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Context Pain is a therapeutic challenge after total knee arthroplasty (TKA), and it could lead to the overuse of opioids. Few methodologically robust clinical studies have been performed to assess the effectiveness of osteopathic manipulative therapy (OMTh; manipulative care performed by non–US-trained osteopaths) for postsurgical pain. Objective To evaluate the effectiveness of standardized preoperative OMTh on early postoperative pain and opioid consumption after TKA. Methods This comparative, nonrandomized study took place from 2013 to 2015 and included patients who had primary unilateral TKA for osteoarthritis in a knee that had not undergone any previous surgery. Patients were divided into 2 consecutive groups: 1 group received traditional preoperative management, and the other group received associated preoperative OMTh (general OMTh [rhythmic mobilization of all the body joints, from the ankles to the skull, using long-lever manipulation] and myofascial relaxation). The primary evaluation criterion was knee pain at rest 1 month after surgery: 0 (no pain) to 100 (the worst imaginable pain). The secondary evaluation criteria were: (1) knee pain while walking 1 month after surgery, (2) average weekly knee pain during the first month after surgery, (3) the presence of night pain and the consumption of sleeping pills and opioids or morphine at least once per week, (4) the International Knee Society scores and the Western Ontario and McMaster University Osteoarthritis index at postoperative 6 months and 1 year. The number of patients needed for a superiority trial was determined. Results No eligible patient refused OMTh when proposed. Seventy patients were evaluated (mean [SD] age, 75 [8] years; 47 women and 23 men). The 2 treatment groups contained 35 patients each. At postoperative month 1, the OMTh group had significantly less pain at rest (mean [SD], 6.8 [6] vs 20.9 [17.3]; P=.00001) and while walking (7.9 [9.4] vs 23.5 [20.6]; P=.0001) compared with the group that received traditional preoperative management. The consumption of opioids during the first postoperative week was significantly lower in the OMTh group (P=.0001). No statistically significant difference was found in the International Knee Society or Western Ontario and McMaster University Osteoarthritis scores between the 2 groups at 6 months and 1 year of follow-up. Conclusion Standardized preoperative OMTh was found to be effective in reducing pain in the first month after TKA for osteoarthritis and significantly reduced opioid consumption during the first postoperative week.

Introduction Dyspareunia can be a debilitating symptom of endometriosis. We performed this study to examine women's experiences with painful sexual intercourse, the impact of dyspareunia on patients' lives, and perceptions of interactions with healthcare practitioners. Methods An anonymous 24-question online survey was provided through the social media network MyEndometriosisTeam.com and was available internationally to women aged 19-55 years who were self-identified as having endometriosis and had painful sexual intercourse within the past 2 years. Results From June 13 to August 20, 2018, 860 women responded and 638 women completed the survey (United States, n = 361; other countries, n = 277; 74% survey completion rate). Respondents reported high pain levels (mean score, 7.4 ± 1.86; severity scale of 0 [no pain] to 10 [worst imaginable pain]), with 50% reporting severe pain [score of 8 to 10]). Nearly half (47%) reported pain lasting ≥24 hours after intercourse with the pain often leading to avoiding (34%) or stopping (29%) intercourse. Pain impacted patients' lives, causing depression (61%), anxiety (61%), low self-esteem (55%), and relationship strain. Many women feared to seek help (10%). Of those women who approached practitioners, many (36%) did not receive effective treatments. Discussion Women with dyspareunia related to endometriosis experience severe pain that can negatively impact patients' lives. Dyspareunia may be a challenging topic for discussion for both patient and practitioner, leading to a suboptimal treatment approach and management. Results suggest that practitioners need improved education and training regarding dyspareunia to evaluate and treat patients' sexual pain caused by endometriosis.

The aim of the study is to evaluate the effectiveness of two complementary mandibular repositioning splints (SVED and MORA) designed after a preliminary patients’ posture-stabilometric evaluation in treatment for temporomandibular myofascial pain (TMP) using the Pain-Intensity Numeric Rating Scale (PI-NRS) assessment. Eighty-six consecutive sportive non-agonistic subjects with TMP were randomly divided in two groups. Forty-two wear mandibular repositioning splints designed by a posture-stabilometric evaluation, thus constituting the test group. The other 44 subjects were not subjected to any treatment, thus represented the control group. To record pain intensity, subjects in both groups were asked to fill in a PI-NRS which ranged from 0 (no pain) to 10 (worst imaginable pain). In the test group, PI-NRS was assessed three times: before starting therapy (t0), after 4 months (t1) and after 8 months (t2) of treatment. Instead, in the control group PI-NRS was recorded during the first visit (t0) and after 8 months (t2). The Friedman test showed a statistically significant decrease in PI-NRS mean scores after 4 (t1) and 8 (t2) months from the start of the gnathological therapy with mandibular repositioning splints, (p &lt, 0.001) in test group. There is enough evidence to assess that occlusal splint therapy for mandibular repositioning (MORA and SVED) designed through a posture-stabilometric evaluation could be considered in the treatment of temporomandibular myofascial pain.

Objectives: The purpose of this study is a comparison of Valsalva, lidocaine, and Valsalva with administration of lidocaine to reduce the pain associated with administration of etomidate. Methods: The present study is a clinical trial study. The number of samples in each group was 30 and a total of 90 people were selected. This study was a clinical trial and the subjects were randomly divided into three groups: Group 1: Valsalva, 2: Lidocaine, 3: Valsalva and Lidocaine. Pain due to etomidate was rated on a VAS from 1 (painless) to 3 (worst imaginable pain) and their information was recorded. The collected information was entered into SPSS 22 and analyzed with appropriate statistical tests. Results: A total of 90 subjects participated in the present study and were divided into 3 groups: Valsalva, lidocaine, and Valsalva with lidocaine. No significant difference was observed between demographic variables in the study groups. There was a significant relationship between severity of pain in the three groups. According to the results, the highest pain intensity was in the Valsalva group and the lowest pain intensity was in the Valsalva with lidocaine group. Conclusions: Valsalva with lidocaine reduces the severity of pain caused by etomidate to a greater extent than other groups.

