Highlights Of Pain Research

Main Category: Pain / Anesthetics
Also Included In: Bones / Orthopaedics
Article Date: 08 Jun 2009 - 2:00 PDT

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Musculoskeletal problems are among the complaints most frequently reported in health interview surveys. Typically around 50 percent of the population report having had musculoskeletal pain in one or more areas for at least one week during the past month. Musculoskeletal disorders are also the most common work-related health problems in the EU: 25 percent of European workers complain of backache and 23 percent of muscular pains. The trend will become even more acute as demographic changes lead to an ageing society.

The theme of pain is therefore one of the focuses of the 10th EFORT Congress taking place in Vienna from June 3 to 6, 2009. The Congress is organized by the European Federation of National Associations of Orthopaedics and Traumatology. The following are some highlights of the orthopaedic pain research presented at this scientific event.

Shoulder surgery: Greater attention to factors determining quality of life perception

"Factors determining quality of life perception (QLP) should be taken into account when planning surgery strategies for different shoulder disorders," according to Dr. Joan Miquel from Barcelona, Spain, speaking at Europe's largest gathering of orthopaedists. "Age, sex and aetiology of shoulder disorder determine different perceptions of quality of life independently of the shoulder functional scoring."

Dr. Miquel said his and his team's motive for studying 134 patients was to analyze the quality of life in patients affected by different shoulder pathologies and to check how pain and movement influence QLP. Current treatments in shoulder pathology are focused on reducing pain, he said, though it is yet to be established that pain itself is the factor most significantly affecting such patients.

The results of their study showed that there were statistically significant differences among age, sex and diagnosis groups. Patients older than age 65 significantly perceived a worse quality of life. Women and patients affected by a degenerative disorder also significantly perceived a worse quality of life. A relationship (linear trend) between movement and quality of life was ascertained. In patients with preserved range of motion, changes in pain perception significantly affected QLP, while changes in pain perception did not affect the QLP of patients with poor range of motion. A predominant effect of external rotation, that is rotation away from the centre of the body, in QLP was observed.

Pain during activity, at rest and at night: Do we have to measure it all?

The patient alone can provide the information about the most important symptom of musculoskeletal system disease: pain. To assess the pain situation better the symptoms can be measured in routine with the "Pationnaire", a simple tool easy to use and to understand. This instrument allows an objective assessment of pain during activity, at rest and at night. In the end an aggregate score of all three pain categories is calculated. But is that really necessary? Here too, new findings were presented at the EFORT Congress. Dr. Jörg Huber from Switzerland assessed the pain of patients with various degenerative disorders of the musculoskeletal system and evaluated a total of more than 1,000 questionnaires. The results indicated that the degree of pain at rest correlated to a high degree with nocturnal pain. The researcher thus concludes that these two kinds of pain can be asked in one single question. Dr. Huber: "It would suffice, therefore, to inquire about and to document pain during activity and pain at rest/night, thereby facilitating the assessment of the clinical situation."

Emergency surgical admissions: Every fifth patient's regularly prescribed medication overlooked

Particularly during hospital emergency cases, "more care and emphasis need to be given to individual drug history when admitting a patient." Presenting the study "Errors in Prescription of Regular Medication in Emergency Surgical Admissions - Clinical Audit," Dr. Amit Sharma of the Luton & Dunstable Hospital in the UK emphasized at the EFORT Congress in Vienna that "the results of our audit are surprising and alarming." In 21% of cases, the admitting doctors failed to prescribe at least one regular medication the patient was dependent on. Missing out on regular medication can have potentially life-threatening effects on patients as well as severe medico-legal implications.

The data for this audit was taken from all surgical admissions over an approximately one month period. Prescribed drugs for each patient were checked the morning after admission. If the patient was unable to provide this information, their regular medication list was obtained from the General Practitioner (GP). A total of 71 admissions were studied, 58% were referred from the accident and emergency department (A&E), whereas 34% from the GP/primary care and a small percentage came from referrals from other wards within the hospital. Out of the 71 admissions, 46 patients were receiving at least one regular medication.

Dr. Sharma: "From all 71 admissions, 21% of them had at least one error, i.e. at least one regular medication was not prescribed upon admission. Analyzing each co-morbidity individually: 42% of ischemic heart disease (IHD) medication was not prescribed for patients who regularly depended on them; 33% for hypertensive and diabetic medication; 50% for asthmatic and psychiatric medication and 29% for medication for other less serious conditions." Of the errors made, 81% were on patients referred from A&E, while 15% where from patients received from the GP/primary care. Patients referred from the A&E department are generally more unwell than the ones referred from the GP or primary care. Quite often, they are elderly patients on a multitude of drugs that are unable to remember some or all of their medications. Patients admitted out of hours present an added difficulty in that GPs are not available for confirmation of the patient's regular medication, notes Dr. Sharma.

