Effects of breathing exercise techniques on the pain and anxiety of burn patients: A systematic review and meta-analysis

This systematic review and meta-analysis aim to summarise the effect of breathing exercise techniques (BET) on the pain and anxiety of burn patients during burn care. A systematic search was performed on international electronic databases such as Scopus, PubMed, and Web of Science, as well as on Iranian electronic databases such as Iranmedex and Scientific Information Database (SID) with keywords extracted from Medical Subject Headings such as ‘Burns’, ‘Bandages’, ‘Pain’, ‘Pain management’, ‘Anxiety’, ‘Breathing’, and ‘Breathing exercise’, which were performed from the earliest to 4 April 2022. The Joanna Briggs Institute (JBI) critical appraisal checklist assessed the quality of randomised control trials (RCTs) and quasi-experimental studies. The current meta-analysis was performed using STATA V.14.0 software. A 95% confidence interval (CI) was used to determine significance levels. Random effect model was used to calculate the weighted mean difference (WMD). A total of 469 burn patients participated in 10 studies. Exactly 58.60% of burn patients were male, and the number of people in the intervention and control groups was equal. The mean age of burn patients was 32.84 (SD = 10.39). Exactly 78.05% of patients had second-degree burns. The mean study duration was 19 weeks. Results of analysis of RCT studies showed BET decreased insignificantly pain severity (WMD: −1.17, 95%CI: −2.54 to 0.21, Z = 1.66, P = .096, I²:97.1%) in the intervention group than control group. However, the results of non-RCTs studies indicated BET significantly decreased pain (WMD: −1.38, 95%CI: −2.16 to −0.61, Z = 3.49, P < .001, I²:88.4%) and anxiety (WMD: −4.91, 95%CI: −9.35 to −0.47, Z = 2.71, P = .03 0.001, I²:88.4%) in the intervention group than control group. Overall, the results of RCTs found BET intervention decreased pain in the intervention group when compared with the control group; however, it was statistically insignificant. Also, results of non-RCT studies showed intervention of BET significantly decreased pain and anxiety in burns patients. More RCTs studies are required for better judgement of the effectiveness of BET intervention in clinical settings.     

A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol

Postoperative pain might be different after intravenous vs. oral paracetamol. We systematically reviewed randomised controlled trials in patients >15 years that compared intravenous with oral paracetamol for postoperative pain. We identified 14 trials with 1695 participants. There was inconclusive evidence for an effect of route of paracetamol administration on postoperative pain at 0–2 h (734 participants), 2–6 h (766 participants), 6–24 h (1115 participants) and >24 h (248 participants), with differences in standardised mean (95%CI) pain scores for intravenous vs. oral of −0.17 (−0.45 to 0.10), −0.09 (−0.24 to 0.06), 0.06 (−0.12 to 0.23) and 0.03 (−0.22 to 0.28), respectively. Trial sequential analyses suggested that a total of 3948 participants would be needed to demonstrate a meaningful difference in pain or its absence at 0–2 h. There were no differences in secondary outcomes. Intravenous paracetamol is more expensive than oral paracetamol. Substitution of oral paracetamol in half the patients given intravenous paracetamol in our hospital would save around £ 38,711 (€ 43,960 or US$ 47,498) per annum.     

