed using STATA v.11. Results: The median age of the sample was 28 years with a male to female ratio 1.8:1. The majority of the victims (38%) sustained flame burns. The median total body surface area was 19.5%. Pain assessment was done in 2% with a visual analogue scale and face pain recognition scale. Mean Visual Analogue score was 7. Analgesia was offered to 96% of participants, and it was unimodal in the majority, 76.7%, and the preferred drug of choice was morphine. The majority of all burn patients had sustained moderate to major burns. The tools used to assess pain in this hospital were Face Pain Recognition Scale and Visual Analogue Scale; however, pain assessment was done on a meagre 2% of the sample. Conclusions: A minority of the patients had any sort of pain assessment done at the emergency department. As a result, burn pain was inappropriately managed. There is a need to improve the assessment of burn pain and improve its management by encouraging training of ED burn care providers by burn surgeons and pain therapists.

Differences in Estimates of Post-Herpetic Neuralgia Between Medical Chart Review and Self-Report

PURPOSE

Post-herpetic neuralgia (PHN) is a common herpes zoster (HZ) complication, where pain persists 90 days after the initial HZ diagnosis. Evaluating PHN risk is essential for determining the burden on patients and health-care systems, but research shows variable estimates. The extent to which these differences are related to the assessment method has not been examined. The purpose of this study is to compare the proportion of PHN among HZ patients measured by medical chart review and self-report surveys.

METHODS

PHN risk was assessed among a sample of Kaiser Permanente Southern California members with HZ. Chart reviews identified lingering pain 90-180 days post-HZ diagnosis and the Zoster Brief Pain Inventory was administered 90 days post-HZ diagnosis by telephone. Frequencies of PHN identified with each approach were cross-tabulated and stratified by sex, age group, and zoster vaccine live vaccination status.

RESULTS

Chart review and self-report were largely concordant (n=875, 89.20%); however, chart review yielded lower PHN risk overall and for the stratified subgroups. PHN from self-report was substantially higher (6.30-8.33%) among patients who were male, ≥70 years, or unvaccinated. Among those who typically seek care more often (female, younger, vaccinated), the discrepancy between each method was notably lower (1.60-2.92%).

CONCLUSION

Our findings suggest that chart review underestimates cases among those less likely to seek health care, including males, the elderly, and unvaccinated individuals. The agreement between the methods indicates that each can provide a reasonable approximation of PHN, but analyses should carefully control for health-care utilization.

Classification of Pain Event Related Potential for Evaluation of Pain Perception Induced by Electrical Stimulation

Variability in individual pain sensitivity is a major problem in pain assessment. There have been studies reported using pain-event related potential (pain-ERP) for evaluating pain perception. However, none of them has achieved high accuracy in estimating multiple pain perception levels. A major reason lies in the lack of investigation of feature extraction. The goal of this study is to assess four different pain perception levels through classification of pain-ERP, elicited by transcutaneous electrical stimulation on healthy subjects. Nonlinear methods: Higuchi's fractal dimension, Grassberger-Procaccia correlation dimension, with auto-correlation, and moving variance functions were introduced into the feature extraction. Fisher score was used to select the most discriminative channels and features. As a result, the correlation dimension with a moving variance without channel selection achieved the best accuracies of 100% for both the two-level and the three-level classification but degraded to 75% for the four-level classification. The best combined feature group is the variance-based one, which achieved accuracy of 87.5% and 100% for the four-level and three-level classification, respectively. Moreover, the features extracted from less than 20 trials could not achieve sensible accuracy, which makes it difficult for an instantaneous pain perception levels evaluation. These results show strong evidence on the possibility of objective pain assessment using nonlinear feature-based classification of pain-ERP.

