Reliability and responsiveness of three different pain assessments

Pulsed Shortwave (Radiofrequency) Therapy With a Noninvasive, Wearable, Disposable Device: A Randomized, Participant- and Assessor-Masked, Sham-Controlled Pilot Study

OBJECTIVES

Pulsed shortwave therapy (PSWT) is a nonpharmacologic/noninvasive modality that may offer analgesic benefits without notable side effects or complications. This pilot study aimed to assess the feasibility of a PSWT protocol and provide an estimate of its treatment effects.

MATERIALS AND METHODS

The study included adults who underwent cholecystectomy or unilateral total hip or knee arthroplasty. Participants were randomized to eight days of either PSWT with a single functioning device (SofPulse, Endonovo Therapeutics, Woodland Hills, CA) or a sham device placed over the surgical bandages in a participant- and assessor-masked fashion. The primary end point was the sum of the average and worst (maximum) daily pain intensity as measured with the numeric rating scale collected over the first seven postoperative days.

RESULTS

No systemic side effects or significant complications occurred. During the first seven postoperative days, the sum of the daily pain intensity scores in the active group was a mean (SD) of 28 (11) vs 34 (14) in sham: difference -6.5 (95% CI, -12.4 to -0.6), p = 0.032. During the same period, cumulative oxycodone consumption in the active group was a mean (SD) of 4.6 (4.9) mg vs 5.1 (7.3) mg in sham: difference -0.5 (95% CI, -3.4 to 2.5), p = 0.761. Subgroup analysis suggested that the analgesic effect for knee arthroplasty was greater than for the other surgical procedures.

CONCLUSIONS

PSWT is feasible for inpatients and outpatients, and reduced pain over the first postoperative week. These results are preliminary and should be replicated with a subsequent study before being considered definitive. Although this pilot study was inadequately powered to conclusively identify statistically significant differences between treatments for the secondary end points, if the analgesic improvements are successfully replicated in a definitive trial, they would meet or exceed the benefits identified for oral acetaminophen. Data from this pilot study may be used to help plan future trials.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT05796583.

Wearable, noninvasive, pulsed shortwave (radiofrequency) therapy for postoperative analgesia: A randomized, double-masked, sham-controlled pilot study

BACKGROUND

Nonthermal, pulsed shortwave (radiofrequency) therapy (PSWT) is a nonpharmacologic, noninvasive modality that limited evidence suggests provides analgesia. Its potential favorable risk-benefit ratio stems from its lack of side effects and significant medical risks, applicability to any anatomic location, long treatment duration, and ease of application by simply affixing it with tape. Even with a relatively small treatment effect, PSWT might contribute to a multimodal analgesic regimen, similar to acetaminophen. However, widespread clinical use is hindered by a lack of systematic evidence. The current randomized, controlled pilot study was undertaken to determine the feasibility and optimize the protocol for a subsequent definitive investigation and estimate the treatment effect of PSWT on postoperative pain and opioid consumption.

METHODS

Within the recovery room following primary knee and hip arthroplasty, cholecystectomy, hernia repair, and non-mastectomy breast surgery, we applied 1-3 PSWT devices (Model 088, BioElectronics Corporation, Frederick, Maryland) over the surgical bandages. Participants were randomized to 28 days of either active or sham treatment in a double-masked fashion. The outcomes of primary interest were the cumulative opioid consumption and the mean of the "average" and "worst" daily pain measured with the Numeric Rating Scale over the first 7 postoperative days.

RESULTS

During the first 7 postoperative days, oxycodone consumption in participants given active treatment (n = 55) was a mean (SD) of 21 mg (24) versus 17 mg (26) in patients given sham (n = 57): difference 4 (95% CI, -5 to 13), p = 0.376. During this same period, the "average" daily pain intensity in patients given active treatment was 2.4 (1.6) versus 2.6 (1.7) in sham: difference -0.2 (95% CI -0.8 to 0.5), p = 0.597. Concurrently, the worst/maximum pain for the active group was 4.6 (2.0) versus 4.7 (2.1) in sham: difference -0.1 (95% CI -0.8 to 0.7), p = 0.888. No device-related systemic side effects or serious adverse events were identified.

CONCLUSIONS

Pulsed shortwave (radiofrequency) therapy did not reduce pain scores and opioid requirements to a statistically significant or clinically relevant degree during the initial postoperative week in this pilot study. These results must be replicated with a subsequent study before being considered definitive. Data from this preliminary study may be used to help plan future trials.

Pain Management Following Total Hip Arthroplasty With Percutaneous Auricular Stimulation (Neuromodulation): A Randomized, Double-Masked, Sham-Controlled Pilot Study

Objectives Percutaneous auricular neuromodulation involves implanting electrodes around the ear and administering an electric current. A device is currently available in the United States, cleared to treat symptoms from opioid withdrawal, with multiple reports suggesting a possible postoperative analgesic effect. This randomized, controlled pilot study aimed to (1) assess the feasibility of a postoperative auricular neuromodulation protocol and (2) provide an estimate of its treatment effects on postoperative pain and opioid consumption following total hip arthroplasty. Methods Adults undergoing unilateral, primary, total hip arthroplasty received an auricular neuromodulation device (NSS-2 BridgeTM, Masimo, Irvine, California) applied following surgery. Participants were randomized to five days of either electrical stimulation or sham in a double-masked fashion and discharged home with their devices in situ. Participants or their caretakers removed the devices at home. Results One participant randomized to active treatment removed the device the morning of postoperative day one and withdrew from the study prior to any data collection. The remaining 29 participants were included in the analysis. For the first primary outcome measure, the median (IQR) pain level in the first five days for those receiving active stimulation (n=14) was 2.5 (1.0, 3.8) versus 3.0 (1.9, 4.0) for the sham group (n=15) (P=0.721). Concurrently, the median oxycodone use for the active stimulation group was 3.5 mg (0.1, 9.5) compared to 9.0 mg (2.0, 15.3) for the sham group (P=0.263). No statistically significant differences between treatments were identified for any of the secondary outcome measures. The protocol was successful regarding participant recruitment, intervention administration, data collection, outcomes assessment, and analysis. Six participants (three from each treatment group) removed their device prior to postoperative day five due to either difficulty sleeping while using the device or pain at one of the electrode sites. Conclusions While this randomized, controlled pilot study demonstrated the feasibility of using percutaneous auricular nerve stimulation following total hip arthroplasty for both the inpatient and outpatient portions of the postoperative period, it failed to identify improvements in analgesia, opioid-sparing, or pain interference in psychological and physical functioning. Therefore, it remains unclear whether a definitive clinical trial is warranted to investigate its use following total hip arthroplasty. Further research is advisable, possibly with a different auricular neuromodulation device and larger sample sizes.

Percutaneous auricular neuromodulation (nerve stimulation) for the treatment of pain following total knee arthroplasty: a randomized, double-masked, sham-controlled pilot study

BACKGROUND

Percutaneous auricular nerve stimulation (neuromodulation) is an analgesic technique involving the percutaneous implantation of multiple leads at various points on/around the ear followed by the delivery of electric current using an external pulse generator. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized, controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following total knee arthroplasty.

METHODS

Within the recovery room following primary, unilateral, total knee arthroplasty, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied using three percutaneous leads and one ground electrode. Participants were randomized to 5 days of either electrical stimulation or sham stimulation in a double-masked fashion. Participants were discharged with the stimulator in situ and removed the disposable devices at home. The dual primary treatment effect outcome measures were the cumulative opioid use (oral oxycodone) and the mean of the "average" daily pain measured with the Numeric Rating Scale for the first 5 postoperative days.

RESULTS

During the first five postoperative days, oxycodone consumption in participants given active stimulation (n=15) was a median (IQR) of 4 mg (2-12) vs 13 mg (5-23) in patients given sham (n=15) treatment (p=0.039). During this same period, the average pain intensity in patients given active stimulation was a median (IQR) of 2.5 (1.5-3.3) vs 4.0 (3.6-4.8) in those given sham (p=0.014). Awakenings due to pain over all eight postoperative nights in participants given active stimulation was a median (IQR) of 5 (3-8) vs 11 (4-14) in those given sham (p<0.001). No device-related localized cutaneous irritation, systemic side effects, or other adverse events were identified.

CONCLUSIONS

Percutaneous auricular neuromodulation reduced pain scores and opioid requirements during the initial week after total knee arthroplasty. Given the ease of application as well as the lack of systemic side effects and reported complications, a definitive clinical trial appears warranted.

TRIAL REGISTRATION NUMBER

NCT05521516.

Identification of Pain through Actigraphy-Recorded Patient Movement: A Comprehensive Review

Chronic pain affects over 50 million people in the United States, particularly older adults, making effective assessment and treatment essential in primary care. Actigraphy, which monitors and records limb movement to estimate wakefulness and sleep, has emerged as a valuable tool for assessing pain by providing insights into activity patterns. This review highlights the non-invasive, cost-effective nature of actigraphy in pain monitoring, along with its ability to offer continuous, detailed data on patient movement. However, actigraphy's reliance on physical activity as a proxy for pain, and its inability to directly measure pain intensity, limit its applicability to certain pain types, such as neuropathic pain. Further research is needed to overcome these limitations and to improve the effectiveness of actigraphy in diverse clinical settings.

Investigation of the effects of different treatment approaches on lumbar stabilizer muscles and diaphragm motility in individuals with chronic low back pain

Objectives

This study aimed to examine effects of core stabilization and aerobic exercises on lumbar stabilizer muscles and diaphragm motility in individuals with chronic low back pain (CLBP).

