Search results for: neuropathic pain

Authors: O. Casasayas, M. Vigo, R. Navarro, P. Ragazzi, P. Alvarez, A. Perez-Bellmunt

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Introduction: The blood flow restriction training (BFR) is a method of muscle training that allows increasing the stress of muscle tissue to enhance the muscle cross-section and strength. This type of training has clear benefits in the rehabilitation field since it can improve muscle strength using low mechanical loads. The aim of this study is to know in which knee pathologies BFR has been used, what methodology was used and what were the obtained results. Study design: We performed a systematic literature search using strategies for the concepts of “blood flow restriction OR blood flow restriction training AND knee” in Medline. Articles were screened by authors and included if they used the blood flow restriction training in pathology of the knee. Results: The pathology more frequently treated by BFR was knee osteoarthritis and the variables most analyzed were strength and pain. The vascular occlusion used was 80% in the major part of studies. The groups of BFR obtained an increase of strength with less pain but not always the results are statistically significant. The evidence levels are poor in the high number of studies because in some cases there is not a control group or the evaluators were not blinded. Conclusion: The use of BFR is useful to improve muscle strength in knee pathology since it does not increase the pain, but more studies are needed to see (comprehend) if this type of treatment obtains better results than a conventional therapy. No studies have been found that compare the different occlusion effects in both the strength improvement and the pain reduction. Neither studies that analyse the effects of BFR on the muscle contractile parameters have been found.

Keywords: blood flow restriction training, knee, arthroscopy knee, physical therapy

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Authors: Ching-Yuan Chen, Lung-Kwang Pan

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Objective: Back pain is a major health problem costing billions of health budgets annually in Taiwan. Thousands of back pain surgeries are performed annually with up to 40% of patients complaining of back pain at time of post-surgery causing failed back surgery syndrome (FBSS), although diagnosis in these patients may be complex. The aim of study is to assess the feasibility of using bone SPECT-CT imaging to localize the active lesions causing persistent, recurrent or new backache after spine surgery. Materials and Methods: Bone SPECT-CT imaging was performed after the intravenous injection of 20 mCi of 99mTc-MDP for all the patients with diagnosis of FBSS. Patients were evaluated using status of subjectively pain relief, functional improvement and degree of satisfaction by reviewing the medical records and questionnaires in a 2 more years’ follow-up. Results: We enrolled a total of 16 patients were surveyed in our hospital from Jan. 2015 to Dec. 2016. Four people on SPEC/CT imaging ensured significant lesions were undergone a revised surgery (surgical treatment group). The mean visual analogue scale (VAS) decreased 5.3 points and mean Oswestry disability index (ODI) improved 38 points in the surgical group. The remaining 12 on SPECT/CT imaging were diagnosed as no significant lesions then received drug treatment (medical treatment group). The mean VAS only decreased 2 .1 point and mean ODI improved 12.6 points in the medical treatment group. In the posttherapeutic evaluation, the pain of the surgical treatment group showed a satisfactory improvement. In the medical treatment group, 10 of the 12 were also satisfied with the symptom relief while the other 2 did not improve significantly. Conclusions: Findings on SPECT-CT imaging appears to be easily explained the patients' pain. We recommended that SPECT/CT imaging was a feasible and useful clinical tool to improve diagnostic confidence or specificity when evaluating patients with FBSS.

Keywords: failed back surgery syndrome, oswestry disability index, SPECT-CT imaging, 99mTc-MDP, visual analogue scale

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Authors: Jeounghee Kim

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Objective: To describe the incidence of complication, according to the stage of Traumatic Spinal Cord Injury (TSCI) which was treated at Asan Medical Center (AMC), Korea. Hereafter, it should be developed in nursing management protocol of traumatic SCI. Methods. Retrospectively reviewed hospital records about the patients who were admitted AMC Patients with traumatic spinal cord injury until January 2005 and December 2016 were analyzed (n=97). AMC is a single institution of 2,700 beds where patients with trauma and severe trauma can be treated. Patients who were admitted to the emergency room due to spinal cord injury and who underwent intensive care unit, general ward, and rehabilitation ward. To identify long-term complications, we excluded patients who were operated on to other hospitals after surgery. Complications such as respiratory(pneumonia, atelectasis, pulmonary embolism, and others), cardiovascular (hypotension), urinary (autonomic dysreflexia, urinary tract infection (UTI), neurogenic bladder, and others), and skin systems (pressure ulcers) from the time of admission were examined through medical records and images. Results: SCI was graded according to ASIA scale. The initial grade was checked at admission. (grade A 55(56.7%), grade B 14(14.4)%, grade C 11(11.3%), grade D 15(15.5%), and grade E 2(2.1%). The grade was rechecked when the patient was discharged after treatment. (grade A 43(44.3%), grade B 15(15.5%), grade C 12(12.4%), grade D 21(21.6%), and grade E 6(6.2%). The most common complication after SCI was UTI 24cases (mean 36.5day), sore 24cases (40.5day), and Pneumonia which was 23 cases after 10days averagely. The other complications after SCI were neuropathic pain 19 cases, surgical site infection 4 cases. 53.6% of patient who had SCI were educated about intermittent catheterization at discharge from hospital. The mean hospital stay of all SCI patients was 61days. Conclusion: The Complications after traumatic SCI were developed at various stages from acute phase to chronic phase. Nurses need to understand fully the time-course of complication in traumatic SCI to provide evidence-based practice.

Keywords: spinal cord injury, complication, nursing, rehabilitation

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Authors: Helena Costa Oliveira, Carmem Oliveira, Rita Moutinho

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The Balanced Scorecard (BSC) is a continuous strategic monitoring model focused not only on financial issues but also on internal processes, patients/users, and learning and growth. Initially dedicated to business management, it currently serves organizations of other natures - such as hospitals. This paper presents a BSC designed for a Portuguese Acute Pain Unit (APU). This study is qualitative and based on the experience of collaborators at the APU. The management of APU is based on four perspectives – users, internal processes, learning and growth, and financial and legal. For each perspective, there were identified strategic objectives, critical factors, lead indicators and initiatives. The strategic map of the APU outlining sustained strategic relations among strategic objectives. This study contributes to the development of research in the health management area as it explores how organizational insufficiencies and inconsistencies in this particular case can be addressed, through the identification of critical factors, to clearly establish core outcomes and initiatives to set up.

Keywords: acute pain unit, balanced scorecard, hospital management, organizational performance, Portugal

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Authors: Nursyafiq Ali Shibramulisi, Nor Farah Fauzi, Nur Azniza Zawin Anuar, Nurul Atikah Azmi, Janice Hew Pei Fang