Effects of massage therapy on pain and anxiety intensity in patients with burns: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to examine the effects of massage therapy on pain and anxiety intensity in patients with burns. A comprehensive, systematic search was conducted in various international electronic databases, such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex, and Scientific Information Database using keywords extracted from Medical Subject Headings such as ‘Massage therapy’, ‘Musculoskeletal manipulations’, ‘Acute pains’, ‘Burning pain’, and ‘Burn’ from the earliest to October 17, 2022. Cochran's tool is used to check the risk of bias for randomised clinical trial (RCT) articles. The methodological index for non-randomised studies was used to assess the risk of bias in quasi-experimental studies. STATA version 14 software was used to perform the meta-analysis. A 95% confidence interval (CI) was used to determine statistical significance. Heterogeneity was investigated with I². A P-value less than .1 was considered statistically significant for publication bias value. A total of 733 patients with burns were included in seven studies. Five studies had an RCT design and two studies had a quasi-experimental design. The duration of the study was reported in five studies, with a mean of 42.40 weeks. The duration of the intervention was reported in seven studies with a mean of 22.86 minutes. The results of the meta-analysis showed using various types of massage therapy interventions significantly reduced pain intensity in the intervention group compared with the control group (weighted mean difference: −2.08, 95% CI: −2.55 to −1.62, Z = 8.77, I²: 67.1%, P < .001). Massage therapy intervention significantly reduced the intensity of anxiety in burn patients (standard mean difference: −7.07, 95% CI: −10.13 to −4.01, Z = 4.53, I²: 98.2, P < .001). Overall, the present systematic review and meta-analysis showed that massage therapy can reduce the intensity of pain and anxiety in burn patients. Therefore, it is recommended that health managers and policymakers pay special attention to massage therapy as a simple, low-cost, and efficient non-pharmacological treatment to relieve pain and anxiety in burn patients.     

Peri-articular infiltration analgesia for shoulder surgery: a systematic review and meta-analysis

Effective analgesic alternatives to interscalene brachial plexus block are sought for shoulder surgery. Peri-articular infiltration analgesia is a novel, less invasive technique, but evidence surrounding its use is unclear. This systematic review and meta-analysis aims to evaluate the utility of peri-articular infiltration analgesia in shoulder surgery. We searched literature for trials comparing peri-articular infiltration analgesia with control or with interscalene brachial plexus block. Control groups received no intervention, placebo or systemic opioids. The primary outcome was cumulative oral morphine equivalent consumption during the first 24 h postoperatively. Secondary outcomes included: rest pain scores up to 48 h; risk of side-effects; and durations of post-anaesthetic care unit and hospital stay. Data were pooled with random-effects modelling. Seven trials (383 patients) were included. Compared with control, peri-articular infiltration analgesia reduced 24-h oral morphine consumption by a mean difference (95%CI) of −38.0 mg (−65.5 to −10.5; p = 0.007). It also improved pain scores up to 6 h, 36 h and 48 h, with the greatest improvement observed at 0 h (−2.4 (−2.7 to −1.6); p < 0.001). Peri-articular infiltration analgesia decreased postoperative nausea and vomiting by an odds ratio (95%CI) of 0.3 (0.1–0.7; p = 0.006). In contrast, peri-articular infiltration analgesia was not different from interscalene brachial plexus block for analgesic consumption, pain scores or side-effects. This review provides moderate evidence supporting peri-articular infiltration for postoperative analgesia following shoulder surgery. The absence of difference between peri-articular infiltration analgesia and interscalene brachial plexus block for analgesic outcomes suggests that these interventions are comparable, but further trials are needed to support this conclusion and identify the optimal peri-articular infiltration technique.     

Virtual reality for acute and chronic pain management in adult patients: a narrative review

Virtual reality is a computer-generated environment that immerses the user in an interactive artificial world. This ability to distract from reality has been utilised for the purposes of providing pain relief from noxious stimuli. As technology rapidly matures, there is potential for anaesthetists and pain physicians to incorporate virtual reality devices as non-pharmacological therapy in a multimodal pain management strategy. This systematic narrative review evaluates clinical studies that used virtual reality in adult patients for management of acute and chronic pain. A literature search found 690 citations, out of which 18 studies satisfied the inclusion criteria. Studies were assessed for quality using the Jadad and Nottingham-Ottawa Scales. Agreement on scores between independent assessors was 0.87 (95%CI 0.73–0.94). Studies investigated virtual reality use: intra-operatively; for labour analgesia; for wound dressing changes; and in multiple chronic pain conditions. Twelve studies showed reduced pain scores in acute or chronic pain with virtual reality therapy, five studies showed no superiority to control treatment arms and in one study, the virtual reality exposure group had a worsening of acute pain scores. Studies were heterogeneous in: methods; patient population; and type of virtual reality used. These limitations suggest the evidence-base in adult patients is currently immature and more rigorous studies are required to validate the use of virtual reality as a non-pharmacological adjunct in multimodal pain management.     