Loxapine for Treatment of Patients With Refractory, Chemotherapy-Induced Neuropathic Pain: A Prematurely Terminated Pilot Study Showing Efficacy But Limited Tolerability

Neuropathic pain is a debilitating and commonly treatment-refractory condition requiring novel therapeutic options. Accumulating preclinical studies indicate that the potassium channel Slack (K_Na1.1) contributes to the processing of neuropathic pain, and that Slack activators, when injected into mice, ameliorate pain-related hypersensitivity. However, whether Slack activation might reduce neuropathic pain in humans remains elusive. Here, we evaluated the tolerability and analgesic efficacy of loxapine, a first-generation antipsychotic drug and Slack activator, in neuropathic pain patients. We aimed to treat 12 patients with chronic chemotherapy-induced, treatment-refractory neuropathic pain (pain severity ≥ 4 units on an 11-point numerical rating scale) in a monocentric, open label, proof-of-principle study. Patients received loxapine orally as add-on analgesic in a dose-escalating manner (four treatment episodes for 14 days, daily dose: 20, 30, 40, or 60 mg loxapine) depending on tolerability and analgesic efficacy. Patient-reported outcomes of pain intensity and/or relief were recorded daily. After enrolling four patients, this study was prematurely terminated due to adverse events typically occurring with first-generation antipsychotic drugs that were reported by all patients. In two patients receiving loxapine for at least two treatment episodes, a clinically relevant analgesic effect was found at a daily dose of 20-30 mg of loxapine. Another two patients tolerated loxapine only for a few days. Together, our data further support the hypothesis that Slack activation might be a novel strategy for neuropathic pain therapy. However, loxapine is no valid treatment option for painful polyneuropathy due to profound dopamine and histamine receptor-related side effects. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02820519.

Efficacy and safety of loxoprofen sodium topical patch for the treatment of pain in patients with minor acute traumatic limb injuries in Brazil: a randomized, double-blind, noninferiority trial

Posttraumatic injury pain is commonly treated with oral nonsteroidal anti-inflammatory drugs. However, oral nonsteroidal anti-inflammatory drugs cause several adverse events, with topical formulations arising as an important alternative. Therefore, we aimed at evaluating the efficacy and safety of loxoprofen patch (LX-P) in the treatment of patients with posttraumatic pain. This phase III, randomized, double-blind, noninferiority study enrolled Brazilian patients aged 18 to 65 years diagnosed with lower and upper limb posttraumatic injury who were experiencing moderate or severe pain. Patients were assigned to active LX-P or to loxoprofen tablet (LX-T), and pain intensity was measured based on a visual analog scale score variation after 7 days of treatment. Data on clinical symptoms, rescue medication use, and adverse events were also collected. Visual analog scale score variation was compared using a 10% noninferiority margin. Two hundred forty-two patients were randomly assigned to LX-P (n = 123) or to LX-T (n = 119). The results showed a reduction in pain after 7 days of treatment: -49.96 (n = 118; SE 1.7) in the LX-P and -47.71 (n = 117; SE 1.6) in the LX-T groups (difference of -2.25; 95% CI: -5.97 to 1.47; P = 0.23). On the safety analysis, the LX-T group presented twice as many patients with treatment-emergent adverse events as the LX-P group (30.8% and 14.2%, respectively). A sensitivity analysis demonstrated that rescue medication use has not affected the primary end point. This study showed that LX-P has a comparable efficacy to LX-T, but with a better safety profile, being a therapeutic option for the treatment of posttraumatic injury pain.

Scope of physiological and behavioural pain assessment techniques in children - a review

Pain is an unpleasant subjective experience. At present, clinicians are using self-report or pain scales to recognise and monitor pain in children. However, these techniques are not efficient to observe the pain in children having cognitive disorder and also require highly skilled observers to measure pain. Using these techniques it is also difficult to choose the analgesic drug dosages to the patients after surgery. Thus, this conceptual work explains the demand for automatic coding techniques to evaluate pain and also it documents some evidence of techniques that act as an alternative approach for objectively determining pain in children. In this review, some good indicators of pain in children are explained in detail; they are facial expressions from an RGB image, thermal image and also feature from well proven physiological signals such as electrocardiogram, skin conductance, body temperature, surgical pleth index, pupillary reflex dilation, analgesia nociception index, photoplethysmography, perfusion index etc.

