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1.  Laparoscopic Adhesiolysis and Relief of Chronic Pelvic Pain 
To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy.
Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief.
We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50% or no pain relief. Some patients required between 1 and 3 subsequent laparoscopic adhesiolysis. A total of 3 enterotomies and 2 cystotomies occurred, all of which were repaired laparoscopically.
We conclude that laparoscopic enterolysis may offer significant long-term relief of chronic pelvic pain in some patients.
PMCID: PMC3113188  PMID: 11051185
Laparoscopy; Adhesiolysis; Pain relief; Complications
2.  Laparoscopic Presacral Neurectomy in the Treatment of Primary Dysmenorrhea 
Sixty-one laparoscopic presacral neurectomies were performed in Chang Gung Memorial Hospital, Keelung Center over a 1-year period for patients with primary dysmenorrhea who failed to respond to medical management. Eighty-three percent (50) had complete relief of pain, 10% (6) had significant relief, 3.5% (2) had moderate relief, and 3.5% (2) had no relief from their dysmenorrhea at their first menstruation after the procedure. One vascular complication requiring laparotomy occurred. Average total operation time was 24 minutes, and the average hospital stay was 2 days. Six months follow-up was done in 35 patients with complete symptom relief, and all reported continued relief of menstrual pain. The efficacy of laparoscopic presacral neurectomy for the pain relief of primary dysmenorrhea is justified in this report.
PMCID: PMC2362488  PMID: 18493369
3.  Memory decay and susceptibility to amnesia dissociate punishment- from relief-learning 
Biology Letters  2013;9(4):20121171.
Painful events shape future behaviour in two ways: stimuli associated with pain onset subsequently support learned avoidance (i.e. punishment-learning) because they signal future, upcoming pain. Stimuli associated with pain offset in turn signal relief and later on support learned approach (i.e. relief-learning). The relative strengths of such punishment- and relief-learning can be crucial for the adaptive organization of behaviour in the aftermath of painful events. Using Drosophila, we compare punishment- and relief-memories in terms of their temporal decay and sensitivity to retrograde amnesia. During the first 75 min following training, relief-memory is stable, whereas punishment-memory decays to half of the initial score. By 24 h after training, however, relief-memory is lost, whereas a third of punishment-memory scores still remain. In accordance with such rapid temporal decay from 75 min on, retrograde amnesia erases relief-memory but leaves a half of punishment-memory scores intact. These findings suggest differential mechanistic bases for punishment- and relief-memory, thus offering possibilities for separately interfering with either of them.
PMCID: PMC3730614  PMID: 23658002
Drosophila melanogaster; memory stability; punishment-learning; relief-learning; retrograde amnesia; reinforcement
4.  Ultrasound-Assisted Mental Nerve Block and Pulsed Radiofrequency Treatment for Intractable Postherpetic Neuralgia: Three Case Studies 
The Korean Journal of Pain  2013;27(1):81-85.
Postherpetic neuralgia (PHN) is one of the most difficult pain syndromes to treat. Invasive treatments may be considered when patients fail to obtain adequate pain relief from noninvasive treatment approaches. Here, we present three cases of PHN in the mandibular branch treated with ultrasound-assisted mental nerve block and pulsed radiofrequency treatment. None of the patients had adequate pain relief from the medical therapy, so we performed the mental nerve block on the affected side under ultrasound assistance. Two patients showed satisfactory pain relief continuously over 12 months without any further interventions, whereas one patient only had short-term pain relief. For the patient had short-term pain relief we performed pulsed radiofrequency treatment (PRFT) on the left mental nerve under ultrasound assistance. After PRFT, the patient had adequate pain relief for 6 months and there was no need for further management.
PMCID: PMC3903807  PMID: 24478907
mental nerve; postherpetic neuralgia; pulsed radiofrequency treatment; ultrasound
5.  Pain relief in labor: a survey of awareness, attitude, and practice of health care providers in Zaria, Nigeria 
Journal of Pain Research  2011;4:227-232.
The purpose of this study was to assess the attitudes of maternal health care providers to pain relief during labor in Zaria, Nigeria.
This was a multicenter, collaborative, cross-sectional pilot study of provider perspectives concerning pain relief during labor. A structured, self-administered, questionnaire was completed by 95 consenting maternal health care providers at three high-volume facilities in Zaria, an ancient northern Nigerian city. Descriptive statistics was performed on the data.