BACKGROUND CONTEXT The consequences of public health protection measures may include loss of income, lack of access to basic resources (including health care), and increased psychological burdens. This has led to cancellation of elective surgical cases and greater reliance on telemedicine to conduct consultations and maintain patient access to orthopedic providers. Little is currently known regarding the effects that this has on spine surgery patients and their recovery. The effects of the COVID-19 pandemic may affect individuals differently according to their access to socioeconomic resources, preexisting burden of psychological distress, and knowledge, skills, and confidence to manage their health care. Evidence suggests that the presence of psychological distress, defined as a high burden of symptoms of anxiety and/or depression, is associated with poorer postoperative outcomes than those for patients without psychological distress. Because of the effects of the pandemic, patients may need to rely more than ever on their internal strengths as they recover from spine surgery. One measure of internal strength is “patient activation,” which is a hierarchical construct that encompasses the knowledge, skills, and confidence to manage one's health care. Patient activation may mitigate the negative effects of psychological stress in patients undergoing spine surgery. PURPOSE We tested the hypotheses that patients with greater socioeconomic resources would experience less disruption of access to basic resources; those with psychological distress would experience worsening pain and HRQOL; and those with high patient activation would experience less worsening of pain and HRQOL. STUDY DESIGN/SETTING This was a prospective survey of patients presenting to an academic medical center. PATIENT SAMPLE We selected adults who had undergone or were scheduled to undergo spine surgery for cervical or lumbar spine degeneration or deformity correction at our academic center. Between May 1, 2020 and July 31, 2020, patients were asked to complete a survey regarding the effects of COVID-19 on their health, well-being, and personal life. Surveys were sent to 1,506 patients, 431 of whom (29%) completed and returned them. The mean (± standard deviation [SD]) age of the 431 respondents was 61 ± 15 years. Fifty-five percent of respondents identified as female, and most respondents were non-Hispanic (92%) and white (81%). Most reported living with a partner (71%) and were not currently employed (68%). Approximately one-fifth of respondents reported an annual household income of ≤$50,000, and 120 reported having less than a college education. Two hundred twenty-nine patients were being treated for a degenerative lumbar condition, 118 for a degenerative cervical condition, and 84 for spinal deformity. We found no significant differences between groups in terms of demographic characteristics. OUTCOME MEASURES Respondents reported on their access to basic resources and health care and on their health and wellness. Patients scored their worst back, leg, neck and arm pain during the previous week on a numeric rating scale, with 0 representing no pain and 10 representing the worst imaginable pain. Patients completed the Patient-Reported Outcome Measurement Information System 29-Item profile (PROMIS-29), version 2, which assesses HRQOL using the following domains: pain interference, Physical Function, Fatigue, Anxiety, Depression, Sleep Disturbance, and Satisfaction with Participation in Social Roles. At their preoperative visit, patients provided information on their annual income and highest level of education attained and completed assessments of psychological distress (anxiety and depression) and patient activation. Patient activation was assessed using the Patient Activation Measure. Psychological distress was assessed from PROMIS-29 domains. Methods We surveyed 431 patients who had undergone or were scheduled for surgical treatment of lumbar or cervical spine degeneration or deformity at 1 institution. The survey inquired about the effects of COVID-19 on patients’ access to basic resources and health care and assessed pain (numeric rating scale) and HRQOL (PROMIS-29). We compared the proportions of patients who reported worsening pain and HRQOL between groups defined by presence of psychological distress and high patient activation measured before the pandemic. Alpha = 0.05. Results Respondents reported only minor disruptions in access to basic resources but significant worsening of pain and HRQOL during COVID-19. Health care access was interrupted, with 117 respondents (43%) reporting a canceled health care appointment. Respondents who had undergone spine surgery before the pandemic (N = 296) reported significantly worse outcomes between the most recent pre-pandemic and COVID-19. assessments. During COVID-19, respondents reported worsening of the following: back pain (mean increase, 0.57 ± 3.0 points; p=.027), leg pain (mean increase, 0.74 ± 3.4 points; p=.013), physical function (mean decrease, 2.4 ± 7.5 points; p Conclusions Spine surgery patients reported little disruption in access to basic resources during COVID-19. Psychological distress was associated with worsening of pain and HRQOL. High patient activation appeared to mitigate the worsening of physical function during COVID-19. Health care systems should screen for psychological distress and patient activation and, during times of disruption, enhance supports to manage pain and maintain HRQOL. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Pain intensity is frequently measured on the 11-point numerical pain rating scale (NRS-PI), ranging from 0 (no pain) to 10 points (worst imaginable pain). However, it is difficult to interpret the clinical importance of changes from baseline to endpoint on this instrument.To estimate the minimal detectable change (MDC) and the minimal clinically important difference (MCID) for average pain intensity in patients with specific back pain.Data on 1232 subjects with specific back pain from a German hospital were included in this study. A score combining the patient's (PGIC) and the physician's global impression of change (CGIC) over the in-patient length of stay was used as an external criterion. A priori, we considered the score value "slightly improved" as the MCID. MDC was calculated using the standard error of measurement (SEM) and the standard deviation (SD) of the sample. MCID was estimated by the mean value of PI-NRS change in patients who self-assess as "slightly improved", and by sensitivity/specificity analyses, computed by the receiver operating characteristic method (ROC).MDC was 1.77. The MCS and ROC methods consistently showed an MCID of 2 for the total sample. Both methods showed the dependence of the MCID on the initial pain: 1 for mild to moderate pain at baseline (1 - 4 NRS points), 2 for moderate to severe pain (5 - 7) and 3 - 4 for very severe to extreme pain (8 - 10). For patients with lumbosacral intervertebral disc disorders and patients in the acute phase (duration of pain 6 weeks), the ROC method resulted in a higher limit than the MCS method.In order to facilitate the interpretation of changes and to take into account the patient's perspective, the global assessment of the success of treatment should be used as an anchor criterion. In addition to dealing with pain measurement, function-related and psychosocial aspects of pain symptoms should be kept in mind.Schmerzstärke wird häufig mit numerischen Ratingskalen (NRS) gemessen, deren Spannbreite von 0 (kein Schmerz) bis 10 (maximal vorstellbarer Schmerz) reicht. Schwer zu interpretieren ist die klinische Relevanz einer Veränderung zwischen 2 Messzeitpunkten. ZIEL: Schätzung des kleinsten nachweisbaren Unterschieds (minimal detectable change – MDC) und des kleinsten klinisch relevanten Unterschieds (minimal clinically important difference – MCID) in der Reduktion von durchschnittlicher Schmerzintensität bei Patienten mit spezifischen Rückenschmerzen.Datensätze von 1232 Patienten mit spezifischen Rückenschmerzen aus einer deutschen Klinik für konservative Krankenhausbehandlung von Wirbelsäulenbeschwerden wurden ausgewertet. Als Ankerkriterium diente eine Kombination aus den Globalurteilen von Patienten und Arzt am Ende der Behandlung. Die Ankerkategorie „etwas gebessert“ betrachteten wir a priori als kleinstes klinisch relevantes Ergebnis. Der MDC wurde mithilfe des Standardmessfehlers (SEM) und der Standardabweichung (SD) der Stichprobe berechnet. Der MCID wurde über die mittlere Schmerzreduktion der „etwas gebesserten“ Patienten (Mean Change Score – MCS) und mittels der Receiver-Operating-Characteristic-Methode (ROC) geschätzt.Der MDC lag bei 1,77. Der MCS und die ROC-Methode ergaben übereinstimmend eine MCID für das Gesamtkollektiv von 2. Beide Methoden zeigten die Abhängigkeit des MCID vom Ausgangsschmerz: 1 für geringen bis mäßigen Schmerz bei Behandlungsbeginn (1 – 4 NRS-Punkte), 2 für mittleren bis starken Schmerz (5 – 7) und 3 – 4 für sehr starken bis extremen Ausgangsschmerz (8 – 10). Für Patienten mit lumbalen Bandscheibenschäden und Patienten in der akuten Phase ergab die ROC-Methode einen höheren Grenzwert als die MCS-Methode.Die globale Einschätzung des Behandlungserfolgs sollte als Ankerkriterium neben der Verlaufsmessung mit NRS verwendet werden, um die Interpretation von Veränderungen zu erleichtern und dabei die Patientenperspektive zu berücksichtigen. Neben der Beschäftigung mit der Schmerzmessung dürfen funktionsbezogene und psychosoziale Aspekte der Schmerzsymptomatik nicht aus dem Blickfeld geraten.

Labor pain is the worst imaginable pain that women experience during their childbearing years. Untreated labor pain has numerous negative consequences, for both the mother and her fetus. Low levels of awareness and attitudes among pregnant women about labor analgesia is a major challenge that affects outcomes for both the mother and fetus. Therefore, this study aimed to assess the awareness of, attitude towards and desire for labor analgesia and its associated factors among pregnant women who visited an antenatal care facility. An institution-based, cross-sectional study was conducted from February to March 2019. Data were collected using semi-structured questionnaires by a convenience sampling technique. Data were entered using EpiData 4.2 and exported to SPSS version 20 software for analysis. Both bivariate and multivariate binary logistic regression analysis were used to identify factors associated with awareness, attitude and desire for labor analgesia among pregnant women. Crude odds ratio (COR) and adjusted odds ratio (AOR) were calculated to show the strength of association. A total of 410 participants were included. Thirty-three (8%) of the pregnant women who visited the antenatal care facility were found to have an awareness of labor analgesia. In multivariate analysis, the likelihood of having awareness of labor analgesia was 7.227 times (AOR: 7.227, 95%, CI 2.406–21.720) greater among parous versus nulliparous mothers. The odds of having awareness of labor analgesia were 3.133 times (AOR: 3.133, 95%; CI 1.144–8.581) greater among government employees than among housewives. The odds of having a good attitude towards labor analgesia were 6.488 times (AOR: 6.488, 95% CI 1.894–22.227) higher in government employees than in farmers. Women in the age group of 25–31 years were 1.815 times more likely to want labor analgesia for their next delivery (AOR: 1.815, 95% CI 1.103–2.989). The awareness of labor analgesia among pregnant women was low. There is a need for teamwork by all stakeholders in health sectors to improve attitudes and increase the desire for labor analgesia among pregnant women who visit antenatal care facilities.

BACKGROUND Pain on injection is a limitation with propofol use. The effect of the Valsalva maneuver on pain during propofol injection has not been studied. This maneuver reduces pain through the sinoaortic baroreceptor reflex arc and by distraction. We aimed to assess the efficacy of the Valsalva maneuver in reducing pain during propofol injection. METHODS Eighty American Society of Anesthesiologists class I adult patients undergoing general anesthesia were enrolled and divided into two groups of 40 each. Group I (Valsalva) patients blew into a sphygmomanometer tube raising the mercury column up to 30 mmHg for 20 seconds, while Group II (Control) patients did not. Anesthesia was induced with 1% propofol immediately afterwards. Pain was assessed on a 10-point visual analog scale (VAS), where 0 represented no pain, and 10, the worst imaginable pain, and a 4-point withdrawal response score, where 0 represented no pain, and 3, the worst imaginable pain. Scores were presented as median (interquartile range). RESULTS We analyzed the data of 70 patients. The incidence of pain was significantly lower in the Valsalva than in the control group (53% vs. 78%, P = 0.029). The withdrawal response score was significantly lower in the Valsalva group (1.00 [0.00-1.00] vs. 2.00 [2.00-3.00], P < 0.001). The VAS score was significantly lower in the Valsalva group (1.00 [0.00-4.00] vs. 7.00 [6.25-8.00], P < 0.001). CONCLUSIONS A prior Valsalva maneuver is effective in attenuating injection pain due to propofol; it is advantageous in being a non-pharmacological, safe, easy, and time-effective technique.

OBJECTIVE To summarize results from pain and opioid use assessments with naloxegol in adults with opioid-induced constipation (OIC) and chronic noncancer pain. METHODS Two phase 3 randomized, double-blind, 12-week studies evaluated the efficacy and safety of oral naloxegol (12.5 or 25 mg daily) in adults (18 to < 85 years) with confirmed OIC and chronic noncancer pain: KODIAC-04 (NCT01309841) and KODIAC-05 (NCT01323790). Pain level was assessed daily (11-point numeric rating scale [NRS]; 0 = no pain, 10 = worst imaginable pain). Changes from baseline in mean weekly pain scores and opioid dose (weeks 1 through 12) were analyzed using mixed-model repeated measures. RESULTS At baseline, mean daily NRS average pain scores ranged from 4.5 to 4.8 for all groups in KODIAC-04 (N = 652) and were 4.6 for each group in KODIAC-05 (N = 700). Respective mean ± SD changes from baseline average pain for placebo, naloxegol 12.5 mg, and naloxegol 25 mg were -0.2 ± 1.07, -0.3 ± 1.05 (P = 0.773 vs. placebo), and 0.2 ± 0.95 (P = 0.837 vs. placebo; KODIAC-04) and -0.1 ± 0.94, -0.1 ± 0.87 (P = 0.744), and 0.0 ± 1.18 (P = 0.572; KODIAC-05). At baseline, mean daily opioid doses ranged from 135.6 to 143.2 morphine equivalent units (MEUs)/day in KODIAC-04, and from 119.9 to 151.7 MEUs/day in KODIAC-05. Respective mean ± SD changes from baseline dose were -1.8 ± 30.19, -2.3 ± 20.52 (P = 0.724 vs. placebo), and 0.4 ± 13.01 (P = 0.188 vs. placebo; KODIAC-04) and -0.3 ± 17.14, -1.3 ± 17.11 (P = 0.669 vs. placebo), and 0.1 ± 8.54 (P = 0.863 vs. placebo; KODIAC-05). Changes in maintenance opioid dose were few; reasons for such changes were similar across treatment groups. CONCLUSION Centrally mediated opioid analgesia was maintained during treatment with naloxegol in patients with noncancer pain and OIC.