Patients and methods

Fifty-one patients (19 males, 32 females; mean age: 32.7±8.8 years; range, 20 to 60 years) with CLBP were included in this randomized controlled trial between March 2021 and May 2022. The patients were divided into three groups: the core group, the aerobic group, and the control group. Conventional treatments (hotpack, transcutaneous electrical nerve stimulation, ultrasound, and McKenzie exercises) were applied to all three patient groups. The core group received core stabilization exercises, and the aerobic group received aerobic exercises. The control group received only conventional treatments. Exercises were continued for six weeks. All patients were assessed through the Beck Depression Inventory (BDI), Visual Analog Scale (VAS), Roland Morris Disability Questionnaire (RMDQ), and Nottingham Health Profile (NHP). Trunk flexor and extensor strength, as well as trunk flexor and back extensor endurance, was examined. Structural features of the multifidus (MF), transversus abdominis (TrA), external oblique (EO), internal oblique (IO), and diaphragm muscles, as well as diaphragm motility, were evaluated with ultrasound imaging. All measurements were repeated before and after six weeks of treatment.

Results

In all groups, post-treatment values of VAS rest/activity, trunk flexor endurance, back extensor endurance, trunk flexor/extensor muscle strength, BDI, RMDQ and, NHP scores improved significantly compared to pre-treatment (p=0.001). Resting and contraction thicknesses of TrA, MF, EO, and IO muscles increased significantly in both the core (p=0.001/0.001, p=0.001/0.002, p=0.001/0.001, and p=0.001/0.001, respectively) and aerobic groups (p=0.001/0.013, p=0.002/0.020, p=0.001/0.004, and p=0.001/0.010, respectively), while the control group did not show any significant difference (p=0.229/0.064, p=0.052/0.102, p=0.069/0.449, and p=0.094/0.146, respectively). After treatment, all groups showed significant increments in end-expiratory thickness (p=0.001), end-inspiratory thickness (p=0.001), motility of diaphragm during normal breathing (control, p=0.003; core, p=0.001; aerobic, p=0.001), and deep breathing (control, p=0.007; core, p=0.001; aerobic, p=0.001).

Conclusion

While aerobic and core stabilization exercises provided significant improvements in individuals with CLBP, the core stabilization group showed the best improvement in all parameters. Accordingly, the necessity of aerobic and core stabilization exercises in treatment programs comes to the fore in individuals with CLBP.

Abnormal Static Sagittal Cervical Curvatures following Motor Vehicle Collisions: A Retrospective Case Series of 41 Patients before and after a Crash Exposure

Previous investigations have found a correlation between abnormal curvatures and a variety of patient complaints such as cervical pain and disability. However, no study has shown that loss of the cervical curve is a direct result of exposure to a motor vehicle collision (MVC). This investigation presents a retrospective consecutive case series of patients with both a pre-injury cervical lateral radiograph (CLR) and a post-injury CLR after exposure to an MVC. Computer analysis of digitized vertebral body corners on CLRs was performed to investigate the possible alterations in the geometric alignment of the sagittal cervical curve.

METHODS

Three spine clinic records were reviewed over a 2-year period, looking for patients where both an initial lateral cervical X-ray and an examination were performed prior to the patient being exposed to a MVC; afterwards, an additional exam and radiographic analysis were obtained. A total of 41 patients met the inclusion criteria. Examination records of pain intensity on numerical pain rating scores (NPRS) and neck disability index (NDI), if available, were analyzed. The CLRs were digitized and modeled in the sagittal plane using curve fitting and the least squares error approach. Radiographic variables included total cervical curve (ARA C2-C7), Chamberlain's line to horizontal (skull flexion), horizontal translation of C2 relative to C7, segmental translations (retrolisthesis and anterolisthesis), and circular modelling radii.

RESULTS

There were 15 males and 26 females with an age range of 8-65 years. Most participants were drivers (28) involved in rear-end impacts (30). The pre-injury NPRS was 2.7 while the post injury was 5.0; p < 0.001. The NDI was available on 24/41 (58.5%) patients and increased after the MVC from 15.7% to 32.8%, p < 0.001. An altered cervical curvature was identified following exposure to MVC, characterized by an increase in the mean radius of curvature (265.5 vs. 555.5, p < 0.001) and an approximate 8° reduction of lordosis from C2-C7; p < 0.001. The mid-cervical spine (C3-C5) showed the greatest curve reduction with an averaged localized mild kyphosis at these levels. Four participants (10%) developed segmental translations that were just below the threshold of instability, segmental translations < 3.5 mm.

CONCLUSIONS

The post-exposure MVC cervical curvature was characterized by an increase in radius of curvature, an approximate 8° reduction in C2-C7 lordosis, a mild kyphosis of the mid-cervical spine, and a slight increase in anterior translation of C2-C7 sagittal balance. The modelling result indicates that the post-MVC cervical sagittal alignment approximates a second-order buckling alignment, indicating a significant alteration in curve geometry. Future biomechanics experiments and clinical investigations are needed to confirm these findings.

How to make calibration less painful-A proposition for an automatic, reliable and time-efficient procedure

In behavioral and neurophysiological pain studies, multiple types of calibration methods are used to quantify the individual pain sensation stimuli. Often, studies lack a detailed calibration procedure description, data linearity, and quality quantification and omit required control for sex pain differences. This hampers study repetition and interexperimental comparisons. Moreover, typical calibration procedures require a high number of stimulations, which may cause discomfort and stimuli habituation among participants. To overcome those shortcomings, we present an automatic calibration procedure with a novel stimuli estimation method for intraepidermal stimulation. We provide an in-depth data analysis of the collected self-reports from 70 healthy volunteers (37 males) and propose a method based on a dynamic truncated linear regression model (tLRM). We compare its estimates for the sensation (t) and pain (T) thresholds and mid-pain stimulation (MP), with those calculated using traditional estimation methods and standard linear regression models. Compared to the other methods, tLRM exhibits higher R2 and requires 36% fewer stimuli applications and has significantly higher t intensity and lower T and MP intensities. Regarding sex differences, t and T were found to be lower for females compared to males, regardless of the estimation method. The proposed tLRM method quantifies the calibration procedure quality, minimizes its duration and invasiveness, and provides validation of linearity between stimuli intensity and subjective scores, making it an enabling technique for further studies. Moreover, our results highlight the importance of control for sex in pain studies.

The effect of neck-specific exercise and prescribed physical activity on headache and dizziness in individuals with cervical radiculopathy: Further analyses of a randomized study with a 1-year follow-up

OBJECTIVE

To evaluate the effect of neck-specific exercise (NSE) compared to prescribed physical activity (PPA) on headache and dizziness in individuals with cervical radiculopathy (CR). Also, to investigate associations between headache or dizziness and pain, neck muscle endurance (NME), neck mobility, physical activity, and fear avoidance beliefs.

METHODS

Individuals randomized to either NSE or PPA were selected to a headache subgroup (n = 59) and/or a dizziness subgroup (n = 73). Data were evaluated, according to headache and/or dizziness outcomes at baseline and at 3, 6, and 12-month follow-ups.

RESULTS

No significant between-group differences were found between NSE and PPA in either subgroup. In the headache subgroup, significant within-group improvements were seen at all follow-ups for NSE (p < .001) and from baseline to 3 (p = .037) and 12 (p = .003) months for PPA. For dizziness, significant within-group improvements were seen from baseline to 3 months for NSE (p = .021) and from baseline to 3 (p = .001) and 6 (p = .044) months for PPA. Multiple regression models showed significant associations at baseline between headache intensity and neck pain (adjusted R-square = 0.35, p < .001), and for dizziness with neck pain and dorsal NME (adjusted R-square = 0.34, p < .001).

CONCLUSION

NSE and PPA show similar improvements in headache intensity and dizziness in individuals with CR. Headache intensity is associated with neck pain, and dizziness with neck pain and dorsal NME, highlighting the importance of these factors when evaluating headache and dizziness.

Joint position sense testing at the wrist and its correlations with kinesiophobia and pain intensity in individuals who have sustained a distal radius fracture: A cross-sectional study

BACKGROUND

Sensorimotor impairment following distal radius fracture (DRF) has been associated with a significant decline in function. Joint position sense (JPS) testing is a meaningful and responsive way to assess sensorimotor impairment for individuals who have sustained a DRF; however, there are factors that may influence the results of JPS testing, including kinesiophobia and pain intensity.

PURPOSE

This study aimed to evaluate the influence kinesiophobia may have on wrist JPS testing and if pain intensity impacts kinesiophobia and JPS in individuals with a DRF.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Participants referred from two medical centers with a diagnosis of DRF treated with at least 3 weeks of immobilization were enrolled in the study. Data were collected at 1 week and 6 weeks postimmobilization period. Demographics were summarized with descriptive statistics, and linear relationships between kinesiophobia, pain intensity, and wrist JPS were examined using Pearson correlation coefficient.

RESULTS

Forty-eight participants were included in this study (mean age 42.9 years). Significant positive correlations were found between the Tampa Scale for Kinesiophobia (TSK) and Numeric Rating Scale (NRS; r = 0.951, p < 0.001), TSK and JPS error (r = 0.942, p < 0.001), as well as NRS and JPS error (r = 0.898, p < 0.001). These correlations indicate that higher levels of kinesiophobia are associated with increased pain intensity and greater JPS error. T-tests reveal no significant difference between male and female for the TSK, NRS, or JPS scores.

CONCLUSIONS

There is an association for individuals with high levels of kinesiophobia and both greater pain and errors with JPS testing.

Early post-surgical rehabilitation and functional outcomes of a traumatic ulnar nerve injury: a pediatric case report

Background

Peripheral nerve injuries (PNIs) of the upper limb are very common events within the pediatric population, especially following soft tissue trauma and bone fractures. Symptoms of brachial plexus nerve injuries can differ considerably depending on the site and severity of injury. Compared to median and radial nerves, the ulnar nerve (UN) is the most frequently and severely injured nerve of the upper extremity. Indeed, due to its peculiar anatomical path, the UN is known to be particularly vulnerable to traumatic injuries, which result in pain and substantial motor and sensory disabilities of the forearm and hand. Therefore, timely and appropriate postoperative management of UN lesions is crucial to avoid permanent sensorymotor deficits and claw hand deformities leading to lifelong impairments. Nevertheless, the literature regarding the rehabilitation following PNIs is limited and lacks clear evidence regarding a solid treatment algorithm for the management of UN lesions that ensures full functional recovery.