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Background: Work related musculoskeletal disorders (WRMD) among dental personnel have been underestimated and under-reported worldwide and specifically in Malaysia. The problem will arise and progress slowly over time, as it results from accumulated injury throughout the period of work. Several risk factors, such as repetitive movement, static posture, vibration, and adapting poor working postures, have been identified to be contributing to WRMSD in dental practices. Dental personnel is at higher risk of getting this problem as it is their working nature and core business. This would cause pain and dysfunction syndrome among them and result in absence from work and substandard services to their patients. Methodology: A cross-sectional study involving 19 government dental clinics in Perak was done over the period of 3 months. Those who met the criteria were selected to participate in this study. Malay version of the Self-Reported Nordic Musculoskeletal Discomfort Form was used to identify the prevalence of WRMSD, while the intensity of pain in the respective regions was evaluated using a 10-point scale according to ‘Pain as The 5ᵗʰ Vital Sign’ by MOH Malaysia and later on were analyzed using SPSS version 25. Descriptive statistics, including mean and SD and median and IQR, were used for numerical data. Categorical data were described by percentage. Pearson’s Chi-Square Test and Spearman’s Correlation were used to find the association between the prevalence of WRMSD and other socio-demographic data. Results: 159 dentists, 73 dental therapists, 26 dental lab technicians, 81 dental surgery assistants, and 23 dental attendants participated in this study. The mean age for the participants was 34.9±7.4 and their mean years of service was 9.97±7.5. Most of them were female (78.5%), Malay (71.3%), married (69.6%) and right-handed (90.1%). The highest prevalence of WRMSD was neck (58.0%), followed by shoulder (48.1%), upper back (42.0%), lower back (40.6%), hand/wrist (31.5%), feet (21.3%), knee (12.2%), thigh 7.7%) and lastly elbow (6.9%). Most of those who reported having neck pain scaled their pain experiences at 2 out of 10 (19.5%), while for those who suffered upper back discomfort, most of them scaled their pain experience at 6 out of 10 (17.8%). It was found that there was a significant relationship between age and pain at neck (p=0.007), elbow (p=0.027), lower back (p=0.032), thigh (p=0.039), knee (p=0.001) and feet (p=0.000) regions. Job position also had been found to be having a significant relationship with pain experienced at the lower back (p=0.018), thigh (p=0.011), knee, and feet (p=0.000). Conclusion: The prevalence of WRMSD among dental personnel in Perak was found to be high. Age and job position were found to be having a significant relationship with pain experienced in several regions. Intervention programs should be planned and conducted to prevent and reduce the occurrence of WRMSD, as all harmful or unergonomic practices should be avoided at all costs.

Keywords: WRMSD, ergonomic, dentistry, dental

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Authors: Anna Mucha, Ewa Wojtyna, Anita Pollak

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The environment in which an individual resides and observes may play a meaningful role in well-being and related constructs. Contact with nature may have a positive influence of natural environments on individuals, impacting mood and psychophysical sensations, such as pain relief. Conversely, urban settings, dominated by concrete elements, might lead to mood decline and heightened stress levels. Similarly, the situation may appear in the case of the perception of virtual environments. However, this is a topic that requires further exploration, especially in the context of relationships with pain. The aforementioned matters served as the basis for formulating and executing the outlined experimental research within the realm of environmental psychology, leveraging new technologies, notably virtual reality (VR), which is progressively gaining prominence in the domain of mental health. The primary objective was to investigate the impact of a simulated virtual environment, mirroring a natural setting abundant in greenery, on the perception of acute pain induced by thermal stimuli (high temperature) – encompassing intensity, unpleasantness, and pain tolerance. Comparative analyses were conducted between the virtual natural environment (intentionally constructed in the likeness of a therapeutic garden), virtual urban environment, and a control group devoid of virtual projections. Secondary objectives aimed to determine the mutual relationships among variables such as positive and negative emotions, preferences regarding virtual environments, sense of presence, and restorative experience in the context of the perception of presented virtual environments and induced thermal pain. The study encompassed 126 physically healthy Polish adults, distributing 42 individuals across each of the three comparative groups. Oculus Rift VR technology and the TSA-II neurosensory analyzer facilitated the experiment. Alongside demographic data, participants' subjective feelings concerning virtual reality and pain were evaluated using the Visual Analogue Scale (VAS), the original Restorative Experience in the Virtual World questionnaire (Doświadczenie Regeneracji w Wirtualnym Świecie), and an adapted Slater-Usoh-Steed (SUS) questionnaire. Results of statistical and psychometric analyses, such as Kruskal-Wallis tests, Wilcoxon tests, and contrast analyses, underscored the positive impact of the virtual natural environment on individual pain perception and mood. The virtual natural environment outperformed the virtual urban environment and the control group without virtual projection, particularly in subjective pain components like intensity and unpleasantness. Variables such as restorative experience, sense of presence and virtual environment preference also proved pivotal in pain perception and pain tolerance threshold alterations, contingent on specific conditions. This implies considerable application potential for virtual natural environments across diverse realms of psychology and related fields, among others as a supportive analgesic approach and a form of relaxation following psychotherapeutic sessions.

Keywords: environmental psychology, nature, acute pain, emotions, vitrual reality, virtual environments

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Authors: Hossam N. Alhawatmeh, Areen I. Albustanji

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Hemodialysis negatively affects physical and psychological health. Pain, poor sleep quality, and low self-esteem are highly prevalent among patients with end-stage renal disease (ESRD) who receive hemodialysis, significantly increasing mortality and morbidity of those patients. Mind-body interventions (MBI), such as mindfulness meditation, have been recently gaining popularity that improved pain, sleep quality, and self-esteem in different populations. However, to our best knowledge, its effects on these health problems in patients receiving hemodialysis have not been studied in Jordan. Thus, the purpose of the study was to examine the effect of mindfulness meditation on pain, sleep quality, and self-esteem in patients with ESR receiving hemodialysis in Jordan. An experimental repeated-measures, randomized, parallel control design was conducted on (n =60) end-stage renal disease patients undergoing hemodialysis between March and June 2023 in the dialysis center at a public hospital in Jordan. Participants were randomly assigned to the experimental (n =30) and control groups (n =30) using a simple random assignment method. The experimental group practiced mindfulness meditation for 30 minutes three times per week for five weeks during their hemodialysis treatments. The control group's patients continued to receive hemodialysis treatment as usual for five weeks during hemodialysis sessions. The study variables for both groups were measured at baseline (Time 0), two weeks after intervention (Time 1), and at the end of intervention (Time 3). The numerical rating scale (NRS), the Rosenberg Self-Esteem Scale (RSES-M), and the Pittsburgh Sleep Quality Index (PSQI) were used to measure pain, self-esteem, and sleep quality, respectively. SPSS version 25 was used to analyze the study data. The sample was described by frequency, mean, and standard deviation as an appropriate. The repeated measures analysis of variance (ANOVA) tests were run to test the study hypotheses. The results of repeated measures ANOVA (within-subject) revealed that mindfulness meditation significantly decrease pain by the end of the intervention in the experimental group. Additionally, mindfulness meditation improved sleep quality and self-esteem in the experimental group, and these improvements occurred significantly after two weeks of the intervention and at the end of the intervention. The results of repeated measures ANOVA (within and between-subject) revealed that the experimental group, compared to the control group, experienced lower levels of pain and higher levels of sleep quality and self-esteem over time. In conclusion, the results provided substantial evidence supporting the positive impacts of mindfulness meditation on pain, sleep quality, and self-esteem in patients with ESRD undergoing hemodialysis. These results highlight the potential of mindfulness meditation as an adjunctive therapy in the comprehensive care of this patient population. Incorporating mindfulness meditation into the treatment plan for patients receiving hemodialysis may contribute to improved well-being and overall quality of life.

Keywords: hemodialysis, pain, sleep quality, self-esteem, mindfulness

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Authors: Mohamed Salaheldien Mohamed Alayat, Ahmed Mohamed Elsoudany, Roaa Abdulghani Sroge, Bayan Muteb Aldhahwani

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Background: Neck pain is a common illness that could affect individual’s daily activities. Class IV laser with longer wavelength can stimulate tissues and penetrate more than the classic low-level laser therapy. Objectives: The aim of the study was to investigate the efficacy of class IV diode laser in the treatment of patients with chronic neck pain (CNP). Methods: Fifty-two patients participated and completed the study. Their mean age (SD) was 50.7 (6.2). Patients were randomized into two groups and treated with laser plus exercise (laser + EX) group and placebo laser plus exercise (PL+EX) group. Treatment was performed by Class IV laser in two phases; scanning and trigger point phases. Scanning to the posterior neck and shoulder girdle region with 4 J/cm2 with a total energy of 300 J applied to 75 cm2 in 4 minutes and 16 seconds. Eight trigger points on the posterior neck area were treated by 4 J/cm2 and the time of application was in 30 seconds. Both groups received exercise two times per week for 4 weeks. Exercises included range of motion, isometric, stretching, isotonic resisted exercises to the cervical extensors, lateral bending and rotators muscles with postural correction exercises. The measured variables were pain level using visual analogue scale (VAS), and neck functional activity using neck disability index (NDI) score. Measurements were taken at baseline and after 4 weeks of treatment. The level of statistical significance was set as p < 0.05. Results: There were significant decreases in post-treatment VAS and NDI in both groups as compared to baseline values. Laser + EX effectively decreased VAS (mean difference -6.5, p = 0.01) and NDI scores after (mean difference -41.3, p = 0.01) 4 weeks of treatment compared to PL + EX. Conclusion: Class IV laser combined with exercise is effective treatment for patients with CNP as compared to PL + EX therapy. The combination of laser + EX effectively increased functional activity and reduced pain after 4 weeks of treatment.