Objectives To evaluate whether inhaled nitrous oxide with oxygen (N 2 O/O 2 ) is associated with less pain compared to oral sedation for pain management during in-office hysteroscopic sterilization. Study design This double blinded randomized controlled trial enrolled women undergoing in-office hysteroscopic sterilization. All participants received pre-procedure intramuscular ketorolac and a standardized paracervical block. The intervention group also received N 2 O/O 2 via a nasal mask titrated to a maximum 70%:30% mixture by a nurse during the procedure and placebo pills pre-procedure and the active control group received inhaled O 2 during the procedure and 5/325 mg hydrocodone/acetaminophen and 1 mg lorazepam pre-procedure. The primary outcome was maximum procedure pain on a 100 mm Visual Analog Scale (VAS with anchors at 0=no pain and 100=worst imaginable pain) assessed 3–5 min post procedure. Thirty women per treatment arm were required to detect a clinically significant pain difference of 20 mm. Results Seventy-two women, 36 per study arm, were randomized. Mean age of participants was 34.1±5.7 years and mean BMI was 30.1±6.6kg/m 2 . Mean maximum procedure pain scores were 22.8±27.6 mm and 54.5±32.7 mm for intervention and control groups, respectively (p 2 O/O 2 should be offered for gynecologic office procedures and 86% would pay for it if not a covered benefit. Conclusions N 2 O/O 2 decreased pain with in-office hysteroscopic sterilization compared to oral sedation and is an effective pain management option for this procedure. Implications Given its safety and favorable side effect profile, N 2 O/O 2 can be used for pain management for in-office hysteroscopic sterilization and adds a safe, easily administered option to currently available strategies.

Problem There is a knowledge gap regarding women's experiences of coping with labour pain when not soliciting or not having access to pharmacological pain relief. Background How women manage labour pain is complex, multifaceted and only the woman giving birth can assess the experienced pain. Women in the Nordic countries planning for a homebirth have little or no access to pharmacologic pain relief during labour. Aim The aim of this study was to explore how women experience and work with labour pain when giving birth in their own home. Methods Quantitative and qualitative data was prospectively collected and altogether 1649 women with a planned homebirth answered closed and open-ended questions about labour pain and birth experience. Results While labour pain was often experienced as positive or very positive, the intensity was experienced as severe or the worst imaginable pain. Two main themes arose from the womens´ descriptions of their birth experience regarding labour pain: An encounter with extremes and Being in charge at home. Discussion Women perceived labour pain as severe but manageable and were dedicated to completing the birth at home. Being at home enabled the women to exercise autonomy and work with labour pain on their own terms, together with the midwife and support persons. Conclusions This study provides knowledge about women’s experiences of labour pain in a home birth setting who used varying strategies to work with labour pain. This is a subject that should be explored further since results could also apply to facility-based birth settings.

Background: Obesity and cancer are recognized worldwide health threats. While there is no reported causal relationship, the increasing frequency of both conditions results in a higher incidence of obese patients who are being treated for cancer. Physiological data indicate that there is a relationship between obesity and susceptibility to pain; however, currently, there are no specific pharmacological interventions.Objective: To evaluate the self-reported intensity of postoperative pain in obese and nonobese lung cancer who receive either thoracotomy or video-assisted thoracic surgery (VATS) surgical therapy.Material and Methods: In 50 obese [mean body mass index (BMI) of 34.1 ± 3.2 kg/m2] and 62 nonobese (mean BMI of 24.9 ± 3 kg/m2) lung cancer patients, the intensity of pain was estimated every 4 h using a visual analog scale (VAS, 0 indicating no pain and 10 indicating “worst imaginable pain”) beginning shortly after surgery (Day O) and continuing until the day of discharge (Day D).Results: The self-reported pain was more severe in obese than in nonobese patients, both at the time of the operation [Day O (4.5 ± 1.2 vs 3.4 ± 1.1; p < 0.0001)] and at the day of discharge [Day D (3.9 ± 1.4 vs 2.6 ± 0.9, p < 0.0001)]. This finding was consistent both in the patients after thoracotomy and after video-assisted thoracic surgery (VATS, p < 0.0001). The patients with severe pain shortly after surgery (VAS score >4) had significantly higher BMI (31.8 ± 5.6 kg/m2vs 28.8 ± 5.2 kg/m2, p < 0.01) and were hospitalized longer than the remaining patients (13.0 ± 13.6 days vs 9.5 ± 3.6 days, p < 0.05).Conclusion: The reported perception of pain in obese lung cancer patients is greater than in nonobese patients undergoing the same thoracic surgery. In obese patients, severe pain persisted longer. Pain management is an important consideration in the postoperative care of lung cancer patients, even more so with obese patients.

Background:Studies regarding excess mortality among patients with psoriatic arthritis (PsA) are conflicting due to the heterogenous nature of the disease. Thus, identifying risk factors for mortality is crucial, but few studies have examined these in PsA. Presence of chronic pain can cause excess mortality and since pain is prevalent among patients with PsA this association should be explored.Objectives:To investigate whether higher cumulative pain intensity is associated with an excess mortality ratio in patients with PsA.Methods:A nested case-control study was performed using data from the national Danish healthcare registers and the DANBIO rheumatology register. Cases were patients who died while followed in routine care. Cases were matched on sex, year of birth and calendar period of DANBIO entry with up to five controls. The main exposure of interest was the mean pain intensity (all causes) reported during the time followed in routine rheumatology practice. The pain intensity was measured on a visual analogue scale (VAS) ranging from 0 (no pain) to 100 (worst imaginable pain). Conditional logistic regression was used to calculate the odds of mortality per 5 unit increase in VAS pain while adjusting for inflammatory markers.Results:The Danbio PsA cohort consisted of 8019 patients. In total, 266 cases, i.e. PsA patients who died during the observational period, were identified and matched with 1198 controls (4.5 controls per case). Increasing pain intensity was associated with increased odds of mortality (OR 1.05, 95%CI 1.01 to 1.09) in the crude model, but the association disappeared when adjusting for age, sex, calendar time, socioeconomic status, average c-reactive protein and swollen joint count during the observation period (OR 0.98, 95%CI 0.93-1.03).Age, average CRP, biological DMARD use, glucocorticoid use, and comorbidities (see table) increased the odds of mortality.Tableregression estimates from fully adjusted modelOdds Ratio95% CIAge2,731,60-4,68C-reactive protein1,051,03-1,07Swollen joint count1,080,97-1,22Health assessment questionnaire1,250,84-1,86bDMARD use2,621,51-4,57cDMARD use0,690,46-1,03Glucocorticoid use3,902,51-6,05Chronic obstructive pulmonary disease2,191,20-4,02Diabetes mellitus2,651,62-4,31Cancer6,153,88-9,76Cardiovascular disease2,611,71-3,97Conclusion:These results indicate that experienced pain in itself is not associated with excess mortality. Age, recent glucocorticoid use, biological DMARD use, chronic pulmonary disease, diabetes, cancer and cardiovascular disease were all associated with an increased mortality.Disclosure of Interests: :None declared

Postoperative pain management and pain assessment are still lacking the perspective of the patient. We have developed and studied a prototype smartphone application for patients to self-record postoperative pain. The main objective was to collect patient and stakeholder critique of improvements on the usability in order to develop a definitive version. The secondary objective was to investigate if patient self-recording compared to nurse-led assessment is a suitable method for postoperative pain management. Fifty patients and a stakeholder group consisting of ten healthcare- and ICT professionals and two members of the patient council participated in this study. Main outcome Thirty patients (60%) found it satisfying or very satisfying to communicate their pain with the app. Pain experienced after surgery was scored by patients as ‘no’: 3 (6%), ‘little’: 5 (10%), ‘bearable’: 25 (50%), ‘considerable’: 13 (26%) and ‘severe’: 1 (2%). Forty-five patients (90%) were positive about the ease of recording. Forty-five patients (90%) could correctly record their pain with the app. Thirty-eight patients (76%) agreed that in-app notifications to record pain were useful. Two patients (4%) were too ill to use the application. Based on usability feedback, we will redesign the pain intensity wheel and the in-app pain chart to improve clarity for patients to understand the course of their pain. Secondary outcomes The median patient recorded pain app score 4.0 (range 0 to 10) and nurse recorded numerical rating scale (NRS) for pain NRS 4.0 (range 0 to 9) were not statistically different (p = 0.06). Forty-two percent from a total of 307 patient pain app scores were ≥ 5 (on a scale from 0 no pain at all to 10 worst imaginable pain). Of these, 83% were recorded as ‘bearable’ while only in 18% of the recordings patients asked for additional analgesia. The results suggest that self-recording the severity of postoperative pain by patients with a smartphone application could be useful for postoperative pain management. The application was perceived as user-friendly and had high satisfaction rates from both patients and stakeholders. Further research is needed to validate the 11-point numeric and faces pain scale with the current gold standards visual analogue scale (VAS) and NRS for pain.