Case presentation

The patient is a 11-year-old child who experienced left-hand pain, stiffness, and disability secondary to a domestic accident. The traumatic UN lesion occurred about 8 cm proximal to Guyon's canal and it was surgically treated with termino-terminal (end-to-end) neurorrhaphy. One month after surgery, the patient underwent multimodal rehabilitative protocol and both subjective and functional measurements were recorded at baseline (T0) and at 3- (T1) and 5-month (T2) follow-up. At the end of the rehabilitation protocol, the patient achieved substantial reduction in pain and improvement in quality of life. Of considerable interest, the patient regained a complete functional recovery with satisfactory handgrip and pinch functions in addition with a decrease of disability in activities of daily living.

Conclusion

A timely and intensive rehabilitative intervention done by qualified hand therapist with previous training in the rehabilitation of upper limb neuromuscular disorders is pivotal to achieve a stable and optimal functional recovery of the hand, while preventing the onset of deformities, in patients with peripheral nerve injuries of the upper limb.

Improvements after dry needling for craniofacial pain in a patient with chronic rhinosinusitis: a case report

BACKGROUND

Typically treated medically, chronic rhinosinusitis (CRS) is a prevalent condition characterized by multiple craniofacial symptoms, some of which may respond favorably to dry needling intervention.

OBJECTIVE

To describe the outcomes of a patient presenting with craniofacial pain and symptoms consistent with a diagnosis of CRS who was treated with dry needling. Case Description: A 41-year-old male, self-referred to physical therapy with a diagnosis of CRS, with a 20-year history of signs and symptoms associated with CRS, including craniofacial pain and headaches. The patient had been treated with multiple medication regimens over this time, including antihistamines, anti-inflammatories, decongestants, leukotriene inhibitors, and antibiotics; all of which provided only short-term relief. On initial examination, the patient was tender to palpation in multiple muscles of the head, neck, and face. Intervention consisted of dry needling to these muscular tender points once or twice weekly over 2 months.

OUTCOMES

After 2 months of dry needling, the patient demonstrated clinically meaningful improvements in pain and quality of life, which included a decrease in both medication usage and the frequency of sinus infections.

CONCLUSION

Although CRS is generally managed medically, we observed areas of muscular tenderness in this case, which were effectively managed with dry needling. Rehabilitative providers may consider screening CRS patients for muscular impairments that may be modifiable with dry needling. Further research should be performed to determine whether dry needling has a role in the management of CRS.

Translation and validation of the Pelvic Girdle Questionnaire in the Urdu language

INTRODUCTION AND HYPOTHESIS

The Pelvic Girdle Questionnaire (PGQ) is designed to determine pain and limited activities in pregnant and postpartum women with pelvic girdle pain (PGP). The purpose of this study was to translate the PGQ into the Urdu language and find out the cross-cultural validity and reliability of the Urdu PGQ among pregnant and postpartum women.

METHODS

A translation and cultural adaptation study was performed following international guidelines. The PGQ (the Urdu version) was drafted and a pilot study was conducted on 16 pregnant and postpartum women. A total of 125 pregnant and postpartum females participated in this study for validity and test-retest reliability. SPSS 25 was used for data analysis.

RESULTS

Content validity was analyzed by the content validity index ranging from (0.92 to 1). Convergent validity was determined by correlating the Urdu version of the PGQ with the Oswestry Disability Index (ODI). Pearson rank correlation coefficient between the PGQ and the ODI (p=0.84) showed convergent validity. Internal consistency and test-retest reliability of the Urdu version of the PGQ were calculated by Cronbach's alpha (α=0.98), and intra-class correlation coefficient (ICC=0.98) respectively.

CONCLUSION

The Urdu version of the PGQ showed good content and convergent validity as well as high internal consistency and test-retest reliability.

Neurocognitive Functioning in Patients with Painful Temporomandibular Disorders

Aim

To investigate psychosocial factors in painful TMD (pTMD) which could have consequences for mastering chronic pain.

Methods

Our study included 22 patients (20 women, 2 men) with pTMD, refractory to conservative treatment, and 19 healthy controls. The control group was matched for gender, age, and educational level, and IQ tested on the Wechsler Abbreviated Scale of Intelligence. Neurocognitive function was tested with the Color-Word Interference Test (CWIT). Pain intensity was reported according to the General Pain Intensity Questionnaire (GPI), using the Numeric Rating Scale (NRS). Self-perceived cognitive difficulties were reported by the Perceived Deficits Questionnaire-Depression 5-item (PDQ-5). Two measures of rumination were included: the Rumination-Reflection Questionnaire (RRQ) and the Ruminative Response Scale (RRS). The Montgomery Åsberg Depression Rating Scale Self-report (MADRS-S) was used to measure depressive symptoms, and the Oral Health Impact Profile-TMD (OHIP-TMD) to measure QoL related to oral health.

Results

There were no statistical differences in age (median pTMD: 55 years, median control: 53 years), educational level, and IQ between pTMD and controls. Median pain intensity in pTMD was NRS 8 at maximum and the median pain duration was 18 years. There were no significant differences in CWIT between pTMD and controls. Self-perceived cognitive function (PDQ) was significantly poorer in pTMD. Rumination scores from both measures, and the depression score from MADRS, were significantly higher in pTMD. The OHIP-TMD score revealed a significantly poorer QoL in pTMD.

Conclusion

The group of pTMD patients have self-perceived cognitive difficulties that may make it more difficult to master chronic pain and common everyday tasks. They reported significantly more self-perceived cognitive difficulties, higher rumination, more depressive symptoms, and lower QoL compared to healthy controls, suggesting that these psychosocial factors could be targeted in treatment and interventions. However, the tested neurocognitive performance was equivalent to the control group.

Is Thoracic Kyphosis Relevant to Pain, Autonomic Nervous System Function, Disability, and Cervical Sensorimotor Control in Patients with Chronic Nonspecific Neck Pain?

There is great interest in thoracic kyphosis, as it is thought to be a contributor to neck pain, neck disability, and sensorimotor control measures; however, this has not been completely investigated in treatment or case control studies. This case control design investigated participants with non-specific chronic neck pain. Eighty participants with a defined hyper-kyphosis (>55°) were compared to eighty matched participants with normal thoracic kyphosis (<55°). Participants were matched for age and neck pain duration. Hyper-kyphosis was further categorized into two distinct types: postural kyphosis (PK) and Scheuermann's kyphosis (SK). Posture measures included formetric thoracic kyphosis and the craniovertebral angle (CVA) to assess forward head posture. Sensorimotor control was assessed by the following measures: smooth pursuit neck torsion test (SPNT), overall stability index (OSI), and left and right rotation repositioning accuracy. A measure of autonomic nervous system function included the amplitude and latency of skin sympathetic response (SSR). Differences in variable measures were examined using the Student's t-test to compare the means of continuous variables between the two groups. One-way ANOVA was used to compare mean values in the three groups: postural kyphosis, Scheuermann's kyphosis, and normal kyphosis group. Pearson correlation was used to evaluate the relationship between participant's thoracic kyphosis magnitude (in each group separately and as an entire population) and their CVA, SPNT, OSI, head repositioning accuracy, and SSR latency and amplitude. Hyper-kyphosis participants had a significantly greater neck disability index compared to the normal kyphosis group (p < 0.001) with the SK group having greatest disability (p < 0.001). Statistically significant differences between the two kyphosis groups and the normal kyphosis group for all the sensorimotor measured variables were identified with the SK group having the most decreased efficiency of the measures in the hyper-kyphosis group, including: SPNT, OSI, and left and right rotation repositioning accuracy. In addition, there was a significant difference in neurophysiological findings for SSR amplitude (entire sample of kyphosis vs. normal kyphosis, p < 0.001), but there was no significant difference for SSR latency (p = 0.07). The CVA was significantly greater in the hyper-kyphosis group (p < 0.001). The magnitude of the thoracic kyphosis correlated with worsening CVA (with the SK group having the smallest CVA; p < 0.001) and the magnitude of the decreased efficiency of the sensorimotor control measures and the amplitude and latency of the SSR. The PK group, overall, showed the greatest correlations between thoracic kyphosis and measured variables. Participants with hyper-thoracic kyphosis exhibited abnormal sensorimotor control and autonomic nervous system dysfunction compared to those with normal thoracic kyphosis.

Maximum bilateral bite strength and RMS EMG for the diagnosis of myogenic TMD

Aim: The study aimed to evaluate the accuracy of the maximum bilateral molar bite force and the Root Mean Square (RMS) Electromyography (EMG) index of the masticatory muscles in the maximum bilateral molar bite (MMBMax) of women with myogenic Temporomandibular Disorder (TMD) and asymptomatic. Methods: This is a cross-sectional study, composed of 86 women allocated to the TMD Group (n=43) and Control Group (n=43) diagnosis through the Diagnostic Criteria for Temporomandibular Disorders. The maximum bilateral molar bite force was evaluated using a bite dynamometer and the RMS EMG index of the masticatory muscles (anterior temporalis, masseter) during 5 seconds of the MMBMax task. Student t-test was used for data comparison between accuracy of the bite force and RMS EMG of masticatory muscles during the MMBMax. Results: The maximum bilateral molar bite force showed high accuracy (AUC=0.99) for the diagnosis of women with myogenic TMD and asymptomatic women, and the RMS EMG index evaluated during the MMBMax showed a moderate level of accuracy for all masticatory muscles (AUC=0.70 to 0.75). Conclusion: The bilateral bite dynamometer with a surface EMG during bilateral bite can be used to diagnose TMD in young women.

