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Moore RA, Clephas PRD, Straube S, Wertli MM, Ireson-Paige J, Heesen M. Comparing pain intensity rating scales in acute postoperative pain: boundary values and category disagreements. Anaesthesia 2024; 79:139-146. [PMID: 38058028 DOI: 10.1111/anae.16186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/08/2023]
Abstract
Pain intensity assessment scales are important in evaluating postoperative pain and guiding management. Different scales can be used for patients to self-report their pain, but research determining cut points between mild, moderate and severe pain has been limited to studies with < 1500 patients. We examined 13,017 simultaneous acute postoperative pain ratings from 913 patients taken at rest and on activity, between 4 h and 48 h following surgery using both a verbal rating scale (no, mild, moderate or severe pain) and 0-100 mm visual analogue scale. We determined the best cut points on the visual analogue scale between mild and moderate pain as 35 mm, and moderate and severe pain as 80 mm. These remained consistent for pain at rest and on activity, and over time. We also explored the presence of category disagreements, defined as patients verbally describing no or mild pain scored above the mild/moderate cut point on the visual analogue scale, and patients verbally describing moderate or severe pain scored below the mild/moderate cut point on the visual analogue scale. Using 30 and 60 mm cut points, 1533 observations (12%) showed a category disagreement and using 35 and 80 mm cut points, 1632 (13%) showed a category disagreement. Around 1 in 8 simultaneous pain scores implausibly disagreed, possibly resulting in incorrect pain reporting. The reasons are not known but low rates of literacy and numeracy may be contributing factors. Understanding these disagreements between pain scales is important for pain research and medical practice.
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Affiliation(s)
| | - P R D Clephas
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Straube
- Division of Preventive Medicine, Department of Medicine, University of Alberta, Alberta, Canada
- School of Public Health, University of Alberta, Alberta, Canada
| | - M M Wertli
- Department of Internal Medicine, Kantonsspital Baden, Baden, Switzerland
- Division of General Internal Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - M Heesen
- Department of Anaesthesia, Bethanien Hospital, Zurich, Switzerland
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Affiliation(s)
- H C Laycock
- Department of Paediatric Anaesthesia and Pain Medicine, Great Ormond Street Hospital, London, UK.,Faculty of Medicine, Imperial College, London, UK
| | - W Harrop-Griffiths
- Department of Surgery and Cancer, Imperial College, London, UK.,Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
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Righini M, Robert-Ebadi H, Glauser F, Blondon M, Ouvry P, Diamand JM, Tissot A, Frappe P, Quere I, Kahn SR, Galanaud JP, Le Gal G. Effect of anticoagulant treatment on pain in distal deep vein thrombosis: an ancillary analysis from the cactus trial. J Thromb Haemost 2019; 17:507-510. [PMID: 30656824 DOI: 10.1111/jth.14387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Indexed: 02/04/2023]
Abstract
Essentials Management of patients with calf deep vein thrombosis remains controversial. We conducted a post-hoc analysis of a placebo controlled LMWH randomized clinical trial. Pain was assessed using visual analogue scale at inclusion, one and six weeks. There was no difference in pain control between the two arms. SUMMARY: Background The optimal management of distal deep vein thrombosis (DVT) is highly debated. The only available placebo-controlled trial suggested the absence of clear benefit of anticoagulation. Many physicians feel that, beyond preventing thromboembolic complications, anticoagulation with low-molecular-weight heparin (LMWH) has the potential to improve pain control. Objectives To analyze whether LMWHs decrease pain in patients with distal deep vein thrombosis. Patients and methods Two-hundred and fifty-two patients included in a multicenter, placebo-controlled, randomized clinical trial of LMWH in patients with acute distal DVT and who were asked to rate their pain at inclusion and at each medical visit, using a visual analogue pain scale (VAS). Results One hundred and thirty patients were randomized in the therapeutic nadroparin arm and 122 patients were randomized in the placebo arm. Mean VAS values were 4.6 (standard deviation [SD] 2.5) at inclusion, 2.1 (SD 2.0) at 1 week and 0.4 (SD 1.2) at 6 weeks. We calculated the individual variation in VAS between inclusion and 1 week in patients in whom VAS was available at the two study time-points. There was no difference in the mean VAS reduction between patients treated with therapeutic nadroparin (n = 106) and with placebo (n = 109): -2.6 (SD 2.4) vs. -2.3 (SD 2.0) after 1 week and -4.4 (SD 2.8) vs. -4.0 (SD 2.4) after 6 weeks, respectively. The use of compression stockings was associated with a reduction in pain. Conclusion These data suggests that LMWH use does not improve pain control as compared with placebo in patients with acute distal DVT.
