Comparing quantification of pain severity by verbal rating and numeric rating scales

Patient Education on Exercise Prehabilitation Among Patients Receiving Neoadjuvant Therapy for Cancer Surgery in China: A Mixed-Methods Study

Background/Objectives: Patients undergoing neoadjuvant therapy have ample time to engage in exercise prehabilitation. This study aimed to describe the current status, facilitators, and barriers of exercise prehabilitation among this population. Methods: This sequential explanatory mixed-methods evaluation was conducted at a general tertiary hospital in Beijing. It included a quantitative survey of patients who received neoadjuvant therapy before cancer surgery and qualitative semi-structured interviews with both patients and physicians. Thematic analysis was conducted using the Capability, Opportunity, and Motivation Behavior model. Results: A total of 269 patients participated in the survey, with a completion rate of 99.6%. Only 52.6% and 1.1% of patients met the standards for aerobic and muscle-strengthening activities, respectively. Fewer than 40% of patients reported learning about exercise prehabilitation from physicians. Patients' knowledge was associated with meeting aerobic activity standards after adjusting for confounders (Level 1: odds ratio [OR] of 2.06, 95% confidence interval [CI] of 1.02-4.22; Level 2: OR of 2.56, 95% CI of 1.25-5.36). In total, 28 participants were interviewed. Facilitators of patient education on exercise prehabilitation included the surgeon's ability to gain trust and patients' prior commitment to exercise. Barriers included physicians' lack of awareness of exercise benefits, insufficient knowledge or time for patient education, concerns about patients' exercise ability, lack of referrals to rehabilitation clinics, challenges in follow-up, conflicts with cultural beliefs, and inadequate insurance coverage. Conclusions: This study revealed a lack of physician-led patient education on exercise prehabilitation. Efforts are needed to enhance physician education, implement collaborative clinics, and provide remote supervision.

Comparison of Pain Assessment Tools and Numeric Rating Scale Thresholds for Analgesic Administration in the Postanaesthetic Care Unit

PURPOSE

The aim of this study was to assess the correlation between the Visual Analog Scale (VAS), Numeric Rating Scale (NRS), and Verbal Rating Scale (VRS). Additionally, the study aimed to determine NRS threshold values for both mild analgesic administration (= without risk of nausea and vomiting [NV] side effects) and strong analgesic administration (= with risk of NV side effects) in the postanaesthetic care unit (PACU).

DESIGN

Prospective, observational study design.

METHODS

The study was conducted between August 2019 and April 2022. Patients scheduled for elective surgery under general anesthesia were included. The primary outcome was the correlation between the VAS, NRS, and VRS, assessed at PACU admission and discharge. Secondary outcomes included pain evolution, desire for analgesic administration with or without risk of NV side effects, and preferred tool for pain assessment.

FINDINGS

VAS, NRS, and VRS were significantly correlated (r = 0.82 to 0.94, P < .001) at both PACU admission and discharge. The median VAS scores significantly improved from 32 (interquartile range [IQR]: 9 to 22) at PACU admission to 27 (IQR: 8 to 39) at PACU discharge (P < .001), while the median NRS scores significantly improved from 3 (IQR: 1 to 6) at PACU admission to 3 (IQR: 1 to 4) at PACU discharge (P < .001). At PACU admission, receiver-operating characteristics curve analysis indicated that an optimal NRS threshold value for the administration of a mild analgesic (= without risk of NV side effects) was greater than 2, and greater than 5 for the administration of a strong analgesic (= with risk of NV side effects). At PACU discharge, patients reported a preferred median NRS score of 5 to be treated with a mild analgesic (= without risk of NV side effects), and a preferred median NRS score of 8 to be treated with a strong analgesic (= with risk of NV side effects).

CONCLUSIONS

All three pain assessment tools can be used to evaluate postoperative pain in the PACU setting during the recovery from general anesthesia.

The impact of intravenous versus submucosal dexamethasone on short-term patient response: A randomized controlled trial

BACKGROUND

The purpose of this randomized, cross-over trial was to determine if a preoperative dose of dexamethasone administered submucosally is as effective as intravenous (IV) dexamethasone in reducing pain, swelling, and analgesic consumption after periodontal flap surgery.

METHODS

Thirty-nine patients planned for two similar flap surgeries under IV sedation were included. Before the first surgery, patients were randomized to receive 8 mg of IV or submucosal dexamethasone. Via the alternate route, 0.9% sodium chloride (placebo) was administered. Dexamethasone was administered via the opposite route during the second surgery. A standardized regimen of 600 mg ibuprofen and 325 mg acetaminophen was used to manage postoperative pain. Patients recorded pain and swelling levels on a 21-point numerical rating scale (NRS-21) and a four-point visual rating scale (VRS-4), as well as analgesic usage via a phone application at 12, 24, 48, 72, and 168 h postoperatively.

RESULTS

While NRS-21 and VRS-4 data suggest a trend toward decreased pain and swelling with IV administration, there were no significant differences in analgesic usage or pain at any time and a significant difference in swelling only at 72 h in favor of IV administration (p = 0.047).

CONCLUSIONS

There was no significant difference in pain or analgesic usage following periodontal flap surgery comparing IV and submucosal dexamethasone. A statistically significant difference in swelling between groups at 72 h is likely of limited clinical relevance. Submucosal dexamethasone is an effective way to mitigate pain following periodontal surgery, particularly when IV access for sedation is not required.

The comparison of effectiveness of acupressure on Spleen 6 and Hugo points on the severity of postpartum pain: A randomized clinical trial

Background and aims

Postpartum pain poses a significant challenge for new mothers. Various nonpharmacological methods are employed to manage postpartum pain. This study aimed to compare the effectiveness of acupressure on Spleen 6 and Hugo points on the severity of postpartum pain.

Methods

In this parallel randomized trial study, 68 eligible primiparous women who had vaginal deliveries and experienced postpartum pain at Farabi Hospital in Malekan (a city in East Azarbaijan Province in Iran) were selected according to inclusion/exclusion criteria and then allocated to the Hugo (n = 34) and Spleen 6 (n = 34) acupressure groups using a randomized block design (six blocks). The data collection process took place from November 2022 to April 2023. The participants were blinded; however, the analysts and investigators were not blinded. Acupressure interventions were applied bilaterally for 20 min, consisting of 10 s of pressure followed by 2 s of rest. Pain intensity was assessed using a visual pain scale before, immediately after, and 1 h after the intervention. In total, 68 participants fulfilled the study. Data were analyzed using Statistical Package for the Social Sciences version 25 with chi-square, Mann-Whitney, and Friedman tests.

Results

Both groups exhibited a statistically significant reduction in postpartum pain intensity across all periods (p < 0.001). Although there was a significant difference in pain intensity between the groups before the intervention (p = 0.039), this distinction was not observed immediately and 1 h after the intervention (p ≥ 0.05). Both Hugo and Spleen's 6 acupressure interventions reduced postpartum pain intensity. No significant adverse events or side effects were observed.

Conclusion

Acupressure on Spleen 6 and Hugo points helped decrease the severity of postpartum pain in primiparous women who had vaginal deliveries. Healthcare providers are encouraged to consider acupressure for postpartum pain management.

Pain medication misuse in the South African spinal cord injury context

Background

Pain after spinal cord injury (SCI) is debilitating and has been reported to be difficult to treat, despite pharmacological interventions. Pain medication misuse (PMM) and associated individual factors among people with spinal cord injury (PWSCI) are scarce.

Aim

To determine PMM and the associated factors in PWSCI.