Botulinum Toxin and Dynamic Splint Restore Grasping Function after Stroke: A Case Report

Evidence on the effectiveness of upper extremity rehabilitation post-stroke is inconclusive. We evaluated a tailored therapeutic program with dynamic splint and botulinum toxin injections for the treatment of upper extremity muscle spasticity. A case of a 43-year-old woman with chronic spastic hemiparesis after ischemic stroke with significant mobility impairment in the left upper extremity was described. A 16-week program consisted of three 50-min sessions daily and focused on grasping and releasing with and without the splint. The patient was evaluated before botulinum toxin injection and after 6, 12 and 16 weeks according to the International Classification of Functioning, Disability and Health, and included the following scales: Fugl-Meyer Upper Extremity Assessment (FMA-UE), Modified Ashworth Scale, Numerical Rating Scale (NRS), MyotonPro, Stroke Impact Scale, Box and Blocks. Photographic documentation made before and after the experiment was compared. Motor functions improved by 19.7% on FMA-UE, spasticity was reduced by one degree and pain at rest and during activity decreased by one score on NRS. A reduction in the oscillation frequency of the relaxed muscle and the stiffness of the examined muscles was observed. The patient regained grasping function. Health-related quality of life was systematically improving with a 35% increase at week 16 compared to the baseline. The combination treatment for spasticity based on botulinum toxin and SaeboFlex^® dynamic splint in a patient with chronic spastic hemiparesis reduces disability and improves quality of life. However, further research is needed to investigate the treatment results.

High- Versus Low-Dose Exercise Therapy for Knee Osteoarthritis : A Randomized Controlled Multicenter Trial

BACKGROUND

The benefits of exercise in patients with knee osteoarthritis are well documented, but the optimal exercise dose remains unknown.

OBJECTIVE

To compare high-dose versus low-dose exercise therapy with regard to knee function, pain, and quality of life (QoL) in patients with long-term symptomatic knee osteoarthritis.

DESIGN

A Swedish and Norwegian multicenter randomized controlled superiority trial with multiple follow-ups up to 12 months after the intervention. (ClinicalTrials.gov: NCT02024126).

SETTING

Primary health care facilities.

PATIENTS

189 patients with diagnosed knee osteoarthritis and a history of pain and decreased knee function were assigned to high-dose therapy (n = 98; 11 exercises; 70 to 90 minutes) or low-dose therapy (n = 91; 5 exercises; 20 to 30 minutes).

INTERVENTION

Patient-tailored exercise programs according to the principles of medical exercise therapy. Global (aerobic), semiglobal (multisegmental), and local (joint-specific) exercises were performed 3 times a week for 12 weeks under supervision of a physiotherapist.

MEASUREMENTS

The Knee Injury and Osteoarthritis Outcome Score (KOOS) was measured biweekly during the 3-month intervention period and at 6 and 12 months after the intervention. The primary end point was the mean difference in KOOS scores between groups at the end of the intervention (3 months). Secondary outcomes included pain intensity and QoL. The proportion of patients with minimal clinically important changes in primary and secondary outcomes was compared between groups.

RESULTS

Both groups improved over time, but there were no benefits of high-dose therapy in most comparisons. One exception was the KOOS score for function in sports and recreation, where high-dose therapy was superior at the end of treatment and at 6-month follow-up. A small benefit in QoL at 6 and 12 months was also observed.

LIMITATION

There was no control group that did not exercise.

CONCLUSION

The results do not support the superiority of high-dose exercise over low-dose exercise for most outcomes. However, small benefits with high-dose exercise were found for knee function in sports and recreation and for QoL.

PRIMARY FUNDING SOURCE

Swedish Rheumatic Fund.

Reduction of Thoracic Hyper-Kyphosis Improves Short and Long Term Outcomes in Patients with Chronic Nonspecific Neck Pain: A Randomized Controlled Trial

This study investigates thoracic hyper kyphosis (THK) rehabilitation using the Denneroll™ thoracic traction orthosis (DTTO). Eighty participants, with chronic non-specific neck pain (CNSNP) and THK were randomly assigned to the control or intervention group (IG). Both groups received the multimodal program; IG received the DTTO. Outcomes included formetric thoracic kyphotic angle ICT—ITL, neck pain and disability (NDI), head repositioning accuracy (HRA), smooth pursuit neck torsion test (SPNT) and overall stability index (OSI). Measures were assessed at baseline, after 30 treatment sessions over the course of 10 weeks, and 1-year after cessation of treatment. After 10 weeks, the IG improved more in neck pain intensity (p < 0.0001) and NDI (p < 0.001). No differences were found for SPNT (p = 0.48) and left-sided HRA (p = 0.3). IG improved greater for OSI (p = 0.047) and right sided HRA (p = 0.02). Only the IG improved in THK (p < 0.001). At 1-year follow-up, a regression back to baseline values for the control group was found for pain and disability such that all outcomes favored improvement in the IG receiving the DTTO; all outcomes (p < 0.001). The addition of the DTTO to a multimodal program positively affected CNSNP outcomes at both the short and 1-year follow-up.

Clinical effects of proprioceptive thumb exercise for individuals with carpometacarpal joint osteoarthritis: A randomized controlled trial

STUDY DESIGN

Randomized Control Trial.

INTRODUCTION

Thumb CMC joint OA is a common diagnosis. Currently there is no evidence available to under if proprioceptive neuromuscular training is an effective intervention for this population.

PURPOSE OF THE STUDY

To establish the effectiveness of a proprioceptive training program as a complementary therapy for patients with thumb CMC joint OA.

METHODS

Standard conservative thumb CMC joint OA treatments were received by both the control (n = 26) and experimental groups (n = 26) for a period of 12 weeks. The experimental group received a proprioceptive training program during the same intervention period. Outcome measures included severity of pain with activity according to the numerical rating scale (NRS), QuickDASH, Canadian Occupational Performance Measure (COPM), and proprioception via joint position sense (JPS).

RESULTS

Fifty-two females participated in the study. Both the experimental and control group made both clinically and statistically significant changes in the mean VAS and COPM scores over time. Only the experimental group achieved a statistically and clinically significant change in JPS error score over time.

DISCUSSION

Experimental group achieved a statistically significant change in JPS over time in concordance with previous investigations. Changes in pain scores differed from prior investigations and the between-group comparison was not statistically significant. Changes in the Quick DASH was similar to previous findings.

CONCLUSION

Proprioceptive training in addition to a traditional rehabilitation program decreased error scores on the joint position sense test.

High Pain Intensity is a Risk Factor of Non-Resolving TMD: A Three-Year Follow-Up of a Patient Group in a Norwegian Interdisciplinary Evaluation Program

Purpose

To investigate the outcome of patients with long-term refractory temporomandibular disorders (TMD) three years after a Norwegian interdisciplinary evaluation program with attention to patient satisfaction, function, pain, and psychosocial variables.

Patients and Methods

The study population consisted of 60 long-term refractory TMD patients who were investigated by a Norwegian interdisciplinary team. A questionnaire that covered medical history, function, pain, lifestyle factors, TMD-status and follow-up from their general medical practitioner (GMP) was sent to the patients three years after the evaluation. Questionnaires that assessed function (Mandibular Functional Index Questionnaire [MFIQ] and Roland Morrison Scale [RMS]), pain intensity (General Pain Intensity questionnaire [GPI]) and psychosocial factors (Hospital Anxiety and Depression scale [HADS]); a 2-item version of the Coping Strategies Questionnaire [CSQ]) were included in the package.

Results

Thirty-nine out of 60 TMD patients completed the questionnaires. Improvements in TMD symptoms were reported in 10 patients (26%), were unchanged in 16 patients (41%) and worsened in 13 patients (33%). Only 8 patients (21%) were satisfied with the follow-up of the suggested treatments from their GMP. Significant improvements of symptoms were noted in MFIQ (jaw function), GPI (including pain intensity at maximum and suffering from pain), and CSQ (pain related catastrophizing), in all 39 TMD patients as one group. However, a subgroup analysis showed that the significant improvements were mostly within patients who reported improvement of TMD symptoms. A high pain intensity at baseline was a significant risk factor (OR = 5.79, 95% CI: 1.34, 24.96) for patients who reported worsening of TMD symptoms at follow-up.

Conclusion

High pain intensity at baseline was a significant risk factor for poorer recovery three years after an interdisciplinary evaluation. Our data support the notion that improved coping with TMD pain includes both decreased pain intensity, CSQ and MFIQ scores.

The Effect of Proprioception Training on Pain Intensity in Thumb Basal Joint Osteoarthritis: A Randomized Controlled Trial

A randomized controlled trial of forty-five females over 18 years of age with diagnosis of thumb basal osteoarthritis in their dominant hand and with a minimum pain rating of 4/10 on the Visual Analogue Scale (VAS) during activities of daily living (ADLs) were recruited from March to June 2021. The group receiving proprioception training was compared to routine conservative physiotherapy treatment. The main purpose of this clinical trial is to test the effect of proprioception training on pain intensity in subjects with thumb osteoarthritis. Primary outcome was joint position sense (JPS) for the assessment of CMC proprioception and secondary outcomes were Visual Analogue Scale (VAS) and Canadian Occupational Performance Measure (COPM) for the assessment of patient satisfaction and the Quick-DASH which assessed upper limb function. A block randomization was carried out for the control group (n = 22) and experimental group (n = 23). Participants and evaluator were blinded to the group assignment. Proprioception training produced a statistically significant reduction in pain post intervention, but this reduction was small (d = 0.1) at the 3-month follow-up. JPS accuracy demonstrated statistically significant differences between the groups (p = 0.001) post-intervention and at the 3-month follow-up (p < 0.003). Statistically significant differences between means were found in both the Quick-Dash and COPM post intervention (both, p < 0.001), as well as at the 3-month follow-up (both, p < 0.001). There was a significant time factor for the reduction of pain intensity over time but effect sizes between groups was small at the 3-month follow-up period. Proprioceptive training improves thumb JPS accuracy; however, it does not contribute to a reduction in pain intensity in the long term. The inclusion of a proprioceptive program may be beneficial for improving individuals with thumb CMC OA sensorimotor performance. The study was registered at ClinicalTrials.gov NCT04738201. No funding was provided for this study.