Discussions with a physician reduce pain and improve shoulder function

New study results on the influence of physician-patient communications indicate that patients with shoulder disorders have significantly less pain perception following clinical doctor-patient interviews. Patients who had received surgery because of a shoulder disorder perceived significantly better shoulder function and less pain after doctor visits. The conclusion results from a study presented at the EFORT Congress in Vienna by Dr. Carlos Torrens (Barcelona, Spain) on the "Change in Patient Self-evaluation of Pain, Function and Satisfaction Before and After Clinical Visit." The study involved 95 consecutive patients (mean age: 64.18) with varying shoulder problems such as fractures, cuff disorders, instabilities and glenohumeral arthritis. Just under half of the patients had undergone surgery.

The objective of the study was to analyze the effect of the doctor-patient interview on the patient's self-evaluation of his/her pain level as well as the level of function and satisfaction during different shoulder procedures. Before and after the clinical visit, the patients were asked to fill 3 analogical scales related to: the level of shoulder pain; the level of shoulder function; and satisfaction with the procedure. Self-administered questionnaires are commonly used to evaluate functional and satisfaction results of different treatments applied.

An analysis of the whole series indicated that there were significant differences between the pain experienced in the shoulder before and after a visit. There were marginally significant differences between the level of function of the shoulder experienced before and after a visit, and there were no differences in satisfaction with the procedure.

If the cohort of patients that had received surgery is analyzed separately, significant differences emerge in perceptions of pain and function. Females significantly considered less pain after visits than males; no differences were noted because of age, diagnosis or time elapsed since surgery. No differences were noted with satisfaction, even though patients tend to perceive more satisfaction after a visit.

Dr. Torrens concludes that "when planning patient self-evaluation of pain and function, the effect of the clinical visit has to be considered in order to avoid masking results."

British pain researcher: "We require improved alternative analgesic regimes following hip arthroscopy"

British pain researchers, analyzing the results of post-operative pain measurement of 71 patients, reported at the EFORT Congress that better analgesic regimes are needed after day-case hip arthroscopic surgery.

Background: Day-case hip arthroscopic surgery is frequently carried out using an intra-articular depot of local anaesthetic as post-operative analgesia plus additional opiate or oral analgesia as required. Although problems with chondral toxicity caused by prolonged exposure to local anaesthetics have been increasingly recognized, Dr Jonathan Robert Bunn (Craigavon Area Hospital, Northern Ireland, UK) and his team nevertheless set out to evaluate the efficacy of three different hip arthroscopy post-operative analgesic regimes. In particular, they wanted to examine whether or not intra-articular local anaesthetics provided any benefit.

Dr Bunn: "There are no previous studies relating to hip arthroscopy post-operative analgesic requirements." He investigated 71 consecutive patients and prospectively audited their post-operative analgesic requirements. Each patient was given one of three alternative post-operative analgesic regimes: Group A received the local anaesthetic Bupivacaine 0.25% 10ml intra-articular and 20ml periportal skin infiltration; group B had Bupivacaine 0.25% 20ml periportal skin infiltration only; and group C had no infiltration. Outcome measures were visual analogue scores (VAS) immediate postoperatively, one hour post-operatively, two hours post-operatively and four hours post-operatively. Total opiate consumption was also recorded.

The result: There was significantly less post-operative pain in group A (Bupivacaine intra-articular and periportal skin infiltration), compared with group C (no infiltration) immediate postoperatively and one hour post-operatively, and compared with group B (Bupivacaine periportal skin infiltration) two hours and four hours post-operatively. There were no significant differences in visual analogue scores between groups B and C at any time-points. Group A used significantly less opiates post-operatively compared with group B or C but there was no significant difference in opiate use between groups B and C.

Dr Bunn: "Intra-articular local anaesthetic significantly reduces post-operative pain, but at what cost to the chondral surface? Local skin infiltration of the arthroscopy portals does not significantly alter pain levels or opiate requirements. Avoidance of 'intra-articular' local anaesthetic raises opiate requirements. We require improved alternative analgesic regimes."

Abstracts:

EFORT 2009 Abstract: Sharma A et al, Errors in prescription of regular medication in emergency surgical admissions-clinical audit.

EFORT 2009 Abstract: Torrens C et al, Change in patient self-evaluation of pain, function and satisfaction before and after clinical visit.

EFORT 2009 Abstract: Miquel J et al, Influence of pain and mobility in quality of life perception in shoulder disorders.

EFORT 2009 Abstract: Huber J et al, Assesment of pain during activity, at rest and at night - do we have to assess all three different pains?

EFORT 2009 Abstract: Bunn J et al, The efficacy of post-operative regimes following hip arthroscopy.

Source
EFORT