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Affiliation(s)
- Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Frédéric Glauser
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | | | | | | | - Paul Frappe
- Département de Médecine Générale and EA 3065, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Isabelle Quere
- Clinical Investigation Centre and Department of Internal and Vascular Medicine, Montpellier University Hospital, Montpellier, France
| | - Susan R Kahn
- Department of Medicine and Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Jean-Philippe Galanaud
- Clinical Investigation Centre and Department of Internal and Vascular Medicine, Montpellier University Hospital, Montpellier, France
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
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Phillips N, Hach S, Mannion J, Moran R. Effect of acute experimental hand pain on left-right discrimination response latency for hand recognition. Physiother Theory Pract 2019; 36:1232-1240. [PMID: 30724639 DOI: 10.1080/09593985.2019.1571133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Recent work has indicated that acute experimental pain affects left-right discrimination latency. This phenomenon highlights an effect of pain on the cortex that may have significant clinical importance in the form of pain state assessment. However, to date only limited study has further qualified this effect. A more thorough understanding of the magnitude and characteristics of this phenomenon is needed to determine its potential clinical utility. Objective: This study aimed to closely replicate previous studies investigating response latency changes for left-right discrimination judgements as a result of acute experimental pain. Methods: Twenty-two right-handed participants (n = 11 female, n = 11 male) free from pain, analgesia use, pain-related conditions, upper limb trauma/conditions, visual impairment, and dyslexia took part in this study. Participants completed a hand left-right discrimination judgement task before, during, and after an experimental pain stimulus was delivered to each hand separately. Experimental pain was achieved using an intramuscular injection of hypertonic (5%) saline into the thenar eminence of the left and right hands. Mean response times for the left-right discrimination task were determined and compared for pain location (right, left), pain condition (before, during, after), and image laterality (right, left). Pain intensity was rated at 20 s intervals during each left-right discrimination task. Results: A main effect of pain condition (p = 0.028) confirmed that pain intensity was significantly higher in the "during pain" condition compared to the "before pain" and "after pain" conditions. A main effect of image laterality (p = 0.002) further showed that response latency for right-hand pain was significantly shorter compared to left-hand pain. No significant interaction between the factors pain location and image laterality (p = 0.086) was found. For right-hand pain, response latencies for the unaffected hand were, however, descriptively greater compared to the affected hand, and this was not the case for left-hand pain. Furthermore, no main effect of pain stimulus or of pain location on response times was found (p = 1.00 and p = 0.202, respectively). Conclusion: Our results were not consistent with previous hand left-right discrimination response latency results and may cast doubt on the attentional bias hypothesis that is currently considered to underpin response latency changes during acute experimental hand pain. Individual responses to pain, subsets of participants, and differing mental rotation strategies during the left-right discrimination task may have influenced the results.