The Management of Multiple Morton's Neuromas in the Same Foot: A Systematic Review

The optimal treatment strategy for the presentation of multiple Morton's neuromas in adjacent intermetatarsal spaces of the same foot is yet to be determined. We aimed to summarize and assess the efficacy of current treatment strategies. A systematic review, adhering to PRIMSA guidelines was performed. A computer base search was completed in PubMed, Embase, Cinahl, ISI Web of Science, Scopus and Emcare, for articles reporting the treatment of multiple neuromas in the same foot. The review is registered in the international prospective register of systematic reviews (CRD42020213631). A total of 253 articles were identified, with 7 articles being included in the review. The most common treatment strategy reported was simultaneous neuroma excision using a single incision, while 2 studies each describe simultaneous excision with 2 separate incisions and delayed excision respectively. There is no strong evidence favoring use of delayed excision or multiple incisions. Further high-quality research is required to make more definitive conclusions and future research should investigate other strategies such as non-operative treatment.

Pain Perception of Patients Undergoing Laser Panretinal Photocoagulation: Comparison of Single-Spot Versus Multispot Techniques

BACKGROUND AND OBJECTIVE

To compare pain intensity with single-spot versus multispot technique in laser panretinal photocoagulation, using a 532-nm, solid-state laser system.

MATERIALS AND METHODS

This was a prospective, interventional, randomized, single-masked comparison trial. Patients received two types of intervention: conventional single-spot technique, with an exposure time of 150 ms, and multispot technique, done with an exposure time of 20 ms, Both techniques used power sufficient to produce visible gray-white burns, and spot size of 20 μm. Participants received both treatments in the same eye, each one in one hemiretina, and were randomized to receive first single- or multispot technique and to the initial site of treatment. We assessed pain intensity using a numerical pain scale immediately after completion of each treatment.

RESULTS

A significantly lower pain scale was observed with the multispot when compared with the single-spot technique (coefficient [Coef]: -1.61; 95% CI, -2.49 to -0.74; P < .001), which was not affected by treatment order, the hemiretina treated, or treatment duration (P > .05). Among demographic characteristics, multiracial patients had a pain scale 1.25 greater than that of White patients (Coef: 1.25; 95% CI, 0.47 to 2.04; P = .002), but there is no effect of age or sex on the pain scale (P > .05). Regarding treatment duration, a shorter procedure was also observed in the multispot technique (Coef: -1.13; 95% CI, -1.43 to -0.82; P < .001), and it was not affected by order of treatment (P = .098), hemiretina (P = .327), pain (P = .141), or demographic data, such as age, sex, and race (P > .05).

CONCLUSION

The use of the multispot technique, with a short pulse duration (20 ms), is significantly less painful and less time-consuming for patients with proliferative retinopathy compared with the conventional single-spot technique using an exposure time of 150 ms. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:40-45.].

Criterion validation and interpretability of the Single Assessment Numerical Evaluation (SANE) of self-reported recovery in patients with neck pain

BACKGROUND

The SANE is a PROM of recovery, which may assist clinicians in clinical decision-making and discharge planning. The psychometric measurement properties of the SANE have yet to be determined for neck pain.

OBJECTIVES

Threefold objectives included: 1)determine the numerical threshold for the SANE at which patients with neck pain determine their symptoms are acceptable; 2)determine the association between scores for the NDI and VAS, with the SANE; 3)determine the average number of visits, costs and value associated with the management of neck pain.

DESIGN

Longitudinal repeated measures cohort design.

METHODS

Threshold measures for self-reported recovery with the SANE anchored to the PASS were examined using ROC. PCC determined the relationship between the VAS/pain and NDI raw/percentage change scores and the SANE at discharge. Descriptive statistics were used for number of visits and cost. Value was calculated as the proportion of change on the NDI and VAS/$100 US dollars spent.

RESULTS

57 subjects completed full observation. ROC analysis indicates a threshold value of 82.5%(Sn = 56.0, Sp = 85.7,+LR = 1.68,-LR = 0.29) on the SANE with an AUC of 0.820(95%CI = 0.638, 1.00). A weak correlation was found between raw NDI(r = 0.39 p < 0.05)/Pain(r = 0.45 p < 0.05) scores and the SANE with a moderate correlation between percent change scores of NDI(r = 0.52 p < 0.05)/PAIN(r = 0.54 p < 0.05) and the SANE. The value proposition indicated cost of care amounted to a 10.5% and 12.9%; improvement in the NDI and pain scores/$100 spent.

CONCLUSIONS

Patients reporting greater than 82.5% on the SANE are likely to find their present status acceptable and potentially stop seeking care.

Randomized cross-over evaluation of investigator gender on pain thresholds in healthy volunteers

Background and aims: This randomized cross-over study in healthy volunteers was designed primarily to evaluate the potential impact of investigator gender on electrical pain threshold (EPT) and corresponding pain intensity levels, and secondly to evaluate potential differences in those interventions between female and male study participants. Methods: Forty adult volunteers (22 females) were included. An electrical stimulation device was used to determine EPT levels (in pain magnitude scores) in series of three in each study participant - once by a female, and once by a male investigator - according to a predefined cross-over design schedule. Corresponding levels of pain intensity were scored on a visual analog scale (VAS) slide ruler. Results: Study data was obtained and analysed in all participants. Significantly higher EPT levels were determined by the female investigator compared with the male investigator (median 22 (IQR 12-31) vs. 8 (6-10) pain magnitude scores; p<0.0001), despite similar levels of reported pain intensity (1.9 (1.2-3.0) vs. 2.0 (1.1-3.4) VAS units; p>0.300). There were no differences in EPT levels between female and male subjects evaluated by female (p>0.300) and male (p=0.125) investigators, or between the first and second series of stimulation (p>0.300). Conclusions: Our finding of significantly higher EPT levels when study participants of both genders - despite no difference in reported pain intensity - were evaluated by a female than by a male investigator, indicates a potential impact of investigator gender on the individual perception of pain. Implications: By contributing to a better understanding of how individual pain threshold levels are potentially influenced by investigator gender, this study might facilitate future evaluation of pain conditions in both preclinical and clinical settings.

Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study

BACKGROUND

Percutaneous peripheral nerve stimulation is an analgesic technique involving the percutaneous implantation of a lead followed by the delivery of electric current using an external pulse generator. Percutaneous peripheral nerve stimulation has been used extensively for chronic pain, but only uncontrolled series have been published for acute postoperative pain. The current multicenter study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent clinical trial and (2) estimate the treatment effect of percutaneous peripheral nerve stimulation on postoperative pain and opioid consumption.

METHODS

Preoperatively, an electrical lead was percutaneously implanted to target the sciatic nerve for major foot/ankle surgery (e.g., hallux valgus correction), the femoral nerve for anterior cruciate ligament reconstruction, or the brachial plexus for rotator cuff repair, followed by a single injection of long-acting local anesthetic along the same nerve/plexus. Postoperatively, participants were randomized to 14 days of either electrical stimulation (n = 32) or sham stimulation (n = 34) using an external pulse generator in a double-masked fashion. The dual primary treatment effect outcome measures were (1) cumulative opioid consumption (in oral morphine equivalents) and (2) mean values of the "average" daily pain scores measured on the 0 to 10 Numeric Rating Scale within the first 7 postoperative days.

RESULTS

During the first 7 postoperative days, opioid consumption in participants given active stimulation was a median (interquartile range) of 5 mg (0 to 30) versus 48 mg (25 to 90) in patients given sham treatment (ratio of geometric means, 0.20 [97.5% CI, 0.07 to 0.57]; P < 0.001). During this same period, the average pain intensity in patients given active stimulation was a mean ± SD of 1.1 ± 1.1 versus 3.1 ± 1.7 in those given sham (difference, -1.8 [97.5% CI, -2.6 to -0.9]; P < 0.001).

CONCLUSIONS

Percutaneous peripheral nerve stimulation reduced pain scores and opioid requirements free of systemic side effects during at least the initial week after ambulatory orthopedic surgery.

EDITOR’S PERSPECTIVE

Immediate changes in trunk muscle activation patterns during a lifting task following an abdominal drawing-in exercise in subjects with recurrent low back pain

BACKGROUND

The abdominal drawing-in exercise could help improve delayed transversus abdominis (TrA) activation during limb movement in subjects with recurrent low back pain (rLBP). However, little is known about whether the same effect is observed during lifting tasks in subjects with rLBP.

OBJECTIVE

This study aimed to clarify whether a single session of abdominal drawing-in exercise could correct the altered trunk muscle activation patterns during a lifting task in subjects with rLBP.

METHODS

Fifteen subjects with rLBP performed lifting tasks before and immediately after three sets of 10 repetitions of isolated TrA voluntary contractions. The time of onset and activation amplitude during the lifting tasks were measured by surface electromyography (EMG) and compared between the trials before and immediately after exercise.

RESULTS

During lifting, the onset of internal abdominal oblique/TrA (IO/TrA) and multifidus activation occurred earlier, the EMG amplitude of IO/TrA increased, and the EMG amplitude of erector spinae and multifidus decreased, compared with the pre-exercise data.

CONCLUSIONS

These results suggest a possibility that the abdominal drawing-in exercise might be effective in improving the muscle recruitment pattern in people with rLBP.

A comparison of mobilization and mobilization with movement on pain and range of motion in people with lateral ankle sprain: A randomized clinical trial

BACKGROUND

Maitland and Mulligan mobilization techniques are two manual therapy methods to increase the range of motion following immobility treatment. The present study was conducted to compare two therapeutic methods, namely mobilization and mobilization with movement (MWM), on the pain and range of motion in people with lateral ankle sprain.