Mladen Lesin,1,* Mirna Dzaja Lozo,1,* Zeljka Duplancic-Sundov,1 Ivana Dzaja,1 Nikolina Davidovic,2 Adriana Banozic,3 Livia Puljak3 1Department of Ophthalmology, 2Department of Psychiatry, University Hospital Split, 3Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia *These authors contributed equally to this work Background: Risk factors associated with postoperative pain intensity and duration, as well as consumption of analgesics after ophthalmic surgery are poorly understood. Methods: A prospective study was conducted among adults (N=226) who underwent eye surgery at the University Hospital Split, Croatia. A day before the surgery, the patients filled out questionnaires assessing personality, anxiety, pain catastrophizing, sociodemographics were given and details about the procedure, anesthesia, and analgesia for each postoperative day. All scales were previously used for the Croatian population. The intensity of pain was measured using a numerical rating scale from 0 to 10, where 0 was no pain and 10 was the worst imaginable pain. The intensity of pain was measured before the surgery and then 1 hour, 3 hours, 6 hours, and 24 hours after surgery, and then once a day until discharge from the hospital. Univariate and multivariate analyses were performed. Results: A multivariate analysis indicated that independent predictors of average pain intensity after the surgery were: absence of premedication before surgery, surgery in general anesthesia, higher pain intensity before surgery and pain catastrophizing level. Independent predictors of postoperative pain duration were intensity of pain before surgery, type of anesthesia, and self-assessment of health. Independent predictors of pain intensity ≥5 during the first 6 hours after the procedure were the type of procedure, self-assessment of health, premedication, and the level of pain catastrophizing. Conclusion: Awareness about independent predictors associated with average postoperative pain intensity, postoperative pain duration, and occurrence of intensive pain after surgery may help health workers to improve postoperative pain management in ophthalmic surgery. Keywords: postoperative pain, factors, personality, psychology, affect, pain catastrophizing, sociodemographics

The autonomic nervous system is influenced by many stimuli including pain. Heart rate variability (HRV) is an indirect marker of the autonomic nervous system. Because of paucity of data, this study sought to determine the optimal thresholds of HRV above which the patients are in pain after minor spinal surgery (MSS). Secondly, we evaluated the correlation between HRV and the numeric rating scale (NRS).Following institutional review board approval, patients who underwent MSS were assessed in the postanesthesia care unit after extubation. A laptop containing the HRV software was connected to the ECG monitor. The low-frequency band (LF: 0.04 to 0.5 Hz) denoted both sympathetic and parasympathetic activities, whereas the high-frequency band (HF: 0.15 to 0.4 Hz) represented parasympathetic activity. LF/HF was the sympathovagal balance. Pain was quantified by the NRS ranging from 0 (no pain) to 10 (worst imaginable pain). Simultaneously, HRV parameters were noted. Optimal thresholds were calculated using receiver operating characteristic curves with NRS3 as cutoff. The correlation between HRV and NRS was assessed using the Spearman rank test.We included 120 patients (64 men and 56 women), mean age 51±14 years. The optimal pain threshold values were 298 ms for LF and 3.12 for LF/HF, with no significant change in HF. NRS was correlated with LF (r=0.29, P0.005) and LF/HF (r=0.31, P0.001) but not with HF (r=0.09, NS).This study suggests that, after MSS, values of LF298 m and LF/HF3.1 denote acute pain (NRS3). These HRV parameters are significantly correlated with NRS.

Background Venipuncture pain is an uncomfortable suffering to the patient. It creates anxiety, fear and dissatisfaction. The ketoprofen transdermal patch is a proven treatment for musculoskeletal and arthritic pain. We planned this study to evaluate the efficacy of the ketoprofen patch to reduce venipuncture pain. Methods Two hundred adult patients, aged 18-60 years, of either sex, ASA grade I or II, were enrolled. Presuming that therapy would decrease venipuncture pain by 30%, a power calculation with α = 0.05 and β = 0.80 required enrollment of at least 24 patients into each group. However, 100 patients in each group were recruited. Group I (Control) received a placebo patch; Group II (Ketoprofen) received a 20 mg ketoprofen patch. A selected vein on the dorsum of the patient's non-dominant hand was cannulated with 18 g intravenous cannula 1 h after the application of the respective patch. Assessment of pain was done by a 10 cm visual analogue scale (VAS) of 0-10, where 0 depicts "no pain" and 10 is "the worst imaginable pain". The venipuncture site was assessed for the presence of skin erythema, swelling and rashes at 12 h, 24 h and at the time of decannulation. Results Incidence of pain was 100% (94/94) in the control group as compared to 93% (85/91) in the ketoprofen group. The severity of the venipuncture pain was 6 (2) and 2 (2) for control and ketoprofen groups respectively (P < 0.05). Conclusions Application of a ketoprofen patch at the proposed site of venipuncture one hour before the attempt is effective and safe for attenuating venipuncture pain.

Neuropathic pain is common in patients with spinal cord injury (SCI) and often difficult to treat. We report a case where epidural spinal cord stimulation (SCS) below the level of injury has been successfully applied in a patient with a complete spinal cord lesion. A 53-year-old female presented with neuropathic below-level SCI pain of both lower legs and feet due to complete SCI below T5. Time and pain duration since injury was 2 years. Pain intensity was reported on numeric rating scale with an average of 7/10 (0 meaning no pain, 10 meaning the worst imaginable pain), but also with about 8–10 pain attacks during the day with an intensity of 9/10, which lasted between some minutes and half an hour. SCS was applied below the level of injury at-level T11-L1. After a successful 2 weeks testing period the pulse generator has been implanted permanently with a burst-stimulation pattern. The average pain was reduced to a bearable intensity of 4/10, in addition attacks could be reduced both in frequency and in intensity. This effects lasted for at least three months of follow-up. Even in case of complete SCI, SCS might be effective. Mechanisms of pain relief remain unclear. A modulation of suggested residual spinothalamic tract function may play a role. Further investigation has to be carried out to support this theory.

The Visual Analogue Scale (VAS) is one of the most widely used pain assessment scales in clinical practice and research. However, the VAS is used less frequently in midwifery than in other clinical contexts. The issue of how people interpret the meaning of the VAS endpoints (i.e. no pain and worst imaginable pain) has been discussed. The aim of this study was to explore midwifery students' conceptions of 'worst imaginable pain'.A sample of 230 midwifery students at seven universities in Sweden responded to an open-ended question: 'What is the worst imaginable pain for you?' This open-ended question is a part of a larger study. Their responses underwent manifest content analysis.Analysis of the midwifery students' responses to the open-ended question revealed five categories with 24 sub-categories. The categories were Overwhelming pain, Condition-related pain, Accidents, Inflicted pain and Psychological suffering.The midwifery students' conceptions of 'worst imaginable pain' are complex, elusive and diverse.

A preliminary study to compare cervical lordosis by means of cervical cephalometric analysis, before and after six months of continuous mandibular advancement appliance (MAA) use, and to show how physical therapy posture re-education would improve the cervical lordosis angle.Twenty-two female patients with temporomandibular disorders (TMD) and cervical pain with lordosis20° were included. Patients had to have a muscle pain history for at least six months, and with an intensity ⩾6, measured by means of a visual analog scale (a horizontal 0-10 numeric rating scale with 0 labeled as 'no pain' and 10 as 'worst imaginable pain'). Patients had to present the angle formed by the posterior tangents to C2 and C7 of equal or less than 20°. Cephalometric and clinical diagnostics were performed initially (baseline) and at the end of the study period (six months). During the third month with MAA treatment, a physical therapist evaluated the postural deficit and performed a program of postural re-education. Angular and linear dimension data presented a normal distribution (P0·05; Shapiro Wilk Test), so the paired comparison of the cephalometric measurements was made by t-test for dependent samples.Angle 1 (OPT/7CVT); angle 3 (CVT/EVT) and angle 4 (2CL/7CL) showed a significant increase in the cervical lordosis. Angle 2 (MGP/OP), angle 5 (HOR/CVT) and the distances C0-C2 and Pt-VER, presented no significant changes.The increase in cervical lordosis implies that six months of continuous MAA use, together with a program of postural re-education, promotes the homeostasis of the craniocervical system.

Background Insertion of an epidural catheter for pain relief is frequently used in anaesthetic practice. Little is known regarding patients' expected vs. experienced pain and discomfort due to the epidural block procedure. The purpose of this study was to investigate the expected and experienced pain, respectively, associated with the epidural procedure in patients undergoing major abdominal surgery. Methods Thirty adult, unselected patients scheduled for elective major abdominal surgery were included in this study, which was approved by the ethics committee. Pre-operative insertion of an epidural catheter had to be a part of the anaesthetic routine procedure. Immediately before the epidural procedure, the patients were asked to grade the pain they expected from the procedure on an 11-point numeric rating system scale, ranging from 0 to 10, where ‘0’ is no pain and ‘10’ is worst imaginable pain. When the procedure had been carried out, the patients were once again asked to grade how much pain they had experienced. Results The median expected pain as a result of the epidural procedure was 5.0. Median experienced pain was 2.0. The median difference between the expected and experienced pain was −3.0 (P

Background Lifestyle modification has a significant role in chronic daily headache (CDH) management. Participatory action research (PAR) can play an important role in managing chronic medical conditions. However, it has been scarcely used in CDH management. Objectives This study aimed to empower patients with CDH to modify their lifestyle in order to reduce both their headache and related psychiatric co-morbidities in a multidisciplinary headache clinic at Baqiyatallah hospital, Tehran, IR Iran. Methods In the PAR plan, 37 patients (27 females) diagnosed with CDH were selected using purposeful sampling. Along with face-to-face group sessions, all available communication means such as phone calls, emails, short message system (SMS), and social media (Telegram) were used to facilitate the process. Questionnaires of health promotion lifestyle profile (HPLPІІ), visual analog scale (VAS), and depression-anxiety-stress scale (DASS21) were used to collect data. The data were analyzed using SPSS software. Results Mean age of the patients was 38.33 (± 9.7) years. Both “general pain” and “the worst imaginable pain” reduced (mean of reduction: 2.56 ± 2.7 and 2.3 ± 2.9, respectively, P < 0.001). > 50% of pain reduction occurred in “the worst imaginable pain" category (-1.45 ± 2.02, P < 0.001) and mean VAS score reduced to 5.20 (± 2.3) compared to the start of the study (7.50 ± 1.9, P < 0.001). Mean DASS-21 score also reduced significantly for depression (P < 0.016), anxiety (P < 0.026), and stress (P < 0.008). HPLPІІ score significantly improved (118.17 ± 14.8 vs. 160.83 ± 16.4, P < 0.001) and the highest increase was seen in the subscale of "stress management" (17.73 ± 2.8 vs. 25.53 ± 3.9, P < 0.001). Conclusions The empowering PAR plan combined with new communication tools helped the CDH patients better handle their lifestyle, reduce their headache, and lower their symptoms. Further studies with better use of currently available communication tools and social media are recommended for action research to be more applicable.