Most respondents (94.8%) agreed that pain relief is needed during labor. Only 2.1% of respondents were undecided about the provision of pain relief during labor and 3.2% were of the opinion that pain relief was not necessary during labor. Most respondents (93.7%) had attended a woman in labor in the 4 weeks preceding the survey. Of these, 56.8% had counseled a parturient in labor. Most of the counseling (42.1%) took place during labor. Less than half of the respondents (48.4%) had administered pain relief in labor in the preceding 4 weeks and systemic opioids was the most commonly form of pain relief. Among the respondents who did not offer pain relief agents in labor, the majority (54.5%) had no reason for not offering it. Unavailability of methods, inability to afford the cost of pain relief, lack of knowledge and skills, as well as lack of essential equipment to provide the procedure were also given by respondents as reasons for not offering pain relief.
Even though maternal health care providers in this environment have a positive attitude to pain relief in labor, most women go through labor without the benefit of analgesia. There exists a gap between provider attitudes to pain relief in labor and practice of the same, with many providers having no genuine reason(s) for not offering pain relief to their clients during labor. Providers need to align their practice to their attitudes, and need to be helped to do this through training as well as enhancing their ability to think critically about their practice.
PMCID: PMC3160836  PMID: 21887120
pain relief; providers; attitudes; practice; labor; conflict
6.  A new transmucosal drug delivery system for patients with breakthrough cancer pain: the fentanyl effervescent buccal tablet 
Journal of pain research  2008;2:13-20.
Breakthrough pain, a transitory severe pain with the background of otherwise controlled persistent pain has a prevalence between 52% and 67% in outpatients with cancer. Medications for such sudden-onset pain require non-invasive delivery of a potent and short-acting opioid for rapid pain relief. Although oral transmucosal delivery of fentanyl citrate (OTFC) has been shown to provide better pain relief than a typical oral opioid administration such as morphine sulfate immediate release (MSIR) in the management of breakthrough pain in patients with cancer-related pain, newer delivery systems offer a potential for further enhancement of pain relief. The fentanyl effervescent buccal tablet (FBT) formulation employs a novel drug delivery system that relies on an effervescence reaction to improve buccal fentanyl absorption. Using the effervescence reaction results in the production and dissipation of carbon dioxide with a dynamic shift in pH as the tablet dissolves. The induced low pH favors dissolution of fentanyl citrate in saliva (higher water solubility). The subsequent increase in pH thereafter favors the buccal absorption of non-ionized fentanyl across the buccal mucosa. Such a pH “pumping” mechanism increases the permeation of fentanyl into and through the buccal to the vascular system from where the agent is transported to the specific opioid receptor sites in the CNS. Compared with OTFC, data in healthy volunteers show that the effervescence reaction employed in FBT increases the total amount and the speed of absorption of fentanyl being absorbed. Compared with OTFC there is an increase in peak fentanyl blood concentrations, and an enhancement of the amount of buccal delivery of fentanyl. Such favorable data are underlined by the results of clinical studies where the FBT technology was studied in patients with breakthrough pain in chronic malignant pathologies.
PMCID: PMC3004632  PMID: 21197291
breakthrough pain; fentanyl effervescent buccal tablet (FBT); cancer pain; effervescent technology
7.  The importance of context: When relative relief renders pain pleasant 
Pain  2013;154(3):402-410.
When moderate pain was presented in a context of intense pain, it induced a relief and ‘hedonic flip’ such that pain was reported as pleasant.
Context can influence the experience of any event. For instance, the thought that “it could be worse” can improve feelings towards a present misfortune. In this study we measured hedonic feelings, skin conductance, and brain activation patterns in 16 healthy volunteers who experienced moderate pain in two different contexts. In the “relative relief context,” moderate pain represented the best outcome, since the alternative outcome was intense pain. However, in the control context, moderate pain represented the worst outcome and elicited negative hedonic feelings. The context manipulation resulted in a “hedonic flip,” such that moderate pain elicited positive hedonics in the relative relief context. Somewhat surprisingly, moderate pain was even rated as pleasant in this context, despite being reported as painful in the control context. This “hedonic flip” was corroborated by physiological and functional neuroimaging data. When moderate pain was perceived as pleasant, skin conductance and activity in insula and dorsal anterior cingulate were significantly attenuated relative to the control moderate stimulus. “Pleasant pain” also increased activity in reward and valuation circuitry, including the medial orbitofrontal and ventromedial prefrontal cortices. Furthermore, the change in outcome hedonics correlated with activity in the periacqueductal grey (PAG) of the descending pain modulatory system (DPMS). The context manipulation also significantly increased functional connectivity between reward circuitry and the PAG, consistent with a functional change of the DPMS due to the altered motivational state. The findings of this study point to a role for brainstem and reward circuitry in a context-induced “hedonic flip” of pain.