METHODS

A total of 40 individuals with grade two lateral ankle sprain were randomly divided into two groups, including the Maitland's mobilization intervention group, and the Mulligan's mobilization intervention group. Both groups underwent treatment every other day for two consecutive weeks. The pain intensity was measured using the Visual Analogue Scale (VAS), and the ankle dorsiflexion movement range using the Weight Bearing Lunge Test (WBLT) before and one day after the intervention.

RESULTS

There were no significant differences between the two groups in terms of pain (P = 0.297) and range of motion (P = 0.294) before the intervention. Meanwhile, after the intervention, a significant change was observed in both groups in terms of these variables, which indicates the effectiveness of both interventions (P < 0.001) and the greater effect of the mobilization with movement in reducing pain (P = 0.037) and increasing the range of motion (P = 0.021).

CONCLUSIONS

Both techniques significantly improved the range of motion and reduced pain in people with lateral ankle sprain, but Mulligan's technique was significantly more effective among the two, perhaps due to joining active and passive mobilizing tensile forces as well as interaction of afferents and efferents in the reflex arc.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: A Pragmatic Effectiveness Trial of a Nonpharmacologic Alternative for the Treatment of Postoperative Pain

BACKGROUND

Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducer needle followed by the delivery of electric current after needle withdrawal. This modality has been used extensively to treat chronic pain, but only small series have been published involving postoperative pain. The ultimate objective of this study is to determine the postoperative effects of percutaneous PNS following moderately to severely painful ambulatory surgery within a real-world clinical practice setting. The primary hypothesis is that surgical pain and opioid consumption during the initial 7 days after surgery will be reduced by percutaneous PNS compared with usual and customary analgesia (dual primary outcome measures).

DESIGN

A multicenter pragmatic effectiveness trial. We are randomizing participants having painful orthopedic surgical procedures of the upper and lower extremity to receive 14 days of either 1) electrical stimulation or 2) sham in a double-masked fashion. End points are being assessed at various time points over 12 postoperative months.

SUMMARY

The postoperative experience will be much improved if percutaneous PNS provides potent analgesia while concurrently decreasing opioid requirements following painful surgery. Because this modality can be administered for up to 60 days at home, it may provide postoperative analgesia that outlasts surgical pain yet has relatively few risks and, unlike opioids, has no systemic side effects or potential for abuse, addiction, and overdose. Percutaneous PNS has the potential to revolutionize postoperative analgesia as it has been practiced for the past century. This study will inform key stakeholders regarding an evidence-based nonpharmacologic approach to the management of postoperative pain.

Pressure algometry and palpation of the upper limb peripheral nervous system in subjects with hand osteoarthritis are repeatable and suggest central changes

STUDY DESIGN

Case-control study.

INTRODUCTION

A subset of patients with hand osteoarthritis (OA) shows evidence of central pain phenotypes.

PURPOSE OF THE STUDY

To examine whether differences exist in experimental pain responses in the affected and nonaffected sides of patients with unilateral hand OA. To investigate the test-retest reliability of pressure algometry and manual digital palpation in patients with unilateral hand OA.

METHODS

The hand OA group consisted of 20 patients, and the control group consisted of 20 healthy subjects. Pressure pain threshold (PPT) measurements were made 2 times, consisting of 3 repeat trials, each using computerized algometry and manual digital palpation. Grip and key strength (dynamometer), pain (visual analog scale), and function (Disabilities of the Arm, Shoulder and Hand [short version]) were also measured. The 2-way analysis of variance was conducted to determine the differences between sides and groups. Intraclass correlation coefficient (ICC) and standard error of measurement were calculated.

RESULTS

Patients with hand OA had decreased PPTs over the thumb carpometacarpal joint as well as radial and median nerves compared with controls (all P < .01). No significant group effect by side interaction was detected for any measure. The minimal detectable change values needed to detect change in subjects with hand OA were C5-C6 joint (0.3-0.5 kg/cm²), carpometacarpal joint (0.3-0.5 kg/cm²), hamate bone (0.2-0.4 kg/cm²), radial nerve (0.2-0.8 kg/cm²), median nerve (0.3-0.6 kg/cm²), and ulnar nerve (0.2-0.4 kg/cm²) for PPT. Test-retest reliability was calculated for both hands of participants with OA (ICC, 0.98-0.99) and healthy participants (ICC, 0.74-0.99).

DISCUSSION

Although pressure algometry and manual digital palpation are techniques already used in previous studies and have been shown to be reproducible and moderately reliable for joint palpation, this current study suggests that pressure algometry and manual digital palpation could also be reliable methods of determining nerve sensitivity of the radial, ulnar and median nerves in subjects with hand OA.

CONCLUSIONS

Hyperalgesia in patients with hand OA might be associated with clinical measures, and bilateral signs in unilateral OA could suggest central changes.

"Short- and mid-term effects of adding upper cervical manual therapy to a conventional physical therapy program in patients with chronic mechanical neck pain. Randomized controlled clinical trial."

OBJECTIVE

To evaluate the effect of adding an Upper Cervical Translatoric Mobilization (UCTM) or an Inhibitory Suboccipital Technique (IST) to a physiotherapy treatment in the symptomatology and function of mechanical chronic neck pain patients.

DESIGN

Randomized controlled trial.

SETTING

Primary Care Center in Cornellà, Spain.

SUBJECTS

78 patients (64 women), with mean age (SD) of 59.96 (13.30) years with mechanical chronic neck pain were divided in three groups: control, IST and UCTM groups.

INTERVENTIONS

All groups received 15 physiotherapy sessions for three weeks. The UCTM and IST groups added 5 minutes of the assigned technique during six sessions.

MAIN MEASURES

Neck disability index (NDI) and numeric pain rating scale (NPRS) for neck pain were measured baseline, three-weeks and 15-weeks follow-up.

RESULTS

NDI (SD) at baseline, three-weeks and 15-weeks were 11.62 (7.08), 9.65 (6.25), 7.58 (5.64) for the control group, 14.38 (6.92), 8.50 (6.11), 7.12 (4.98) for the IST group and 13.19(7.23), 5.35(6.10), 4.35(2.76) for the UCTM group. NPRS (SD) at baseline, three-weeks and 15-weeks were 58.69 (19.46), 45.19 (23.43), 44.58 (24.08) for the control group; 64.08 (19.26), 42.19 (19.69), 34 (21.14) for the IST group; and 67.65 (20.65), 36.23 (20.10), 39.85 (25.44) for the UCTM group.

CONCLUSIONS

Compared with no treatment, both forms of mobilization were associated with reduced disability at three weeks, and UCTM remained better than control at 15 weeks; there were no significant differences between the two mobilization groups.

TRIAL REGISTRATION

This study was registered in Clinicaltrials.gov (NCT02832232).

Reliability of Visual Analog Scale and Numeric Rating Scale for the Assessment of Disease Activity in Systemic Lupus Erythematosus

OBJECTIVE

To determine the reliability of SLE patients' disease activity measurements.

METHODS

This was a cross-sectional study conducted (August 2016-December 2017) at 2 main public Peruvian hospitals, 1 with a comprehensive lupus care program. Patients assessed their disease activity with a visual analog scale (VAS) (0-100 mm) or a numerical rating scale (NRS) (0-4) before and after their physician's (MD's) assessment. Demographic and disease-related characteristics were recorded. Reliability of patients' disease activity before and after MD's assessment was determined using Spearman rank correlation. Factors possibly associated with this variability were examined with Spearman rank correlation and Mann-Whitney U test.

RESULTS

Two hundred forty, mostly Mestizo, SLE patients were included; mean (SD) age and disease duration (diagnosis) were 34.9 (12.9) years and 10.1 (7.0) years, respectively. The Mexican version of the Systemic Lupus Erythematosus Disease Activity Index was 1.9 (2.7), and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was 1.2 (1.5). The correlations between NRS and VAS before and after the MD's assessment were ρ = 0.839; p < 0.001; and ρ = 0.872; p < 0.001, respectively. Visual analog scale and NRS were higher before than after the MD's assessment (VAS 29.3 [26.5] and 26.5 [24.9], p = 0.052; and NRS (1.5 [1.2] and 1.3 [1.1], p = 0.003); only the comprehensive program explained this variability (p = 0.043). The reliability of VAS and NRS was ρ = 0.917 and ρ = 0.861, p < 0.001, before and after for the comprehensive program and ρ = 0.710 and ρ = 0.785, p < 0.001, for before and after for the regular program.

CONCLUSIONS

Both VAS an NRS are highly reliable. Patients scored higher before than after their physicians' assessment but that these differences were smaller for the patients in the comprehensive care program than in the regular one.

Patients' experiences of early postoperative cognition and its relation to cognitive decline and inflammatory responses: a protocol for a mixed-methods study

INTRODUCTION

In the early weeks after surgery, patients may experience cognitive changes and impaired memory and concentration-changes commonly referred to as postoperative cognitive decline. It is often the patient and/or a relative that initially detects a change in cognitive capacity after surgery, typically when resuming daily activities. We lack information about how patients experience early postoperative cognition (delayed neurocognitive recovery) and if these experiences can be reflected in biochemical pattern of inflammatory signalling molecules, cognitive function as well as on quality of postoperative recovery.

METHODS AND ANALYSIS

The study has a mixed-methods design that is integration of qualitative and quantitative data within a single investigation. Participants included will be patients aged ≥60 years that are undergoing major elective joint replacement surgery (n=40) and their relative. Patient's experience of his/her early cognition will be captured by interviews on postoperative day 13-16 during the follow-up visit. A relative will also be interviewed on the same day or the day after. Cognitive function will be measured preoperatively and on postoperative day 13-16 using the International Study Group of Postoperative Cognitive Dysfunction test battery. Symptoms/discomfort will be measured preoperatively and postoperatively (on postoperative day 1 and 2 and at the follow-up visit day 13-16) by the Swedish version of Quality of Recovery and by a visual analogue scale assessing pain intensity. Biomarkers will also be collected at the same time points. The findings from the interviews will be sorted out depending on group stratification (no delayed neurocognitive recovery and delayed neurocognitive recovery). The qualitative and quantitative findings will be compared to seek for similarities and differences.

