Identification of intrinsic and reflexive contributions to trunk stabilization in patients with low back pain: a case-control study.

PURPOSE: The goal of this study was to assess differences in low back stabilization and underlying mechanisms between patients with low back pain (LBP) and healthy controls. It has been hypothesized that inadequate trunk stabilization could contribute to LBP through high tissue strains and/or impingement. Evidence to support this is inconsistent, and not all methods that have been used to study trunk stabilization are equally suitable. We have recently developed a method to assess intrinsic and reflexive contributions to trunk stabilization, which aims to circumvent the limitations of previous studies. METHODS: Forty-nine participants suffering from chronic LBP and a control group of fifty healthy subjects participated in this study. Trunk stabilization was measured using force-controlled perturbations directly applied to the trunk. The actuator displacement and contact force between the actuator and subject were measured as well as electromyography (EMG) of the M. Longissimus. Underlying mechanisms were characterized using system identification. RESULTS: LBP patients showed lower admittance, i.e., less displacement per unit of force applied, mainly due to higher position, velocity and acceleration feedback gains. Among patients, lower trunk admittance and higher reflex gains were associated with more negative pain-related cognitions. CONCLUSION: Trunk stabilization differs between LBP patients and controls, with the same perturbations causing less trunk movement in patients, due to stronger reflexes. We interpret these changes as reflecting protective behavior. These slides can be retrieved under Electronic Supplementary Material.

Palliative sedation and moral distress: A qualitative study of nurses.

BACKGROUND: Clinical nursing practice may involve moral distress, which has been reported to occur frequently when nurses care for dying patients. Palliative sedation is a practice that is used to alleviate unbearable and refractory suffering in the last phase of life and has been linked to distress in nurses. AIM: The aim of this study was to explore nurses' reports on the practice of palliative sedation focusing on their experiences with pressure, dilemmas and morally distressing situations. METHODS: In-depth interviews with 36 nurses working in hospital, nursing home or primary care. RESULTS: Several nurses described situations in which they felt that administration of palliative sedation was in the patient's best interest, but where they were constrained from taking action. Nurses also reported on situations where they experienced pressure to be actively involved in the provision of palliative sedation, while they felt this was not in the patient's best interest. The latter situation related to (1) starting palliative sedation when the nurse felt not all options to relieve suffering had been explored yet; (2) family requesting an increase of the sedation level where the nurse felt that this may involve unjustified hastening of death; (3) a decision by the physician to start palliative sedation where the patient had previously expressed an explicit wish for euthanasia. CONCLUSIONS: Nurses experienced moral distress in situations where they were not able to act in what they believed is the patient's best interest. Situations involving moral distress require nurses to be well informed and able to adequately communicate with suffering patients, distressed family and physicians.

Painful swelling after a noxious event and the development of complex regional pain syndrome 1: A one-year prospective study.

BACKGROUND: The timing of diagnosis of complex regional pain syndrome (CRPS) 1 remains a challenge due to the large heterogeneity of clinical presentations. We describe the distribution and differences in outcomes and clinical manifestations between time points and patient groups with and without CRPS 1 following an initiating event. METHODS: Prospective cohort study with a consecutive registration of patients presenting with painful swelling of the affected extremity after an initiating event and follow-up visits after 3, 6 and 12 months. RESULTS: Forty-two patients were enrolled (37 females, mean age 55.1 years). At baseline, 35 participants (83%, females n = 30) fulfilled the diagnostic criteria for CRPS 1. At 3 months, 19 out of the initial 35 CRPS 1 patients (54%) did not meet the diagnostic criteria anymore. Besides our inclusion criteria of a painful swelling, early manifestations indicating a CRPS 1 primarily include an impaired quality of life (SF-35, EQ5-D), more pain (NRS, MPQ) and restricted range of motion. CONCLUSIONS: CRPS 1 develops within 8 weeks following a noxious event. Although many CRPS 1 patients reach partial remission within the first 3 months, signs and symptoms do not improve significantly at 1 year. In order to identify prognostic risk factors large prospective cohort studies are needed. SIGNIFICANCE: This prospective cohort study follows patients with complaints most suspected for complex regional pain syndrome (CRPS) 1. CRPS 1 develops within 8 weeks following a noxious event. Although many CRPS 1 patients reach partial remission within the 3 months, symptoms do not improve significantly at 1 year.

[Discontinuation of potentially inappropriate medications at the end of life: perspectives from patients, their relatives, and physicians]. / Overbodige medicatie stoppen vlak voor overlijden.