Effects of non-pharmacological interventions on pain intensity of children with burns: A systematic review and meta-analysis

Pain is one of the complications associated with burns, which can lead to anxiety and sleeplessness in children. Various studies evaluated the effects of non-pharmacological interventions on burn wound care. The present study was conducted to determine the effects of non-pharmacological interventions on pain intensity of children with burns. A comprehensive systematic search was conducted in various international electronic databases, such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex, and Scientific Information Database using keywords extracted from Medical Subject Headings such as ‘Non-pharmacological’, ‘Virtual reality’, ‘Pain’, ‘Burn’, ‘Wound’ and ‘Child’ from the earliest to December 1, 2022. The risk of bias in the final articles was also assessed with the Version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2). Finally, a total of 1005 burn patients were included in 19 studies. The age range of the patients was from 0.5 to 19 years. Of the participants, 50.05% were in the intervention group. All studies had a randomised clinical trial design. The results found that non-pharmacological interventions significantly reduced pain intensity in children (ES: −0.73, 95% CI: −1.08 to −0.38, Z = 4.09, I²:79.8, P < .001). Virtual reality (VR) (ES: −0.54, 95% CI: −1.19 to −0.18, Z = 2.90, I²:72.9%, P = .004) and non-VR (ES: -0.86, 95% CI: −1.45 to −0.27, Z = 2.86, I²:91.4%, P = .04) interventions decreased pain intensity significantly in children based sub-group analysis. Non-pharmacological interventions significantly reduced the pain intensity of dressing removal (ES: −0.77, 95% CI: −1.34 to −0.20, Z = 66.3, I²:91.8%, P = .008), dressing application (ES: −0.53, 95% CI: −0.97 to −0.09, Z = 2.37, I²:60.8%, P = .02), and physical therapy (ES: −1.18, 95% CI: −2.10 to −0.26, Z = 2.51, I²:88.0%, P = .01). Also, interventions reduced the pain of burn wound care (ES: −0.29, 95% CI: −1.01 to 0.44, Z = 0.78, I²:72.6%, P = .43), but it was statistically insignificant. In sum, the result of the present study indicated that using non-pharmacological interventions significantly reduced pain intensity in children. The reduction of pain intensity was greater in non-VR than in VR interventions. Future studies should focus on comparing VR interventions with non-VR and single versus multi-modal distraction to clarify the effectiveness of each.     

Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis

The erector spinae plane block is a new regional anaesthesia technique that provides truncal anaesthesia for breast surgery. This systematic review and meta-analysis was undertaken to determine if the erector spinae plane block is effective at reducing pain scores and opioid consumption after breast surgery. This study also evaluated the outcomes of erector spinae plane blocks compared with other regional blocks. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomised controlled trials reporting the use of the erector spinae plane block in adult breast surgery. Risk of bias was assessed with the revised Cochrane risk-of-bias tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess trial quality. Thirteen randomised controlled trials (861 patients; 418 erector spinae plane block, 215 no blocks, 228 other blocks) were included. Erector spinae plane block reduced postoperative pain compared with no block: at 0-2 hours (mean difference (95% CI) −1.63 (−2.97 to −0.29), 6 studies, 329 patients, high-quality evidence, I² = 98%, p = 0.02); at 6 hours (mean difference (95% CI) −0.90 (−1.49 to −0.30), 5 studies, 250 patients, high-quality evidence, I² = 91%, p = 0.003); at 12 hours (mean difference (95% CI) −0.46 (−0.67 to −0.25), 5 studies, 250 patients, high-quality evidence, I² = 58%, p < 0.0001); and at 24 hours (mean difference (95% CI) −0.50 (−0.70 to −0.30), 6 studies, 329 patients, high-quality evidence, I² = 76%, p < 0.00001). Compared with no block, erector spinae plane block also showed significantly lower postoperative oral morphine equivalent requirements (mean difference (95% CI) −21.55mg (−32.57 to −10.52), 7 studies, 429 patients, high-quality evidence, I² = 99%, p = 0.0001). Separate analysis of studies comparing erector spinae plane block with pectoralis nerve block and paravertebral block showed that its analgesic efficacy was inferior to pectoralis nerve block and similar to paravertebral block. The incidence of pneumothorax was 2.6% in the paravertebral block group; there were no reports of complications of the other blocks. This review has shown that the erector spinae plane block is more effective at reducing postoperative opioid consumption and pain scores up to 24 hours compared with general anaesthesia alone. However, it was inferior to the pectoralis nerve block and its efficacy was similar to paravertebral block. Further evidence, preferably from properly blinded trials, is required to confirm these findings.     