Physiological Signal-Based Method for Measurement of Pain Intensity

The standard method for prediction of the absence and presence of pain has long been self-report. However, for patients with major cognitive or communicative impairments, it would be better if clinicians could quantify pain without having to rely on the patient's self-description. Here, we present a newly pain intensity measurement method based on multiple physiological signals, including blood volume pulse (BVP), electrocardiogram (ECG), and skin conductance level (SCL), all of which are induced by external electrical stimulation. The proposed pain prediction system consists of signal acquisition and preprocessing, feature extraction, feature selection and feature reduction, and three types of pattern classifiers. Feature extraction phase is devised to extract pain-related characteristics from short-segment signals. A hybrid procedure of genetic algorithm-based feature selection and principal component analysis-based feature reduction was established to obtain high-quality features combination with significant discriminatory information. Three types of classification algorithms-linear discriminant analysis, k-nearest neighbor algorithm, and support vector machine-are adopted during various scenarios, including multi-signal scenario, multi-subject and between-subject scenario, and multi-day scenario. The classifiers gave correct classification ratios much higher than chance probability, with the overall average accuracy of 75% above for four pain intensity. Our experimental results demonstrate that the proposed method can provide an objective and quantitative evaluation of pain intensity. The method might be used to develop a wearable device that is suitable for daily use in clinical settings.

Hypnosis as a Valuable Tool for Surgical Procedures in the Oral and Maxillofacial Area

Hypnosis is a valuable tool in the management of patients who undergo surgical procedures in the maxillofacial complex, particularly in reducing and eliminating pain during surgery and aiding patients who have dental fear and are allergic to anesthesia. This case report demonstrates the efficacy of hypnosis in mitigating anxiety, bleeding, and pain during dental surgery without anesthesia during implant placement of tooth 14, the upper left first molar.

Patient Perception of Acute Pain Management: Data from Three Tertiary Care Hospitals

Introduction. The primary objectives of this study were to assess patients' description of their acute pain intensity; patients' attitude towards their pain management during hospitalization; and their overall satisfaction with pain treatment. Methodology. A cross-sectional questionnaire-based study was conducted between October 2014 and March 2015 in three medical centers in Lebanon. All participants' responses were reported using descriptive statistics. The association between categorical variables was evaluated using Pearson χ² test or Fisher's exact test where the expected cell count was < 5. Results. A total of 119 women on the maternity services and 177 patients on the orthopedic services were surveyed. Around 50% of obstetric and 37% of orthopedic patients reported pain to be severe at its highest intensity. In maternity and orthopedic patients, respectively, unfavorable practices included pain not being assessed prior to pain medication administration (19.3% and 30.5%), having to wait for ≥30 minutes before getting the pain medication (14.2% and 11.3%), and pain score not being documented on medical chart (95% and 93.2%). Surprisingly, 94.1% of the maternity and 89.2% of orthopedic patients were satisfied to strongly satisfied with their pain management. Conclusion. Pre- and postoperative pain remain a prevalent problem that requires a consensus and joint efforts for improvement.

Diagnosis and treatment of bone metastasis: comprehensive guideline of the Japanese Society of Medical Oncology, Japanese Orthopedic Association, Japanese Urological Association, and Japanese Society for Radiation Oncology

Diagnosis and treatment of bone metastasis requires various types of measures, specialists and caregivers. To provide better diagnosis and treatment, a multidisciplinary team approach is required. The members of this multidisciplinary team include doctors of primary cancers, radiologists, pathologists, orthopaedists, radiotherapists, clinical oncologists, palliative caregivers, rehabilitation doctors, dentists, nurses, pharmacists, physical therapists, occupational therapists, medical social workers, etc. Medical evidence was extracted from published articles describing meta-analyses or randomised controlled trials concerning patients with bone metastases mainly from 2003 to 2013, and a guideline was developed according to the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Multidisciplinary team meetings are helpful in diagnosis and treatment. Clinical benefits such as physical or psychological palliation obtained using the multidisciplinary team approaches are apparent. We established a guideline describing each specialty field, to improve understanding of the different fields among the specialists, who can further provide appropriate treatment, and to improve patients’ outcomes.