PMCID: PMC3590449  PMID: 23352758
Reward; Neuroimaging; Dread; Relief; Value
8.  Who gives pain relief to children? 
OBJECTIVE: To compare pre-hospital parental administration of pain relief for children with that of the accident and emergency (A&E) department staff and to ascertain the reason why pre-hospital analgesia is not being given. DESIGN/METHODS: An anonymous prospective questionnaire was given to parents/guardians of children < 17 years. The children were all self referred with head injuries or limb problems including burns. The first part asked for details of pain relief before attendance in the A&E department. The second part of the questionnaire contained a section for the examining doctor and triage nurse to fill in. The duration of the survey was 28 days. RESULTS: Altogether 203 of 276 (74%) of children did not receive pain relief before attendance at the A&E department. Reasons for parents not giving pain relief included 57/203 (28%) who thought that giving painkillers would be harmful; 43/203 (21%) who did not give painkillers because the accident did not happen at home; and 15/203 (7%) who thought analgesia was the responsibility of the hospital. Eighty eight of the 276 (32%) did not have any painkillers, suitable for children, at home. A&E staff administered pain relief in 189/276 (68%). CONCLUSIONS: Parents often do not give their children pain relief before attending the A&E department. Parents think that giving painkillers may be harmful and often do not have simple analgesics at home. Some parents do not perceive that their child is in pain. Parents require education about appropriate pre-hospital pain relief for their children.
PMCID: PMC1343365  PMID: 10417932
9.  Expectation and patient preference – does it matter?1 
Admission to clinical trials is often based on the assumption of homogeneity of the population. A group of 60 patients, all with pain in the neck or shoulder of at least 3 months duration, were studied. Expectation was graded before treatments were started by sharing out 100 points between freedom from side effects, pain relief, depression relief, improved mobility, improved sleep and speed of action. A double-blind crossover study of two established anti-inflammatory analgesics and placebo was carried out. Using analogue scales, patients were asked to grade their response. Side effects were recorded, and preference was established at the end of the study.
Although all the patients were in sufficient pain to require medical attention, some rated relief of depression, improvement in sleep or lack of side effects as more important than pain relief. Differences between drug and placebo were most clearly demonstrated in those patients whose main concern was improved mobility. In our view it is important to select patients who are in need of a dominant property of a drug for a trial of this property and this may have ramifications across the medical spectrum.
PMCID: PMC1440038  PMID: 6971940
10.  Treatment of pain in acute myocardial infarction. 
British Heart Journal  1989;61(1):9-13.
The treatment of pain in acute myocardial infarction varies with local practice. Narcotic analgesics are still the usual treatment in many hospitals. Knowledge of optimal doses, duration of pain relief, and time between drug administration and pain relief is inadequate. Many studies indicate that the relief of pain is often incomplete after treatment with narcotic analgesics. There is often a need for alternative treatments. Large randomised studies consistently show that beta blockade, initially given intravenously and then orally, relieves pain and reduces the need for analgesics. Studies also indicate that early administration of streptokinase and glyceryl trinitrate relieves pain. There is evidence that drugs that limit ischaemic damage also relieve pain.
PMCID: PMC1216614  PMID: 2563657
11.  Pain intensity measurements in patients with acute pain receiving afferent stimulation. 
Six different pain rating scales, including a "pain relief scale", were compared in 80 patients suffering acute orofacial pain. Pain intensity measurements were made before and after a 30 min period of afferent stimulation (TENS/vibration and placebo). A good correlation was found between pain scores derived from the pain relief scale, visual analogue-, numerical- and graphic rating scales. The verbal rating scale did not perform well. The pain relief scale and the numerical rating scale are interesting alternatives to the established visual analogue scale.