ETHICS AND DISSEMINATION

The project has been approved by the Swedish Ethical Review Authority (2019-02968) and will follow the principles outlined in the 1964 Helsinki Declaration and its later amendments. Results from this study will be disseminated in peer-reviewed journals, scientific conferences and in social media.

Surgical Outcomes After Minimally Invasive Release of Stroke-Related Equinovarus Contracture of the Foot and Ankle

Cerebrovascular accident frequently causes spastic equinovarus contracture of the foot and ankle, for which traditional surgical correction involves tendon transfer, osteotomy, and hindfoot fusion, which can be challenging for patients after cerebrovascular accident. We prospectively assessed the efficacy of a minimally invasive, ambulatory approach to correct this complex deformity in 12 consecutive patients. Surgery included Achilles tendon lengthening, lengthening of the posterior tibial tendon, and flexor tenotomy of all 5 digits. The 10-cm visual-analog scale and the Bristol Foot Score were used to assess pain and subjective foot-related quality of life, respectively. The mean patient age was 61.5 ± 5.68 years, and the duration of follow-up was 29.3 ± 18.5 (range 12.2 to 63.3) months. All patients had a preoperative equinovarus foot structure and all had a rectus foot in weightbearing stance at the 1-year postoperative evaluation. Nine (75.0%) patients showed no residual or recurrent deformity, whereas 3 (25.5%) displayed incomplete release of digital contractures; all patients were treated with in-office flexor tenotomy. Preoperative maximum ankle dorsiflexion was ≤90° in 12 (100%) patients and >90° in 9 (75.0%) patients postoperatively. The mean visual-analog scale score decreased in 10 (83.3%) patients, although a statistically significant decrease was not observed (p = .0535). The Bristol Foot Score improved from 55.17 ± 11.10 preoperatively to 36.83 ± 13.26 postoperatively, and this improvement was statistically significant (p = .0022). These outcomes demonstrate the effectiveness of the minimally invasive, ambulatory surgical approach to spastic equinovarus contracture without identified patient harm.

An infrapatellar nerve block reduces knee pain in patients with chronic anterior knee pain after tibial nailing: a randomized, placebo-controlled trial in 34 patients

Background and purpose - Anterior knee pain is common after tibial nailing. Its origin is poorly understood. Injury of the infrapatellar nerve is a possible cause. In this randomized controlled trial we compared changes in knee pain after an infrapatellar nerve block with lidocaine or placebo in patients with persistent knee pain after tibial nailing. Patients and methods - Patients with chronic knee pain after tibial nailing were randomized to an infrapatellar nerve block with 5 ml 2% lidocaine or placebo (sodium chloride 0.9%), after which they performed 8 daily activities. Before and after these activities, pain was recorded using a numeric rating scale (NRS; 0-10). Primary endpoint was the change in pain during kneeling after the infrapatellar nerve block. Secondary outcomes were changes in pain after the nerve block during the other activities. Results - 34 patients (age 18-62 years) were equally randomized. A significant reduction of the NRS for kneeling pain with an infrapatellar nerve block with lidocaine was found compared with placebo (-4.5 [range -10 to -1] versus -1 [-9 to 2]; p = 0.002). There were no differences between the treatments for the NRS values for pain during other activities. Interpretation - Compared with placebo, an infrapatellar nerve block with lidocaine was more effective in reducing pain during kneeling in patients with chronic knee pain after tibial nailing. Our findings support the contention that kneeling pain after tibial nailing is a peripheral nerve-related problem.

The Effect of Medical Exercise Therapy on Pressure Sensitivity in Patients with Knee Osteoarthritis: A Cohort Pilot Study

Introduction

While continued research into pain and exercise may address the underlying mechanisms, the mechanisms through which exercise may act are still poorly understood. The purpose of this study was to examine the effects of medical exercise therapy on pressure sensitivity in knee osteoarthritis patients, and to assess whether the decreased pain perception after medical exercise therapy can be explained by changes in pressure sensitivity.

Methods

We adopted acohort design in which 16 patients with long term pain were tested before and after 3 months of medical exercise therapy intervention. Pain was detected by visual analogue scale (VAS) and a digital pressure algometer, which also assessed pressure sensitivity. Function (Knee Osteoarthritis Outcome Score, KOOS), anxiety and depression (HAD) and kinesiophobia (Tampa Scale of Kinesiophobia, TSK) were also measured.

Results

The VAS showed a statistically significant reduction of perceived pain, from 5.19 (SD 2.04) to 4.12 (SD 2.09) from pre- to post-test (p < 0.05). There was no significant change in pressure algometry on either the painful side or the non-painful side.

Conclusion

As there were no significant correlations between the reduced pain perception and pressure sensitivity in knee osteoarthritis patients, we suggest that local knee pain does not necessarily alter generalized sensitivity. These findings should be further investigated in a randomized trial in the future.

Trial Registration

Clinicaltrials.gov, identifier NCT02905747.

Long-Term Specialized Physical Therapy in Cervical Dystonia: Outcomes of a Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of a specialized physical therapy (SPT) program on disability in cervical dystonia (CD) compared to regular physical therapy (RPT).

DESIGN

A single-blinded randomized controlled trial.

SETTING

This study was performed by a physical therapist in a primary health care setting. Measurements were performed at baseline, 6 and 12 months in the botulinum toxin (BoNT) outpatient clinic of the neurology department.

PARTICIPANTS

Patients with primary CD and stable on BoNT treatment for 1 year (N=96).

MAIN OUTCOME MEASURES

The primary outcome was disability assessed with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Secondary outcomes were pain, anxiety, depression, quality of life (QOL), and health related costs over 12 months.

RESULTS

A total of 72 participants (30 men, 42 women) finished the study: 40 received SPT, 32 RPT. No significant between group differences were found after 12 months of treatment (P=.326). Over these 12 months both groups improved significantly (P<.001) on the TWSTRS disability scale compared to baseline (SPT 1.7 points, RPT 1.0 points). Short Form 36 (SF-36) General Health Perceptions (P=.046) and self-perceived improvement (P=.007) showed significantly larger improvements after 12 months in favor of SPT. Total health related costs after 12 months were $1373±556 for SPT compared to $1614±917 for RPT.

CONCLUSION

SPT revealed no significant differences compared to RPT after 12 months of treatment on the TWSTRS disability scale. Both groups showed similar improvements compared to baseline. Positive results in the SPT group were higher patient perceived effects and general health perception. Treatment costs were lower in the SPT group. With lower costs and similar effects, the SPT program seems to be the preferred program to treat CD.

Aspects of Pain, Its Assessment and Evaluation from An Acupuncture Perspective

Pain is a major clinical problem that causes great suffering for the individual and incurs costs for society. Accurate assessment and evaluation of perceived pain is necessary for diagnosis, for choice of treatment, and for the evaluation of treatment efficacy. The assessment of an individual's pain is a challenge since pain is a subjective, multidimensional experience, and assessment is based on the person's own self-report. The results are often varied, possibly due to inter-individual variation, but also in relation to gender and aetiology.

A gold standard for pain assessment is still lacking, but rating scales, questionnaires, and methods derived from psychophysical concepts, such as threshold assessments and perceptual matching, are used. In the evaluation of pain and associated variables, both systematic and individual variation should be taken into account, as should pain-associated symptoms.

Recommendations for pain treatment should be based on the patient's specific needs. Therefore, it is important to assess the level of perceived pain taking individual variation into account. The methods used should preferably have proved to be useful in randomised controlled trials, and analysis of pain assessment should consider its non-metric properties. In the future, the use of studies with a naturalistic protocol together with individual assessment of individual pain responses could increase the internal and external validity.

Duration of wrist immobilization is associated with shoulder pain in patients with after wrist immobilization: an observational study

The main goal of this study was to determinate the extent of the relationship between shoulder pain and time of wrist and thumb immobilization required after injury. One hundred twenty-three consecutive subjects presenting to the practice of different Orthopedic Specialist hospitals with a diagnosis of distal radius or scaphoid fracture that required wrist and thumb immobilization were screened for eligibility criteria. Upper extremity pain and the need for shoulder rehabilitation were assessed using the visual analogue scale (VAS) at baseline after immobilization period (T0) 1- and 3-month follow-up (1-FU/2-FU). More than 35% patients had shoulder pain (VAS>40 mm) after immobilization of the wrist. Shoulder pain intensity after immobilization and at follow-up (1 and 3 months) was strongly correlated with the duration of the immobilization. Immobilization for 3.5 weeks or longer was the strongest predictor for the need of subsequent shoulder rehabilitation. An increased the time of immobilization of the wrist is associated with an increase in shoulder pain and need for shoulder rehabilitation in patients after wrist fracture.

Effect of Extracorporeal Shockwave Therapy on Passive Ankle Stiffness in Patients With Plantar Fasciopathy

Plantar fasciopathy (PF) is the most common cause of heel pain. Extracorporeal shockwave therapy (ESWT) improves the gait pattern in patients with PF. However, the effects of ESWT on the biomechanics of the ankle in these patients remains unclear. Sixteen participants were included in the present study. Of the 16 participants, 8 patients with PF were assigned to receive extracorporeal shockwave therapy, and 8 healthy participants served as an external control group. ESWT was applied to the PF group for 1500 pulses at an energy flux of 0.26 mJ/mm² every 3 weeks for 3 sessions. The biomechanics of the ankle joints were then assessed using an isokinetic dynamometer, and a health-related quality of life questionnaire was administered at baseline and at the final follow-up session 12 weeks after the initial treatment. Passive stiffness was calculated and compared between the foot affected with PF, the opposite foot, and both feet of those in the healthy control group. The Kruskal-Wallis 1-way analysis of variance with repeated measures was performed, and statistical significance was considered present at the 5% (p ≤ .05) level. Ankle dorsiflexion in the affected limb increased from 14° ± 3° to 17° ± 2° after ESWT (p < .05). No statistically significant differences were noted in the strength of dorsiflexion or plantarflexion at baseline and after ESWT. However, a statistically significant increase in the ratio of strength in ankle dorsiflexion versus plantarflexion was found after ESWT (p < .05). No differences in the passive stiffness of the ankle joint were demonstrated. Patients reported an improved physical function score after ESWT (p < .05). An increased dorsiflexion/plantarflexion torque ratio and maximal dorsiflexion associated with decreased pain might contribute to the improved physical function after ESWT for PF.