Setting

Homes of community-dwelling manual wheelchair users with SCI in South Africa.

Methods

Community-dwelling PWSCI (n = 122) were consecutively sampled and the Pain Medication Questionnaire (PMQ) was used to determine PMM. Descriptive statistics, Fisher's exact test, independent t-tests, and simple linear regression tests were performed using SPSS v27. Testing was conducted at the 0.05 level of significance.

Results

Eighty-five per cent of the participants reported the presence of pain and 48.1% of them used pain medication. Forty-four percent of people who used pain medication scored ≥ 30, indicative of serious aberrant drug-taking behaviours. Opioids were mainly used for neuropathic pain and in combination with other types of medications such as anticonvulsants and non-steroidal anti-inflammatories (44.0%). Pain severity and the type of pain medication were found to be predictors of PMM (p < 0.01 respectively).

Conclusion

Pain relief after SCI remains difficult to achieve, with an evident high risk of PMM, which may lead to long-lasting side effects, dependency, or overdose.

Contribution

This study has shown the need for the assessment of the potential risk of dependency before prescribing pain medication, particularly opioids to PWSCI.

Objectively and subjectively measured physical activity levels in individuals with whiplash associated disorder and aged-matched healthy controls

BACKGROUND

Whiplash associated disorders (WAD) are the most common non-hospitalised injuries resulting from a motor vehicle crash. Half of individuals with WAD experience ongoing pain and disability. Furthermore, individuals with persistent WAD have lower levels of aerobic capacity and isometric strength compared with age-matched controls. It is not known whether these differences are associated with increased levels of pain and disability, or with reduced physical activity (PA) participation.

OBJECTIVE

Our primary aim was to compare PA levels in individuals with persistent WAD with healthy controls. Secondary aims were to: compare objective and subjective measurements of PA; explore factors that may influence PA; and describe proportions of these populations meeting World Health Organisation PA guidelines.

METHODS

Objective (ActiGraph accelerometer; seven days) and subjective (International Physical Activity Questionnaire (IPAQ)) PA data were collected for n = 53 age-matched participants (WAD n = 28; controls n = 25).

RESULTS

Independent sample t-tests showed no significant difference in objectively measured PA (p>0.05) between WAD and controls. For the subjective measure (IPAQ), controls reported more overall weekly PA (t = 0.219, p<0.05), while WAD participants reported more weekly walking minutes (t = -0.712, p<0.05). Linear regression showed mental health quality-of-life predicted objectively measured moderate intensity PA (R2 = 0.225, F (2, 44) = 6.379, p<0.004) and subjectively reported overall PA (R2 = 0.132, F (1, 41) = 6.226, p<0.017). Bland-Altman analyses indicated that subjects over-reported MVPA and under-reported sedentary time using the IPAQ.

CONCLUSIONS

Individuals with WAD had levels of physical and mental health quality-of-life significantly lower than controls and below population norms yet participated in similar levels of PA. Given that increased perceptions of mental health quality-of-life were positively associated with objectively measured MVPA and subjectively reported overall PA, strategies to help people with WAD achieve adequate doses of MVPA may be beneficial. ActiGraph-measured and IPAQ-reported PA were discordant. Hence, IPAQ may not be a reliable measure of habitual PA in WAD.

Nurses' Assessments Versus Patients' Self-Assessments of Postoperative Pain: Knowledge and Skills of Nurses for Effective Pain Management

Postoperative pain is the most common form of acute pain. Nurses contribute to effective pain management with their knowledge and skills. The aims of this research were to examine differences between nurses' assessments and patients' self-assessments of postoperative pain, differences in the mentioned (self) assessments with respect to characteristics of both groups of respondents, and the correlation between the NRS and the VRS scale. The study included 103 nurses employed at a hospital and 103 patients treated in the surgical departments after the surgical procedures. Data were collected using the standardized Numerical rating scale (NRS) and Verbal rating score (VRS). The median of patients' self-assessments of pain intensity on the NRS scale was 4, while the nursing assessment of patients' pain was 3, with no significant difference (p = 0.083). No significant differences were found on the VRS scale between nurse assessments and patient self-assessments of current pain intensity. The pain was described as moderate by 35% of participants, including 35.9% nurses and 35% patients. Significant positive correlations were recorded between values on the VRS and NRS scales for nurses (Rho = 0.812; p < 0.001) and patients (Rho = 0.830; p < 0.001). The results of this study may have implications for the improvement of postoperative pain management protocols, with regular use of pain assessment scales and individualization of analgesic prescriptions.

Ability of pain scoring scales to differentiate between patients desiring analgesia and those who do not in the emergency department

BACKGROUND AND IMPORTANCE

Pain is one of the most reasons for a visit to an emergency department (ED). Pain scores as the verbal rating scale (VRS) or numerical rating scale (NRS) are used to determine pain management. While it is crucial to measure pain levels, it is equally important to identify patients who desire pain medication, so that adequate provision of analgesia can occur.

OBJECTIVE

To establish the association between pain scores on the NRS and VRS, and the desire for, and provision of, pain medication.

DESIGN, SETTINGS AND PARTICIPANTS

Retrospective monocentric observational cohort study of ED patients presenting with painful conditions.

OUTCOMES MEASURE AND ANALYSIS

The primary outcome was to establish for each pain score (NRS and/or VRS), those patients who desired, and were ultimately provided with, pain medication, and those who did not. Secondary outcomes included establishing the prediction of pain scores to determine desire of pain medication, and the correlation between NRS and VRS when both were reported.

MAIN RESULTS

130,279 patients were included for analysis. For each patient who desired pain medication, pain medication was provided. Proportion of patients desiring pain medication were 4.1-17.8% in the pain score range 0.5-3.5, 31.9-63.4% in the range 4-6.5, and 65-84.6% in the range 7-10. The prediction probability of pain scores to determine desire for pain medication was represented with an AUROC of 0.829 (95% CI 0.826-0.831). The optimal threshold predicting the desire for pain medication would be a pain score of 4.25, with sensitivity 0.86, and specificity 0.68. For the 7835 patients with both NRS and VRS scores available, the Spearman-Rho coefficient assessing correlation was 0.946 (p < 0.001).

CONCLUSIONS

Despite guidelines currently recommending pain medication in patients with a NRS score > 4, we found a discrepancy between pain scores and desire for pain medication. Results of this large retrospective cohort support that the desire for pain medication in the ED might not be derived from a pain score alone.

The presence of pain in community-dwelling South African manual wheelchair users with spinal cord injury

Background

Pain after spinal cord injury (SCI) is common and is likely to continue throughout life with varying levels of severity.

Objective

To determine the presence of pain, the sociodemographic and injury profile of community-dwelling manual wheelchair users.

Method

This quantitative correlational study used a sociodemographic and injury profile sheet and the Douleur Neuropathique 4 Questions (DN4) questionnaire to document demographic, SCI profiles as well as pain characteristics. Pain severity was determined using the Numeric Rating Scale. Data were analysed using the Statistical Package for the Social Sciences (SPSS) v27 at 0.05 level of significance.

Results

The pain rate was 104; 85% of 122 participants and mainly in those with complete SCI (77.9%). Neuropathic pain was more common (76; 62.5%) and significantly associated (p < 0.05) with higher pain severity. Pain was mainly in one area of the body (59; 48.4%) but occurring in up to five areas. The most painful area had a mean severity of 6.7/10; was more common in the lower limbs below the injury level (48; 39.4%); and was burning in nature (40; 32.7%).

Conclusions

Pain after SCI is as problematic in the South African context as it is globally. With the rising SCI prevalence in the country, understanding pain and its presentation is important for holistic management of a person with SCI.