PMCID: PMC1032956  PMID: 3259976
12.  Microcoagulation of Junctional Dorsal Root Entry Zone is Effective Treatment of Brachial Plexus Avulsion Pain: Long-term Follow-up Study 
Croatian medical journal  2006;47(2):271-278.
To analyze long-term clinical results of coagulation lesions of the dorsal root entry zone (DREZ) in patients with deafferentation pain due to brachial plexus avulsion and to correlate the pain relief after DREZ coagulation with pain duration before the DREZ coagulation.
Twenty-six patients with intractable deafferentation pain after brachial plexus avulsion lesion were treated for pain at the Department of Neurosurgery. Junctional coagulation lesion was made with bipolar forceps along the DREZ. The patients assessed post-operative analgesic effect using a visual analog scale at 1 week, 1 year, 3 years, and 5 years after the surgery.
The greatest pain relief was reported immediately after the DREZ procedure. Over the 5-year follow-up period, the pain relief effect gradually and significantly decreased. There were no significant differences between the pain relief evaluated at 1 week and after 1 year and between the pain relief evaluated at 1 week and after 3 years. There was a correlation between the pain duration before the surgery and pain relief after the surgery, with best correlation found between pain duration before surgery and pain relief 5 years after DREZ procedure (r = 0.623, P = 0.007).
The long-term follow up showed that the pain relief gradually decreased over 5 years after surgery. However, the pain relief still did not significantly decrease after 3 years.
PMCID: PMC2080390  PMID: 16625692
13.  Microcurrent skin patches for postoperative pain control in total knee arthroplasty: a pilot study 
International Orthopaedics  2006;31(2):229-233.
Pain control following painful orthopaedic procedures such as total knee arthroplasty (TKA) is an ongoing challenge, as current pain management techniques often result in under-medication and/or complications. In a study designed to test the effect of the micro-current skin patch (MCT) on pain relief in patients following TKA, we followed 24 patients, randomly divided into two groups, one group receiving MCT plus tramadol hydrochloride (tramadol) for pain relief and a control group receiving only tramadol, for 10 days postoperatively. Tramadol was given intramuscularly in increment doses of 100 mg, as needed, for the duration of the study period. Pain was assessed daily using a visual analogue score (VAS). Other parameters, including the effect of MCT on the dose of tramadol needed for pain relief, the degree of wound healing measured at the end of the follow-up period, category of the wound 10 days postoperatively (1, 2 or 3) and total drain fluid volume, were also assessed. During the 10-day postoperative period there was a progressive decrease in pain in patients of both groups, however the patients of the MCT group showed a consistently lower VAS throughout the observation period, most markedly on those follow-up days with the highest pain scores in patients of the control group. This effect was monitored on the basis of the average dose of tramadol administered per day: 200.0±7.0 mg/day in the control group and 63.3±15.8 mg/day in the MCT group. Wound healing was better with the application of the MCT patch: grade 1 wounds were observed in 50% of the patients of the MCT group as compared to 8.3% in control group. The total drain volume was lower in patients of the MCT group compared to the controls (1020.8±211.6 and 1170.8±243.5 ml, respectively). None of the patients indicated that they wished to discontinue MCT therapy. This pilot study shows that MCT therapy led to better pain control with a markedly lower need for tramadol as compared to the control group. This better pain control was accompanied by a better healing of the wound and a lower drain volume.
PMCID: PMC2267564  PMID: 16896874
14.  A rift between implicit and explicit conditioned valence in human pain relief learning 
Pain is aversive, but does the cessation of pain (‘relief’) have a reward-like effect? Indeed, fruitflies avoid an odour previously presented before a painful event, but approach an odour previously presented after a painful event. Thus, event-timing may turn punishment to reward. However, is event-timing also crucial in humans who can have explicit cognitions about associations? Here, we show that stimuli associated with pain-relief acquire positive implicit valence but are explicitly rated as aversive. Specifically, the startle response, an evolutionarily conserved defence reflex, is attenuated by stimuli that had previously followed a painful event, indicating implicit positive valence of the conditioned stimulus; nevertheless, participants explicitly evaluate these stimuli as ‘emotionally negative’. These results demonstrate a rift between the implicit and explicit conditioned valence induced by pain relief. They might explain why humans in some cases are attracted by conditioned stimuli despite explicitly judging them as negative.