MAGnesium-oral supplementation to reduce PAin in patients with severe PERipheral arterial occlusive disease: the MAG-PAPER randomised clinical trial protocol

INTRODUCTION

Magnesium exerts analgaesic effects in several animal pain models, as well as in patients affected by acute postoperative pain and neuropathic chronic pain. There is no evidence that magnesium can modulate pain in patients with peripheral arterial occlusive disease (PAOD). We describe the protocol of a single-centre randomised double-blind clinical trial aimed at assessing the efficacy of oral magnesium supplementation in controlling severe pain in patients with advanced PAOD.

METHODS AND ANALYSIS

Adult patients affected by PAOD at stages III and IV of Lèriche-Fontaine classification, who are opioid-naïve, and who have been admitted to our Acute Pain Service for intractable pain, will be eligible. Patients will be randomised to the control group, treated with standard therapy (oxycodone and pregabalin) plus placebo for 2 weeks, or to the experimental group (standard therapy plus magnesium oxide). Patients will be evaluated on days 0, 2, 4, 6, 8, 12 and 14; the following information will being collected: daily oxycodone dose; average and maximum pain (Numerical Rating Scale); pain relief (Pain Relief Scale); characteristics of the pain (Neuropathic Pain Scale); impact of pain on the patient's daily activities (Brief Pain Inventory). The primary outcome will be oxycodone dosage needed to achieve satisfactory analgaesia on day 14. Secondary outcomes will be pain relief on day 2, time needed to achieve satisfactory analgaesia and time needed to achieve a pain reduction of 50%. A sample size calculation was performed for the primary outcome, which estimated a required sample size of 150 patients (75 per group).

ETHICS AND DISSEMINATION

Ethical approval of the study protocol has been obtained from Comitato Etico Provinciale di Brescia, Brescia, Italy. Trial results will be disseminated through scientific journal manuscripts and scientific conference presentations.

TRIAL REGISTRATION NUMBER

NCT02455726.

MiR-203 involves in neuropathic pain development and represses Rap1a expression in nerve growth factor differentiated neuronal PC12 cells

OBJECTIVES

Although microRNAs (miRNAs) have been shown to play a role in numerous biological processes, their function in neuropathic pain is not clear. The rat bilateral sciatic nerve chronic constriction injury (bCCI) is an established model of neuropathic pain, so we examined miRNA expression and function in the spinal dorsal horn in bCCI rats.

METHODS

Microarray and real-time polymerase chain reaction were used to examine the expression of miRNA in nerve system of bCCI rats, and the targets of miRNA were predicted by bioinformatic approaches. The function of specific miRNA was estimated through the methods of gene engineering.

RESULTS

This study revealed substantially (∼10-fold) decreased miR-203 expression in the spinal dorsal horns but not the dorsal root ganglions, hippocampus, or anterior cingulate cortexes of bCCI rats. Rap1a protein expression was upregulated in bCCI rat spinal dorsal horns. We further verified that miR-203 directly targeted the 3'-untranslated region of the rap1a gene, thereby decreasing rap1a protein expression in neuron-like cells.

DISCUSSION

Rap1a has diverse neuronal functions and their perturbation is responsible for several mental disorders. For example, Rap1a/MEK/ERK is involved in peripheral sensitization. These data suggest a potential role for miR-203 in regulating neuropathic pain development, and Rap1a is a validated target gene in vitro. Results from our study and others indicate the possibility that Rap1a may be involved in pain. We hope that these results can provide support for future research into miR-203 in gene therapy for neuropathic pain.