Clinical implications

In-depth assessment of pain should be conducted and appropriate management interventions for specific pain types be prescribed to effectively reduce pain.

Pain Intensity Assessment Scales for Dermatologic Surgery Patients: A Systematic Review

BACKGROUND

Pain assessment plays an important role in dermatologic surgery. The numeric rating scale (NRS), visual analog scale (VAS), verbal rating scale (VRS), and Faces Pain Scale (FPS) are commonly used scales for pain measurement. Conflicting evidence exists regarding the use of each. Prompt pain recognition and treatment during procedures result in higher patient satisfaction.

OBJECTIVE

Determine the most applicable scale for acute pain measurement in dermatologic surgery.

MATERIALS AND METHODS

This systematic review was performed in accordance with PRISMA-Supplemental Digital Content 4, http://links.lww.com/DSS/A976 (PROSPERO; CRD42018091058). PubMed, Cochrane, EMBASE, Scopus, and Web of Science were searched between April 24, 2018, and May 06, 2018. The search query consisted of pain, pain measurement (NRS, VAS, VRS, and FPS), and assessment/comparison. The inclusion criteria included English language literature with primary/secondary outcome objectives directly comparing ≥2 pain scales in acute pain (age: 13+). Study end points included interscale correlations, patient preferences, provider preferences, study author recommendations, and failure rates.

RESULTS

Eight hundred seven studies were retrieved: A total of 42 studies were included. The visual analog scale (n = 42) was most studied, followed by NRS (n = 29), VRS (n = 27), and FPS (n = 11). 93.1% studies showed a high statistical correlation between VAS and NRS. Patients preferred NRS (n = 8/11), followed by FPS (n = 3/11), VRS (n = 2/11), and VAS (n = 1/11). Study authors recommended NRS/VAS (n = 8/19), VRS (n = 6/19), and FPS (n = 1/19). Providers preferred NRS (n = 2/3) and VRS (n = 1/3). The visual analog scale had the highest failure rate (n = 11/12).

CONCLUSION

The numeric rating scale is most applicable for dermatologic surgery because of reported patient and provider preferences, lowest failure rates, and most frequent study author recommendations.

Efficacy of Different Ibuprofen Formulations with Two Prescription Methods on Post Endodontic Pain of Teeth with Irreversible Pulpitis: A Randomized Clinical Trial

Introduction

Pain management during root canal therapy and after that is of great importance in endodontics. This study aimed to compare the effect of two non-steroidal anti-inflammatory drugs (NSAIDs); ibuprofen and ibuprofen lysine with two methods of prescription on pain after single-visit root canal treatment of first and second mandibular molar teeth with irreversible pulpitis.

Materials and Methods

This randomized study recruited subjects experiencing moderate to severe pain from a tooth diagnosed with symptomatic irreversible pulpitis (n=120). Subjects were randomized to receive 400 mg ibuprofen acid or 400 mg ibuprofen lysine regularly or on demand. The primary objective was to measure changes in pain scores at post-operative time frames of 6, 12, 18, 24, 48 and 72 hours after the root canal treatment on a 0-10 numerical rating scale (NRS). Independent T-test, Non-parametric Kruskal-Wallis Test and Friedman Test were used to analyze the data.

Results

Kruskal-Wallis analysis showed a significant difference in NRS score between on-demand ibuprofen group and regular ibuprofen group and also between regular ibuprofen lysine group and regular ibuprofen group at 6 hours after the treatment (P<0.05). But no remarkable difference was observed in the recorded mean pain intensity of four study groups in the other time frames (P>0.05).

Conclusions

Based on this randomized clinical trial, there was no significant difference in the pain intensity of patients using ibuprofen and ibuprofen lysine. Additionally, there was no significant difference in the degree of pain between the on-demand and regular groups, despite the fact that patients in the on-demand group used less medications. Due to the multiple negative effects of NSAIDs, it would be wise to prescribe ibuprofen on demand.

Diagnostic value of brain MR imaging and its correlation with clinical presentation and cognitive functions in idiopathic intracranial hypertension patients

Background

Idiopathic intracranial hypertension (IIH) is a neurological disorder of unknown etiology and ambiguous pathophysiology due to cerebrospinal fluid dysregulation. This study is designed to evaluate the role of brain magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) in diagnosis of IIH, to clarify the nature and extent of cognitive deficits, and to detect if there is a correlation between radiology, clinical findings, and cognitive dysfunctions in those patients.

Results

The study included 34 patients and 34 age-, sex-, body mass index (BMI)-, and education-matched healthy control subjects. MR brain imaging and Montreal cognitive assessment (MoCA) test were used for both groups. MRI and MRV sensitivity for IIH diagnosis were 85.2% and 85.3% with 100% and 94.1% specificity respectively. 44.1% had cognitive impairment, memory was the most affected domain, followed by attention, abstraction, and orientation with statistically significantly lower total MoCA score (p < 0.005). Domain comparisons reveal a statistically significantly lower memory/delayed recall (p < 0.001) and abstract scores (p < 0.007) in IIH cases versus control subjects. In comparing patients with cognitive impairment (CI) versus those without CI, there were statistically significantly higher CI in low education level, presence of diplopia, hormonal contraceptive use, abnormal MRI brain, papilledema grades, BMI, and opening pressure.

Conclusions

Presence of more than or equal 3 MR imaging findings, bilateral transverse sinus stenosis, and less than or equal 4 combined conduit score increase the specificity and sensitivity of MRI and MRV for IIH diagnosis. IIH had detrimental effect on different cognitive domains especially when patient have low education level, diplopia, papilledema ≥ grade III, high OP ≥ 61.5 cm H2O, and BMI ≥ 34 Kg/m2 with abnormal MRI and MRV findings.

Migraine in patients with rheumatoid arthritis and its relation to disease activity

Background

The comorbidity between rheumatoid arthritis (RA) and migraine is complex and not completely understood.

Objective

This study aimed to evaluate migraine frequency in patients with RA and its relation to disease activity.

Methods

A cross-sectional study was carried out on 210 consecutive RA Egyptian patients fulfilling the 2010 EULAR/ACR criteria (joint distribution, serology, symptom duration and acute phase reaction).

Results

Prevalence of migraine in RA was 28.2%. Disease activity, fibromyalgia and functional losses were significantly higher in migraine group with RA versus non-migraine group (P < 0.001). Disease Activity Score (DAS-28) was independently significant predictor as increasing DAS-28 score was associated with an increased likelihood of exhibiting migraine (5.5-times higher odds per one-unit increase in DAS-28 score). Prevalence of brain MRI white matter hyper-intensities (WMHs) in RA with migraine was 54.8%. WMHs were significantly higher in migraine patients with aura than migraine patients without aura, especially in older patients, longer migraine duration, longer rheumatoid duration and elevated ESR (p < 0.047, p < 0.034, P < 0.004, P < 0.015 and P < 0.22, respectively).

Conclusions

Migraine is highly frequent in RA patients, especially migraine with aura. The presence of rheumatoid activity, fibromyalgia and secondary Sjogren’s syndrome, elevated ESR and CRP are associated with functional losses in RA patients with migraine, especially migraine with aura. MR imaging of brain is a mandatory tool for detection of white matter hyper-intensities in RA patients with migraine, especially migraine with aura.