OBJECTIVE: To obtain insight into the perspectives of patients, relatives and physicians towards potentially inappropriate medications (PIMs) at the end of life. DESIGN: Qualitative interview study. METHOD: An analysis of in-depth interviews with 17 patients who were diagnosed as having a life expectancy of less than three months, 12 patient relatives, and 20 medical specialists and 12 general practitioners who cared for them. For analysis we applied the constant comparative method, which forms part of the grounded theory approach. RESULTS: Patients and their relatives are prepared to discontinue PIMs. Still, some patients reported that stopping might give them the feeling that their attending physician has already thrown in the towel. Physicians mentioned several reasons for not ceasing PIMs: cessation not considered, low priority, and unknown consequences of discontinuation. Some physicians were concerned that discussing the discontinuation of PIMs with patients could make patients acutely aware of the approach of death, and give patients the impression that they are receiving inferior medical care. If physicians communicate with patients the possibility of discontinuing medications, they seem to emphasize the clinical futility of continuing PIMs in light of the patient's limited life expectancy. CONCLUSION: Patients with a limited life expectancy and their relatives may be open to discontinue PIMs; however, in reality this happens rarely. When a physician is of the opinion that it would be of benefit to discontinue certain medications, then the advantages of cessation should be highlighted more in discussions with the patient.

[Classification of pain in the orofacial and craniofacial regions]. / Classificatie van pijn in het orofaciale en craniofaciale gebied.

Pain is a multidimensional, subjective phenomenon that can only be understood within the context of an individual operating in a specific environment. As a consequence, it is difficult from an objective standpoint to satisfy the established criteria for classification. In general, it is the case that available classification systems can only partially capture pain in all of its complexity. There are various general and specific classification systems. In 2017, the International Classification of Diseases will be complemented with classification possibilities related to chronic pain. Recently, a committee established by the Dutch Pain Society has formulated a proposal for the development of a definition and classification system for chronic pain to be applied in the Netherlands.

[Measuring orofacial pain]. / Pijnmeting bij orofaciale pijn.

Pain is a complex neuro-physiological phenomenon affecting mind and behaviour, and is in turn also affected by psyche and behaviour. Differences among individuals in modulation, interpretation and expression complicate the comparison of pain between patients. Pain is a subjective experience and can be expressed by the patient in many different ways. In addition, influential factors from a bio-psycho-social perspective have to be taken into consideration: the interaction among somatic, psychological and social factors determines the ultimate pain experience and pain behaviour. Measuring pain therefor requires a multi-dimensional approach in which the pain, observed from various levels, and the associated problems can be determined.

Methods for assessment of trunk stabilization, a systematic review.

Trunk stabilization is achieved differently in patients with low back pain compared to healthy controls. Many methods exist to assess trunk stabilization but not all measure the contributions of intrinsic stiffness and reflexes simultaneously. This may pose a threat to the quality/validity of the study and might lead to misinterpretation of the results. The aim of this study was to provide a critical review of previously published methods for studying trunk stabilization in relation to low back pain (LBP). We primarily aimed to assess their construct validity to which end we defined a theoretical framework operationalized in a set of methodological criteria which would allow to identify the contributions of intrinsic stiffness and reflexes simultaneously. In addition, the clinimetric properties of the methods were evaluated. A total of 133 articles were included from which four main categories of methods were defined; upper limb (un)loading, moving platform, unloading and loading. Fifty of the 133 selected articles complied with all the criteria of the theoretical framework, but only four articles provided information about reliability and/or measurement error of methods to assess trunk stabilization with test-retest reliability ranging from poor (ICC 0) to moderate (ICC 0.72). When aiming to assess trunk stabilization with system identification, we propose a perturbation method where the trunk is studied in isolation, the perturbation is unpredictable, force controlled, directly applied to the upper body, completely known and results in small fluctuations around the working point.

Trunk stabilization estimated using pseudorandom force perturbations, a reliability study.

Measurement of the quality of trunk stabilization is of great interest to identify its role in first occurrence, recurrence or persistence of low-back pain (LBP). Our research group has developed and validated a method to quantify intrinsic and reflex contributions to trunk stabilization from the frequency response function (FRF) of thorax movement and trunk extensor EMG to perturbations applied by a linear actuator. However, the reliability of this method is still unknown. Therefore, the purpose of this study was to investigate the between-day reliability of trunk FRFs in healthy subjects and LBP patients. The test-retest ICC׳s in patients were substantial for both admittance and reflex gains (ICC3,1>0.73 and 0.67). In healthy subjects, the reliability of admittance gain was also substantial (ICC3,1 0.66), but the reliability of the reflexive gain was only moderate (ICC3,1 0.44). Although sample sizes were limited (13 healthy subjects and 18 LBP patients), these results show that trunk stabilization can be measured reliably, and represent a promising step towards using this method in further research in LBP patients.

