A CHRONIC PAIN PATIENT: MODERN DIAGNOSIS AND CONCEPT OF THERAPY

Ca. 80% der Patienten einer allgemeinmedizinischen Praxis suchen diese wegen ihrer Schmerzen auf. Der Anteil an Patienten mit chronischen Schmerzen liegt im deutschsprachigen Raum bei ca. 20%. Und der Anteil an akuten Schmerzen variiert, abhängig von der fachspezifischen Tätigkeit. So gehören akute Schmerzen zum Alltag eines jeden chirurgisch oder anästhesiologisch tätigen Arztes: Operation = Schmerz. Das gleiche gilt für jede andere invasive Intervention, egal ob beim Zahnarzt, Radiologen, Strahlentherapeuten, Internisten und vielen anderen mehr. Daher gehört die Therapie dieser „Befindlichkeitsstörung“ zu den grundlegendsten Fertigkeiten eines jeden Arztes, egal ob angestellt oder niedergelassen, egal ob Jungarzt oder Routinier, unabhängig von seiner Ausbildung. Und dies gelingt bei ca. 70% der Patienten. Bei den verbleibenden 30% ist die Unzufriedenheit der Patienten mit der angebotenen Schmerztherapie hoch, sowohlApproximately 80 per cent of primary care patients seek their physician’s attention due to pain. A fifth of the population suffers from chronic pain with medium to high intensity, and longer than 3 months. Especially those patients are treated insufficiently when only non-opioids and opioids are applied. Therefore it is necessary to tailor pain therapy by using an interdisciplinary, multimodal treatment regimen. This article presents a holistic concept to chronic pain treatment by using the five columns of pain therapy. Based on the bio-psycho-social approach, pharmaceutical, complimentary (first column), physio- and psychotherapeutic (2nd and 3rd column), social and invasive interventions (4th and 5th column) have to be considered. The 1st column includes the WHO ladder, in chronic pain patients with a large focus on coanalgesics like antidepressants or antiepileptics. Based on the individual history and factors achieved from the bio-psychosocial diagnosis, components of these 5 therapeutic are selected, always in agreement with the patient, and put together to one interdisciplinary therapeutic concep

Manual Khalifa Therapy Improves Functional and Morphological Outcome of Patients with Anterior Cruciate Ligament Rupture in the Knee: A Randomized Controlled Trial

Rupture of the anterior cruciate ligament (ACL) is a high incidence injury usually treated surgically. According to common knowledge, it does not heal spontaneously, although some claim the opposite. Regeneration therapy by Khalifa was developed for injuries of the musculoskeletal system by using specific pressure to the skin. This randomized, controlled, observer-blinded, multicentre study was performed to validate this assumption. Thirty patients with complete ACL rupture, magnetic resonance imaging (MRI) verified, were included. Study examinations (e.g., international knee documentation committee (IKDC) score) were performed at inclusion (t0). Patients were randomized to receive either standardised physiotherapy (ST) or additionally 1 hour of Khalifa therapy at the first session (STK). Twenty-four hours later, study examinations were performed again (t1). Three months later control MRI and follow-up examinations were performed (t2). Initial status was comparable between both groups. There was a highly significant difference of mean IKDC score results at t1 and t2. After 3 months, 47% of the STK patients, but no ST patient, demonstrated an end-to-end homogeneous ACL in MRI. Clinical and physical examinations were significantly different in t1 and t2. ACL healing can be improved with manual therapy. Physical activity can be performed without pain and nearly normal range of motion after one treatment of specific pressure

Is PONV still a problem in pediatric surgery: a prospective study of what children tell us

BackgroundPostoperative nausea and vomiting (PONV) is an unpleasant complication after surgery that commonly co-occurs with pain. Considering the high prevalence among pediatric patients, it is important to explore the main risk factors leading to PONV in order to optimize treatment strategies. The objectives of this study are as follows: (1) to determine the prevalence of PONV on the day of surgery by conducting interviews with pediatric patients, (2) to assess PONV prevalence in the recovery room and on the ward by analyzing nursing records, and (3) to collect information on PONV risk factors on the day of surgery and the following postoperative days. We wanted to investigate real-life scenarios rather than relying on artificially designed studies.MethodsA prospective analysis [according to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines] of PONV on the day of surgery and the following postoperative days was conducted by evaluating demographic and procedural parameters, as well as conducting interviews with the children under study. A total of 626 children and adolescents, ranging in age from 4 to 18 years, were interviewed on the ward following their surgery. The interviews were conducted using a questionnaire, as children aged 4 and above can participate in an outcome-based survey.ResultsOn the day of surgery, several multivariable independent predictors were identified for PONV. The type of surgery was found to be a significant factor (p = 0.040) with the highest odds ratio (OR) in patients with procedural investigations [OR 5.9, 95% confidence interval (CI): 1.8–19.2], followed by abdominal surgery (OR 3.1, 95% CI: 0.9–11.1) when inguinal surgery was used as the reference category. In addition, the study identified several predictors, including the amount of fentanyl administered during anesthesia (µg/kg body weight) (OR 1.4, 95% CI: 1.1–1.8), intraoperative use of piritramide (OR 2.6, 95% CI: 1.5–4.4) and diclofenac (OR 2.0, 95% CI: 1. 3–3.1), opioid administration in the recovery room (OR 3.0, 95% CI: 1.9–4.7), and piritramide use on the ward (OR 4.5, 95% CI: 1.7–11.6).ConclusionsThe main risk factors for PONV include the intraoperative administration of opioids during the recovery room stay and at the ward, the intraoperative use of non-opioids (diclofenac), and the specific type of surgical procedure. Real-life data demonstrated that in clinical praxis, there is a gap between the adherence to established guidelines and the use of antiemetic prophylaxis in surgeries that are generally not associated with a high PONV prevalence. Further efforts are needed to improve the existing procedures and thus improve the overall outcome