Injection of local anaesthetics is an uncomfortable procedure. The purpose of this study was to determine the influence of lidocaine temperature on pain during subcutaneous injection.A randomised, double blind trial with 36 healthy volunteers was performed. Each subject received three injections of 4.5 ml 1% lidocaine subcutaneously on the abdomen; refrigerated (8 °C), at room temperature (21 °C), and warmed to body temperature (37 °C). By giving every subject injections of all three temperatures they served as their own controls. The participants were asked to evaluate the pain felt during the injection by placing a pencil mark on a 100 mm Visual Analogue Scale without intermediate markings immediately after every injection. They were told that the scale ranged from no pain to worst imaginable pain (0 = best; 100 = worst). Retrospectively the participants did a verbal assessment of the most and least painful injection.The median VAS score for the heated lidocaine was 16 (range =11-28), lidocaine at room temperature 25 (13-40) and for the cold 24 (11-35). The VAS scores for the heated lidocaine was significantly lower than for lidocaine at room temperature (p = 0.004). Also, the verbal assessment of heated lidocaine being less painful than the injection at room temperature was statistically significant (p = 0.015).Injection with lidocaine heated to around body temperature was less painful than injection with lidocaine at room temperature. There was no statistically significant difference in verbal assessment or VAS scores between the cold lidocaine and that at room temperature.

Background Numeric pain scores have become important in clinical practice to assess postoperative pain and to help develop guidelines for treating pain. Professionals need the patients' pain scores to administer analgesic medication. However, do professionals interpret the pain scores in line with the actual perception of pain by the patients? Objective The study aim was to assess which Numerical Rating Scale (NRS) pain score was considered bearable on a Verbal Rating Scale (VRS) by patients and professionals. Methods This prospective study examined the relationship between the Numerical Rating Scale and a Verbal Rating Scale. The patients ( n =10,434) rated their pain the day after surgery on the 11-point NRS (0=no pain and 10=worst imaginable pain) and a VRS comprising five descriptors: " no pain "; " little pain "; " painful but bearable "; " considerable pain "; and " terrible pain ". The first three categories together (" no pain ", " little pain " and " painful but bearable ") were considered "bearable" and the last two categories (" considerable pain" and " terrible pain") were deemed as "unbearable" pain. The professionals ( n =303) were asked to relate the numbers of the NRS to the words of the VRS. Results Most patients considered NRS 4–6 as "bearable" pain. Among professionals, anesthesiologists, Post Anaesthesia Care nurses, and ward nurses interpreted NRS scores in the same way as the patients. Only the Acute Pain Nurses interpreted the scores differently; they considered NRS of 5 and higher to be not bearable. Conclusions Some care providers and patients differ in their interpretation of the postoperative NRS scores. A risk of overtreatment might arise when health care providers rigidly follow guidelines that prescribe strong analgesics for pain scores above 3 or 4 without probing the patient's preference for pharmacological treatment.

Questionnaires for measuring the functional status of patients with low back pain (LBP) focus on disability and present responses for each question in a predetermined, fixed relationship between "can do/difficulties and pain." Their design does not permit a separation of the two.To present the development of The Assessment of Pain and Occupational Performance (POP) and to evaluate validity and reliability.A prospective, consecutive study of patients investigated by use of the POP.A total of 220 patients participated in the study.In a cross-sectional study including 53 patients with chronic musculoskeletal pain, empirical tests of content and construct validity established the definitive version of the POP. The POP focuses on performance of activities. It is a disease-specific, discriminative assessment instrument designed for patients with back pain (BP) and LBP. Based on a semi-structured interview the POP investigates each of 36 activities in two dimensions, with separate, defined scales from "normally healthy" to "extremes" for level of activity (x-scale) and pain intensity (y-scale). The final scores are expressed in percent, 0% to 100%. Patients with chronic LBP (CLBP) (n=142) were allocated to the specific (S) group, that is, patients with specific LBP problems (n=97) or to the nonspecific (NS) group, that is, those with NS BP (n=45). The ability of the POP to differentiate between the two known groups was evaluated. Construct-convergent validity between the POP and the Oswestry Disability Index (ODI) was carried out for the S group. Inter-rater reliability was established between six pairs of raters who examined 25 patients recruited from primary health care, the P-LBP group.In construct known group validity, the median, the interquartile range, and the Mann-Whitney U test showed that the S group had a significantly higher level of activity (p.001) combined with worse pain (p=.001) compared with the NS group. There were significant differences between the two groups in performing activities in the forward bending position (10 items) and in the upright standing position (9 items). The result of Spearman rank order correlation showed a strong relationship between the ODI and the POP for level of activity (r=0.70, por=.001). The multiple correlation coefficient between the total score of the ODI (10 items) and the total score of the POP (36 items) was r=0.72 and por=.001. Inter-rater reliability-the standard deviation of the differences was less than 1 point (scale 0-5). A Bland-Altman plot showed the mean differences for the level of activity of the dressing/undressing item. The average percentage agreement was 80% on the x- and y-scales. In POP 36, the average Kappa for level of activity was 0.79, which is good agreement, and for pain 0.84, which is very good agreement.The construction of the POP allows the patient to count, and the occupational therapist to investigate, from full level of activity to avoidance and from no pain to worst imaginable pain for each physically loaded task in personal activities of daily living (ADL), transfer/transport, instrumental ADL, and social activities. The POP can differentiate between groups concerning level of activity and pain, and appears to be a valid and reliable instrument for evaluating LBP. The POP should be considered for use in both clinical and research applications.

Werneke MW, Hart DL, George SZ, Stratford PW, Matheson JW, Reyes A. Clinical outcomes for patients classified by fear-avoidance beliefs and centralization phenomenon. Objectives To (1) determine the prevalence of pain pattern classification subgroups (centralization, noncentralization, and not classified) observed during the initial evaluation of patients experiencing high versus low Fear-Avoidance Beliefs Questionnaire for physical activity (FABQ-PA) scores, (2) examine the association between discharge pain intensity and functional status (FS) outcomes based on FABQ-PA and pain pattern subgroups, and (3) compare minimal clinically important improvement for FS and pain intensity for FABQ-PA and pain pattern classification subgroups. Design Observational cohort design. Setting Suburban hospital-based outpatient rehabilitation clinic. Participants Consecutive patients with low back syndromes (N=238, mean ± SD, 59.1±17.0y; minimum=20, maximum=91). Interventions Interventions were designed to match patient classification by fear-avoidance level and pain pattern. Main Outcome Measures Two outcome measures were assessed: patient self-reported FS and pain intensity. FS was assessed by using computerized adaptive testing methods. Maximal pain intensity was assessed by using an 11-point numeric pain scale: 0 (no pain) to 10 (worst imaginable pain). Results There were no differences (χ 2 2 =3.7, P =.16) in proportion of patients classified by pain pattern experiencing high or low fear-avoidance beliefs. After controlling for the effect of available risk-adjustment variables, only dual-level classification subgroups, symptom acuity, payer type, and intake FS or pain intensity were associated with discharge FS or pain outcomes. The highest proportion of patients achieving minimal clinically important improvement in pain and FS were reported by the following patient subgroup: centralization and low fear. Conclusions Pain pattern and FABQ-PA characteristics impacted rehabilitation outcomes. We recommend that both factors be considered when managing patients with low back pain in an effort to optimize rehabilitation outcomes.

Objective To investigate the memory of labour pain at 2 months, 1 year and 5 years after childbirth and its association with the use of epidural analgesia and overall evaluation of childbirth. Design Longitudinal observational. Setting All hospitals in Sweden. Population One thousand three hundred eighty-three women, who were recruited at their first antenatal visit and who provided complete data up to 5 years after the birth. Methods Postal questionnaires in the second trimester and 2 months, 1 year and 5 years after the birth. Main outcome measures Memory of labour pain measured by a seven-point rating scale (1 = no pain at all, 7 = worst imaginable pain). Results Memory of labour pain declined during the observation period but not in women with a negative overall experience of childbirth. Women who had epidural analgesia reported higher pain scores at all time points, suggesting that these women remember 'peak pain'. Conclusions There was significant individual variation in recollection of labour pain. In the small group of women who are dissatisfied with childbirth overall, memory of pain seems to play an important role many years after the event. These findings challenge the view that labour pain has little influence on subsequent satisfaction with childbirth. In-labour pain and long-term memory of pain are discussed as two separate outcomes involving different memory systems.

The US Advisory Committee on Immunization Practices has recently recommended a new vaccine against herpes zoster (shingles) for routine use in adults aged ≥60 years. However, estimates of the cost effectiveness of this vaccine vary widely, in part because of gaps in the data on the value of preventing herpes zoster. Our aims were to (i) generate comprehensive information on the value of preventing a range of outcomes of herpes zoster; (ii) compare these values among community members and patients with shingles and post-herpetic neuralgia (PHN); and (iii) identify clinical and demographic characteristics that explain the variation in these values. Community members drawn from a nationally representative survey research panel (n = 527) completed an Internet-based survey using time trade-off and willingness-to-pay questions to value a series of scenarios that described cases of herpes zoster with varying pain intensities (on a scale of 0 to 10, where 0 represents no pain and 10 represents the worst imaginable pain) and duration (30 days to 1 year). Patients with shingles (n = 382) or PHN (n = 137) [defined as having symptoms for =90 days] from two large healthcare systems completed telephone interviews with similar questions to the Internet-based survey and also answered questions about their current experience with herpes zoster. We constructed generalized linear mixed models to evaluate the associations between demographic and clinical characteristics, the length and intensity of the health states and time trade-off and willingness-to-pay values. In time trade-off questions, community members offered a mean of 89 (95% CI 24, 182) discounted days to avoid the least severe scenario (pain level of 3 for 1 month) and a mean of 162 (95% CI 88, 259) discounted days to avoid the most severe scenario (pain level of 8 for 12 months). Compared with patients with shingles, community members traded more days to avoid low-severity scenarios but similar numbers of days to avoid high-severity scenarios. Compared with patients with PHN, community members traded fewer days to avoid high-severity scenarios. In multivariate analyses, older age was the only characteristic significantly associated with higher time trade-off values. In willingness-to-pay questions, community members offered a mean of $US450 (95% CI 203, 893) to avoid pain of level 3 for 1 month and a mean of $US1384 (95% CI 873, 2050) [year 2005 values] to avoid pain of level 8 for 12 months. Community members traded less money than patients with either shingles or PHN to avoid both low- and high-severity scenarios (p-values

Objective: This study investigated whether pain characteristics (intensity, frequency, duration and number of pain sites), depression, age, sex and comorbidities are associated with lower levels of selfreported physical activity in older adults with pain at the primary healthcare setting.Methods: A total of 504 participants aged 60 years of age and over were assessed for: socio-demographics, comorbidities, pain, depression, and physical activity. Associations between these variables were investigated using ordinal logistic regression.Results: Reporting severe pain or worst imaginable pain, being older (≥ 75 years), and feeling depressed were significantly associated with lower physical activity in the univariate (OR = 2.33, 2.93, 2.31, and 2.23, respectively) and multivariate models (Adj OR = 2.21, 2.47, 2.49, and 1.97, respectively).Conclusions: Interventions aiming to increase physical activity for older adults in primary care should consider the needs of those reporting higher pain intensity, feeling depressed and who are 75 years or older.