Measuring pain in oncology outpatients: Numeric Rating Scale versus acceptable/non acceptable pain. A prospective single center study

Objectives

During all stages of oncologic diseases, pain is still a major problem. The Numeric Rating Scale (NRS) is one of the most frequently used tools for pain assessment, although interpretation is difficult. The main objective of this study is to compare two types of pain evaluation scales: NRS versus (non) acceptable pain evaluation scale. The secondary aim is to analyze a 10% sample of patients indicating non acceptable pain more in‐depth.

Methods

To assess the pain evaluation scales, a prospective observational study, with a nested retrospective in‐depth exploration, was conducted. One‐year data of patients visiting the outpatient clinic of the oncology center of a university hospital were used. Besides the pain scores of all patients, a 10% sample of patients indicating non acceptable pain was analyzed more in‐depth.

Results

During 1 year, a total of 37,580 patients registered at the outpatient clinic, of whom approximately 10% indicated non acceptable pain. The mean NRS of patients indicating non acceptable pain was 6.5 (n = 2153). For patients indicating acceptable pain, the mean NRS was 1.6 (n = 21,010). Although the presence of pain recorded in the patient record increased substantially over the year, the percentage of reported interventions only slightly increased.

Conclusion

The (non) acceptable pain evaluation seems a valuable addition to the NRS for assessing pain among patients with cancer. As interpretation of the NRS appears to be difficult, using the (non) acceptable pain evaluation is recommended. Moreover, creating awareness among specialists to discuss pain has a positive effect on the amount of pain discussed during consultation.

Validity and Utility of Four Pain Intensity Measures for Use in International Research

Background

The majority of previous research that has examined the validity of pain intensity rating scales has been conducted in western and developed countries. Research to evaluate the generalizability of previous findings in non-developed countries is necessary for identifying the scales that are most appropriate for use in international research.

Purpose

The aims of the current study were to (1) evaluate the validity and utility of four commonly used measures of pain intensity in a sample of patients with chronic pain from Thailand and (2) compare findings in the current sample with published findings from research conducted in other countries, in order to identify the measure or measures which might be most appropriate for cross-country research.

Methods

Three hundred and sixty patients with chronic pain seen in a hospital in Bangkok, Thailand, were asked to rate their current pain and average, worst, and least pain intensity in the past week using the Visual Analogue Scale (VAS), 6-point Verbal Rating Scale (VRS-6), 0–10 Numerical Rating Scale (NRS-11), and Faces Pain Scale-Revised (FPS-R). We evaluated the utility and validity of each measure by examining the (1) rates of correct responding and (2) association of each measure with a factor score representing the variance shared across measures, respectively. We also evaluated the associations between incorrect response rates and both age and education level, and then compared the findings from this sample with the findings from research conducted in other countries.

Results

The results indicated support for the validity of all measures among participants who were able to use these measures. However, there was variability in the incorrect response rates, with the VAS having the highest (45%) and the NRS-11 having the lowest (15%) incorrect response rates. The VAS was also the least preferred (9%) and the NRS-11 the most preferred (52%) scale. Education and age were significantly associated with incorrect response rates, and education level with scale preference.

Conclusion

The findings indicate that the NRS-11 has the most utility in our sample of Thai individuals with chronic pain. However, when considered in light of the findings from other countries, the results of this study suggest that the FPS-R may have the most utility for use in cross-cultural and international research. Research in additional samples in developing countries is needed to evaluate the generalizability of the current findings.

Pain and its impact on functioning and disability in manual wheelchair users with spinal cord injury: a protocol for a mixed-methods study

INTRODUCTION

Approximately 80% of people with spinal cord injury experience clinically significant chronic pain. Pain (whether musculoskeletal or neuropathic) is consistently rated as one of the most difficult problems to manage and negatively affects the individual's physical, psychological and social functioning and increases the risk of pain medication misuse and poor mental health. The aim of this study is to therefore determine the presence of pain and its impact on functioning and disability as well as to develop a framework for self-management of pain for South African manual wheelchair users with spinal cord injury.

METHODS AND ANALYSIS

Community-dwelling participants with spinal cord injury will be invited to participate in this three-phase study. Phase 1 will use a quantitative, correlational design to determine factors related to pain such as pectoralis minor length, scapular dyskinesis, wheelchair functioning, physical quality of life, community reintegration and pain medication misuse. Demographic determinants of pain such as age, gender, type of occupation, completeness of injury and neurological level of injury will also be investigated. Participants with pain identified in phase 1 will be invited to partake in a qualitative descriptive and contextually designed phase 2 to explore their lived experience of pain through in-depth interviews. The results of phases 1 and 2 will then be used with the assistance from experts to develop a framework for self-management of pain using a modified Delphi study. Data analysis will include descriptive and inferential statistics (quantitative data) and thematic content analysis (qualitative data).

ETHICS AND DISSEMINATION

Approval for this study is granted by the Faculty of Health Sciences Research Ethics Committee of the University of the Pretoria (approval number 125/2018). This study is registered with the South African National Health Research Database (reference GP201806005). This study's findings will be shared in academic conferences and published in scientific peer-reviewed journals.

Discontinuation of botulinum neurotoxin type-A treatment during COVID-19 pandemic: an Italian survey in post stroke and traumatic brain injury patients living with spasticity

BACKGROUND

The COVID-19 pandemic has affected health-care systems worldwide, including the outpatient spasticity care with botulinum neurotoxin toxin type A (BoNT-A).

AIM

The aim of this study was to investigate the impact of discontinuation of BoNT-A treatment on patients living with spasticity during the COVID-19 quarantine.

DESIGN

A multicentric cross-sectional study.

SETTING

Outpatients setting.

POPULATION

Patients with spasticity after stroke and traumatic brain injury treated with BoNT-A.

METHODS

A phone-based survey was conducted from March to May, 2020. Based on the International Classification of Functioning, Disability and Health (ICF), an ad hoc questionnaire CORTOX (CORonavirus TOXin survey) was developed to investigate patients' experiences following the discontinuation of their usual treatment for spasticity due to the lockdown and its implication on their health perception. It assessed patients' condition and explored different ICF domains related to spasticity: unpleasant sensations, mobility, self-care, facilitators and psychosocial factors. The sum of those represented the CORTOX score (Max 142). The questionnaire also collected data about the impact of COVID-19 on patients' wellbeing (mood, sleep, relationships, community life, motivation).

RESULTS

A total of 151 participants completed the survey. Most participants (72.2%) experienced a worsening in perceived spasticity, 53% got worse in independence and 70.9% had a negative impact on quality of life. The mean CORTOX score was 52.85±27.25, reflecting a perceived worsening in all ICF domains investigated. Moderate to strong correlations were found between different sub-scores of the questionnaire and severity of spasticity (P<0.001). COVID-19 psychosocial related factors were associated with loss of independence (P<0.05) but only mood was associated with worsening of spasticity (P<0.001). The lack of rehabilitation therapy was significantly associated with the worsening of independence but not with the worsening of spasticity. Finally, respondents reported that BoNT-A was useful to their condition and should not be discontinued.

CONCLUSIONS

The discontinuation of BoNT-A treatment was associated with worsening of activities and participation and perceived spasticity. COVID-19 related problems and rehabilitation showed an association with loss of independence.

CLINICAL REHABILITATION IMPACT

This study will provide useful information in the field of spasticity management using a patient's centred approach, with consistent quantitative and qualitative information.

Core Outcome Measures for Chronic Musculoskeletal Pain Research: Recommendations from a Veterans Health Administration Work Group

OBJECTIVE

Chronic musculoskeletal pain (CMSP) disorders are among the most prevalent and disabling conditions worldwide. It would be advantageous to have common outcome measures when comparing results across different CMSP research studies.