Efficacy of antidepressants on orofacial pain: a systematic review.

Orofacial pain is a common complaint with multiple diagnoses. There is controversy about the effectiveness of antidepressants for the management of orofacial pain disorders. In order to be able to make a best evidence choice between available antidepressants for the treatment of orofacial pain, a systematic review was conducted of existing randomized controlled trials of antidepressants. Trials were identified from the Pubmed database up to March 2012, from references in retrieved reports and from references in review articles. Six articles were found and included in this review. Four studies were randomized placebo-controlled trials and two studies were randomized active-controlled trials. Two independent investigators reviewed these articles using a 15-item checklist. All six trials were of high quality according to the 15-item criteria. Nevertheless there was limited evidence to support the effectiveness of antidepressants in orofacial pain disorders, because of the heterogeneity of treatment modalities and the low number of randomized controlled trials per diagnose. More randomized controlled trials are needed to come to a firm conclusion for the use of antidepressants for orofacial pain disorders.

Motor control in complex regional pain syndrome: a kinematic analysis.

This study evaluated movement velocity, frequency, and amplitude, as well as the number of arrests in three different subject groups, by kinematic analysis of repetitive movements during a finger tapping (FT) task. The most affected hands of 80 patients with complex regional pain syndrome (CRPS) were compared with the most affected hands of 60 patients with Parkinson disease (PD) as well as the nondominant hands of 75 healthy control (HC) subjects. Fifteen seconds of FT with thumb and index finger were recorded by a 60-Hz camera, which allowed the whole movement cycle to be evaluated and the above mentioned movement parameters to be calculated. We found that CRPS patients were slower and tapped with more arrests than the two other groups. Moreover, in comparison with the hands of the HC subjects, the unaffected hands of the CRPS patients were also impaired in these domains. Impairment was not related to pain. Dystonic CRPS patients performed less well than CRPS patients without dystonia. In conclusion, this study shows that voluntary motor control in CRPS patients is impaired at both the affected as well as the unaffected side, pointing at involvement of central motor processing circuits.

The psoas compartment block for hip surgery: the past, present, and future.

A posterior lumbar plexus block or psoas compartment block (PCB) is an effective locoregional anesthetic technique for analgesia and anesthesia of the entire lower extremity including the hip. Since the first description in the early seventies, this technique has been modified based on advanced knowledge of the anatomical localization of the lumbar plexus and the improvement of technical equipment. This paper provides an overview of the history, clinical efficacy, and risk profile of the PCB focused on hip surgery. Current status and future expectations are discussed.

Psoas compartment block for lower extremity surgery: a meta-analysis.

Psoas compartment block (PCB) is a potentially useful but controversial technique for lower limb surgery. We have conducted a systematic review of the efficacy and safety of PCB for anaesthesia and postoperative analgesia for hip and knee surgery. Relevant studies were identified within PubMed, EMBASE, and the Cochrane Library. The main outcome measure for anaesthesia was anaesthetic efficacy. For postoperative analgesia, the severity of postoperative pain was compared. The data were subjected to meta-analysis using relative risks with 95% confidence intervals (95% CI) for dichotomous variables and weighted mean differences with 95% CI for continuous variables. Thirty publications were included. PCB is an effective intervention for analgesia after hip and knee surgery. It appears superior to opioids for pain relief after hip surgery. This analgesic benefit may be extended beyond 8 h by the use of a catheter technique. Compared with Winnie's 3-in-1 block, PCB is associated with more consistent block of the obturator nerve. PCB may be an alternative to postoperative neuraxial block. Although PCB combined with sciatic nerve block and sedation is an effective technique for minor knee surgery, there is currently insufficient data to recommend the use of this approach for hip and major knee surgery. PCB is a safe and effective alternative for analgesia after hip and knee surgery. More research is required to define its role in the intraoperative setting and confirm potentially beneficial effects on variables such as perioperative haemodynamics and blood loss.

[Clinical practice guideline 'Complex regional pain syndrome type I']. / Richtlijn 'Complex regionaal pijnsyndroom type I'.

The development and treatment ofthe complex regional pain syndrome type I (CRPS-I) are a subject of much discussion. Using the method for the development ofevidence-based guidelines, a multidisciplinary guideline for the diagnosis and treatment of this syndrome has been drawn up. The diagnosis of CRPS-I is based on the clinical observation of signs and symptoms. For pain treatment, the WHO analgesic ladder is advised up to step z. In case of pain ofa neuropathic nature, anticonvulsants and tricyclic antidepressants may be considered. For the treatment ofinflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. In order to enhance peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used for a cold extremity ifvasodilatory medication produces insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, the use of vitamin C is recommended. Adequate perioperative analgesia, limitation of operation time and limited use of bloodlessness are advised for the secondary prevention of CRPS-I. Use of regional anaesthetic techniques can also be considered in this connection.