BACKGROUND The aim of this prospective randomized study was to measure patients' discomfort after hysteroscopy with CO(2) or normal saline. METHODS A total of 415 patients was randomized to two groups according to distension medium (CO(2), n = 201; normal saline, n = 214). The nature of randomization was to alternate distension media on a weekly basis. After hysteroscopy, women were asked to rate the pain experienced on a 100-mm visual analogue scale (0 = no pain; 100 = worst imaginable pain). Pain scores were expressed as mean +/- SD (0-40 = minimal; 41-70 = moderate; 71-100 = severe). Data were analysed using Student's t-test. RESULTS Irrespective of the distension medium used, pelvic discomfort was worse in nulliparous women (pain score 39.0 +/- 26.5) than in multiparous women (30.4 +/- 25.9) (P < 0.05), especially if they were premenopausal. For all patients and both distension media, pelvic discomfort was generally minimal but higher in patients who had undergone hysteroscopy with normal saline (P < 0.05). CONCLUSIONS CO(2) and normal saline were comparable with regard to patient discomfort, but in terms of the high frequency of abnormal uterine bleeding, normal saline may be the most appropriate distension medium for outpatient hysteroscopy.

Purpose : To answer the question whether a single fraction of radiotherapy that is considered more convenient to the patient is as effective as a dose of multiple fractions for palliation of painful bone metastases. Patients : 1171 patients were randomised to receive either 8Gy×1 ( n =585) or 4Gy×6 ( n =586). The primary tumour was in the breast in 39% of the patients, in the prostate in 23%, in the lung in 25% and in other locations in 13%. Bone metastases were located in the spine (30%), pelvis (36%), femur (10%), ribs (8%), humerus (6%) and other sites (10%). Method : Questionnaires were mailed to collect information on pain, analgesics consumption, quality of life and side effects during treatment. The main endpoint was pain measured on a pain scale from 0 (no pain at all) to 10 (worst imaginable pain). Costs per treatment schedule were estimated. Results : On average, patients participated in the study for 4 months. Median survival was 7 months. Response was defined as a decrease of at least two points as compared to the initial pain score. The difference in response between the two treatment groups proved not significant and stayed well within the margin of 10%. Overall, 71% experienced a response at some time during the first year. An analysis of repeated measures confirmed that the two treatment schedules were equivalent in terms of palliation. With regard to pain medication, quality of life and side effects no differences between the two treatment groups were found. The total number of retreatments was 188 (16%). This number was 147 (25%) in the 8Gy×1 irradiation group and 41 (7%) in the 4Gy×6 group. It was shown that the level of pain was an important reason to retreat. There were also indications that doctors were more willing to retreat patients in the single fraction group because time to retreatment was substantially shorter in this group and the preceding pain score was lower. Unexpectedly, more pathological fractures were observed in the single fraction group, but the absolute percentage was low. In a cost-analysis, the costs of the 4Gy×6 and the 8Gy×1 treatment schedules were calculated at 2305 and 1734Euro respectively. Including the costs of retreatment reduced this 25% cost difference to only 8%. The saving of radiotherapy capacity, however, was considered the major economic advantage of the single dose schedule. Conclusion : The global analysis of the Dutch study indicates the equality of a single fraction as compared to a 6 fraction treatment in patients with painful bone metastases provided that 4 times more retreatments are accepted in the single dose group. This equality is also shown in long term survivors. A more detailed analysis of the study is in progress.

BACKGROUND: Venous cannulation is often performed without any analgesia, even though pain experienced during this procedure is at times very distressing. Various pharmacological and nonpharmacological measures have been tried with variable results to minimize venous cannulation pain. We designed the present study to evaluate the efficacy of a flash of light on attenuating venous cannulation pain. METHODS: Ninety adults (15-60 yr), ASA physical status I and II, of either sex, undergoing elective laparoscopic cholecystectomy, were included in this prospective and randomized study. Patients were divided into three groups of 30 each. Group I (control); Group II (distraction): photographed without a flash of light; and Group III (flash): photographed with a flash of light just before venous cannulation of a vein on the dorsum of the nondominant hand. Immediately after the photograph, venous cannulation was performed using an 18-gauge cannula. RESULTS: Two patients from each group could not be cannulated on their first attempt and were therefore dropped from subsequent analysis. The incidence of venous cannulation pain in the flash group was lower, i.e., 50% (14 of 28) when compared to 100% (28 of 28) observed in the other two study groups (P < 0.01). Severity of venous cannulation pain as assessed by the Visual Analog Scale scores (between 0 and 100; where 0 = no pain and 100 = worst imaginable pain) presented as median (interquartile range) were reduced in the flash [10(20)] and distraction [20(10)] groups compared with the control group [40(20)] (P < 0.01). The severity of venous cannulation pain was also reduced in the flash group compared with the distraction group (P < 0.01). CONCLUSION: We conclude that a flash of light before venous cannulation is a safe, effective, and easy-to-use method for minimizing venous cannulation pain.

Introduction: The hip arthroplasty has become a very common practice. It concerns young population. The osteoarthritis is the most common indication for total hip prosthesis. Moroccans patients with osteoarthritis often related an alteration of their prayer and are worried about this. Nevertheless, the hip arthroplasty allows restoration. Objectives: The proposal of our studies is to determine what Moroccans patients with total hip prosthesis become. Methodology: A cross-sectional, prospective study has been conducted at the Department of Physical Medicine and Rehabilitation in collaboration with the Department of Traumatology of University Hospital, IbnRochd, Casablanca, Morocco. Patients who took advantage of rehabilitation sessions before and after total hip prosthesis have been included. Patients with secondary prosthesis, post traumatic total hip prosthesis or cognitive impairment have been excluded. The socio demographic characteristics, the prosthesis indications, and complications have been gathered using a questionnaire. Patients mentioned their style of prayer. The style of prayer has been classified in three groups: non difficult standard prayer, difficult standard prayer and impossible (prayer is done at sit position on a chair). An assessment has been carried out before and six months after total hip replacement. For mobility assessment, passive hip movements have been performed and measured with the universal goniometer. Current pain intensity has been assessed using a 101-point numerical rating scale ranging from 0 (non pain) to 100 (the worst imaginable pain). Disability has been assessed using the Western Ontario and Mac Master (WOMAC) Universities Arthritis Index, the Postel-Merle and Aubigne Index (PMA). Results: 79 patients have been included. Average age was 47.7 years. Sex ratio was 0.61. Eighty-two percent (82%) patients were manual laborers against 18% of office workers. All patients were Muslims. The main causes of hip disease were ankylosing spondylitis (25.3%), rheumatoid arthritis (19%), infection (7.6%), hip osteoarthritis (27.8%), and aseptic osteonecrosis (6.3%). All the operations have been performed through the posterior lateral approach. The total hip replacement has improved pain (p=0.0004), mobility (p

Background: Postoperative pain is commonly assessed through a Numerical Rating Scale (NRS), an 11-point scale where 0 indicates no pain and 10 indicates the worst imaginable pain. Guidelines advise the administration of analgesics at NRS pain scores above 3 or 4. In clinical practice, not all patients with pain scores above the treatment threshold are willing to accept additional analgesic treatment, especially when opioids are offered. The objective of this study is to measure the relation between patients’ NRS pain scores and their desire for additional opioids. Methods: This cross-sectional study examined 1,084 patients in an academic hospital the day after surgery between January 2010 and June 2010. The day after surgery, patients were asked to score their pain and desire for opioids. Sensitivity, specificity, positive predictive value, and negative predictive value of the desire for opioids and the different NRS thresholds were calculated. Results: Only when patients scored an 8 or higher on the NRS did the majority express a need for opioids. Many patients did not desire opioids, because they considered their pain tolerable, even at an NRS score above 4. Conclusions: With the current guidelines (i.e., using pain scores above 3 or 4 for prescribing opioids), many patients could be overtreated. Therefore, scores generated by the NRS should be interpreted individually.

We aimed to investigate the role of preoperative single dose of pregabalin for attenuating postoperative pain and analgesic consumption in patients undergoing septoplasty. One hundred forty-three patients with ASA physical status I who underwent elective septoplasty were included in this prospective, randomized, and controlled study. Subjects were randomized to receive pregabalin 75 mg, pregabalin 150 mg, and control group. All the medications were administered orally 1 hour before surgery. A standard septoplasty technique was used for all patients. Postoperative pain intensity was evaluated by a 0- to 100-mm horizontal visual analog scale (VAS) (0, no pain; 100, worst imaginable pain). Total analgesic consumption 1 to 24 h after operation was also recorded.Visual analog scale scores in the 1st, 2nd, 4th, 6th, 12th, and 24th hour were significantly decreased in 75 and 150 mg pregabalin group compared with the control group, and VAS scores in the 12th and 24th hour were significantly decreased in pregabalin 150 mg compared with 75 mg. The 24th total analgesic consumption was significantly decreased in pregabalin 75 mg and 150 mg groups compared with the control group.In conclusion, a single preoperative oral dose pregabalin 75 or 150 mg is an effective method for reducing postoperative pain and total analgesic consumption in patients undergoing septoplasty.