Comparison of Clamp Reduction and Manual Reduction of Syndesmosis in Rotational Ankle Fractures: A Prospective Randomized Trial

An optimal outcome of surgical treatment for a syndesmotic injury depends on accurate reduction and adequate fixation. It has been suggested that the use of a reduction clamp for reduction of the syndesmosis results in better reduction and a lower rate of redisplacement than manual reduction. However, these concepts have never been scientifically evaluated. We compared these 2 methods in a prospective randomized trial. A total of 85 acute ankle rotational fractures combined with syndesmotic injury were randomized to syndesmosis reduction with either a reduction clamp or manual manipulation. Reduction of the syndesmosis was assessed radiographically by measuring the tibiofibular clear space, tibiofibular overlap, and the medial clear space immediately postoperatively and at the final follow-up examination. Ankle joint range of motion, visual analog scale score, Olerud-Molander ankle scoring system, and complications were obtained at the last follow-up visit to assess the clinical outcomes. Of the 3 radiographic measurements, the tibiofibular clear space and tibiofibular overlap differed significantly between the 2 groups (p < .05). The clinical outcomes did not differ significantly between the 2 groups (p > .05). Although differences were found in the radiographic measurements, most syndesmoses in both groups were within the normal range at the final follow-up visit, and the 2 methods of syndesmosis reduction provided similar clinical outcomes. Accordingly, the results of the present study suggest that both of these methods are effective and reliable for reduction of the syndesmosis in rotational ankle fractures.

Necessity of Immobilizing the Metacarpophalangeal Joint in Carpometacarpal Osteoarthritis: Short-term Effect

BACKGROUND

Conservative treatment for carpometacarpal (CMC) joint osteoarthritis (OA) may include orthotic fabrication to decrease pain. Different types of orthoses have been used as conservative interventions to improve symptoms, but there are no guidelines specifying if inclusion of the thumb metacarpophalangeal (MCP) in an orthosis is required in the treatment of thumb CMC joint OA. The main objective of this study is to determine the effectiveness of 2 different thumb CMC joint orthotic designs on pain reduction and improved hand function: one design immobilizes both the MCP joint and the CMC joint and the other design immobilizes only the CMC joint.

METHODS

A total of 66 patients were included in the study. One group of 33 patients received a short thumb orthosis with the MCP joint excluded, and the other group of 33 patients received a short thumb orthosis with the MCP joint included. Outcomes measures included the visual analog scale for pain and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH; Spanish version) for function.

RESULTS

In both patient groups, the orthoses contributed to decreased pain levels and improved functional abilities ( F_1.0 = 315.467 and F_1.0 = 72.419; both, P < .001). There was no significant difference between the 2 groups regarding pain or improvement in daily activities ( F_1.0 = 0.553 and F_1.0 = 2.539; both, P > .05).

CONCLUSION

There are benefits of either thumb orthotic design on pain reduction and functional improvement even after 1 week of using the orthoses as the sole conservative treatment.

Treatment of End-Stage Hallux Rigidus Using Total Joint Arthroplasty: A Short-Term Clinical Study

The treatment of advanced hallux rigidus remains controversial. Only a few studies have analyzed the short- and mid-term results of metatarsophalangeal (MTP) joint arthroplasty to treat patients with advanced hallux rigidus. We present the short-term follow-up results of patients who underwent MTP joint arthroplasty. We reviewed the medical records of 15 consecutive patients (3 males and 12 females) who had had grade 3 or 4 hallux rigidus diagnosed according to the Coughlin and Shurnas classification. The age range at surgery was 44 to 74 (mean 61.6) years. The mean follow-up period was 21.7 (range 18 to 28) months. The mean change in the overall American Orthopaedic Foot and Ankle Society Hallux-First Ray scale score was from 26.9 ± 2.3 preoperatively to 78.7 ± 8.8 postoperatively (p < .005). The mean change in the overall visual analog scale score was from 8.3 ± 0.8 preoperatively to 1.7 ± 0.7 postoperatively (p < .005). The mean preoperative first MTP joint range of motion was 22.3° ± 7.7° (range 15° to 45°), which had increased to 77° (range 65° to 90°) at the final follow-up visit. No patient required revision surgery or removal. These results indicate that for patients with advanced-stage hallux rigidus refractory to conservative treatment, total joint arthroplasty can lead to good satisfaction and good functional results in the short term.

Patient-directed self-management of pain (PaDSMaP) compared to treatment as usual following total knee replacement; a randomised controlled trial

Background

Self-administration of medicines by patients whilst in hospital is being increasingly promoted despite little evidence to show the risks and benefits. Pain control after total knee replacement (TKR) is known to be poor.

The aim of the study was to determine if patients operated on with a TKR who self-medicate their oral analgesics in the immediate post-operative period have better pain control than those who receive their pain control by nurse-led drug rounds (Treatment as Usual (TAU)).

Methods

A prospective, parallel design, open-label, randomised controlled trial comparing pain control in patient-directed self-management of pain (PaDSMaP) with nurse control of oral analgesia (TAU) after a TKR. Between July 2011 and March 2013, 144 self-medicating adults were recruited at a secondary care teaching hospital in the UK. TAU patients (n = 71) were given medications by a nurse after their TKR. PaDSMaP patients (n = 73) took oral medications for analgesia and co-morbidities after two 20 min training sessions reinforced with four booklets. Primary outcome was pain (100 mm visual analogue scale (VAS)) at 3 days following TKR surgery or at discharge (whichever came soonest). Seven patients did not undergo surgery for reasons unrelated to the study and were excluded from the intention-to-treat (ITT) analysis.

Results

ITT analysis did not detect any significant differences between the two groups’ pain scores. A per protocol (but underpowered) analysis of the 60% of patients able to self-medicate found reduced pain compared to the TAU group at day 3/discharge, (VAS -9.9 mm, 95% CI -18.7, − 1.1). One patient in the self-medicating group over-medicated but suffered no harm.

Conclusion

Self-medicating patients did not have better (lower) pain scores compared to the nurse-managed patients following TKR. This cohort of patients were elderly with multiple co-morbidities and may not be the ideal target group for self-medication.

Trial Registration

ISRCTN10868989. Registered 22 March 2012, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3146-2) contains supplementary material, which is available to authorized users.

How does exercise dose affect patients with long-term osteoarthritis of the knee? A study protocol of a randomised controlled trial in Sweden and Norway: the SWENOR Study

INTRODUCTION

Osteoarthritis (OA) of the knee is characterised by knee pain, disability and degenerative changes, and places a burden on societies all over the world. Exercise therapy is an often-used modality, but there is little evidence of what type of exercise dose is the most effective, indicating a need for controlled studies of the effect of different dosages. Thus, the aim of the study described in this protocol is to evaluate the effects of high-dose versus low-dose medical exercise therapy (MET) in patients with knee OA.

METHODS AND ANALYSIS

This is a multicentre prospective randomised two-arm trial with blinded assessment and data analysis. We are planning to include 200 patients aged 45-85 years with symptomatic (pain and decreased functioning) and X-ray verified diagnosis of knee OA. Those eligible for participation will be randomly allocated to either high-dose (n=100) or low-dose (n=100) MET. All patients receive three supervised treatments each week for 12 weeks, giving a total of 36 MET sessions. The high-dose group exercises for 70-90 min compared with 20-30 min for the low-dose group. The high-dose group exercises for a longer time, and receives a greater number of exercises with more repetitions and sets. Background and outcome variables are recorded at inclusion, and outcome measures are collected after every sixth treatment, at the end of treatment, and at 6-month and 12-month follow-ups. Primary outcome is self-rated knee functioning and pain using the Knee Injury and Osteoarthritis Outcome Score (KOOS). The primary end point is at the end of treatment after 3 months, and secondary end points are at 6 months and 12 months after the end of treatment.

ETHICS AND DISSEMINATION

This project has been approved by the Regional Research Ethics Committees in Stockholm, Sweden, and in Norway. Our results will be submitted to peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02024126; Pre-results.

Evaluating Pictures of Nature and Soft Music on Anxiety and Well-Being During Elective Surgery

Background:

Patients going through surgery being awake often have a sense of anxiety and need support to relax.

Objective:

The aim of this study was to investigate whether looking at pictures of natural scenery could reduce anxiety and pain and increase relaxation and well-being being awake during the elective surgery.

Methods:

This three-arm, randomized intervention study consisted of one group viewing pictures of natural scenery, one group listening to soft instrumental music, and one control group without distraction, all adult patients (n=174). The State Trait Anxiety Inventory short form and a visual analogue scale on well-being were used as well as sedation treatment if necessary.

Results:

No differences related to anxiety after surgery were found among the three groups. When controlling for the effect of sedative treatment, however, patients without sedation had a lower degree of anxiety postoperatively (p=0.014). Younger patients had a higher degree of anxiety and lower degree of postoperative relaxation and well-being.

Conclusion:

Viewing pictures of natural scenery while being awake during elective surgery is as relaxing as listening to soft instrumental music. Offering nature scenery pictures for patients to view could be relaxing during the elective surgery.