Keywords: chronic neck pain, class IV laser, exercises, neck disability index, visual analogue scale

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Authors: Junaid Hamid Bhat

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Background: Musculoskeletal disorders are one of the main causes of occupational illness. Mechanisms and the factors like repetitive work, physical effort and posture, endangering the risk of musculoskeletal disorders would now appear to have been properly identified. Teacher’s exposure to work-related musculoskeletal disorders appears to be insufficiently described in the literature. Little research has investigated the prevalence and risk factors of musculoskeletal disorders in teaching profession. Very few studies are available in this regard and there are no studies evident in India. Purpose: To determine the prevalence of musculoskeletal disorders and to identify and measure the association of such risk factors responsible for developing musculoskeletal disorders among school teachers. Methodology: An observational cross sectional study was carried out. 500 school teachers from primary, middle, high and secondary schools were selected, based on eligibility criteria. A signed consent was obtained and a self-administered, validated questionnaire was used. Descriptive statistics was used to compute the statistical mean and standard deviation, frequency and percentage to estimate the prevalence of musculoskeletal disorders among school teachers. The data analysis was done by using SPSS version 16.0. Results: Results indicated higher pain prevalence (99.6%) among school teachers during the past 12 months. Neck pain (66.1%), low back pain (61.8%) and knee pain (32.0%) were the most prevalent musculoskeletal complaints of the subjects. Prevalence of shoulder pain was also found to be high among school teachers (25.9%). 52.0% subjects reported pain as disabling in nature, causing sleep disturbance (44.8%) and pain was found to be associated with work (87.5%). A significant association was found between musculoskeletal disorders and sick leaves/absenteeism. Conclusion: Work-related musculoskeletal disorders particularly neck pain, low back pain, and knee pain, is highly prevalent and risk factors are responsible for the development of same in school teachers. There is little awareness of musculoskeletal disorders among school teachers, due to work load and prolonged/static postures. Further research should concentrate on specific risk factors like repetitive movements, psychological stress, and ergonomic factors and should be carried out all over the country and the school teachers should be studied carefully over a period of time. Also, an ergonomic investigation is needed to decrease the work-related musculoskeletal disorder problems. Implication: Recall bias and self-reporting can be considered as limitations. Also, cause and effect inferences cannot be ascertained. Based on these results, it is important to disseminate general recommendations for prevention of work-related musculoskeletal disorders with regards to the suitability of furniture, equipment and work tools, environmental conditions, work organization and rest time to school teachers. School teachers in the early stage of their careers should try to adapt the ergonomically favorable position whilst performing their work for a safe and healthy life later. Employers should be educated on practical aspects of prevention to reduce musculoskeletal disorders, since changes in workplace and work organization and physical/recreational activities are required.

Keywords: work related musculoskeletal disorders, school teachers, risk factors funding, medical and health sciences

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Authors: Nantawan Soonklang, Linda Chularojanamontri, Urarat Nanna

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Ethnopharmacological relevance: Thunbergia laurifolia Lindl. belongs to the family Acanthaceae commonly known as Rang jeud in Thailand. This plant is traditionally used in Thailand for centuries as an antidote for several poisons and drug overdose. Aim of the study: This research aimed to study the analgesic and antipyretic activities of T. laurifolia water extract by using animal models. Materials and Methods: The analgesic activity was studied using 2 methods of pain induction including acetic acid and heat induced pain. And the antipyretic activity study was performed by yeast-induced hyperthermia. Results: The results showed that the administration of T. laurifolia extract possessed analgesic activity by reducing acetic acid-induced writhing response and heat-induced pain as well as showed antipyretic activity by decreasing body temperature of hyperthermic rats induced by brewer’s yeast. Conclusion: The study indicates that the T. laurifolia extract possesses analgesic and antipyretic activities in animals.

Keywords: Thunbergia laurifolia extract, analgesic activity, antipyretic activity, hyperthermia

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Authors: Geum Yeon Sim, Tyler Pigott, Julio Vasquez

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A 38-year-old obese female with no apparent past medical history presented with left knee pain. Six months ago, she sustained a left knee dislocation in a motor vehicle accident that was managed with a skin graft over the left lower extremity without any reconstructive surgery. She developed persistent pain and stiffness in her left knee that worsened with walking and stair climbing. Examination revealed healed extensive skin graft over the left lower extremity, including the left knee. Palpation showed moderate tenderness along the superior border of the patella, exquisite tenderness over MCL, and mild tenderness on the tibial tuberosity. There was normal sensation, reflexes, and strength in her lower extremities. There was limited active and passive range of motion of her left knee during flexion. There was instability noted upon the valgus stress test of the left knee. Left knee magnetic resonance imaging showed high-grade (grade 2-3) injury of the proximal superficial fibers of the MCL and diffuse thickening and signal abnormality of the cruciate ligaments, as well as edema-like subchondral marrow signal change in the anterolateral aspect of the lateral femoral condyle weight-bearing surface. There was also notable extensive scarring and edema of the skin, subcutaneous soft tissues, and musculature surrounding the knee. The patient was managed with left knee immobilization for five months, which was complicated by limited knee flexion. Physical therapy consisting of quadriceps, hamstrings, gastrocnemius stretching and strengthening, range of motion exercises, scar/soft tissue mobilization, and gait training was given with marked improvement in pain and range of motion. The patient experienced a further reduction in pain as well as an improvement in function with home exercises consisting of continued strengthening and stretching.

Keywords: ligamentous injury, trauma, rehabilitation, knee pain

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Authors: Kamal Tolani, Sandeep Kumar, Rohit Luthra, Ankit Dadhania, Krishnaprasad K., Ram Gupta, Deepa Joshi

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Background: Post-operative analgesia remains a clinical challenge, with central and peripheral sensitization playing a pivotal role in treatment-related complications and impaired quality of life. Centrally acting opioids offer poor risk benefit profile with increased intensity of gastrointestinal or central side effects and slow onset of clinical analgesia. The objective of this study was to assess the clinical feasibility of induction and maintenance therapy with Tapentadol Nasal Spray (NS) in moderate to severe acute post-operative pain. Methods: Phase III, randomized, active-controlled, non-inferiority clinical trial involving 294 cases who had undergone surgical procedures under general anesthesia or regional anesthesia. Post-surgery patients were randomized to receive either Tapentadol NS 45 mg or Tramadol 100mg IV as a bolus and subsequent 50 mg or 100 mg dose over 2-3 minutes. The frequency of administration of NS was at every 4-6 hours. At the end of 24 hrs, patients in the tramadol group who had a pain intensity score of ≥4 were switched to oral tramadol immediate release 100mg capsule until the pain intensity score reduced to <4. All patients who had achieved pain intensity ≤ 4 were shifted to a lower dose of either Tapentadol NS 22.5 mg or oral Tramadol immediate release 50mg capsule. The statistical analysis plan was envisaged as a non-inferiority trial involving comparison with Tramadol for Pain intensity difference at 60 minutes (PID60min), Sum of Pain intensity difference at 60 minutes (SPID60min), and Physician Global Assessment at 24 hrs (PGA24 hrs). Results: The per-protocol analyses involved 255 hospitalized cases undergoing surgical procedures. The median age of patients was 38.0 years. For the primary efficacy variables, Tapentadol NS was non-inferior to Inj/Oral Tramadol in relief of moderate to severe post-operative pain. On the basis of SPID60min, no clinically significant difference was observed between Tapentadol NS and Tramadol IV (1.73±2.24 vs. 1.64± 1.92, -0.09 [95% CI, -0.43, 0.60]). In the co-primary endpoint PGA24hrs, Tapentadol NS was non–inferior to Tramadol IV (2.12 ± 0.707 vs. 2.02 ±0.704, - 0.11[95% CI, -0.07, 0.28). However, on further assessment at 48hr, 72 hrs, and 120hrs, clinically superior pain relief was observed with the Tapentadol NS formulation that was statistically significant (p <0.05) at each of the time intervals. Secondary efficacy measures, including the onset of clinical analgesia and TOTPAR, showed non-inferiority to Tramadol. The safety profile and need for rescue medication were also similar in both the groups during the treatment period. The most common concomitant medications were anti-bacterial (98.3%). Conclusion: Tapentadol NS is a clinically feasible option for improved compliance as induction and maintenance therapy while offering a sustained and persistent patient response that is clinically meaningful in post-surgical settings.