METHODS

The Veterans Health Administration appointed a work group to recommend core outcome measures for assessing pain intensity and interference as well as important secondary domains in clinical research. The work group used three streams of data to inform their recommendations: 1) literature synthesis augmented by three recently completed trials; 2) review and comparison of measures recommended by other expert groups; 3) two Delphi surveys of work group members.

RESULTS

The single-item numerical rating scale and seven-item Brief Pain Inventory interference scale emerged as the recommended measures for assessing pain intensity and interference, respectively. The secondary domains ranked most important included physical functioning and depression, followed by sleep, anxiety, and patient-reported global impression of change (PGIC). For these domains, the work group recommended the Patient-Reported Outcome Information System four-item physical function and sleep scales, the Patient Health Questionnaire two-item depression scale, the Generalized Anxiety Disorder two-item anxiety scale, and the single-item PGIC. Finally, a single-item National Health Interview Survey item was favored for defining chronic pain.

CONCLUSIONS

Two scales comprising eight items are recommended as core outcome measures for pain intensity and interference in all studies of chronic musculoskeletal pain, and brief scales comprising 13 additional items can be added when possible to assess important secondary domains.

Assessing the physiological strain of physical therapists according to work experience: A cross-sectional study

OBJECTIVES

This cross-sectional study aimed to assess the physiological response of physical therapists to compare the physiological workload within three groups of varying work experience and their comparative physiological responses during a 15-min recovery period.

METHODS

Thirty therapists participated in the present study. They were divided into three groups with varying levels of work experience based on the number of years they had been in active employment: 1) Early Career (EC) group = 2-6 years); 2) Mid-Career (MC) group = 7-11 years), and 3) Late career (LC) group = over 11 years). Each group included 10 subjects comprised of both males and females. To conduct the measurements, each therapist treated one hemiplegic patient for 20 min using a passive range of motion protocol and then rested for 15 min. The maximum voluntary contraction on trapezius and deltoid muscles were tested using electromyography before and after treatment. During treatment, the muscle workload, muscle fatigue, and cardiovascular load were measured. The perceived workload was assessed using a subjective workload index (SWI) questionnaire following treatment.

RESULTS

The three work experience groups of physical therapists performed a similar workload. The SWI corresponded well with physiological measurement. The muscle capacity after treatment of the EC group was significantly lower than that of the MC group (p < 0.05). Notably, the right deltoid of the LC group was significantly lower than that of the MC group.

CONCLUSIONS

The physical therapists worked with a moderate, objectified workload. A 15-min rest period brought the cardiovascular load below 30% and lowered fatigue in the right deltoids. This result may indicate a musculoskeletal disorder warning signal for the physical therapists.

What does "moderate pain" mean? Subgroups holding different conceptions of rating scales evaluate experimental pain differently

BACKGROUND

Pain ratings are almost ubiquitous in pain assessment, but their variability is high. Low correlations of continuous/numerical rating scales with categorical scales suggest that individuals associate different sensations with the same number on a scale, jeopardizing the interpretation of statistical results. We analysed individual conceptions of rating scales and whether these conceptions can be utilized in the analysis of ratings of experimental stimuli in pain-free healthy individuals and people with reoccurring/persistent pain.

METHODS

Using a free positioning task, healthy participants (N = 57) and people with reoccurring/persistent pain (N = 57) ad libitum positioned pain descriptors on lines representing intensity and un-/pleasantness scales. Furthermore, participants rated experimental thermal stimuli on visual analogue scales with the same end anchors. A latent class regression approach was used to detect subgroups with different response patterns in the free positioning task, indicating different conceptions of pain labels, and tested whether these subgroups differed in their ratings of experimental stimuli.

RESULTS

Subgroups representing different conceptions of pain labels could be described for the intensity and the un-/pleasantness scale with in part opposing response patterns in the free positioning task. Response patterns did not differ between people with and without pain, but in people with pain subgroups showed differential ratings of high intensity experimental stimuli.

CONCLUSIONS

Individuals' conceptions of pain labels differ. These conceptions can be quantified and utilized to improve the analysis of ratings of experimental stimuli. Identifying subgroups with different conceptions of pain descriptions could be used to improve predictions of responses to pain in clinical contexts.

SIGNIFICANCE

The present results provide a novel approach to incorporate individual conceptualizations of pain descriptors, which can induce large distortions in the analysis of pain ratings, in pain assessment. The approach can be used to achieve better pain estimates, representing individual conceptions of pain and achieving a better comparability between individuals but also between pain-free persons and patients with chronic pain. Particularly, in clinical settings this could improve quantification of perceived pain and the patient-clinician communication.

Beyond the Relief of Pain: Dentin Hypersensitivity and Oral Health-Related Quality of Life

Pain is a constant symptom of dentin hypersensitivity (DH), which is a common condition that affects daily life and negatively affects the quality of life (QoL). Diagnosis and outcome measurements following the treatment of the disease require accurate pain assessment. The definition of pain underlies the complexity of its measurement as different factors modulate daily experience. The reproducibility of the prescribed stimuli for inducing DH pain clinically is difficult to achieve. This pain mevaasurement is made with unidimensional scales that are inadequate to capture the other dimensions of pain. The only specific QoL tool available for DH still requires testing in other populations and cultures. This article reviews the appropriateness of the current methods of DH pain assessment and the tools that consider the other pain dimensions. It also looks at its impact on the oral health-related quality of life (OHRQoL) of people with DH. The findings will create interest and facilitate research in this field of DH pain measurement and management.

Do Commonly Used Measures of Pain Intensity Only Reflect Pain Intensity in Youths With Bothersome Pain and a Physical Disability?

The objective of this cross-sectional study was to evaluate the extent to which non-pain intensity factors influence the ratings of pain intensity on two commonly used measures: the Wong-Baker Faces pain rating scale (FACES) and the Verbal Rating Scale (VRS) in a sample of youths with physical disabilities and bothersome pain. Study participants came from a convenience sample of 115 youths (age: X ¯ = 14.4 years; SD = 3.3), who participated in a survey on the impact of pain in young people with a physical disability. They were administered measures of pain intensity, pain catastrophizing, depressive symptoms, pain interference, and pain control beliefs. Zero-order correlation analyses were used to examine the associations among the pain intensity scores, while regression analyses were used to test the influence of the non-pain intensity factors on the pain intensity scores. Although pain intensity scores from all scales were significantly associated with one another, the correlations were moderate. Regression analyses showed that the FACES and VRS also reflect pain interference, in addition to pain intensity. The fact that the FACES and VRS ratings reflect more than pain intensity should be considered when selecting a pain measure. The results of this study also provide information to help interpret results after treatment.

Pain Management Issues as Part of the Comprehensive Care of Patients with Sickle Cell Disease

BACKGROUND

Vaso-occlusive pain crisis is one of the primary complications of sickle cell disease (SCD) and is responsible for the majority of hospital visits in patients with SCD. Stints of severe pain can last for hours to days and are difficult to treat and manage, often resulting in drastically reduced quality of life.

PURPOSE

Our purpose is to provide an overview of pain management issues in SCD populations.

METHODS

We explored literature using PubMed and Embase for the etiology and management of pain in SCD. Databases were searched employing the following terms: sickle cell, pain pathways, pain perception, pharmacological therapies, psychological therapies, physical therapies and genetics.

RESULTS

Pain in SCD can vary from acute to chronic (persistent) or mixed and understanding of the underlying mechanisms is important for proper pain management. Currently, there are many means of managing pain in children with SCD, which involve pharmacological and non-pharmacological approaches. A combination of psychotherapy and pain medications can be used for treatment of pain and other psychosocial co-morbidities in complex persistent pain.