Symptoms Reported by Head and Neck Cancer Patients during Radiotherapy and Association with Mucosal Ulceration Site and Size: An Observational Study

Background

Self-reported pain and impairment of oral functions varies markedly and often in spite of extensive oral mucositis (OM). The aim of the current study was to appraise how patient-reported debilitation caused by OM is influenced by the extent and possibly location of the OM lesions.

Methods

Patients with head and neck cancer undergoing radiotherapy were examined before treatment, twice weekly during 6-7 weeks of therapy, and 3-4 weeks after therapy completion. OM signs of 33 participants were evaluated using the Oral Mucositis Assessment Scale (OMAS), while OM symptoms were recorded using Patient-Reported Oral Mucositis Symptom (PROMS)-questionnaires. Changes in OM experience as a function of OM signs was undertaken by comparing the aggregated and individual PROMS scale values at the point of transition of OMAS ulceration scores between 0 to 1, 1 to 2 and 2 to 3, respectively in the nine intra-oral locations designated in the OMAS. ANOVA with pairwise contrasts using the LSD procedure was applied for comparisons of mean changes of PROMS scale values for the participants who experienced an OMAS score of 2 or more during therapy (n=24).

Results

Impairment of eating hard foods was more when the OMAS score for ulceration anywhere in the mouth or in the soft palate changed from 1 to 2, compared to between score 0 and 1 (p=.002 and p=.05) or between score 2 and 3 (p=.001 and p=.02). Mouth pain increased more upon transition of OMAS score anywhere in the mouth from 1 to 2 compared to 0 to 1 (p=.05).

Conclusion

The relationship between patient-reported impairment of oral function and pain caused by OM ulceration is not linear, but rather curvilinear. Our findings should prompt investigators of future interventional trials to consider using a less severe outcome than maximum OM scores as the primary study outcome.

Lymphedema Characteristics and the Efficacy of Complex Decongestive Physiotherapy in Malignant Lymphedema

The aim of this study is to identify the lymphedema characteristics and the efficacy of complex decongestive physiotherapy (CDP) in 29 patients with malignant lymphedema. After CDP, total decreased volume of lymphedema was 306 mL, percentage of excess volume (PEV) changed from 43.4% to 22.7%, and lymphedema severity improved from severe to moderate status. The CDP efficacy-percentage reduction in excess volume (PREV) was 46.6%. The stage of lymphedema ( P = .004), range of motion ( P < .001), pain, heaviness, and tension scores ( P < .001) were significantly improved after CDP. This shows that CDP is efficacious and useful in malignant lymphedema.

Consumption of dried apple peel powder increases joint function and range of motion

The goal for this study was to evaluate the effects of consumption of dried apple peel powder (DAPP) on joint function and range of motion (ROM). Additional in vitro and clinical testing was performed to suggest specific mechanisms of action. An open-label clinical pilot study involved 12 healthy people with moderate loss of joint ROM and associated chronic pain. The subjects consumed 4.25 g DAPP daily for 12 weeks, with evaluations at baseline, 2, 4, 8, and 12 weeks. ROM was evaluated at each visit using dual digital inclinometry. Pain scores were collected using Visual Analogue Scales. Blood draws enabled testing of serum antioxidant protective capacity using the cellular antioxidant protection (CAP-e) bioassay. Additional in vitro testing involved testing of cyclooxygenase-2 (COX-2) and lipoxygenase inhibition, cellular antioxidant protection by the CAP-e bioassay, and formation of reactive oxygen species (ROS) by polymorphonuclear (PMN) cells by flow cytometry. Twelve weeks of consumption of DAPP was associated with improved ROM. DAPP provided antioxidants that were available to enter into and protect cells from oxidative damage in vitro, and consumption of DAPP for 12 weeks was associated with a statistically significant improvement in serum antioxidant protective status. DAPP inhibited both COX-2 and lipoxygenase enzymes, and pretreatment of inflammatory PMN cells with DAPP before inflammatory stimulus resulted in reduced ROS formation. This suggests multifaceted anti-inflammatory properties of DAPP. Consumption of DAPP was associated with improved joint function and improved serum antioxidant protection status. The observed pain reduction may be associated with the improved antioxidant status and linked to the apple polyphenols' anti-inflammatory effects.