Keywords: tapentadol nasal spray, acute pain, tramadol, post-operative pain

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Authors: Hosam Alzahrani, Martin Mackey, Emmanuel Stamatakis, Marina B. Pinheiro, Manuela Wicks, Debra Shirley

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Objective: To investigate the effectiveness of incidental (non-structured) physical activity interventions compared with other commonly prescribed interventions for the management of people with low back pain (LBP). Methods: We performed a systematic review with meta-analyses of eligible randomized controlled trials obtained by searching Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This review considered trials investigating the effect of incidental physical activity interventions compared to other interventions in people aged 18 years or over, diagnosed with non-specific LBP. Analyses were conducted separately for short-term (≤3 months), intermediate-term (> 3 and < 12 months), and long-term (≥ 12 months), for each outcome. The analyses were conducted using the weighted mean difference (WMD). The overall quality of evidence was assessed using the GRADE system. Meta-analyses were only performed for pain and disability outcomes as there was insufficient data on the other outcomes. Results: For pain, the pooled results did not show any significant effects between the incidental physical activity intervention and other interventions at any time point. For disability, incidental physical activity was not statistically more effective than other interventions at short-term; however, the pooled results favored incidental physical activity at intermediate-term (WMD= -6.05, 95% CI: -10.39 to -1.71, p=0.006) and long-term (WMD= -6.40 95% CI: -11.68 to -1.12, p=0.02) follow-ups among participants with chronic LBP. The overall quality of evidence was rated “moderate quality” based on the GRADE system. Conclusion: The incidental physical activity intervention provided intermediate and long disability relief for people with chronic LBP, although this improvement was small and not likely to be clinically important.

Keywords: physical activity, incidental, low back pain, systematic review, meta-analysis

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Authors: Denisa Mackova, Andrea Pokorna

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The management of postoperative pain is a meaningful part of quality care. The experience and knowledge of registered nurses in postoperative pain management can be influenced by local know-how. Therefore, the research helps to understand the cultural differences between two countries with the aim of evaluating the management of postoperative pain management among the nurses from the Czech Republic and the Kingdom of Saudi Arabia. Both countries have different procedures on managing postoperative pain and the research will provide an understanding of both the advantages and disadvantages of the procedures and also highlight the knowledge and experience of registered nurses in both countries. Between the Czech Republic and the Kingdom of Saudi Arabia, the expectation is for differing results in the usage of opioid analgesia for the patients postoperatively and in the experience of registered nurses with Patient Controlled Analgesia. The aim is to evaluate the knowledge and awareness of registered nurses and to merge the data with the postoperative pain management in the early postoperative period in the Czech Republic and the Kingdom of Saudi Arabia. Also, the aim is to assess the knowledge and experience of registered nurses by using Patient Controlled Analgesia and epidural analgesia treatment in the early postoperative period. The criteria for those providing input into the study, are registered nurses, working in surgical settings (standard departments, post-anesthesia care unit, day care surgery or ICU’s) caring for patients in the postoperative period. Method: Research is being conducted by questionnaires. It is a quantitative research, a comparative study of registered nurses in the Czech Republic and the Kingdom of Saudi Arabia. Questionnaire surveys were distributed through an electronic Bristol online survey. Results: The collection of the data in the Kingdom of Saudi Arabia has been completed successfully, with 550 respondents, 77 were excluded and 473 respondents were included for statistical data analysis. The outcome of the research is expected to highlight the differences in treatment through Patient Controlled Analgesia, with more frequent use in the Kingdom of Saudi Arabia. A similar assumption is expected for treatment conducted by analgesia. We predict that opioids will be used more regularly in the Kingdom of Saudi Arabia, whilst therapy through NSAID’s being the most common approach in the Czech Republic. Discussion/Conclusion: The majority of respondents from the Kingdom of Saudi Arabia were female registered nurses from a multitude of nations. We are expecting a similar split in gender between the Czech Republic respondents; however, there will be a smaller number of nationalities. Relevance for research and practice: Output from the research will assess the knowledge, experience and practice of patient controlled analgesia and epidural analgesia treatment. Acknowledgement: This research was accepted and affiliated to the project: Postoperative pain management, knowledge and experience registered nurses (Czech Republic and Kingdom of Saudi Arabia) – SGS05/2019-2020.

Keywords: acute postoperative pain, epidural analgesia, nursing care, patient controlled analgesia

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Authors: Justin Durham, Chanda Rooney, Robert Mather, Mickie Vanhoy

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The psychological construct of empathy is to understand a person’s cognitive perspective and experience the other person’s emotional state. Deciphering emotional states is conducive for interpreting vicarious pain. Observing others' physical pain activates neural networks related to the actual experience of pain itself. The study addresses empathy as a nonlinear dynamic process of simulation for individuals to understand the mental states of others and experience vicarious pain, exhibiting self-organized criticality. Such criticality follows from a combination of neural networks with an excitatory feedback loop generating bistability to resonate permutated empathy. Cortical networks exhibit diverse patterns of activity, including oscillations, synchrony and waves, however, the temporal dynamics of neurophysiological activities underlying empathic processes remain poorly understood. Mu rhythms are EEG oscillations with dominant frequencies of 8-13 Hz becoming synchronized when the body is relaxed with eyes open and when the sensorimotor system is in idle, thus, mu rhythm synchrony is expected to be highest in baseline conditions. When the sensorimotor system is activated either by performing or simulating action, mu rhythms become suppressed or desynchronize, thus, should be suppressed while observing video clips of painful injuries if previous research on mirror system activation holds. Twelve undergraduates contributed EEG data and survey responses to empathy and psychopathy scales in addition to watching consecutive video clips of sports injuries. Participants watched a blank, black image on a computer monitor before and after observing a video of consecutive sports injuries incidents. Each video condition lasted five-minutes long. A BIOPAC MP150 recorded EEG signals from sensorimotor and thalamocortical regions related to a complex neural network called the ‘pain matrix’. Physical and social pain are activated in this network to resonate vicarious pain responses to processing empathy. Five EEG single electrode locations were applied to regions measuring sensorimotor electrical activity in microvolts (μV) to monitor mu rhythms. EEG signals were sampled at a rate of 200 Hz. Mu rhythm desynchronization was measured via 8-13 Hz at electrode sites (F3 & F4). Data for each participant’s mu rhythms were analyzed via Fast Fourier Transformation (FFT) and multifractal time series analysis.