CONCLUSIONS

Providing more appropriate medication and optimal dosage based on individual's genomic variations is the future of medicine, and this will allow the physicians to hone in on optimal pain management in patients with SCD.

Do health beliefs affect pain perception after pectus excavatum repair?

PURPOSE

The pain experience is highly variable among patients. Psychological mindsets, in which individuals view a particular characteristic as either fixed or changeable, have been demonstrated to influence people's actions and perceptions in a variety of settings including school, sports, and interpersonal. The purpose of this study was to determine if health mindsets influence the pain scores and immediate outcomes of post-operative surgical patients.

METHODS

As part of a multi-institutional, prospective, randomized clinical trial involving patients undergoing a minimally invasive pectus excavatum repair of pectus excavatum, patients were surveyed to determine whether they had a fixed or growth health mindset. Their post-operative pain was followed prospectively and scored on a Visual Analog Scale and outcomes were measured according to time to oral pain medication use.

RESULTS

Fifty patients completed the Health Beliefs survey, 17 had a fixed mindset (8 epidural, 9 PCA) and 33 had a growth mindset (17 epidural, 16 PCA). Patients with a growth mindset had lower post-operative pain scores than patients with a fixed mindset although pain medication use was not different.

CONCLUSION

This is the first usage of health mindsets as a means to characterize the perception of pain in the post-operative period. Mindset appears to make a difference in how patients perceive and report their pain. Interventions to improve a patient's mindset could be effective in the future to improve pain control and patient satisfaction.

Test-retest reliability, validity, and minimum detectable change of visual analog, numerical rating, and verbal rating scales for measurement of osteoarthritic knee pain

Objective

Several scales are commonly used for assessing pain intensity. Among them, the numerical rating scale (NRS), visual analog scale (VAS), and verbal rating scale (VRS) are often used in clinical practice. However, no study has performed psychometric analyses of their reliability and validity in the measurement of osteoarthritic (OA) pain. Therefore, the present study examined the test-retest reliability, validity, and minimum detectable change (MDC) of the VAS, NRS, and VRS for the measurement of OA knee pain. In addition, the correlations of VAS, NRS, and VRS with demographic variables were evaluated.

Methods

The study included 121 subjects (65 women, 56 men; aged 40-80 years) with OA of the knee. Test-retest reliability of the VAS, NRS, and VRS was assessed during two consecutive visits in a 24 h interval. The validity was tested using Pearson's correlation coefficients between the baseline scores of VAS, NRS, and VRS and the demographic variables (age, body mass index [BMI], sex, and OA grade). The standard error of measurement (SEM) and the MDC were calculated to assess statistically meaningful changes.

Results

The intraclass correlation coefficients of the VAS, NRS, and VRS were 0.97, 0.95, and 0.93, respectively. VAS, NRS, and VRS were significantly related to demographic variables (age, BMI, sex, and OA grade). The SEM of VAS, NRS, and VRS was 0.03, 0.48, and 0.21, respectively. The MDC of VAS, NRS, and VRS was 0.08, 1.33, and 0.58, respectively.

Conclusion

All the three scales had excellent test-retest reliability. However, the VAS was the most reliable, with the smallest errors in the measurement of OA knee pain.

Managing severe pain and abuse potential: the potential impact of a new abuse-deterrent formulation oxycodone/naltrexone extended-release product

Proper management of severe pain represents one of the most challenging clinical dilemmas. Two equally important goals must be attained: the humanitarian/medical goal to relieve suffering and the societal/legal goal to not contribute to the drug abuse problem. This is an age-old problem, and the prevailing emphasis placed on one or the other goal has resulted in pendulum swings that have resulted in either undertreatment of pain or the current epidemic of misuse and abuse. In an effort to provide efficacious strong pain relievers (opioids) that are more difficult to abuse by the most dangerous routes of administration, pharmaceutical companies are developing products in which the opioid is manufactured in a formulation that is designed to be tamper resistant. Such a product is known as an abuse-deterrent formulation (ADF). ADF opioid products are designed to deter or resist abuse by making it difficult to tamper with the product and extracting the opioid for inhalation or injection. To date, less than a dozen opioid formulations have been approved by the US Food and Drug Administration to carry specific ADF labeling, but this number will likely increase in the coming years. Most of these products are extended-release formulations.

What Determines Whether a Pain is Rated as Mild, Moderate, or Severe? The Importance of Pain Beliefs and Pain Interference

Reliable and valid measures of pain intensity are needed to accurately evaluate the efficacy of pain treatments. Perhaps with the exception of faces pain intensity scales, which are thought to reflect both pain intensity and pain affect, the other most commonly used pain intensity scales-Numerical Rating Scales (NRSs), Visual Analog Scales, and Verbal Rating Scales (VRSs)-are all thought to reflect primarily pain intensity or the magnitude of felt pain. However, to our knowledge, this assumption has not been directly tested for VRSs.

METHODS

We evaluated whether VRS pain severity ratings are influenced by pain beliefs, catastrophizing, or pain interference over and above any effects of pain intensity, as measured by a NRS, in 4 samples of individuals with physical disabilities and chronic pain.

RESULTS

As hypothesized, and while controlling for pain intensity as measured by a NRS, higher scores on factors representing pain interference with function, pain catastrophizing, and a number of pain-related beliefs were all associated with a tendency for the study participants to rate their pain as more severe on a VRS.

DISCUSSION

These findings indicate VRSs of pain severity cannot necessarily be assumed to measure only pain intensity; they may also reflect patient perceptions about pain interference and beliefs about their pain. Clinicians and researchers should take these findings into account when selecting measures and when interpreting the results of studies using VRSs as outcome measures.

Development and psychometric validation of the Nausea/Vomiting Symptom Assessment patient-reported outcome (PRO) instrument for adults with secondary hyperparathyroidism

Background

We developed the Nausea/Vomiting Symptom Assessment (NVSA^©) patient-reported outcome (PRO) instrument to capture patients’ experience with nausea and vomiting while on calcimimetic therapy to treat secondary hyperparathyroidism (SHPT) related to end-stage kidney disease. This report summarizes the content validity and psychometric validation of the NVSA^©.

Methods

The two NVSA^© items were drafted by two health outcomes researchers, one medical development lead, and one regulatory lead: it yields three scores: the number of days of vomiting or nausea per week, the number of vomiting episodes per week, and the mean severity of nausea. An eight-week prospective observational study was conducted at ten dialysis centers in the U.S. with 91 subjects. Criterion measures included in the study were the Functional Living Index-Emesis, Kidney Disease Quality of Life Instrument, EQ-5D-5 L, Static Patient Global Assessment, and Patient Global Rating of Change. Analyses included assessment of score distributions, convergent and known-groups validity, test-retest reliability, ability to detect change, and thresholds for meaningful change.

Results

Qualitative interviews verified that the NVSA^© captures relevant aspects of nausea and vomiting. Patients understood the NVSA^© instructions, items, and response scales. Correlations between the NVSA^© and related and unrelated measures indicated strong convergent and discriminant validity, respectively. Mean differences between externally-defined vomiting/nausea groups supported known-groups validity. The scores were stable in subjects who reported no change on the Patient Global Rating of Change indicating sufficient test-retest reliability. The no-change group had mean differences and effect sizes close to zero; mean differences were mostly positive for a worsening group and mostly negative for the improvement group with predominantly medium or large effect sizes. Preliminary thresholds for meaningful worsening were 0.90 days for number of days of vomiting or nausea per week, 1.20 for number of episodes of vomiting per week, and 0.40 for mean severity of nausea.