Minimally invasive video-assisted versus minimally invasive nonendoscopic thyroidectomy

Minimally invasive video-assisted thyroidectomy (MIVAT) and minimally invasive nonendoscopic thyroidectomy (MINET) represent well accepted and reproducible techniques developed with the main goal to improve cosmetic outcome, accelerate healing, and increase patient's comfort following thyroid surgery. Between 2007 and 2011, a prospective nonrandomized study of patients undergoing minimally invasive thyroid surgery was performed to compare advantages and disadvantages of the two different techniques. There were no significant differences in the length of incision to perform surgical procedures. Mean duration of hemithyroidectomy was comparable in both groups, but it was more time consuming to perform total thyroidectomy by MIVAT. There were more patients undergoing MIVAT procedures without active drainage in the postoperative course and we also could see a trend for less pain in the same group. This was paralleled by statistically significant decreased administration of both opiates and nonopiate analgesics. We encountered two cases of recurrent laryngeal nerve palsies in the MIVAT group only. MIVAT and MINET represent safe and feasible alternative to conventional thyroid surgery in selected cases and this prospective study has shown minimal differences between these two techniques.

Can a theory-based educational intervention change nurses' knowledge and attitudes concerning cancer pain management? A quasi-experimental design

BACKGROUND

Registered Nurses (RNs) play an important role in caring for patients suffering from cancer pain. A lack of knowledge regarding pain management and the RNs' own perception of cancer pain could act as barriers to effective pain management. Educational interventions that target RNs' knowledge and attitudes have proved promising. However, an intervention consisting of evidence-based practice is a multifaceted process and demands behavioural and cognitive changes to sustain the effects of the intervention. Therefore, our study aimed to investigate if a theory-based educational intervention could change RNs' knowledge and attitudes to cancer pain and pain management, both four and 12 weeks after the start of the intervention.

METHODS

A quasi-experimental design with non-equivalent control groups was used. The primary outcome was measured using a modified version of the instrument Nurses' Knowledge and Attitudes Survey Regarding Pain (NKAS) at baseline, four weeks and 12 weeks after the start of the intervention to evaluate its persistence. The intervention's educational curriculum was based on the principles of Ajzen's Theory of Planned Behaviour and consisted of interactive learning activities conducted in workshops founded on evidence-based knowledge. The RN's own experiences from cancer pain management were used in the learning process.

RESULTS

The theory-based educational intervention aimed at changing RNs knowledge and attitudes regarding cancer pain management measured by primary outcome NKAS resulted in a statistical significant (p<0.05) improvement of total mean score from baseline to four weeks at the intervention ward.

CONCLUSIONS

The findings of this study, suggest that a theory-based educational intervention focused at RNs can be effective in changing RN's knowledge and attitudes regarding cancer pain management. However, the high number of dropouts between baseline and four weeks needs to be taken into account when evaluating our findings. Finally, this kind of theory-based educational intervention with interactive learning activities has been sparsely researched and needs to be evaluated further in larger projects.

TRIAL REGISTRATION

Clinical Trials. Gov: NCT01313234.

The effectiveness of a self-reporting bedside pain assessment tool for oncology inpatients

BACKGROUND

Pain is common during cancer treatment, and patient self-reporting of pain is an essential first step for ideal cancer pain management. However, many studies on cancer pain management report that, because pain may be underestimated, it is often inadequately managed.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of bedside self-assessment of pain intensity for inpatients using a self-reporting pain board.