Keywords: desynchronization, dynamical systems theory, electroencephalography (EEG), empathy, multifractal time series analysis, mu waveform, neurophysiology, pain simulation, social cognition

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Authors: Ozge Tahran, Sevgi Sevi Yesilyaprak

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Objective: The aim of the study was to investigate the effect of the Wilk’s modified two different stretching exercises on posterior shoulder tightness, pain, and dysfunction in patients with subacromial impingement syndrome (SIS). Method: This study was carried out on 67 patients who have more than 15° difference in shoulder internal rotation range of motion between two sides and had been diagnosed as SIS. Before treatment, all patients were randomly assigned into three groups. Standard physiotherapy programme was applied to the Group 3 (n=23), standard physiotherapy program with Wilk’s modified cross-body stretching exercises were applied to Group 1 (n=22), and standard physiotherapy program with Wilk’s modified sleeper stretching exercises were applied to Group 2 (n= 23). All the patients received 20 sessions of physiotherapy during 4 weeks, 5 days in a week by a physiotherapist. The patients continued their exercises at home at the weekends. Pain severity, shoulder rotation range of motion, posterior shoulder tightness, upper extremity functionality with Constant and Murley Score (CMS) and disability level with The Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) were evaluated before and after physiotherapy programme. Results: Before treatment, demographic and anthropometric characteristics were similar in groups and there was no statistical difference (p > 0.05). It was determined that pain severity decreased, shoulder rotation range of motion, posterior shoulder tightness, upper extremity functionality, and disability were improved after physiotherapy in both groups (p < 0.05). Group 1 and 2 had better results in terms of reduction of pain severity during activity, increase in shoulder rotation range of motion, posterior shoulder mobility and upper extremity functionality and improvement in upper extremity disability, compared to Group 3 (p < 0.05). Conclusion: Modified posterior shoulder stretching exercises in addition to standard physiotherapy programme is more effective for reduction of pain during activity, to improve shoulder rotation range of motion, posterior shoulder mobility, and upper extremity functionality in patients with SIS compared to standard physiotherapy programme alone.

Keywords: modified posterior shoulder stretching exercises, posterior shoulder tightness, shoulder complex, subacromial impingement syndrome

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Authors: Les Moncrieff

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In a world awash with potent opioids flaming an international crisis, the need to explore safe alternatives has never been more urgent. Bio-electrode Therapy is a novel adjunctive treatment method for relieving acute opioid withdrawal symptoms and many types of complex acute and chronic pain (often the underlying cause of opioid dependence). By combining the science of developmental bioelectricity with Traditional Chinese Medicine’s theory of meridians, rapid relief from pain is routinely being achieved in the clinical setting. Human body functions are dependent on electrical factors, and acupuncture points on the body are known to have higher electrical conductivity than surrounding skin tissue. When tiny gold- and silver-plated electrodes are secured to the skin at specific acupuncture points using established Chinese Medicine principles and protocols, an enhanced microcurrent and electrical field are created between the electrodes, influencing the entire meridian and connecting meridians. No external power source or electrical devices are required. Endogenous DC electric fields are an essential fundamental component for development, regeneration, and wound healing. Disruptions in the normal ion-charge in the meridians and circulation of blood will manifest as pain and development of disease. With the application of these simple electrodes (gold acting as cathode and silver as anode) according to protocols, the resulting microcurrent is directed along the selected meridians to target injured or diseased organs and tissues. When injured or diseased cells have been stimulated by the microcurrent and electrical fields, the permeability of the cell membrane is affected, resulting in an immediate relief of pain, a rapid balancing of positive and negative ions (sodium, potassium, etc.) in the cells, the restoration of intracellular fluid levels, replenishment of electrolyte levels, pH balance, removal of toxins, and a re-establishment of homeostasis.

Keywords: bioelectricity, electrodes, electrical fields, acupuncture meridians, complex pain, opioid withdrawal management

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Authors: Neil Singla, Derek Muse, Karen DiDonato, Pamela Palmer

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Introduction: Pain is the most common reason people visit emergency rooms. Studies indicate however, that Emergency Department (ED) physicians often do not provide adequate analgesia to their patients as a result of gender and age bias, opiophobia and insufficient knowledge of and formal training in acute pain management. Novel classes of analgesics have recently been introduced, but many patients suffer from acute pain in settings where the availability of intravenous (IV) access may be limited, so there remains a clinical need for rapid-acting, potent analgesics that do not require an invasive route of delivery. A sublingual sufentanil tablet (SST), dispensed using a single-dose applicator, is in development for treatment of moderate-to-severe acute pain in a medically-supervised setting. Objective: The primary objective of this study was to demonstrate the repeat-dose efficacy, safety and tolerability of sufentanil 20 mcg and 30 mcg sublingual tablets compared to placebo for the management of acute pain as determined by the time-weighted sum of pain intensity differences (SPID) to baseline over the 12-hour study period (SPID12). Key secondary efficacy variables included SPID over the first hour (SPID1), Total pain relief over the 12-hour study period (TOTPAR12), time to perceived pain relief (PR) and time to meaningful PR. Safety variables consisted of adverse events (AE), vital signs, oxygen saturation and early termination. Methods: In this Phase 2, double-blind, dose-finding study, an equal number of male and female patients were randomly assigned in a 2:2:1 ratio to SST 20 mcg, SS 30 mcg or placebo, respectively, following bunionectomy. Study drug was dosed as needed, but not more frequently than hourly. Rescue medication was available as needed. The primary endpoint was the Summed Pain Intensity Difference to baseline over 12h (SPIDI2). Safety was assessed by continuous oxygen saturation monitoring and adverse event reporting. Results: 101 patients (51 Male/50 Female) were randomized, 100 received study treatment (intent-to-treat [ITT] population), and 91 completed the study. Reasons for early discontinuation were lack of efficacy (6), adverse events (2) and drug-dosing error (1). Mean age was 42.5 years. For the ITT population, SST 30 mcg was superior to placebo (p=0.003) for the SPID12. SPID12 scores in the active groups were superior for both male (ANOVA overall p-value =0.038) and female (ANOVA overall p-value=0.005) patients. Statistically significant differences in favour of sublingual sufentanil were also observed between the SST 30mcg and placebo group for SPID1(p<0.001), TOTPAR12(p=0.002), time to perceived PR (p=0.023) and time to meaningful PR (p=0.010). Nausea, vomiting and somnolence were more frequent in the sufentanil groups but there were no significant differences between treatment arms for the proportion of patients who prematurely terminated due to AE or inadequate analgesia. Conclusions: Sufentanil tablets dispensed sublingually using a single-dose applicator is in development for treatment of patients with moderate-to-severe acute pain in a medically-supervised setting where immediate IV access is limited. When administered sublingually, sufentanil’s pharmacokinetic profile and non-invasive delivery makes it a useful alternative to IM or IV dosing.

Keywords: acute pain, pain management, sublingual, sufentanil

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Authors: Amina Bayazid, Habiba Fetati, Houari Toumi

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Introduction: The clinical value of vitamin K antagonists (VKA) has been widely demonstrated in numerous indications. Unfortunately, VKA are not devoid of drawbacks and risk of serious bleeding. The iatrogenic induced by these drugs is a major public health problem. Patients & Methods: We conducted a retrospective study period extending from February 2012 to August 2013 in the pharmacovigilance service of EHUO (clinical pharmacology unit). The prescription of painkillers was analyzed in patients on VKA followed at our level. The influence of these analgesics on the evolution of the INR is an important component in our work. Results: We counted a total of 195 patients, of whom 32 (or 16.41% of the total population) had received analgesic treatment. The frequencies of different categories of analgesics administered were: • Analgesics opioids: 0% • Analgesics weak opioids: Tramadol: 21.87% • The non-opioid analgesics: -AINS: 71.87% (indomethacin: 68.75% ibuprofen: 3.12%) - Paracetamol: 6.25% -Salicyles (Acetylsalicylic acid): 0%. Conclusion: The management of pain in patients under vitamin K antagonists has special features, given their many drug interactions with analgesics and their influence on the evolution of the INR which can have dramatic consequences. As such, special attention must be paid to the use of analgesics in this type of patient.