Conclusions

The NVSA^© instrument demonstrated content validity, convergent and known-groups validity, test-retest reliability, and the ability to detect change. Preliminary thresholds for minimally important change should be further refined with additional interventional research. The NVSA^© may be used to support study endpoints in clinical trials comparing the nausea/vomiting profile of novel SHPT therapies.

Characterization of pain, disability, and psychological burden in Marfan syndrome

The clinical manifestations of Marfan syndrome frequently cause pain. This study aimed to characterize pain in a cohort of adults with Marfan syndrome and investigate demographic, physical, and psychological factors associated with pain and pain-related disability. Two hundred and forty-five participants (73% female, 89% non-Hispanic white, 90% North American) completed an online questionnaire assessing clinical features of Marfan syndrome, pain severity, pain-related disability, physical and mental health, depressive symptoms, pain catastrophizing, and insomnia. Eighty-nine percent of respondents reported having pain with 28% of individuals reporting pain as a presenting symptom of Marfan syndrome. Almost half of individuals reported that pain has spread from its initial site. Participants in our study reported poor physical and mental health functioning, moderate pain-related disability, and mild levels of depressive symptoms, sleep disturbances, and pain catastrophizing. Those who identified pain as an initial symptom of Marfan syndrome and those who reported that pain had spread from its initial site reported greater psychological burden compared with those without pain as an initial symptom or pain spreading. Physical health is the largest predictor of pain severity and pain-related disability. While pain catastrophizing and worse mental health functioning are significant correlates of pain severity and pain-related disability, respectively. Pain is a significant and persistent problem in Marfan syndrome and is associated with profound disability and psychological burden. Further studies are indicated to better characterize the directionality of pain, pain-related disability, and psychological burden in Marfan syndrome. © 2016 Wiley Periodicals, Inc.

How Do Patients with Chronic Neck Pain Experience the Effects of Qigong and Exercise Therapy? A Qualitative Interview Study

Background. The high prevalence of chronic neck pain in high income countries impacts quality of life and the social and work-related activities of those afflicted. We aimed to understand how mind-body therapies and exercise therapy may influence the experience of pain among patients with chronic neck pain. Methods. This qualitative interview study investigated how patients with chronic neck pain experienced the effects of exercise or qigong therapy at two time points: during an intervention at three months and after the intervention at six months. Interviews were analysed thematically across interviews and within person-cases. Based on other qualitative studies, a sample size of 20 participants was deemed appropriate. Results. The sample (n = 20) consisted of 16 women and four men (age range: 29 to 59). Patients' experiences differed according to the therapies' philosophies. Exercise therapy group interviewees described a focus on correct posture and muscle tension release. Qigong group interviewees discussed calming and relaxing effects. Maintaining regular exercise was easier to achieve with exercise therapy. Conclusions. The findings of this study may help health care providers when counselling chronic pain patients on self-help interventions by informing them of different bodily and emotional experiences of mind-body interventions compared to exercise therapy.

The Development and Validation of Hundred Paisa Pain Scale for Measuring Musculoskeletal Pain: A Prospective Observational Study

The reduction in the pain intensity is one of the most important outcome measures in musculoskeletal disorders. The assessment of pain required reliable and valid scale. The aims of this prospective observational study were to develop and evaluate concurrent validity and test-retest reliability of hundred paisa pain scale (HPPS) for measuring musculoskeletal pain. A consecutive 74 patients with musculoskeletal pain with a wide variety of diagnoses were enrolled. Patients reported their intensity of pain on the following scale: HPPS, "visual analog scale (VAS)," and "numerical rating scale (NRS)." Patients were asked to complete another HPPS, VAS, and NRS after 2 days to determine the reproducibility of the scales. Spearman rank correlation coefficients between the HPPS and the NRS, and VAS were used to determine the validity of the scales. The correlation between the change score of HPPS, VAS, and NRS was used to determine the responsiveness of HPPS. Results of test-retest indicate that the reproducibility of HPPS was good to excellent with the intraclass correlation coefficient (ICC) value of 0.85 (95% confidence interval [CI], 0.76-0.91). The standard error of measurement (SEM) was 5.24. The minimum detectable change based on the SEM for test-retest was 14.52. The reproducibility of VAS is moderate to good with the ICC value of 0.82 (95% CI, 0.72-0.88). The reproducibility of NRS is good to excellent with the ICC value of 0.88 (95% CI, 0.81-0.92). There was a strong correlation between the HPPS and the VAS, and NRS (P < 0.01), which confirm the validity. The HPPS was responsive as the correlation of the change score of HPPS with the change score of VAS, and NRS were good (0.80 and 0.86, respectively). The HPPS is a valid and reliable scale to assess musculoskeletal pain, with psychometric properties in agreement with other comparable scale.

Study of Ebola Virus Disease Survivors in Guinea

BACKGROUND

There is a paucity of data regarding health consequences of Ebola virus disease among survivors.

METHODS

We surveyed 105 Ebola virus disease survivors postdischarge from an Ebola treatment unit in Guinea using a standard data collection form. Patients rated recovery as the percentage of improvement in functional status, where 0% represents "unable to perform" and 100% represents "able to perform at prior level."

RESULTS

The mean ± standard deviation time interval between hospital discharge and administration of questionnaire was 103.5 ± 47.9 days in 105 survivors. Anorexia was reported by 103 patients, with varying severity levels: mild (n = 33), moderate (n = 65), or severe (n = 5). Reported pain according to site was chest (30.7%), joint (86.7%), muscle (26.7%), and back (45.7%), among others. Recovery in functional status was graded as mild (10%-30%) (n = 2 [1.9%]), moderate (40%-70%) (n = 52 [50.0%]), and excellent (80%-100%) (n = 50 [48.1%]). Severity of arthralgia (R(2) = 0.09; P = .008) was directly associated with lower recovery in functional status in multivariate analysis.

CONCLUSIONS

Ebola virus disease survivors frequently reported anorexia and arthralgia. Severity of arthralgia was related to lower functional recovery. There may be a role for focused screening and intervention for symptoms identified in this study of survivors.

The effect of early ambulation on the incidence of neurological complication after spinal anesthesia with lidocaine

BACKGROUND

Transient neurological symptoms (TNS), was described in patients recovering from spinal anesthesia with lidocaine but its etiology remains unknown this study was evaluated the influence of ambulation time on the occurrence of TNSs after spinal anesthesia with lidocaine 5%.

MATERIALS AND METHODS

This randomized clinical trial was conducted on 60 patients with American Society of Anesthesiologists Grades I and II, who were candidates for lower abdominal surgery in supine or lithotomy positions. Patients were randomly divided into early ambulation group (Group A) who were asked to start walking as soon as the anesthesia was diminished or to the late ambulation group (Group B) who walked after at least 12 h bedridden. Participants were contacted 2 days after spinal anesthesia to assess any type of pain at surgical or anesthesia injection site, muscle weakness, fatigue, vertigo, nausea, vomiting, headache, and difficult urination or defecation.

RESULTS

Four subjects (13.3%) in Group A and two patients (6.7%) in Group B had pain at anesthesia injection site (P = 0.019). Fourteen patients in Group A (46.7%) and six patients in Group B (20%) had post-dural puncture headache (P = 0.014). Participants in Group B reported difficult urination more than Group A (P = 0.002). there were not statistically significant differences between two groups regarding frequency of fatigue, muscle weakness, vertigo, nausea, vomiting, difficult defecation, paresthesia, and the mean of visual analogue scale at the surgical site.