PMCID: PMC2894900  PMID: 20356893
relief; pain; startle reflex
15.  A randomised sham controlled trial of vertebroplasty for painful acute osteoporotic vertebral fractures (VERTOS IV) 
Trials  2011;12:93.
The standard care in patients with a painful osteoporotic vertebral compression fracture (VCF) is conservative therapy. Percutaneous vertebroplasty (PV), a minimally invasive technique, is a new treatment option. Recent randomized controlled trials (RCT) provide conflicting results: two sham-controlled studies showed no benefit of PV while an unmasked but controlled RCT (VERTOS II) found effective pain relief at acceptable costs. The objective of this study is to compare pain relief after PV with a sham intervention in selected patients with an acute osteoporotic VCF using the same strict inclusion criteria as in VERTOS II. Secondary outcome measures are back pain related disability and quality of life.
The VERTOS IV study is a prospective, multicenter RCT with pain relief as primary endpoint. Patients with a painful osteoporotic VCF with bone edema on MR imaging, local back pain for 6 weeks or less, osteopenia and aged 50 years or older, after obtaining informed consent, are included and randomized for PV or a sham intervention. In total 180 patients will be enrolled. Follow-up is at regular intervals during a 1-year period with a standard Visual Analogue Scale (VAS) score for pain and pain medication. Necessary additional therapies and complications are recorded.
The VERTOS IV study is a methodologically sound RCT designed to assess pain relief after PV compared to a sham intervention in patients with an acute osteoporotic VCF selected on strict inclusion criteria.
Trial registration
This study is registered at, NCT01200277.
PMCID: PMC3083362  PMID: 21466679
16.  Pain predictability reverses valence ratings of a relief-associated stimulus 
Relief from pain is positively valenced and entails reward-like properties. Notably, stimuli that became associated with pain relief elicit reward-like implicit responses too, but are explicitly evaluated by humans as aversive. Since the unpredictability of pain makes pain more aversive, this study examined the hypotheses that the predictability of pain also modulates the valence of relief-associated stimuli. In two studies, we presented one conditioned stimulus (FORWARDCS+) before a painful unconditioned stimulus (US), another stimulus (BACKWARDCS+) after the painful US, and a third stimulus (CS−) was never associated with the US. In Study 1, FORWARDCS+ predicted half of the USs while the other half was delivered unwarned and followed by BACKWARDCS+. In Study 2, all USs were predicted by FORWARDCS+ and followed by BACKWARDCS+. In Study 1 both FORWARDCS+ and BACKWARDCS+ were rated as negatively valenced and high arousing after conditioning, while BACKWARDCS+ in Study 2 acquired positive valence and low arousal. Startle amplitude was significantly attenuated to BACKWARDCS+ compared to FORWARDCS+ in Study 2, but did not differ among CSs in Study 1. In summary, predictability of aversive events reverses the explicit valence of a relief-associated stimulus.
PMCID: PMC3782145  PMID: 24068989
backward conditioning; forward conditioning; implicit and explicit responses; pain relief; threat unpredictability
17.  An Audit of Aspects of Informed Consent and Pain Relief in General Surgical Units of Korle Bu Teaching Hospital 
Ghana Medical Journal  2005;39(2):63-67.
There is the need to adequately inform patients about their disease, treatment options, surgery and post-operative complications. Adequate pain relief after surgery leads to less morbidity. Two important aspects of surgical practice are being addressed in this paper, the need for informed consent and post operative pain relief.
A questionnaire survey was carried out in 100 patients on the four general surgical wards of the Korle Bu Teaching Hospital, just before they were discharged from hospital. They were asked what they knew or had been informed about their diagnosis, operation and complications of surgery. On pain relief, patients were asked about their experiences on the first post-operative day and what relief they had from analgesics.
Twenty four did not know the diagnosis and 36 were not told what operation they were going to have before surgery. Although 75 were eventually told what operation they had, only 64 said they knew the operation. Sixty eight did not know what to expect after surgery; 87 did not know about possible complications. On the first post-operative day there was significant pain (scores 4 and 5) felt by 24 patients at rest and 46 on movement. The most frequently prescribed analgesic was pethidine.
Patient information in General surgery at the Korle Bu Teaching Hospital is unsatisfactory. Post-operative analgesia is also poor. There is the need for surgeons to either train doctors to administer consent or administer it themselves. Anaesthetists should assume a leading role in managing post-operative pain.