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Affiliation(s)
- Nichole Phillips
- School of Health and Human Sciences, Southern Cross University , Gold Coast, Australia
| | - Sylvia Hach
- Health, Education and Community, Unitec Institute of Technology , Auckland, New Zealand
| | - Jamie Mannion
- Health, Education and Community, Unitec Institute of Technology , Auckland, New Zealand.,Department of Computer Science, Unitec Institute of Technology , Auckland, New Zealand
| | - Robert Moran
- Health, Education and Community, Unitec Institute of Technology , Auckland, New Zealand
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Marakhouski KY, Karaseva GA, Ulasivich DN, Marakhouski YK. Omeprazole-Domperidone Fixed Dose Combination vs Omeprazole Monotherapy: A Phase 4, Open-Label, Comparative, Parallel Randomized Controlled Study in Mild to Moderate Gastroesophageal Reflux Disease. Clin Med Insights Gastroenterol 2017; 10:1179552217709456. [PMID: 28607547 PMCID: PMC5457029 DOI: 10.1177/1179552217709456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 04/09/2017] [Indexed: 12/15/2022]
Abstract
AIM To compare the efficacy and safety of omeprazole-domperidone combination vs omeprazole monotherapy in gastroesophageal reflux disease (GERD). METHODS In a comparative, randomized controlled, phase 4 study, outpatients with GERD were randomly allocated to either group 1 (omeprazole 20 mg + domperidone 30 mg) or group 2 (omeprazole 20 mg) in an equal ratio; 2 capsules daily in the morning were administered for 8 weeks. RESULTS Sixty patients were enrolled. Esophagitis reversal was observed in 92% patients in group 1 vs 65.2% in group 2. Approximately, 83.3% patients in group 1 vs 43.3% patients in group 2 demonstrated full cupping of reflux symptoms at 8 weeks. Combined therapy resulted in significantly longer period of heartburn-free days (23 vs 12 days on omeprazole). There were no safety concerns. CONCLUSIONS Omeprazole-domperidone combination was more effective than omeprazole alone in providing complete cupping of reflux symptoms and healing of esophagitis in patients with GERD. Both the treatments were well tolerated with few reports of adverse events. TRIAL REGISTRATION This trial is registered with http://clinicaltrials.gov, number NCT02140073.
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Affiliation(s)
- KY Marakhouski
- Diagnostic Department, Republican Research and Practical Center for Pediatric Surgery, Minsk, Belarus
| | - GA Karaseva
- Department of Gastroenterology and Nutritiology, State Educational Establishment “Belarusian Medical Academy of Post-Graduate Education,” Minsk, Belarus
| | - DN Ulasivich
- Department of Gastroenterology and Nutritiology, State Educational Establishment “Belarusian Medical Academy of Post-Graduate Education,” Minsk, Belarus
| | - Y Kh Marakhouski
- Department of Gastroenterology and Nutritiology, State Educational Establishment “Belarusian Medical Academy of Post-Graduate Education,” Minsk, Belarus
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Abstract
BACKGROUND Pain after total knee arthroplasty (TKA) is a big problem in orthopaedic surgery. Although opioids and continuous epidural analgesia remain the major options for the postoperative pain management of TKA, they have some undesirable side effects. Epidural analgesia is technically demanding, and the patient requires close monitoring. Different types of local anesthetic applications can successfully treat TKA pain. Local anesthetics have the advantage of minimizing pain at the source. This study investigates the efficacy of different local anesthetic application methods on early, (1st day) pain control after total knee arthroplasty. MATERIALS AND METHODS 200 patients who underwent unilateral TKA surgery under spinal anesthesia were randomly assigned into four different groups (fifty in each group) and were administered pain control by different peri- and postoperative regimens. Group A was the control group wherein no postsurgical analgesia was administered to assess spinal anesthesia efficacy; in Group B, only postsurgical one-shot femoral block was applied; in Group C, intraoperative periarticular local anesthetic was applied; in Group D, a combination of the one-shot femoral block and intraoperative periarticular local anesthetics were applied. Demographic data consisting of age, weight, gender and type of deformity of patients were collected. The data did not differ significantly between the four groups. RESULTS Group D patients experienced significantly better postoperative pain relief (P < 0.05) and were therefore more relaxed in pain (painless time, VAS score) and knee flexion (degrees) than the other patient groups in the 1st postoperative day followup. Painless time of Group D was 10.5 hours and was better than Group C (6.8 hours), Group B (6.2 hours) and Group A (3.0 hours) (P < 0.05). Group A got the best pain Vas score degrees in the 1st postoperative day which showed the success of combined periarticülar local anesthetic injection and femoral nerve block. CONCLUSION The intraoperative periarticular application of local anesthetics in addition to one-shot femoral block is an efficient way of controlling postsurgical pain after TKA.