Compound A and carbon monoxide production from sevoflurane and seven different types of carbon dioxide absorbent in a patient model.

BACKGROUND: The degradation of sevoflurane can lead to the production of compound A (CA) and carbon monoxide (CO) and an increase in temperature of the absorbent. CA is known to be nephrotoxic in rats. These reactions depend on the strong base and water contents of the carbon dioxide absorbent used. The purpose of this study was to measure the maximum amounts of CA and CO produced, and the temperature increase, for seven different carbon dioxide absorbents for sevoflurane containing different contents of strong bases. METHODS: Seven absorbents [some free of strong bases (f)] were employed in hydrated (h) and completely desiccated (d) conditions in a patient model, using a circle anesthesia system connected to an artificial lung. Low-flow anesthesia with an oxygen-nitrous oxide mixture was maintained using 0.8% sevoflurane. For the quantification of CA and CO, a portable gas chromatograph was used. The temperature was measured inside the absorbent. RESULTS: In consecutive order of CA-producing potency, Amsorb(f)(d), Drägersorb(h), Medisorb(h), lithium hydroxide(f)(d), Drägersorb(d), Medisorb(d), Spherasorb(h) and Spherasorb(d) produced small amounts of CA. Loflosorb and Superia, which are free of strong bases, did not produce any CA or CO in hydrated or desiccated conditions. Only desiccated Drägersorb, Medisorb and Spherasorb demonstrated small amounts of CO accompanied by a significant temperature increase. CONCLUSION: In this patient model, we demonstrated that different types of absorbent produced small amounts of CA and CO or none at all. No relationship could be established between temperature and CA concentration.

[Limited possibilities for the evidence-based treatment and prevention of postherpetic neuralgia]. / Beperkte mogelijkheden voor evidence-based behandeling en preventie van postherpetische pijn.

Postherpetic neuralgia is a disorder that occurs frequently in the elderly. As the effect of the treatment of postherpetic neuralgia is often disappointing, studies have focussed on the prevention of this complaint. A commonly used preventive intervention is the administration ofa single epidural injection of a local anaesthetic and a corticosteroid, combined with oral antiviral agents and analgesics. In a large, multicentre, randomised controlled trial, the investigators found that the single injection of a corticosteroid and a local anaesthetic had no added value in the prevention of long-term postherpetic neuralgia.

Postoperative condition after the use of remifentanil with a small dose of piritramide compared with a fentanyl-based protocol in patients undergoing craniotomy.

BACKGROUND AND OBJECTIVE: The use of remifentanil requires other analgesics for postoperative pain relief compared to fentanyl in patients undergoing craniotomy. This could possibly reduce the postoperative advantages of this short-acting opioid. METHODS: We compared remifentanil and fentanyl-based anaesthesia in a randomized observer and patient blinded trial on patients, undergoing an elective craniotomy. Twenty patients received anaesthesia using remifentanil with a small dose of piritramide (0.1 mg kg(-1)) after closure of the dura mater. Twenty patients underwent a fentanyl-based protocol. In both groups, anaesthesia was induced with thiopental and rocuronium, and maintained with 0.6-1 minimum alveolar concentration (MAC) isoflurane in a nitrous oxide/oxygen mixture 2:1 and rocuronium. Patients received 1 g of paracetamol rectally postoperatively. A visual analogue scale (VAS) for pain, the Glasgow Coma Score, a modified Aldrete Score, arterial carbon dioxide tension (PaCO2) and piritramide consumption were evaluated every half an hour postoperatively. RESULTS: No significant differences were found for pain, Aldrete or Glasgow Coma scores or for PaCO2 between the groups when controlled for age, although the pain and Glasgow Coma Scores were consistently higher and PaCO2 lower in the remifentanil group. Furthermore, 11 out of 20 patients in the remifentanil group requested extra piritramide as opposed to 7 out of 20 in the fentanyl group (P = 0.11). CONCLUSIONS: Despite the intraoperative use of piritramide in the remifentanil group, patients experienced more pain postoperatively. A significant influence of age on pain intensity was found. The use of remifentanil with a small dose of piritramide of 0.1 mg kg(-1) has no evident advantage over the use of fentanyl considering the postoperative conditions after craniotomy.