PMCID: PMC1790812  PMID: 17299545
Consent; post-operative analgesia; patient information; complications; surgery; Korle Bu
18.  Early migraine intervention with sumatriptan 100 mg in patients with a history of nonresponse to sumatriptan 50 mg: an open-label, prospective study of multiple attacks 
Early treatment with sumatriptan tablets (50 and 100 mg) has been shown to be effective in retrospective and prospective study designs. Despite the efficacy of sumatriptan 50 mg and early intervention, however, some patients continue not to respond completely to this dose. New evidence with a scientific basis for early intervention suggests that some patients may need to treat early to prevent the establishment of central sensitization. Also, patients cite complete pain relief as the most important attribute of a migraine medication.
The primary objective of this study was to determine the 2-hour efficacy of sumatriptan 100 mg in achieving complete pain relief in patients with a history of nonresponse to sumatriptan 50 mg in an early-intervention treatment paradigm. Secondary end points included complete pain relief at 4 hours, consistency of complete relief in at least 2 of 3 attacks, sustained complete relief over 24 hours, satisfaction with the 100-mg dose, and relief of associated symptoms.
This open-label, prospective study was conducted at the Wesley Headache Clinic (Memphis, Tennessee). Male and female patients between the ages of 18 and 65 years who fulfilled International Headache Society classification criteria for migraine, and who had a documented history of nonresponse to sumatriptan 50 mg at 2 hours after dosing when treating in the early, mild-pain phase in at least 2 of 3 migraine attacks were eligible for the study. Patients were instructed to receive one 100-mg sumatriptan tablet at the earliest sign of pain, while still mild, in 3 subsequent migraine attacks. After each treated attack, patients were to record a detailed diary entry.
Twenty patients (17 women, 3 men; mean age, 44 years) treated all 3 migraines during the early, mild-pain phase and completed the study. Of the 60 attacks treated, 48 (80%) were pain free at 2 hours, 56 (93%) were pain free at 4 hours, and 45 (75%) were pain free at 2 hours and continued to be pain free at 24 hours (sustained pain-free response). Sumatriptan 100 mg was well tolerated; none of the patients reported any adverse events.
In this study of migraineurs with a history of nonresponse to sumatriptan 50 mg at 2 hours after dosing in the early, mild-pain phase of migraine, increasing the dose of sumatriptan from 50 mg to 100 mg in the early-intervention paradigm, in most attacks complete pain relief was achieved for up to 24 hours. Because patients have indicated that becoming pain free was their therapeutic goal, based on the results of this study, physicians may want to consider increasing the dose of sumatriptan to 100 mg at the first sign of pain if the patient has consistently not responded to sumatriptan 50 mg in the early-intervention model.
PMCID: PMC3964575
early intervention; nonresponders; migraine; sumatriptan
19.  Oral Morphine Prescribing Practices in Severe Cancer Pain 
Indian Journal of Palliative Care  2009;15(2):127-131.
Nearly one million cancer patients in India need oral morphine for pain relief. Despite doctors prescribing oral morphine in our center, many cancer patients with severe pain found to be not facilitated with adequate pain relief.
This audit was conducted to look at the “oral morphine prescribing practices for severe cancer pain” at a tertiary care hospital.
Materials and Methods:
Twenty case files of patients, who were admitted with severe cancer pain, and receiving oral morphine were analyzed in pre- and posteducational session. Local standards were set to assess the adequacy of pain relief. Deficiency in achieving analgesia was found in preinterventional audit. A clinical audit was conducted before and after the educational session on oral morphine prescribing. The education for doctors and nurses focused on starting patients on morphine, titration, and administering rescue dose. Then local guidelines on oral morphine prescribing were circulated. And analysis of following factors were done following pre- and posteducational session: Pain intensity at the beginning of treatment, starting dose of morphine, increments in morphine dose, number of rescue doses given, and fall in pain intensity at the end of 1 week. The outcomes were compared with the standards.
Preintervention audit showed that only 50% of patients achieved adequate pain relief. Rescue dose was administered in only 20% of patients. While reaudit following the educational session showed that 80% of patients achieved adequate pain relief and 100% received rescue doses.