A CHRONIC PAIN PATIENT: MODERN DIAGNOSIS AND CONCEPT OF THERAPY

Ca. 80% der Patienten einer allgemeinmedizinischen Praxis suchen diese wegen ihrer Schmerzen auf. Der Anteil an Patienten mit chronischen Schmerzen liegt im deutschsprachigen Raum bei ca. 20%. Und der Anteil an akuten Schmerzen variiert, abhängig von der fachspezifischen Tätigkeit. So gehören akute Schmerzen zum Alltag eines jeden chirurgisch oder anästhesiologisch tätigen Arztes: Operation = Schmerz. Das gleiche gilt für jede andere invasive Intervention, egal ob beim Zahnarzt, Radiologen, Strahlentherapeuten, Internisten und vielen anderen mehr. Daher gehört die Therapie dieser „Befindlichkeitsstörung“ zu den grundlegendsten Fertigkeiten eines jeden Arztes, egal ob angestellt oder niedergelassen, egal ob Jungarzt oder Routinier, unabhängig von seiner Ausbildung. Und dies gelingt bei ca. 70% der Patienten. Bei den verbleibenden 30% ist die Unzufriedenheit der Patienten mit der angebotenen Schmerztherapie hoch, sowohlApproximately 80 per cent of primary care patients seek their physician’s attention due to pain. A fifth of the population suffers from chronic pain with medium to high intensity, and longer than 3 months. Especially those patients are treated insufficiently when only non-opioids and opioids are applied. Therefore it is necessary to tailor pain therapy by using an interdisciplinary, multimodal treatment regimen. This article presents a holistic concept to chronic pain treatment by using the five columns of pain therapy. Based on the bio-psycho-social approach, pharmaceutical, complimentary (first column), physio- and psychotherapeutic (2nd and 3rd column), social and invasive interventions (4th and 5th column) have to be considered. The 1st column includes the WHO ladder, in chronic pain patients with a large focus on coanalgesics like antidepressants or antiepileptics. Based on the individual history and factors achieved from the bio-psychosocial diagnosis, components of these 5 therapeutic are selected, always in agreement with the patient, and put together to one interdisciplinary therapeutic concep

Spirituality in pain medicine: A randomized experiment of pain perception, heart rate and religious spiritual well-being by using a single session meditation methodology.

The aim of this study is to investigate different effects on pain perception among randomly assigned volunteers practicing meditation compared to a relaxation condition. The study examines whether participants of the experimental conditions (meditation versus relaxation) differ in the change of pain perception and heart rate measurement and in religious and spiritual well-being after an intervention. METHOD:147 volunteers (long-term practitioners and novices) were randomly assigned to the experimental conditions with a headphone guided 20-minute single session intervention. The change in their pre- and post-intervention pain perception was measured using Quantitative Sensory Testing and Cold Pressor Testing (CPTest), their stress-level was compared by monitoring heart rate, and their religious and spiritual well-being by using the Multidimensional Inventory for Religious/Spiritual Well-Being (MI-RSB48). Additionally, dimensions of the Brief Symptom Inventory (BSI) measured the psychological resilience of the participants; pain and stress experience, and the state of relaxation and spirituality experience were assessed. Five persons were excluded due to failure in measuring the heart rate and 29 participants had to be excluded because of high values on the BSI. RESULTS:The meditation group showed an increase in their pain tolerance on the CPTest and a decrease in their pain intensity for heat after the experimental condition, in contrast to the relaxation group. Futhermore, the meditation group showed a higher level of religious spiritual well-being (MI-RSB48 Total score) as well as in the sub-dimensions General Religiosity, Forgiveness, and Connectedness after the experimental condition, compared to the relaxation group. Our data is consistent with the hypothesis that meditation increases pain tolerance and reduces pain intensity, however, further work is required to determine whether meditation contains similar implications for pain patients