METHODS

Fifty consecutive inpatients admitted to the Oncology Department of Chungbuk National University Hospital were included in this observational prospective study from February 2011 to December 2011. The medical staff performed pain assessments by asking patients questions and using verbal rated scales (VRS) over 3 consecutive days. Then, for 3 additional days, patients used a self-reporting pain board attached to the bed, which had movable indicators representing 0-10 on a numeric rating scale (NRS) and the frequency of breakthrough pain.

RESULTS

Patient reliability over the medical staff's pain assessment increased from 74% to 96% after applying the self-reporting pain board (p=0.004). The gap (mean±standard deviation [SD]) between the NRS reported by patients and the NRS recorded on the medical records decreased from 3.16±2.08 to 1.00±1.02 (p<0.001), and the level of patient satisfaction with pain management increased from 54% to 82% (p=0.002).

CONCLUSION

This study suggests that the self-reporting bedside pain assessment tool provides a reliable and effective means of assessing pain in oncology inpatients.

Human experimental pain models for assessing the therapeutic efficacy of analgesic drugs

Pain models in animals have shown low predictivity for analgesic efficacy in humans, and clinical studies are often very confounded, blurring the evaluation. Human experimental pain models may therefore help to evaluate mechanisms and effect of analgesics and bridge findings from basic studies to the clinic. The present review outlines the concept and limitations of human experimental pain models and addresses analgesic efficacy in healthy volunteers and patients. Experimental models to evoke pain and hyperalgesia are available for most tissues. In healthy volunteers, the effect of acetaminophen is difficult to detect unless neurophysiological methods are used, whereas the effect of nonsteroidal anti-inflammatory drugs could be detected in most models. Anticonvulsants and antidepressants are sensitive in several models, particularly in models inducing hyperalgesia. For opioids, tonic pain with high intensity is attenuated more than short-lasting pain and nonpainful sensations. Fewer studies were performed in patients. In general, the sensitivity to analgesics is better in patients than in healthy volunteers, but the lower number of studies may bias the results. Experimental models have variable reliability, and validity shall be interpreted with caution. Models including deep, tonic pain and hyperalgesia are better to predict the effects of analgesics. Assessment with neurophysiologic methods and imaging is valuable as a supplement to psychophysical methods and can increase sensitivity. The models need to be designed with careful consideration of pharmacological mechanisms and pharmacokinetics of analgesics. Knowledge obtained from this review can help design experimental pain studies for new compounds entering phase I and II clinical trials.

Improvement of joint range of motion (ROM) and reduction of chronic pain after consumption of an ergothioneine-containing nutritional supplement

OBJECTIVE

To evaluate anti-inflammatory properties of a nutraceutical blend containing L-ergothioneine in concert with other anti-inflammatory and analgesic ingredients, combined with nutritional cartilage support.

METHODOLOGY

Twelve human subjects were tested over a 6-week period of product consumption followed by a 6-week wash-out period, conducted at NIS Labs during late fall/early winter 2010. Range of motion (ROM) assessment of joint motility was performed using JTECH dual digital inclinometry and included flexion, extension, and rotation through the vertical weight-bearing column (neck, thorax, lumbar, hip, knees) and shoulders. Pain evaluation included questionnaires and Visual Analogues Scales regarding primary and secondary pain complaints at rest and at use.

RESULTS

ROM improvements were seen after 1 week, and further improved at 6 weeks (primary pain area P<0.2, secondary pain area P<0.03). Pain in primary and secondary areas at use was significantly reduced already at 1 week, compared to baseline (P<0.05). Pain reduction for both primary and secondary pain areas during use reached a high level of statistical significance at 6 weeks (P<0.004), and remained highly significant after the 6-week wash-out period.

CONCLUSION

Pain reduction and improved ROM were observed during the 6-week consumption. Residual effects were seen 6 weeks after stopping consumption of the ergothioneine supplement.