CONCLUSION

Early ambulation after spinal anesthesia with lidocaine did not increase the risk of neurologic complication.

Effects of chronic pain on function, depression, and sleep among patients with traumatic spinal cord injury

BACKGROUND AND OBJECTIVES

The main objectives of this cross-sectional study were (1) to examine chronic pain using the Multidimensional Pain Inventory-Spinal Cord Injury (MPI-SCI) version and (2) to assess the relationship between chronic pain and functional status, depression, and sleep quality among patients with SCI.

DESIGN AND SETTINGS

This was a cross-sectional study of all eligible patients admitted to the Ministry of Health Ankara Diskapi Yildirim Beyazit Education and Research Hospital Physical Therapy and Rehabilitation Clinic between January 2007 and July 2010.

METHODS

Forty-four patients (33 male, 11 female) with traumatic SCI, aged >=18 years, who had pain continuing for >=6 months and were hospitalized in the physical therapy and rehabilitation clinic were included in this cross-sectional study. Chronic pain intensity, functional status, depression, and sleep quality were assessed according to the MPI-SCI, Functional Independence Measure (FIM), Hamilton Rating Scale for Depression (HAM-D), and Pittsburg Sleep Quality Index (PSQI), respectively.

RESULTS

A positive correlation was observed between "Pain Severity" (one of the subscales of the MPI-SCI) and HAM-D (r=0.487, P=.001) and PSQI (r=0.312, P=.039). "Pain Severity" was significantly higher in the "impaired sleep" group (P < .05) than in the "normal sleep" group and in the "depression" group (P < .05) than in the "no depression" group.

CONCLUSION

We identified a strong interrelationship between SCI-related "Pain Severity" and both depression and sleep quality. Hence, a comprehensive pain examination and management strategies including psychosocial interventions should be given particular consideration to address the critical issue of chronic pain in individuals with SCI.

Healthcare professionals' perceptions of the use of pain scales in postoperative pain assessments

AIM

To describe how healthcare professionals perceive the use of pain scales in postoperative care.

BACKGROUND

Pain scales are important but not an obvious choice to use in postoperative care. No study has explored how healthcare professionals experience the use of pain scales.

METHODS

An explorative design with a phenomenographic approach was used. The sample consisted of 25 healthcare professionals. Semistructured interviews were performed.

RESULTS

Four descriptive categories emerged - the use of pain scales facilitated the understanding of postoperative pain, facilitated treatment, demanded a multidimensional approach and was affected by work situations.

CONCLUSIONS

Healthcare professionals described that pain scales contribute to the understanding of patient's postoperative pain. It is important to ensure patient understanding and be aware about variations in pain ratings. Dialogue and observations are necessary to be certain what the ratings mean to the patient. The use of pain scales depends on patient's needs and organization.

Validity of four pain intensity rating scales

The Visual Analogue Scale (VAS), Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), and the Faces Pain Scale-Revised (FPS-R) are among the most commonly used measures of pain intensity in clinical and research settings. Although evidence supports their validity as measures of pain intensity, few studies have compared them with respect to the critical validity criteria of responsivity, and no experiment has directly compared all 4 measures in the same study. The current study compared the relative validity of VAS, NRS, VRS, and FPS-R for detecting differences in painful stimulus intensity and differences between men and women in response to experimentally induced pain. One hundred twenty-seven subjects underwent four 20-second cold pressor trials with temperature order counterbalanced across 1°C, 3°C, 5°C, and 7°C and rated pain intensity using all 4 scales. Results showed statistically significant differences in pain intensity between temperatures for each scale, with lower temperatures resulting in higher pain intensity. The order of responsivity was as follows: NRS, VAS, VRS, and FPS-R. However, there were relatively small differences in the responsivity between scales. A statistically significant sex main effect was also found for the NRS, VRS, and FPS-R. The findings are consistent with previous studies supporting the validity of each scale. The most support emerged for the NRS as being both (1) most responsive and (2) able to detect sex differences in pain intensity. The results also provide support for the validity of the scales for use in Portuguese samples.

Pain measurement: Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS) in clinical trials with OTC analgesics in headache

AIM

The aim was to assess the performance of the Visual Analogue Scale (VAS) in patients recruited in a clinical trial with over the counter analgesics in headache.

METHODS

The Thomapyrin Study showed the significant superiority of the fixed combination of acetylsalicylic acid + paracetamol + caffeine over the combination without caffeine, the single preparations, and placebo in the treatment of headache. Patients enrolled into the study were trained in the handling of the VAS by naming categories of a 6-point Verbal Rating Scale (VRS). These data were used to evaluate the level of order consistency between the VAS and VRS, to deduce cut-off points for rescaling the continuous VAS into a discrete ordinal scale using the receiver operating characteristic methodology, and to assess the test-retest performance.

RESULTS

Approximately 75% of the patients recorded the pain intensity on the VAS in the same order as given on the VRS. However, in 12.6% of patients, the German terms 'leicht' (mild) and 'mäßig' (moderate) were mixed up regarding their order on the VAS. Substantial overlapping of the frequency distributions of the VAS assessment were found for the VRS categories mild and moderate pain as well as severe and very severe pain. Grouping of the VAS assessments into a discrete ordinal scale necessitated a non-equidistant rescaling based on the categories of the VRS. By means of analysis of the receiver operating characteristic curves, the following cut-off points were determined on a 100 mm VAS: no pain 0-2 mm, mild pain 2-17 mm, moderate pain 17-47 mm, severe pain 47-77 mm, very severe pain 77-96 mm, most severe pain imaginable 96-100 mm. Repeated assessment up to several months after the first assessment demonstrated a test-retest agreement on the VAS in 61.0-91.4% of the patients, depending on the VRS category.

CONCLUSIONS

This study shows that the VRS categories cannot be presented in an equidistant manner on the VAS, and that contrary to previous assumptions, the pain intensity descriptors are less clear and can have different meanings in different languages. Therefore, both in the 3rd edition of the International Headache Classification (ICHD-III) and in the guidelines for clinical trials of patients with headache illnesses, rather than a 4-grade VRS, a 6-grade or higher level VRS or a VAS should be recommended, with correspondingly broadly defined anchor points.

Medical rehabilitation of people with spinal cord injury during 40 years of academic physiatric practice

There are many different paths that lead to an academic physiatric career and a lifelong interest in spinal cord injury (SCI) medicine. It is unfortunate that after decades of cellular-based research in multiple laboratories, there are still no interventions available that can reverse the neurologic loss that follows SCI. In contrast, medical rehabilitation research during the last 40 yrs has led to remarkable improvements in the lives of persons with SCI as evident in their increased life expectancy, shorter hospitalizations, fewer rehospitalizations, and more effective treatments for male sexual dysfunction and fertility, as well as spasticity, heterotrophic ossification, and neuropathic pain. Application of modern technology has improved the mobility of persons with SCI with better designed wheelchairs, decreased their dependency on others, facilitated their access to information, made communication and community integration easier, and so on. Although deaths related to urinary tract complications are now rare, better methods of managing the neurogenic bladder are still needed. Furthermore, better management methods are also needed for the neurogenic bowel, SCI pain, and osteoporosis of the paralyzed limbs. Even with proper prophylaxis, deep vein thrombosis and pulmonary embolism are still common, and clinicians have paid too little attention to reducing the risk for persons with SCI of developing obesity, diabetes mellitus, and cardiovascular disease. These challenges need to be met by medical rehabilitation research, by advocating for insurance policies that support the healthcare needs of persons with SCI, and by developing comprehensive disability policies, all with the support and leadership of academic physiatrists.