Keywords: vitamin K antagonists, pain killers, interactions, INR

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Authors: Maha E. Ibrahim, Mona Abdel Aziz

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Background: Chronic low back pain (CLBP) in urban communities represents a challenge to healthcare systems worldwide. The traditional biomedical approach to back pain has been particularly inadequate. Failure of the biomedical model to explain the poor correlation between pain and disability on the one hand, and biological and physical factors that explain those symptoms on the other has led to the adoption of the biopsychosocial model, to recognize the reciprocal influence of physical, social and psychological factors implicated in CLBP, a condition that shows higher prevalence among women residing in urban areas. Urban design of the built community has been shown to exert a significant influence on physical and psychological health. However, little research has investigated the relationship between elements of the built environment, and the level of pain and disability of women with CLBP. As Egypt embarks on building a new capital city, and new settlements proliferate, better understanding of this relationship could greatly reduce the economic and human costs of this widespread medical problem for women. Methods: This study was designed as an exploratory mixed qualitative and quantitative study. Twenty-Six women with CLBP living in two neighborhoods in Cairo, different in their urban structure, but adjacent in their locations (Old Maadi and New Maadi) were interviewed using semi-structured interviews (8 from Old Maadi and 18 from New Maadi). Located in the South of Cairo, New Maadi is a neighborhood with the characteristic modern urban style (narrow streets and tall, adjacent buildings), while Old Maadi is known for being greener, quieter and more relaxed than the usual urban districts of Cairo. The interviews examined their perceptions of the built environment, including building shapes and colors and street light, as well as their sense of safety and comfort, and how it affects their physical and psychological health in general, and their back condition in particular. In addition, they were asked to rate their level of pain and to fill the Oswestry Disability Index (ODI), and the General Health Questionnaire (GHQ-12) to rate their level of disability and psychological status, respectively. Results: Women in both districts had moderate to severe pain and moderate disability with no significant differences between the two districts. However, those living in New Maadi had significantly worse scores on the GHQ-12 than those living in Old Maadi. Most women did not feel that specific elements of the built environment affected their back pain, however, they expressed distress of the elements that were ugly, distorted or damaged, especially where there were no ways of avoiding or fixing them. Furthermore, most women affirmed that the unsightly and uncomfortable elements of their neighborhoods affected their mood states and were a constant source of stress. Conclusion: This exploratory study concludes that elements of the urban built environment do not exert a direct effect on CLBP. However, the perception of women regarding these elements does affect their mood states, and their levels of stress, making them a possible indirect cause of increased suffering in these women.

Keywords: built environment, chronic back pain, disability, urban Cairo

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Authors: Linda Chularojmontri, Seewaboon Sireeratawong, Suvara Wattanapitayakul

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Terminalia arjuna Roxb. (family Combretaceae) is commonly known as ‘Sa maw thet’ in Thai. The fruit is used in traditional medicine as natural mild laxatives, carminative and expectorant. Aim of the study: This research aims to study the anti-inflammatory, analgesic and antipyretic activities of Terminalia arjuna extract by using animal models in comparison to the reference drugs. Materials and Methods: The anti-inflammatory study was conducted by two experimental animal models namely ethyl phenylpropionate (EPP)-induced ear edema and carrageenan-induced paw edema. The study of analgesic activity used two methods of pain induction including acetic acid and heat-induced pain. In addition, the antipyretic activity study was performed by induced hyperthermia with yeast. Results: The results showed that the oral administration of Terminalia arjuna extract possessed acute anti-inflammatory effect in carrageenan-induced paw edema. Terminalia arjuna extract showed the analgesic activity in acetic acid-induced writhing response and heat-induced pain. This indicates its peripheral effect by inhibiting the biosynthesis and/or release of some pain mediators and some mechanism through Central nervous system. Moreover, Terminalia arjuna extract at the dose of 1000 and 1500 mg/kg body weight showed the antipyretic activity, which might be because of the inhibition of prostaglandins. Conclusion: The findings of this study indicated that the Terminalia arjuna extract possesses the anti-inflammatory, analgesic and antipyretic activities in animals.

Keywords: analgesic activity, anti-inflammatory activity, antipyretic activity, Terminalia arjuna extract

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Authors: Zehra Betül Karakoç

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Aim: The aim of our study is to determine the changement pf plantar pressure after extracorporeal shock wave therapy (ESWT) in a patient with calcaneal spur (CS). Method: Thirty patients with CS who received ESWT treatment at Kartal Yavuz Selim State Hospital between May 2020 and November 2022 participated in this study. Demographic information of the cases was obtained. Pain levels and plantar pressure were measured with Visuel Analog Scale (VAS) and pedobarography, respectively. Pedobarography measured the maximal strength, peak pressure level, and contact area values of the hind, middle, forefoot, and toes. The cases were re-evaluated 4 weeks after the application of 15 Hz, 2-3 bar, 2,000 beats ESWT for 3 sessions. 22 cases participated in the second evaluation. The data of all patients were evaluated bilaterally. Results: Pain intensity levels after treatment were statistically significantly decreased compared to before treatment (p=0.012). Maximum force and contact area values of total foot and forefoot increased significantly (p < 0.05). Conclusion: We consider that the increased max force value of total foot and forefoot area after ESWT is due to the normal walking rate gained related to decreased pain. ESWT treatment may have positive effects on foot pressure distribution and body biomechanics. In order to interpret the results of our study more clearly, randomized controlled studies with a larger number of cases were planned in the future.

Keywords: calcaneal spur, ESWT, plantar pressure, pain

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Authors: Johnson C. Y. Pang, Amy S. N. Fu, Ryan K. L. Lee, Allan C. L. Fu

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Dry needling (DN) is one of the puncturing methods that involves the insertion of needles into the tender spots of the human body without the injection of any substance. DN has long been used to treat the patient with knee pain caused by knee osteoarthritis (KOA) and patellofemoral pain syndrome (PFPS), but the effectiveness is still inconsistent. This study aimed to conduct a systematic review and meta-analysis to assess the intervention methods and effects of DN with and without ultrasound guidance for treating pain and dysfunctions in people with KOA and PFPS. Design: This systematic review adhered to the PRISMA reporting guidelines. The registration number of the study protocol published in the PROSPERO database was CRD42021221419. Six electronic databases were searched manually through CINAHL Complete (1976-2020), Cochrane Library (1996-2020), EMBASE (1947-2020), Medline (1946-2020), PubMed (1966-2020), and Psychinfo (1806-2020) in November 2020. Randomized controlled trials (RCTs) and controlled clinical trials were included to examine the effects of DN on knee pain, including KOA and PFPS. The key concepts included were: DN, acupuncture, ultrasound guidance, KOA, and PFPS. Risk of bias assessment and qualitative analysis were conducted by two independent reviewers using the PEDro score. Results: Fourteen articles met the inclusion criteria, and eight of them were high-quality papers in accordance with the PEDro score. There were variations in the techniques of DN. These included the direction, depth of insertion, number of needles, duration of stay, needle manipulation, and the number of treatment sessions. Meta-analysis was conducted on eight articles. DN group showed positive short-term effects (from immediate after DN to less than 3 months) on pain reduction for both KOA and PFPS with the overall standardized mean difference (SMD) of -1.549 (95% CI=-0.588 to -2.511); with great heterogeneity (P=0.002, I²=96.3%). In subgroup analysis, DN demonstrated significant effects in pain reduction on PFPS (p < 0.001) that could not be found in subjects with KOA (P=0.302). At 3-month post-intervention, DN also induced significant pain reduction in both subjects with KOA and PFPS with an overall SMD of -0.916 (95% CI=-0.133 to -1.699, and great heterogeneity (P=0.022, I²=95.63%). Besides, DN induced significant short-term improvement in function with the overall SMD=6.069; 95% CI=8.595 to 3.544; with great heterogeneity (P<0.001, I²=98.56%) when analyzed was conducted on both KOA and PFPS groups. In subgroup analysis, only PFPS showed a positive result with SMD=6.089, P<0.001; while KOA showed statistically insignificant with P=0.198 in short-term effect. Similarly, at 3-month post-intervention, significant improvement in function after DN was found when the analysis was conducted in both groups with the overall SMD=5.840; 95% CI=9.252 to 2.428; with great heterogeneity (P<0.001, I²=99.1%), but only PFPS showed significant improvement in sub-group analysis (P=0.002, I²=99.1%). Conclusions: The application of DN in KOA and PFPS patients varies among practitioners. DN is effective in reducing pain and dysfunction at short-term and 3-month post-intervention in individuals with PFPS. To our best knowledge, no study has reported the effects of DN with ultrasound guidance on KOA and PFPS. The longer-term effects of DN on KOA and PFPS are waiting for further study.

