Bilateral arm power imbalance in swim bench exercise to exhaustion.

We examined the supposition that swimmers may exhibit an imbalance in bilateral arm power output during simulated swimming exercise. Ten competitive front crawl swimmers (5 males, 5 females; age 20.5+/-2.3 years; height 1.74+/-0.09 m; body mass 72.0+/-16.7 kg; 400 m freestyle swim time 278+/-20.5 s; mean +/- s) performed four incremental (10 W x min(-1)) swim ramp tests on a computer-interfaced biokinetic swim bench ergometer. External power output from each arm was measured continuously to exhaustion. The results showed that, throughout the course of the simulated swim, external power output clearly favoured the left arm (F1,9 = 12.5, P= 0.006). This was especially evident in the final 30 s to exhaustion, when 54.0+/-3.87% of external power output was derived from the left arm versus 46.0+/-3.87% from the right arm. The disparity in external power output was further highlighted when the participants were grouped into unilateral and bilateral breathers. Unilateral breathers (n = 5) produced 57.1+/-2.62% of external power output from the left armversus 42.9+/-2.62% from the right arm (P= 0.001). Bilateral breathers (n = 5) exhibited a more balanced external power output of 51.0+/-1.82% from the left arm and 49.0+/-1.82% from the right arm (P = 0.177). Evidence of power imbalance in the simulated swimming stroke may have important implications for optimizing swim performance. The observed power imbalance may be reduced when a bilateral breathing technique is adopted.

Audit in pain clinics: changing the management of low-back and nerve-damage pain.

This audit study took place in ten outpatient pain clinics and focused on the management of low back pain and nerve-damage pain. The objective was to identify and promote appropriate changes in management. An analysis of the treatment of 1236 patients with low back pain and/or nerve-damage pain highlighted wide variations in practice. Presentation of these data to the clinics was used as a means of promoting change. Data on a further 1791 patients were used to assess the extent of any changes in practice. Prior to the audit feedback, treatments were used often in some clinics, but only rarely in other clinics, for seemingly similar patients. During the feedback sessions three treatments were identified for more frequent use by several of the clinics: antidepressant and anticonvulsant drugs, and transcutaneous electrical nerve stimulation. Many changes in practice occurred after the audit intervention, with large increases in the utilisation of these three treatments. Since there is reasonable evidence to support the use of these treatments for chronic pain this represents an improvement in the process of care. The audit demonstrated that patient management can be improved by a combination of active feedback and discussions based around comparisons between centres.

Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods.

A prospective audit of upper gastrointestinal endoscopy in 36 hospitals across two regions provided data from 14,149 gastroscopies of which 1113 procedures were therapeutic and 13,036 were diagnostic. Most patients received gastroscopy under intravenous sedation; midazolam was the preferred agent in the North West and diazepam was preferred in East Anglia. Mean doses of each agent used were 5.7 mg and 13.8 mg respectively, although there was a wide distribution of doses reported. Only half of the patients endoscoped had some form of intravenous access in situ and few were supplied with supplementary oxygen. The death rate from this study for diagnostic endoscopy was 1 in 2000 and the morbidity rate was 1 in 200; cardiorespiratory complications were the most prominent in this group and there was a strong relation between the lack of monitoring and use of high dose benzodiazepines and the occurrence of adverse outcomes. In particular there was a link between the use of local anaesthetic sprays and the development of pneumonia after gastroscopy (p < 0.001). Twenty perforations occurred out of a total of 774 dilatations of which eight patients died (death rate 1 in 100). A number of units were found to have staffing problems, to be lacking in basic facilities, and to have poor or virtually non-existent recovery areas. In addition, a number of junior endoscopists were performing endoscopy unsupervised and with minimal training.

Cancer pain management.

Cancer pain can be relieved with oral analgesics in most cases but 10 to 20% of patients do not respond. They are presently called opioid-resistant. While mild pain can be treated by paracetamol and non steroidal anti-inflammatory drugs, strong opioids are needed frequently. The author believes that there is no place for the weak opioids in cancer pain treatment. With strong opioids side effects are frequent, whether given orally (as is to be tried whenever possible), rectally or by other routes. Epidural or spinal delivery needs a special support system. Associations with steroids, antidepressants or other drugs are recommended. Nerve blocks and neurolytic procedures and methods such as transcutaneous nerve stimulation and acupuncture can be helpful.

Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy.

(1) Safety and monitoring should be part of a quality assurance programme for endoscopy units. (2) Resuscitation equipment and drugs must be available in the endoscopy and recovery areas. (3) Staff of all grades and disciplines should be familiar with resuscitation methods and undergo periodic retraining. (4) Equipment and drugs necessary for the maintenance of airway, breathing, and circulation should be present in the endoscopy unit and recovery area (if outside the unit) and checked regularly. (5) A qualified nurse, trained in endoscopic techniques and adequately trained in resuscitation techniques, should monitor the patient's condition during procedures. (6) Before endoscopy, adverse risk factors should be identified. This may be aided by the use of a check list. (7) The dosage of all drugs should be kept to the minimum necessary. There is evidence that benzodiazepine/opioid mixtures are hazardous. (8) Specific antagonists for benzodiazepines and opioids exist and should be available in the event of emergency. (9) A cannula should be placed in a vein during endoscopy on 'at risk' patients. (10) Oxygen enriched air should be given to 'at risk' patients undergoing endoscopic procedures. (11) The endoscopist should ensure the well being and clinical observation of the patient undergoing endoscopy in conjunction with another individual. This individual should be a qualified nurse trained in endoscopic techniques or another medically qualified practitioner. (12) Monitoring techniques such as pulse oximetry are recommended. (13) Clinical monitoring of the patient must be continued into the recovery area. (14) Records of management and outcome should be collected and will provide data for appropriate audit.