Background: SCD is a chronic disease characterized by painful vaso-occlusive (VOC) episodes and hemolysis which lead to poor HRQL and premature mortality. As curative treatment with hematopoietic stem cell transplant is only an option for a minority of adult patients, current treatments are palliative with focus on pain management. Clinically, pain assessment is commonly performed by Numeric Rating Scale, where patients rate the intensity of pain from 0 (no pain)-10 (worst imaginable pain). However, the incorporation of HRQL through the use of newer PROs into the assessment of pain and the care of patients with SCD is evolving. Our objective was to better inform the multidimensional impact of pain on adults hospitalized with VOC, as measured by the Patient-Reported Outcomes Measurement Information system (PROMIS) Global Health and the Adult Sickle Cell Quality of Life Measurement System (ASCQ-Me). Reported here are the preliminary results of the first 15 patients of our larger inception cohort with planned enrollment of 140 patients. Methods: In this study at an urban tertiary care hospital, 15 of 16 eligible adults with SCD completed the PROMIS short form (v1.1) Global Health and ASCQ-Me questionnaires on hospital admission for VOC. These measures yield scores in the domains of physical health, mental health, and sickle-cell related domains of pain-episode frequency, emotional impact, social functioning impact, pain impact, stiffness, and sleep. Seven days post-discharge, 12 of the 15 patients again completed the assessments. Standardized domain scores have a mean of 50 (SD=10) with higher scores indicating better functioning. We calculated means and standard errors (SE) for the domain scores at both assessment periods and mean change scores. Results: One eligible patient declined enrollment due to poor mental health, stating "I have lost all hope with this disease." Two of the initial 15 patients had hospital readmissions within 7 days and were censored from further analysis; the third did not respond to follow up and was readmitted within 30 days. Sixty percent of patients were female. The mean age was 30.1 years (range 22-36). The most frequent disease genotype was Hb SS (66%), followed by Hb SC (27%) and Hb Sβ+ thalassemia (7%). Eleven patients (73%) identified as black, non-Hispanic; 4 (27%) identified as Hispanic. At hospital admission, 66% of patients had 4 or more pain crises in the last 12 months. The mean score for the most severe pain during the last pain attack was 8.8 (SD = 1.4) on a scale from 0-10. The most recent pain crisis for 66% of patients lasted at least 1 week; 26% reported crisis lasting longer than 2 weeks. Of the 12 patients who completed all assessments, the table presents mean domain scores at each assessment period and the change scores. Of note, 83.3% scored at least 1 SD below the population mean for the PROMIS global physical health subscale on admission. This was unchanged 7 days post-discharge (83.3%). Half scored at least 1 SD below the population mean for PROMIS global mental health subscale, compared to 33% 7 days post-discharge. Conclusions: Administering disease-specific PRO measures at point of care is feasible. Patients who did not complete assessments following hospital discharge were all readmitted within 30 days, indicating a particularly high-risk group. At both admission and 7 days post-discharge, a significant number of patients had physical and mental health scores that were 1 SD below population norms, indicating substantial suffering. Compared to admission, scores for global mental health, social functioning and stiffness worsened following discharge on average. Scores in global physical health, emotional impact, pain impact and sleep impact improved. Further study of incorporating PRO measures in the clinical care and improvement in health outcomes among adults with SCD is warranted. Disclosures No relevant conflicts of interest to declare.

BACKGROUND Robotic or endoscopic thyroidectomy using bilateral axillo-breast approach (BABA) is frequently performed for excellent cosmesis. However, postoperative pain is remained as concerns due to the extent tissue dissection and tension during the operation. Ketamine is a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist that reduces acute postoperative pain. We evaluated the effects of intraoperative ketamine infusion on postoperative pain control and recovery profiles following BABA robotic or endoscopic thyroidectomy. METHODS Fifty-eight adult patients scheduled for BABA robotic or endoscopic thyroidectomy were randomized into a control group (n = 29) and ketamine group (n = 29). Following induction of anesthesia, patients in each group were infused with the same volume of saline or ketamine solution (1 mg/kg bolus, 60 μg/kg/h continuous infusion). Total intravenous anesthesia with propofol and remifentanil was used to induce and maintain anesthesia. Pain scores (101-point numerical rating scale, 0 = no pain, 100 = the worst imaginable pain), the consumption of rescue analgesics, and other postoperative adverse effects were assessed at 1, 6, 24, and 48 hours postoperatively. RESULTS Patients in the ketamine group reported lower pain scores than those in the control group at 6 hours (30 [30] vs 50 [30]; P = 0.017), 24 hours (20 [10] vs 30 [20]; P

The dominant theories of human placebo effects rely on a notion that consciously perceptible cues, such as verbal information or distinct stimuli in classical conditioning, provide signals that activate placebo effects. However, growing evidence suggest that behavior can be triggered by stimuli presented outside of conscious awareness. Here, we performed two experiments in which the responses to thermal pain stimuli were assessed. The first experiment assessed whether a conditioning paradigm, using clearly visible cues for high and low pain, could induce placebo and nocebo responses. The second experiment, in a separate group of subjects, assessed whether conditioned placebo and nocebo responses could be triggered in response to nonconscious (masked) exposures to the same cues. A total of 40 healthy volunteers (24 female, mean age 23 y) were investigated in a laboratory setting. Participants rated each pain stimulus on a numeric response scale, ranging from 0 = no pain to 100 = worst imaginable pain. Significant placebo and nocebo effects were found in both experiment 1 (using clearly visible stimuli) and experiment 2 (using nonconscious stimuli), indicating that the mechanisms responsible for placebo and nocebo effects can operate without conscious awareness of the triggering cues. This is a unique experimental verification of the influence of nonconscious conditioned stimuli on placebo/nocebo effects and the results challenge the exclusive role of awareness and conscious cognitions in placebo responses.

Surgical repair of pectus excavatum can be associated with significant postoperative pain. Various analgesic modalities have been suggested including thoracic epidural analgesia and intravenous patient-controlled analgesia (IV PCA). The current study compares the efficacy and adverse efficacy profile of these 2 analgesic modalities. The charts of 18 adolescents who had undergone pectus excavatum repair were retrospectively reviewed and divided into 2 groups: thoracic epidural analgesia (E) or IV PCA (I). Demographic data included age, weight, sex, and anesthesia/surgical times. Treatment days (defined as the number of days the patients received intravenous or epidural analgesia), time to oral intake, and time to discharge from the hospital were also recorded. Pain scores using a visual analogue scale ranging from 0 (no pain) to 10 (worst imaginable pain) and sedation scores were recorded in the postanesthesia care unit and at 6, 12, 24, 36, 48, and 60 hours postoperatively. The charts were also reviewed for side effects including nausea and/or vomiting, pruritus, oxygen desaturation, and respiratory depression. The study cohort included 18 patients divided equally into group E (epidural analgesia) (n = 9) and group I (IV PCA). There were no statistically significant differences between the 2 groups with regard to demographic data, time to oral intake, and time to hospital discharge. Anesthesia to surgery times were longer in group E compared with group I (43 +/- 11 versus 25 +/- 11 minutes, P = 0.004), but there was no difference in overall surgery and anesthesia times. The number of treatment days (days that the patients received intravenous or epidural medications) was decreased in group E versus group I (2.3 +/- 0.7 versus 3.3 +/- 1.0 days, P = 0.027). There was no difference between the 2 groups in regard to the onset of oral intake or hospital discharge time. Pain scores were initially higher in the postanesthesia care unit in group E versus group I (6.78 +/- 2.17 versus 5.78 +/- 3.77); however, after that point, pain scores were lower in group E than in group I. There was no difference between the 2 groups in regard to sedation scores or adverse effect profile. Epidural analgesia provided better pain control than the intravenous route for the management of patients after pectus excavatum repair. No adverse effects related to epidural analgesia were noted. The only issue identified with thoracic epidural anesthesia was a mean increase of 18 minutes for anesthesia time required for catheter placement before the start of the case.

Background Postoperative pain is the dominating complaint and the primary reason for prolonged convalescence after laparoscopic cholecystectomy. We have evaluated the efficacy of a single preoperative dose of pregabalin for attenuating postoperative pain and fentanyl consumption after laparoscopic cholecystectomy. Methods Sixty adults (16–60 yr), ASA physical status I and II, of either sex undergoing elective laparoscopic cholecystectomy were included in this prospective, randomized placebo controlled, double-blind study. Subjects were divided into two groups of 30 each to receive either a matching placebo or pregabalin 150 mg, administered orally 1 h before surgery. Postoperative pain (static and dynamic) was assessed by a 100 mm visual analogue scale, where 0, no pain; 100, worst imaginable pain. Subjects received patient-controlled i.v. fentanyl analgesia during the postoperative period. Results were analysed by Student's t-test, χ2 test, Mann–Whitney U-test, and Fisher's exact test. Results Postoperative pain (static and dynamic) and postoperative patient-controlled fentanyl consumption were reduced in the pregabalin group compared with the placebo group (P Conclusions A single preoperative oral dose of pregabalin 150 mg is an effective method for reducing postoperative pain and fentanyl consumption in patients undergoing laparoscopic cholecystectomy.