Educational sessions have significant impact on improving oral morphine prescribing practice among doctors and nurses. It was found failing to administer regular as well as rescue doses resulted in inadequate pain relief in patients receiving oral morphine.
PMCID: PMC2902113  PMID: 20668591
Cancer pain; Oral morphine; Pain relief; Prescribing practices
20.  Treatments for Chronic Pain in Persons With Spinal Cord Injury: A Survey Study 
To determine the degree and duration of pain relief provided by specific pain treatments used by individuals with spinal cord injury (SCI) who have chronic pain.
Postal survey.
Participants were 117 individuals who had traumatic SCI, were 18 years of age or older, and reported a chronic pain problem.
Main Outcome Measures:
Questions assessing current or past use of 26 different pain treatments, the amount of relief each treatment provided, and the length of time that any pain relief usually lasts.
The medications tried most often were nonsteroidal anti-inflammatory drugs (tried by 71%) and acetaminophen (tried by 70%); these medications were still being used by more than one half of the patients who had tried them. Opioids produced the greatest degree of pain relief on average (mean, 6.27 ± 3.05 [SD] on a 0–10 scale, with 0 = no relief and 10 = complete relief) but were unlikely to be continued by those who tried them. Although 38% of respondents with pain had tried gabapentin, only 17% were still using it, and average pain relief was only moderate (mean, 3.32 ± 3.03 on the 0–10 relief scale). Seventy-three percent of the respondents had tried at least 1 of 7 alternative pain treatments, and the most frequently tried were massage, marijuana, and acupuncture. The most relief was provided by massage (mean, 6.05 ± 2.47] on the 0–10 relief scale) and marijuana (mean, 6.62 ± 2.54 on the 0–10 relief scale). The relief from the various treatments, including most medications, tended to last only minutes or hours; however, pain relief from alternative treatments such as massage, acupuncture, and hypnosis was reported to last for days in 25% to 33% of those who tried these treatments.
Many patients are not finding adequate pain relief from commonly prescribed medications. Alternative therapies should be considered as additional treatment options in this population.
PMCID: PMC1864800  PMID: 16739554
Spinal cord injuries; Pain; Chronic; Neuropathic; Musculoskeletal; Analgesia; Gabapentin; Massage; Acupuncture; Alternative therapy
21.  Cancer pain management in ambulatory care: can we link assessment and action to outcomes? 
Good cancer pain control requires appropriate assessment and treatment. The purpose of this study was to examine the relationships among physician, nurse practitioner, and nurse knowledge, documentation of assessment, treatment, and pain reduction in cancer patients seen in ambulatory settings.
The study method included an assessment of pain knowledge of providers (physicians, nurse practitioners, and nurses) who worked in cancer clinics and a retrospective review of patients' records treated for cancer-related pain in their clinics. Fifty-eight providers from eight cancer clinics completed the knowledge questionnaire; 56 patient records were reviewed for assessment, treatment, and outcome data. Pain relief, the outcome, was obtained from documentation at the next clinic visit.
Of the 54 patient records that documented pain relief at the next clinic visit, 61.9% reported no relief. Chi square analysis revealed clinics with a higher level of pain knowledge documented a greater number of elements of an ideal pain assessment (p=0.03) but was unrelated to treatment and pain relief reported. Assessment and treatment were unrelated to reported pain relief at the next clinic visit.
These data suggest that providers' pain knowledge is related to pain assessment but not treatment or outcome. In addition, these data showed no relationship between assessment, treatment prescribed, and pain relief in these ambulatory settings.
PMCID: PMC3103757  PMID: 21052733
Cancer pain management; Healthcare provider pain knowledge; Ambulatory settings; Cancer pain guideline
22.  Mindfulness meditation-related pain relief: Evidence for unique brain mechanisms in the regulation of pain 
Neuroscience letters  2012;520(2):165-173.
The cognitive modulation of pain is influenced by a number of factors ranging from attention, beliefs, conditioning, expectations, mood, and the regulation of emotional responses to noxious sensory events. Recently, mindfulness meditation has been found attenuate pain through some of these mechanisms including enhanced cognitive and emotional control, as well as altering the contextual evaluation of sensory events. This review discusses the brain mechanisms involved in mindfulness meditation-related pain relief across different meditative techniques, expertise and training levels, experimental procedures, and neuroimaging methodologies. Converging lines of neuroimaging evidence reveal that mindfulness meditation-related pain relief is associated with unique appraisal cognitive processes depending on expertise level and meditation tradition. Moreover, it is postulated that mindfulness meditation-related pain relief may share a common final pathway with other cognitive techniques in the modulation of pain.