Management of sympathetic pain.

Successful treatment of sympathetic pain is directed at the restoration of normal function. This can be achieved in the majority of cases with a combination of appropriate sympathetic or somatic nerve block, usually coupled with aggressive physiotherapy. It is a matter of regret that there are few controlled trials to demonstrate the efficacy of any of these forms of management. Other non-invasive techniques such as stimulation-produced analgesia and pharmacology, particularly the use of adrenergic blocking agents, hold some promise of future benefit. Here too, more effort should be made to carry out properly designed studies, as there is scepticism about the place of permanent or potentially destructive therapy in any painful condition.

Common pain syndromes and their management.

Every anaesthetist can apply knowledge or skills used in routine clinical practice to make a significant contribution to the management and control of acute and chronic pain. This is true whether the pain arises from malignant or non-malignant causes.

An evaluation of dental pain using visual analogue scales and the Mcgill Pain Questionnaire.

A verbal and a visual scale to assess pain, the McGill Pain Questionnaire and the Visual Analogue Scales, were administered to 50 patients suffering from pulpitis and 50 patients suffering from pericoronitis. The results show that words chosen to describe dental pain of different etiologies include throbbing, sharp, aching, and annoying. Additional descriptive words used by patients with pulpitis, pericoronitis, and postoperative dental pain are sore and shooting and tender. Women who have pulpitis and pericoronitis report higher levels of pain than do men. The greater sensitivity of the scores obtained from the variables, number of words chosen, and pain rating intensity scale not only showed a significant difference between males and females, but also could distinguish between the two dental conditions. The value of the MPQ as a diagnostic tool in cases where it is difficult to elucidate the cause is limited.

Factors affecting pain in burned patients--a preliminary report.

Twenty-six patients in a burn unit were given the McGill Pain Questionnaire, Illness Behaviour Questionnaire, State-Trait Anxiety Inventory, Zung self-rating depression questionnaire and visual graphic rating scales of pain, depression and helplessness. Preliminary results indicate significant pain and anxiety related to procedures such as debridement, physiotherapy and skin-grafting. Depression occurred in one third of patients and was associated with prolonged stay in hospital and complicated surgical course. The instruments used in this study are suitable for assessing pain and factors affecting it.

Behavioral observation and analysis of pain behavior in critically burned patients.

Although patients who have been critically burned obviously suffer significant levels of pain, they also appear to engage in adaptive behaviors with greater frequency than previously documented. Observers trained in the use of an objective, reliable coding system recorded 5 min samples of behavior during treatment procedures. Typically, patients report severe pain during procedures such as wound debridement, dressing changes, physical therapy, etc., and many dread having to undergo them. The coding system allowed for the concurrent recording of staff reactions to patients' pain behaviors, well-being behaviors (discussing progress, future plans, complying with therapeutic instructions, etc.), criticism and praise of the hospital and the staff, and focusing on other patient's problems. Results indicate that: (1) patients exhibit a significant higher frequency of psychological and somatic well-being than psychological and somatic complains, even in the context of an intense, typically painful, treatment procedure; (2) differences in the frequency of pain behaviors and of well-beings behaviors were not systematically related to the expected burn-related variables, e.g., total body surface area burned, site of burn, days since onset; and (3) nursing staff who have not received specific training in the behavioral analysis and treatment of pain respond to most patient behaviors with positive reinforcement regardless of whether such reinforcement is therapeutically indicated. Behavioral implications for the theory and treatment of pain are discussed.

Study of sensitivity to curare in certain neurological disorders using a regional technique.

A regional technique for the study of curare sensitivity has been applied to patients with Duchenne type muscular dystrophy, myotonic disorders, certain lower motor neurone disorders, to patients with weakness in the arm after hemiplegia, to patients with hyper-reflexia and hypertonia without weakness, and to Parkinsonism. In the dystrophy patients, sensitivity to curare differs from normal controls in that the neuromuscular block persists. The possibilities that this latent defect of neuromuscular transmission is the result of acetylcholine deficiency due to a prejunctional defect or the result of alterations in the property of the postjunctional membrane are discussed. In the myotonic and lower motor neurone disorders, curare sensitivity was similar to that of normal controls. After hemiplegia, the affected side shows resistance to curare when compared with the unaffected side. In states of hyper-reflexia and hypertonia, however, the sensitivity to curare is greater than in normal controls. In Parkinsonism, sensitivity is similar to that of the controls. The results in upper motor neurone lesions are discussed in relation to the dependence of neuromuscular transmission upon the motor neurone, which, in turn, is dependent upon descending impulses.

A regional technique for the study of sensitivity to curare in human muscle.

A regional technique for the study of curare sensitivity of human muslce in vivo is described. 0-5 mg d-tubocurarine is given intravenously at the wrist while the circulation to the hand and forearm is occluded. Neuromuscular transsmission is then studied by delivering trains of stimuli to the ulnar nerve and recording changes in evoked muscle action potential (map) amplitude from the abductor digiti minimi. In most normal subjects, this dose causes a recognizable block in neuromuscular transmission. The amplitude of a single evoked MAP is depressed and declines further during trains of 3/s repetitive stimulation. Recovery usually takes place gradually during the 20-30 minutes after the release of the tourniquet. The technique will be of value in the study of latent disturbance of neuromuscular transmission in neurological and metabolic disorders.