Keywords: dry needling, knee osteoarthritis, patellofemoral pain syndrome, ultrasound guidance

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Authors: Rachel Ashwell, Sally Millett

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Introduction: Adequate post-operative pain relief is a key priority in the delivery of caesarean sections. This improves patient experience, reduces morbidity and enables optimal mother-infant interaction. Recommendations outlined in the NICE guidelines for caesarean section (CS) include offering peri-operative intrathecal/epidural diamorphine and post-operative opioid analgesics; offering non-steroidal anti-inflammatory drugs (NSAIDs) unless contraindicated and taking hourly observations for 12 hours following intrathecal diamorphine. Method: This audit assessed the provision of post-CS analgesia in 29 women over a two-week period. Indicators used were the use of intrathecal/epidural opioids, use of post-operative opioids and NSAIDs, frequency of observations and patient satisfaction with pain management on post-operative days 1 and 2. Results: All women received intrathecal/epidural diamorphine, 97% were prescribed post-operative opioids and all were prescribed NSAIDs unless contraindicated. Hourly observations were not maintained for 12 hours following intrathecal diamorphine. 97% of women were satisfied with their pain management on post-operative day 1 whereas only 75% were satisfied on day 2. Discussion: This service meets the proposed standards for the provision of post-operative analgesia, achieving high levels of patient satisfaction 1 day after CS. However, patient satisfaction levels are significantly lower on post-operative day 2, which may be due to reduced frequency of observations. The lack of an official audit standard for patient satisfaction on postoperative day 2 may result in reduced incentive to prioritise pain management at this stage.

Keywords: Caesarean section, analgesia, postoperative care, patient satisfaction

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Authors: Sarah Hazelwood, Janice Hay

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Methoxyflurane is an inhaled analgesic administered via a disposable inhaler, which has been used in Australia for 40 years for the management of pain in children & adults. However, there is a lack of data for methoxyflurane as a frontline analgesic medication within the emergency department (ED). This study will investigate the usefulness of methoxyflurane in a private inner-city ED. The study concluded that the inclusion of all key stakeholders in the prescribing, administering & use of this new process led to comprehensive uptake & vastly positive outcomes for consumer & health professionals. Method: A 12-week prospective pilot study was completed utilizing patients presenting to the ED in pain (numeric pain rating score > 4) that fit the requirement of methoxyflurane use (as outlined in the Australian Prescriber information package). Nurses completed a formatted spreadsheet for each interaction where methoxyflurane was used. Patient demographics, day, time, initial numeric pain score, analgesic response time, the reason for use, staff concern (free text), & patient feedback (free text), & discharge time was documented. When clinical concern was raised, the researcher retrieved & reviewed patient notes. Results: 140 methoxyflurane inhalers were used. 60% of patients were 31 years of age & over (n=82) with 16% aged 70+. The gender split; 51% male: 49% female. Trauma-related pain (57%) saw the highest use of administration, with the evening hours (1500-2259) seeing the greatest numbers used (39%). Tuesday, Thursday & Sunday shared the highest daily use throughout the study. A minimum numerical pain score of 4/10 (n=13, 9%), with the ranges of 5 - 7/10 (moderate pain) being given by almost 50% of patients. Only 3 instances of pain scores increased post use of methoxyflurane (all other entries showed pain score < initial rating). Patients & staff noted obvious analgesic response within 3 minutes (n= 96, 81%, of administration). Nurses documented a change in patient vital signs for 4 of the 15 patient-related concerns; the remaining concerns were due to “gagging” on the taste, or “having a coughing episode”; one patient tried to leave the department before the procedure was attended (very euphoric state). Upon review of the staff concerns – no adverse events occurred & return to therapeutic vitals occurred within 10 minutes. Length of stay for patients was compared with similar presentations (such as dislocated shoulder or ankle fracture) & saw an average 40-minute decrease in time to discharge. Methoxyflurane treatment was rated “positively” by > 80% of patients – with remaining feedback related to mild & transient concerns. Staff similarly noted a positive response to methoxyflurane as an analgesic & as an added tool for frontline analgesic purposes. Conclusion: Methoxyflurane should be used on suitable patient presentations requiring immediate, short term pain relief. As a highly portable, non-narcotic avenue to treat pain this study showed obvious therapeutic benefit, positive feedback, & a shorter length of stay in the ED. By partnering with key stake holders, this study determined methoxyflurane use decreased work load, decreased wait time to analgesia, and increased patient satisfaction.

Keywords: analgesia, benefits, emergency, methoxyflurane

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Authors: Rune Bjerke

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Psychologists incline to see creativity as a mental and psychological process. However, creativity is as well results of cultural and social interactions. Therefore, creativity is not a product of individuals in isolation, but of social systems. Creative people get ideas from the influence of others and the immediate cultural environment – a space of knowledge, situations, and practices. Therefore, in this study we apply the systems theory in practice to activate creativity processes in the production of our novel and screenplay writing. We, as storytellers actively seek to get into situations in our everyday lives, our systems, to generate ideas. Within our personal systems, we have the potential to induce situations to realise ideas to our texts, which may be accepted by our gate-keepers and can become socially validated. This is our method of writing – get into situations, get ideas to texts, and test them with family and friends in our social systems. Example of novel text as an outcome of our method is as follows: “Is it a matter of obviousness or had I read it somewhere, that the one who increases his knowledge increases his pain? And also, the other way around, with increased pain, knowledge increases, I thought. Perhaps such a chain of effects explains why the rebel August Strindberg wrote seven plays in ten months after the divorce with Siri von Essen. Shortly after, he tried painting. Neither the seven theatre plays were shown, nor the paintings were exhibited. I was standing in front of Munch's painting Women in Three Stages with chaotic mental images of myself crumpled in a church and a laughing x-girlfriend watching my suffering. My stomach was turning at unpredictable intervals and the subsequent vomiting almost suffocated me. Love grief at the worst. Was it this pain Strindberg felt? Despite the failure of his first plays, the pain must have triggered a form of creative energy that turned pain into ideas. Suffering, thoughts, feelings, words, text, and then, the reader experience. Maybe this negative force can be transformed into something positive, I asked myself. The question eased my pain. At that moment, I forgot the damp, humid air in the Munch Museum. Is it the similar type of Strindberg-pain that could explain the recurring, depressive themes in Munch's paintings? Illness, death, love and jealousy. As a beginning art student at the master's level, I had decided to find the answer. Was it the same with Munch's pain, as with Strindberg - a woman behind? There had to be women in the case of Munch - therefore, the painting “Women in Three Stages”? Who are they, what personality types are they – the women in red, black and white dresses from left to the right?” We, the writers, are using persons, situations and elements in our systems, in a systems theory perspective, to prompt creative ideas. A conceptual model is provided to advance creativity theory.