Chronic pain can be debilitating and often becomes the defining factor in patients' lives. Many trials have been developed to evaluate the extent and quality of pain in specific populations. The most important informations result from the study “Pain in Europe”, published in 2006, that showed a prevalence of pain by 19%; low back pain was the most frequent disease; one third of the interviewed people complained the worst imaginable pain; on average, people lived with chronic pain for 7.7 years. In regard to the treatment of pain in Italy, the same survey shows inadequate treatment in 47% of cases; 42% of patients reported the assumption of drugs; in 68% of cases Italian doctors prescribed NSAIDs; no patient was in treatment with strong opioids. The link between the reduced use of opioids in Italy and the fear of physicians has been demonstrated by a recent study, not yet published, about the use of analgesics in emergency setting. It is reasonable to believe that the actual situation in Italy is the consequence of the lack of a specific school on pain therapy and of the teaching of pain therapy in the University, until a few years ago. In this situation, only the scientific societies can obtain results.

Venipuncture is the most common painful event for a hospitalized child. We evaluated the efficacy of balloon inflation for attenuating venipuncture pain in children. Seventy-five pediatric patients aged 6-12 yr, ASA physical status I-II, of either sex, undergoing elective surgery were included in this prospective and randomized study. Patients were randomly divided into 3 equal groups of 25 each; Group I (control), Group II (distraction) pressed a rubber ball, and Group III (balloon) inflated a balloon. A manual venous occlusion was applied on the forearm and venipuncture was performed with a 22-gauge venous cannula. Pain was self-reported by a pain face scale with a 10-cm visual analog scale (VAS) placed at its back, where 0 = "no pain" and 10 = "worst imaginable pain." VAS scores of 1-3 were rated as mild, 4-6 as moderate, and >6 as severe. Median (interquartile range) VAS score in the balloon group was 1 (3), which was reduced as compared with 2 (2) and 4 (2) observed in the distraction and control groups, respectively (P < 0.000). Significant reduction in the incidence and severity of venipuncture pain was also observed in the balloon group compared with the other 2 groups (P < 0.05).

Objectives This study was undertaken to determine whether 400 mg of prophylactic ibuprofen can alleviate pain from insertion of an intrauterine device (IUD) and to measure level of pain with improved techniques. Study design We conducted a randomized, double-blind, placebo-controlled trial of 2019 first-time IUD users: 1008 women received placebo and 1011 women received 400 mg of ibuprofen. Participants took the single tablet at least 45 minutes before IUD insertion. Immediately after insertion, participants recorded level of pain by using a 10-cm visual analog scale, with the value of 10 meaning "worst imaginable pain." Results Median level of pain was 1.0 for both ibuprofen and placebo participants; rank test statistics confirmed no difference. Some subgroups of women experienced higher pain (eg, nulliparous women), but ibuprofen still had no important impact on level of pain. Conclusion Even among first-time users, pain from IUD insertion is generally low. Prophylactic ibuprofen as used in this protocol does not reduce IUD insertion pain.

Perception of pain varies significantly across groups of patients. The primary objective of this study was to measure perceived pain among Emergency Department (ED) patients with headache in response to standardized painful stimuli, including blood pressure (BP) cuff inflation and intravenous catheterization (IVC). In this prospective, case-control series, ED patients undergoing IVC and with a headache were compared to those undergoing IVC but without a headache. Medical care of participants was not altered. Data were collected by trained research assistants, including demographic and historical characteristics, and perceived pain scores. Using a 10-point verbal numeric rating scale (0 = no pain … 10=worst imaginable pain), participants rated their perceived pain of BP measurement and IVC. Ninety-five percent confidence intervals (CI) constructed around means and proportions were used to assess group differences. One hundred participants had headache; 100 participants with no headache served as controls. There were no differences between groups with regard to gender, ethnicity, or insurance status. Intravenous catheterization was successful in all 200 participants, with a median intravenous catheter gauge of 20 (range 18–24). There were no differences between groups in difficulty of insertion of intravenous catheter or number of intravenous catheterization attempts. Participants with headache reported significantly higher pain scores from BP cuff inflation (mean score 2.9) compared to participants without headache (mean 1.4; mean difference between groups 1.5, 95% CI 0.7–2.3). Participants with headache reported slightly higher pain scores from IVC (mean 4.6) compared to participants without headache (mean 3.9; mean difference between groups 0.7, 95% CI −0.2–1.6), but this difference was not significant. Among participants with headache, there were no statistically significant differences between single headache, acute headache ( / past 30 days ), and chronic headache (≥10/past 30 days ) for reported pain scores of BP cuff inflation or IVC . ED participants with headache reported significantly higher pain scores secondary to BP cuff inflation when compared to control participants without headache.

Methods.– This study enrolled 1051 patients (n=196 elderly NP patients) with chronic moderate-to-severe non-malignant pain and constipation. Patients received OXNPR (up to 40mg oxycodone/20mg naloxone) twice daily for 2 months with visits at baseline (V0) and 14, 30 and 60 days (V1, V2, V3). Paracetamol 1000mg was allowed as rescue. Pain intensity was assessed on a numeric rating scale (NRS, 0 =no pain to 10=worst imaginable pain); bowel functionwasassessedusing thevalidatedBowel Function Index (BFI); treatment effectiveness was evaluated using the Patients’ Global Impression of Change (PGIC) scale. Results.– Results for the subgroup of elderly patients (≥75 years) withNParepresentedhere, andwere consistentwith results for the overall population. OXNPR treatment resulted in a clinically relevantdecrease inpain intensityandconstipationseverity.Meanpain intensity scoreswere 7.0, 4.5, 2.6 and 2.3, andmean BFI scoreswere 70.1, 49.5, 34.1 and 32.8 at V0, V1, V2 and V3. 75% of patients rated treatment effectiveness (PGIC) as “much/very much improved” at endpoint. A notable reduction in rescue medication and laxative use and good overall tolerability were also reported. Conclusion.– Oxycodone/naloxone prolonged-release was well tolerated and effective in treating pain and constipation in elderly patients with neuropathic pain.

All women giving birth over a period of 2 weeks in a major city of Sweden, except non-Swedish speaking women and those with elective Caesarean sections, were asked about their experience of pain 2 days after the birth. The sensory (pain intensity) and effective (negative or positive experience) dimensions of pain, as well as need for pain relief during labor were explored. The 278 women who returned completed questionnaires (91%) reported high levels of pain, 41% worst imaginable pain, in spite of wide use of pharmacological pain relief. Only 9% had no analgesia. Pain was not an entirely negative experience, 28% assessing it as more positive than negative, suggesting that coping with pain is a rewarding experience for some women. More than 30 different explanatory variables were included in regression analysis to explain the variation in pain intensity and pain attitude scores, but only five contributed to the respective model. Most of the variables explaining pain intensity, namely anxiety during labor, expected pain, expected birth experience, midwife support and duration of labor, differed from the variables explaining attitude to pain. These were pain intensity, anxiety, expected birth experience physical well-being during pregnancy and emergency Caesarean section. The explanatory values were relatively low, especially for the model explaining pain intensity (R2 = 15%). The findings are discussed in the light of the different character and meaning of childbirth pain compared with pain related to disease.

Visual analog scales (VAS) ranging from 0 cm (no pain) to 10 cm (worst imaginable pain) are used widely for pain measurement, but various investigators have not treated these data consistently. Conventional statistical tests of such data, although evaluating the "statistical significance" may obscure the clinical value of a treatment. On the other hand, confidence intervals (CIs) can illuminate both statistical and clinical importance. CIs give a range of values based on the observed data which contain, with a specified probability, a true but unknown variable typifying a population. We reviewed 112 articles published recently in anesthesia journals for statistical reporting of VAS data. Of the 112 articles, only two used CIs to report mean pain scores and one used CIs to report differences in median pain scores between the study groups. Only two articles presented 95% CI for the mean pain scores graphically. Analgesic techniques that produce VAS values in the range of 0-3 have been reported to represent adequate analgesia. A graphical method using CIs is proposed that allows ready interpretation of VAS data. With this approach, one evaluates whether the 95% CI for the mean pain score in a group during a particular period lies entirely within the zone defined as "analgesic success" (0-3). Such an analysis allows a visual assessment of whether a particular technique would produce clinically important effects in the population at large. This approach seems to provide more information than the use of conventional hypothesis testing in the interpretation of VAS data for pain measurement.

e19632 Background: We conducted this study to analyze the treatment outcomes and the factors associated with pain relief in patients treated with stereotactic body radiotherapy (SBRT) using Cyberknife for spine metastasis. Methods: We retrospectively reviewed patients who received SBRT for spinal metastasis between April 2007 and June 2009 in Konyang University Hospital, Daejeon, Korea. The treatment response was evaluated by the assessment of pain and neurologic status and the review of radiologic studies. Pain was assessed by verbal/visual analogue scale; from 0 (no pain) to 10 (the worst imaginable pain). Pain relief was defined as a decrease of at least three levels of the pain score without an increase in analgesic consumption. Complete relief was defined as no analgesics or score 0 or 1. Pain progression was defined as an increase in the pain score by three levels and/or increase pain medication. Results: 57 patients with 73 lesions have been reviewed. The follow up period was median 6.8 months (ran...

Purpose This study was conducted to compare the efficacy and safety of naproxen 500 mg twice daily (BID) versus naproxen 500 mg as needed (PRN) for treatment of ankle sprain. Methods In this seven-day, randomized, parallel group trial, 135 patients with ankle sprain occurring less than 48 hours prior to the first dose of study medication were randomized to receive naproxen 500 mg BID (67 patients) and naproxen 500 mg as needed (PRN) (68 patients). The ankle pain was assessed at rest and on full weight bearing using Numeric Rating Scale (NRS) from 0 (no pain) to 10 (the worst imaginable pain). Ankle swelling was assessed as a 4-point scale ranging from 0 (no swelling) to 3 (severe swelling) rated by the investigator. The primary efficacy end point was the patient's assessment of ankle pain via NRS and the degree of swelling on day seven. Results Results showed a significant decrease in pain on weight bearing, pain at rest and the extent of swelling (P0.05) after seven days. Assessing the safety profile of the two different dosing, 13.3% of the naproxen BID group and 6.7% of the as needed group had adverse events, showing that the as needed regimen was safer (P