Neuraxial anesthesia in patients with multiple sclerosis – a systematic review

Background and objectives: Current guidelines for neuraxial analgesia in patients with multiple sclerosis are ambiguous and offer the clinician only a limited basis for decision making. This systematic review examines the number of cases in which multiple sclerosis has been exacerbated after central neuraxial analgesia in order to rationally evaluate the safety of these procedures. Methods: A systematic literature search with the keywords “anesthesia or analgesia” and “epidural, peridural, caudal, spinal, subarachnoid or intrathecal” in combination with “multiple sclerosis” was performed in the databases PubMed and Embase, looking for clinical data on the effect of central neuraxial analgesia on the course of multiple sclerosis. Results and conclusions: Over a period of 65 years, our search resulted in 37 reports with a total of 231 patients. In 10 patients multiple sclerosis was worsened and nine multiple sclerosis or neuromyelitis optica was first diagnosed in a timely context with central neuraxial analgesia. None of the cases showed a clear relation between cause and effect. Current clinical evidence does not support the theory that central neuraxial analgesia negatively affects the course of multiple sclerosis. Resumo: Justificativa e objetivos: As diretrizes atuais para analgesia neuraxial em pacientes com esclerose múltipla (EM) são ambíguas e oferecem ao clínico apenas uma base limitada para a tomada de decisão. Esta revisão sistemática examina o número de casos nos quais a EM foi exacerbada após analgesia neuraxial central para avaliar racionalmente a segurança desses procedimentos. Métodos: Uma busca sistemática da literatura usando as palavras-chave “anestesia ou analgesia” e “epidural, peridural, caudal, espinhal, subaracnoideo ou intratecal” em combinação com multiple sclerosis foi feita nas bases de dados PubMed e Embase à procura de dados clínicos sobre a efeito da analgesia neuraxial central sobre o curso da esclerose múltipla. Resultados e conclusões: Durante um período de 65 anos, nossa busca resultou em 37 relatos com um total de 231 pacientes. Em 10 pacientes, a esclerose múltipla foi agravada e, em nove, a esclerose múltipla ou neuromielite óptica foi diagnosticada pela primeira vez em momento concomitante com a analgesia neuraxial central. Nenhum dos casos apresentou uma clara relação entre causa e efeito. A evidência clínica atual não sustenta a teoria de que a analgesia neuraxial central afeta negativamente o curso da esclerose múltipla. Keywords: Multiple sclerosis, Neuromyelitis optica, Neuroaxial anesthesia, Palavras-chave: Esclerose múltipla, Neuromielite óptica, Anestesia neuroaxia

Neuraxial anesthesia in patients with multiple sclerosis - a systematic review

Abstract Background and objectives: Current guidelines for neuraxial analgesia in patients with multiple sclerosis are ambiguous and offer the clinician only a limited basis for decision making. This systematic review examines the number of cases in which multiple sclerosis has been exacerbated after central neuraxial analgesia in order to rationally evaluate the safety of these procedures. Methods: A systematic literature search with the keywords "anesthesia or analgesia" and "epidural, peridural, caudal, spinal, subarachnoid or intrathecal" in combination with "multiple sclerosis" was performed in the databases PubMed and Embase, looking for clinical data on the effect of central neuraxial analgesia on the course of multiple sclerosis. Results and conclusions: Over a period of 65 years, our search resulted in 37 reports with a total of 231 patients. In 10 patients multiple sclerosis was worsened and nine multiple sclerosis or neuromyelitis optica was first diagnosed in a timely context with central neuraxial analgesia. None of the cases showed a clear relation between cause and effect. Current clinical evidence does not support the theory that central neuraxial analgesia negatively affects the course of multiple sclerosis

Implementation and maintenance of a pain management quality assurance program at intensive care units: 360 degree feedback of physicians, nurses and patients.

BACKGROUND:Pain management quality assurance programs (PMQP) have been successfully implemented in numerous hospitals across Europe. We aimed to evaluate the medium-term sustainability of a PMQP implemented at intensive care units (ICUs). METHODS:Two surveys, the first in 2012, immediately after introduction of the PMQP, and the second in 2015, were carried out amongst patients, physicians and nurses. Demographic parameters of all participants were assessed. Patients were asked after their pain levels during ICU stay. Staff members answered a questionnaire regarding familiarity with standards and processes of PMQP and self-perception of their knowledge as well as contentment with interdisciplinary communication. RESULTS:In total (2012/2015), 267 (125/142) patients, 113 (65/48) physicians and 510 (264/246) members of the nursing staff participated. Minimum and maximum pain levels of patients did not differ between both surveys. Patients' tolerance of pain 24 hours before the survey was better (p = 0.023), and vomiting occurred less often (p = 0.037) in 2015. Physicians' and nurses' contentment with the own knowledge about pharmacological pain treatment had increased from 2012 to 2015 (p = 0.002 and 0.004). Satisfaction with communication between nurses and physicians was better in 2015 (p<0.001 and p = 0.002). Familiarity with PMQP standards and processes remained stable in both collectives. CONCLUSION:The implementation of our PMQP achieved a high standard of care, guarantying a high patient and staff member satisfaction. Continuous education, ongoing training, regular updates and implementation of feedback-loops ensure continuity, in some parameters even an increase in knowledge and competencies. This is mirrored in high patient and staff member satisfaction