Keywords: creativity theory, systems theory, novel writing, screenplay writing, sources of creativity in social systems

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Authors: Latifa Alenezi, Liz Croot, Janet Harris

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Chronic Low Back Pain (CLBP) is one of the most common and recurrent musculoskeletal problems that causes patients to access health care services frequently. The Bio-psychosocial Model emphasises that psychological, behavioural and social factors contribute to the development and persistence of CLBP. Cognitive behavioural therapy (CBT) is a psychological pain management strategy that can be used by physiotherapists treating chronic low back pain. However, evidence of the effectiveness of CBT for CLBP varies between different studies. The proposed study was preceded by a mixed methods systematic review that found that CBT has a beneficial effect for CLBP patients when compared to waiting list or other treatments; however, there is variation in effectiveness across different settings. Little is known about how CBT is applied by physiotherapists in physiotherapy settings. The interest of this study is directed towards generating an explanation and understanding of why, when, and how some physiotherapists make decisions and choose to apply CBT for CLBP patients, whereas others do not. Also, how and for what type of CLBP patients does CBT work, and for whom might CBT not work? Therefore, the study will take a qualitative approach to explore CLBP patients’, physiotherapists’ and managers’ perceptions of CBT and how it is used in physiotherapy to enable a deeper understanding and richer explanation of CBT effectiveness and help to inform research and practice. The study will use grounded theory approach to generate an explanatory theory of the clinical application of CBT for CLBP in physiotherapy settings. Physiotherapists, patients and managers of physiotherapy services will be interviewed. Grounded theory techniques will be used to analyse the data. The presentation will describe findings from the interviews and the emerging theory. This research will help to further inform RCTs about the effectiveness of CBT for CLBP in physiotherapy.

Keywords: CBT, CLBP, perception, physiotherapy, theory

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Authors: Sugam Kale, Arif Uzair Bin Mohammed Roslan, Cindy Lee, Syed Beevee Mohammed Ismail

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Preemptive analgesia is an established concept in the modern practice of anaesthesia. To be most effective, it is best instituted earlier than the surgical stimulus and should last beyond the offset of surgically induced pain till healing is complete. Whereas the start of afferent pain blockade with regional anaesthesia is common, its effect often falls short to cover the entire period of pain impulses making their way to CNS in the post-operative period. We tried to use a combination of two regional anaesthetic techniques used sequentially to overcome this handicap. Madam S., a 56 year old lady, was scheduled for elective surgery for pancreatic cancer. She underwent laparotomy and distal pancreatectomy, splenectomy, bilateral salpingo oophorectomy, and sigmoid colectomy. Surgery was expected to be extensive, and it was presumed that the standard pain relief with PCA with opiates and oral analgesics would not be adequate. After counselling the patient pre-operative about the technique of regional anaesthesia techniques, including epidural catheterization and rectus sheath catheter placement, their benefits, and potential complications, informed consent was obtained. Epidural catheter was placed awake, and general anaesthesia was then induced. Epidural infusion of local anaesthetics was started prior to surgical incision and was continued till 60 hours into the postoperative period. Before skin closure, the surgeons inserted commercially available rectus sheath catheters bilaterally along the midline incision used for laparotomy. After 46 hours post-op, local anaesthetic infusion via these was started as bridging while the epidural infusion rate was tapered off. The epidural catheter was removed at 75 hours. Elastomeric pumps were used to provide local anaesthetic infusion with the ability to vary infusion rates. Acute pain service followed up the patient’s vital signs and effectiveness of pain relief twice daily or more frequently as required. Rectus sheath catheters were removed 137 hours post-op. The patient had good post-op analgesia with the minimal additional analgesic requirement. For the most part, the visual analog score (VAS) for pain remained at 1-3 on a scale of 1 to 10. Haemodynamics remained stable, and surgical recovery was as expected. Minimal opiate requirement after an extensive laparotomy also translates to the early return of intestinal motility. Our experience was encouraging, and we are hoping to extend this combination of two regional anaesthetic techniques to patients undergoing similar surgeries. Epidural analgesia is denser and offers excellent pain relief for both visceral and somatic pain in the first few days after surgery. As the pain intensity grows weaker, rectus sheath block and oral analgesics provide almost the same degree of pain relief after the epidural catheter is removed. We discovered that the background infusion of local anaesthetic down the rectus sheath catherter largely reduced the requirement for other classes of analgesics. We aim to study this further with a larger patient cohort and hope that it may become an established clinical practice that benefits patients everywhere.

Keywords: rectus sheath, epidural infusion, post operative analgesia, elastomeric

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Authors: Thidathit Prachanukool, Chaiyaporn Yuksen, Welawat Tienpratarn, Sorravit Savatmongkorngul, Panvilai Tangkulpanich, Chetsadakon Jenpanitpong, Yuranan Phootothum, Malivan Phontabtim, Promphet Nuanprom

Abstract:

Background: Ruptured appendicitis has a high morbidity and mortality and requires immediate surgery. The Alvarado Score is used as a tool to predict the risk of acute appendicitis, but there is no such score for predicting rupture. This study aimed to developed the prediction score to determine the likelihood of ruptured appendicitis in an Asian population. Methods: This study was diagnostic, retrospectively cross-sectional and exploratory model at the Emergency Medicine Department in Ramathibodi Hospital between March 2016 and March 2018. The inclusion criteria were age >15 years and an available pathology report after appendectomy. Clinical factors included gender, age>60 years, right lower quadrant pain, migratory pain, nausea and/or vomiting, diarrhea, anorexia, fever>37.3°C, rebound tenderness, guarding, white blood cell count, polymorphonuclear white blood cells (PMN)>75%, and the pain duration before presentation. The predictive model and prediction score for ruptured appendicitis was developed by multivariable logistic regression analysis. Result: During the study period, 480 patients met the inclusion criteria; of these, 77 (16%) had ruptured appendicitis. Five independent factors were predictive of rupture, age>60 years, fever>37.3°C, guarding, PMN>75%, and duration of pain>24 hours to presentation. A score > 6 increased the likelihood ratio of ruptured appendicitis by 3.88 times. Conclusion: Using the Ramathibodi Welawat Ruptured Appendicitis Score. (RAMA WeRA Score) developed in this study, a score of > 6 was associated with ruptured appendicitis.

Keywords: predictive model, risk score, ruptured appendicitis, emergency room

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Authors: Bonnie Pollak

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As the world continues to suffer grievous injuries, future generations will suffer from trauma that was inflicted on innocent victims. Trauma can result from refugees fleeing their homes, exposure to warfare, loss of loved ones, and lack of shelter and basic necessities. The Holocaust continues to cause pain even though WWII ended nearly 80 years ago. One cannot forget the inhumane treatment and murder of relatives. The pain and trauma may continue for generations. The purpose of the Final Solution was to eliminate Jews in totality. Though Hitler’s plan was not successful, he managed to cause trauma that will continue with no end date in sight. “The Effects of Trauma and Secondary Trauma,” Trauma can cause life-long challenges, eating disorders, cardiovascular disease, cancer, sleeping difficulties, fear of going outside, guilt, separation problems, and epigenetic changes. Secondary Trauma, witnessing a loved one in danger or hearing about the danger, can cause similar symptoms as seen in primary trauma. The transmission of trauma was demonstrated in children of Holocaust survivors and in communities where oppression was commonplace. We are witnessing a repeat of widescale death and horrific injuries today in Ukraine and in other parts of the world, where concern for pain and trauma is not acknowledged by perpetrators. Lessons from the Holocaust can be applied to help others who have been traumatized by widescale terrorism resulting in death of loved ones, loss of home and shelter, food and other life-sustaining measures. The world must help victims by providing basic necessities but also by using trauma-informed care, focusing on strength and resilience, and helping individuals to feel pride in their identity.

Keywords: transmission of intergenerational trauma, impact on religious beliefs and practices, 2nd generation, identity

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