PMCID: PMC3580050  PMID: 22487846
Mindfulness; Meditation; Pain; Neuroimaging
23.  Pain perception among parturients at a University Teaching Hospital, South-Western Nigeria 
Labour pain is a universal experience. Relief of labour pains and companionship in labour are important aspects of quality of care in labour.
To evaluate perception of labour pains among parturients, their knowledge and awareness of pain relief during labour, the types of obstetric analgesia available and the outcome of their labour at the Ekiti State University Teaching Hospital, Ado-Ekiti.
Materials and Methods:
A cross-sectional study using questionnaire administered to pregnant women between 37 and 42 weeks gestational age in labour ward of the hospital.
The study revealed that 75.2% of the parturients experienced severe labour pains and 35.3% of them received analgesia in labour with Pentazocine injection being the only analgesic used. Only 18.3% had maximum relief of their pains. Parturients with increasing parity, higher social class and educational attainment and who had antenatal education on labour pains were associated with severe perception of labour pains with P values of 0.03, 0.03, 0.02 and 0.01, respectively. Parturients who were given Pentazocine injection for pains and had relief in labour had more spontaneous vaginal deliveries, P = 0.030 and better outcome for their babies, P = 0.028. Majority of the women reported that the practice of companionship and back rubbing in labour helped them to cope better with the labour process.
Most women desire relief of pains of labour but the practice is still suboptimal in this centre. Efforts should be made towards developing the practice of obstetric analgesia and companionship in labour in this environment.
PMCID: PMC3821219  PMID: 24249944
Pain; parturients; perception; South-Western Nigeria
24.  Radiation Therapy without Surgery for Spinal Metastases: Clinical Outcome and Prognostic Factors Analysis for Pain Control 
Global Spine Journal  2012;2(3):137-142.
The purpose of radiation therapy (RT) for patients with spinal metastases is pain relief and control of paralysis. The aim of the present study was to assess pain relief using RT and to evaluate prognostic factors for pain control. We evaluated 97 consecutive patients, of mean age 62.7 years (range 28 to 86), with spinal metastases that had been treated by RT. We evaluated the effects of RT using pain level assessed using a drug grading scale based on the World Health Organization standards. The following potential prognostic factors for pain control of RT were evaluated using multivariate logistic regression analysis: age, gender, tumor type, performance status (PS), number of spinal metastases, and a history of chemotherapy. Among the 97 patients who underwent RT for pain relief, 68 patients (70.1%) presented with pain reduction. PS (odds ratio: 1.931; 95% confidence interval: 1.244 to 2.980) was revealed by multivariate logistic regression analysis to be the most important prognostic factor for pain control using RT. In conclusion, we found that RT was more effective for patients with spinal metastases while they maintained their PS.
PMCID: PMC3864466  PMID: 24353960
radiation therapy; spinal metastases; multivariate logistic regression analysis; pain relief
25.  Percutaneous Thoracic Intervertebral Disc Nucleoplasty: Technical Notes from 3 Patients with Painful Thoracic Disc Herniations 
Asian Spine Journal  2011;5(1):15-19.
Symptomatic thoracic disc herniation is an uncommon condition and early surgical approaches were associated with significant morbidity and even mortality. We are the first to describe the technique of percutaneous thoracic nucleoplasty in three patients with severe radicular pain due to thoracic disc herniation. Two of the patients experienced more than 75% pain relief and one patient experienced more than 50% pain relief. Post-procedural pain relief was maintained up to an average of 10 months after nucleoplasty. One patient with preoperative neurological signs improved postoperatively. There were no reported complications in all three patients. In view of the reduced morbidity and shorter operating time, thoracic intervertebral disc nucleoplasty can be considered in patients with pain due to thoracic disc herniation, with no calcification of the herniated disc, and in patients who may be otherwise be unfit for conventional surgery.
PMCID: PMC3047894  PMID: 21386942
Thoracic intervertebral disc herniation; Thoracic nucleoplasty; Percutaneous thoracic disc cannulation; Minimally invasive procedures

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