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Affiliation(s)
- Aykut Sigirci
- Department of Orthopaedics, Evliya Celebi Training and Research Hospital, Kütahya, Turkey,Address for correspondence: Dr. Aykut Sigirci, Department of Orthopaedics, Evliya Celebi Training and Research Hospital, Kütahya, Turkey. E-mail:
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Abstract
BACKGROUND Advanced ankylosing spondylitis is often associated with thoracolumbar kyphosis, resulting in an abnormal spinopelvic balance and pelvic morphology. Different osteotomy techniques have been used to correct AS deformities, unfortunnaly, not all AS patients can gain spinal sagittal balance and good horizontal vision after osteotomy. MATERIALS AND METHODS Fourteen consecutive AS patients with severe thoracolumbar kyphosis who were treated with two-level PSO were studied retrospectively. All were male with a mean age of 34.9 ± 9.6 years. The followup ranged from 1-5 years. Preoperative computer simulations using the Surgimap Spinal software were performed for all patients, and the osteotomy level and angle determined from the computer simulation were used surgically. Spinal sagittal parameters were measured preoperatively, after the computer simulation, and postoperatively and included thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence, pelvic tilt (PT), and sacral slope (SS). The level of correlation between the computer simulation and postoperative parameters was evaluated, and the differences between preoperative and postoperative parameters were compared. The visual analog scale (VAS) for back pain and clinical outcome was also assessed. RESULTS Six cases underwent PSO at L1 and L3, five cases at L2 and T12, and three cases at L3 and T12. TK was corrected from 57.8 ± 15.2° preoperatively to 45.3 ± 7.7° postoperatively (P < 0.05), LL from 9.3 ± 17.5° to -52.3 ± 3.9° (P < 0.001), SVA from 154.5 ± 36.7 to 37.8 ± 8.4 mm (P < 0.001), PT from 43.3 ± 6.1° to 18.0 ± 0.9° (P < 0.001), and SS from 0.8 ± 7.0° to 26.5 ± 10.6° (P < 0.001). The LL, VAS, and PT of the simulated two-level PSO were highly consistent with, or almost the same as, the postoperative parameters. The correlations between the computer simulations and postoperative parameters were significant. The VAS decreased significantly from 6.1 ± 1.9 to 2.0 ± 1.1 (P < 0.001). In terms of clinical outcome, 10 cases were graded "excellent" and 4 cases were graded "good." CONCLUSION Two-level PSO using a preoperative computer simulation is a feasible, safe, and effective technique for the treatment of severe thoracolumbar kyphosis in AS patients with normal cervical motion.
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Affiliation(s)
- Ning Zhang
- Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, PR China
| | - Hao Li
- Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, PR China
| | - Zheng-Kuan Xu
- Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, PR China
| | - Wei-Shan Chen
- Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, PR China
| | - Qi-Xin Chen
- Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, PR China
| | - Fang-Cai Li
- Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, PR China,Address for correspondence: Prof. Fang-Cai Li, Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, #88 Jiefang Road, Hangzhou 310009, PR China. E-mail:
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Jeon SG, Choi EJ, Lee PB, Lee YJ, Kim MS, Seo JH, Nahm FS. Do severity score and skin temperature asymmetry correlate with the subjective pain score in the patients with complex regional pain syndrome? Korean J Pain 2014; 27:339-44. [PMID: 25317283 PMCID: PMC4196499 DOI: 10.3344/kjp.2014.27.4.339] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 08/18/2014] [Accepted: 08/19/2014] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The diagnostic criteria of complex regional pain syndrome (CRPS) have mainly focused on dichotomous (yes/no) categorization, which makes it difficult to compare the inter-patient's condition and to evaluate the intra-patient's subtle severity over the course of time. To overcome this limitation, many efforts have been made to create laboratory methods or scoring systems to reflect the severity of CRPS; measurement of the skin temperature asymmetry is one of the former, and the CRPS severity score (CSS) is one of the latter. However, there has been no study on the correlations among the CSS, temperature asymmetry and subjective pain score. The purpose of this study was to evaluate whether there is any correlation between the CSS, skin temperature asymmetry and subjective pain score. METHODS Patients affected with CRPS in a unilateral limb were included in this study. After making a diagnosis of CRPS according to the Budapest criteria, the CSS and skin temperature difference between the affected and unaffected limb (ΔT) was measured in each patient. Finally, we conducted a correlation analysis among the CSS, ΔT and visual analogue scale (VAS) score of the patients. RESULTS A total of 42 patients were included in this study. There was no significant correlation between the ΔT and VAS score (Spearman's rho = 0.066, P = 0.677). Also, the CSS and VAS score showed no significant correlation (Spearman's rho = 0.163, P = 0.303). CONCLUSIONS The ΔT and CSS do not seem to reflect the degree of subjective pain in CRPS patients.
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Affiliation(s)
- Seung Gyu Jeon
- Department of Anesthesiology and Pain Medicine, KEPCO Medical Center, Seoul, Korea
| | - Eun Joo Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Pyung Bok Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | - Min Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joung Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Rahimzadeh P, Imani F, Faiz SHR, Entezary SR, Nasiri AA, Ziaeefard M. Investigation the efficacy of intra-articular prolotherapy with erythropoietin and dextrose and intra-articular pulsed radiofrequency on pain level reduction and range of motion improvement in primary osteoarthritis of knee. J Res Med Sci 2014; 19:696-702. [PMID: 25422652 PMCID: PMC4235087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 04/29/2014] [Accepted: 05/10/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Osteoarthritis is one of the most common diseases and the knee is the most commonly affected joint. Intra-articular prolotherapy is being utilized in acute and chronic pain management setting. This study was designed to compare the efficacy of three methods of intra-articular knee joint therapies with erythropoietin, dextrose, and pulsed radiofrequency. MATERIALS AND METHODS After approval by the Ethics Committee and explaining the therapeutic method to volunteers, 70 patients who were suffering from primary knee osteoarthrosis went through one of the treatment methods (erythropoietin, dextrose, and pulsed radiofrequency). The study was double-blind randomized clinical trial performed from December 2012 to July 2013. Patients' pain level was assessed through the visual analog pain scale (VAS), and range of motion (ROM) was measured by goniometric method. Furthermore, patients' satisfaction was assessed before and after different treatment methods in weeks 2, 4, and 12. For analysis, Chi-square, one-way ANOVA, and repeated measured ANOVA were utilized. RESULTS The demographic results among the three groups did not indicate any statistical difference. The mean VAS in erythropoietin group in the 2(nd), 4(th), and 12(th) weeks was 3.15 ± 1.08, 3.15 ± 1.08, and 3.5 ± 1.23, respectively (P ≤ 0.005). Knee joint ROM in the erythropoietin group in the 2(nd), 4(th), and 12(th) weeks was 124 ± 1.50, 124 ± 1.4, and 123 ± 1.53 respectively (P ≤ 0.005). Satisfaction score in the 12(th) week in erythropoietin group was extremely satisfied 15%, satisfied 55%, and moderately satisfied 30%, (P = 0.005). No specific side-effects were observed. CONCLUSION Intra-articular prolotherapy with erythropoietin was more effective in terms of pain level reduction and ROM improvement compared with dextrose and pulsed radiofrequency.
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Affiliation(s)
- Poupak Rahimzadeh
- Department of Anesthesiology and Pain Medicine, Hazrat Rasul Medical Complex, Iran University of Medical Sciences, Tehran, Iran
| | - Farnad Imani
- Department of Anesthesiology and Pain Medicine, Hazrat Rasul Medical Complex, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hamid Reza Faiz
- Department of Anesthesiology and Pain Medicine, Hazrat Rasul Medical Complex, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Reza Entezary
- Department of Anesthesiology and Pain Medicine, Hazrat Rasul Medical Complex, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Nasiri
- Department of Anesthesiology and Pain Medicine, Hazrat Rasul Medical Complex, Iran University of Medical Sciences, Tehran, Iran,Address for correspondence: Dr. Ali Akbar Nasiri, Department of Anesthesiology and Pain Medicine, Hazrat Rasul Medical Complex, Nyayesh Street, Sattarkhan Avenue, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. E-mail:
| | - Mohsen Ziaeefard
- Department of Anesthesiology and Pain Medicine, Shahid Rajaee Heart Center, Iran University of Medical Sciences, Tehran, Iran
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