The effect of multimodal balanced anaesthesia and long term gabapentin on neuropathic pain,nitric oxide and interleukin-1β following breast surgery

ObjectivesTo evaluate the effect of multimodal balanced anaesthesia and gabapentin (6 months) on neuropathic pain qualities, nitric oxide (NO) and interleukin 1-beta (IL-1β).MethodologyThis randomized study was conducted on 50 women scheduled for conservative breast surgery for cancer followed by chemotherapy and/or radiotherapy. Women enrolled into two groups; either to receive balanced general anaesthesia (GA) (control group) or ultrasound guided thoracic paravertebral with GA, multimodal balanced anaesthesia, (intervention group). Nociceptive pain was evaluated for 24 h. Neuropathic pain was evaluated using pain questionnaire 1 month postoperatively and neuropathic pain scale at 1, 3, 6 and 9 months. Gabapentin was prescribed to women reporting neuropathic pain 1 month postoperatively and for 6 months. NO and IL-1β were measured before operation, 1, 3, 6 & 9 months, postoperatively. Their relationship with neuropathic pain was assessed.ResultsNociceptive pain was less in intervention group than control group immediately post operative, 4 h after surgery at rest and 8 h with movement. Neuropathic pain started few days postoperatively, in both groups. Its onset, sites, duration and precipitating factors did not differ between the groups. Sensitive, hot pain and unpleasantness reduced significantly 1 month postoperatively, in intervention group. Two months later, itchy, dull and sharp pain was significantly less in intervention group. At 6 months, most of neuropathic pain items except sharp and deep pain lowered significantly in intervention group. At 9 months, hot and superficial pain was still less in intervention group. NO decreased significantly 1 and 3 months postoperatively, while IL-1β was significantly lower through different times, in intervention group. IL-1β correlated well with neuropathic pain intensity and unpleasantness.ConclusionBreast surgery for cancer was associated with neuropathic pain that continued for 9 months after surgery. Multimodal balanced GA had positive impact on acute nociceptive and neuropathic pain. Gabapentin reduced almost all neuropathic pain qualities.     

Effects of aromatherapy with Rosa damascene and lavender on pain and anxiety of burn patients: A systematic review and meta-analysis

Pain and anxiety were considered the most common complications of treatment procedures in burn patients. Non-pharmacological drugs, including aromatherapy, can decrease these issues. This systematic review and meta-analysis aim to summarise the effects of aromatherapy with Rosa damascene (RD) and lavender on the pain and anxiety of burn patients. A systematic search was performed on international electronic databases such as Scopus, PubMed, and Web of Science, as well as on Iranian electronic databases such as Iranmedex and Scientific Information Database (SID) with keywords extracted from Medical Subject Headings such as “Burns”, “Pain”, “Pain management”, “Anxiety”, and “Aromatherapy” were performed from the earliest to November 1, 2022. The Joanna Briggs Institute (JBI) critical appraisal checklist assessed the quality of randomised control trials (RCTs) and quasi-experimental studies. STATA v.14 software was used to estimate pooled effect size. Heterogeneity was assessed with I² value. Random effect model and inverse-variance method using sample size, mean, and standard deviation changes were applied to determine standard mean differences (SMD). The confidence interval of 95% was considered to determine the confidence level. A total of 586 burn patients participated in six studies, including three RCT studies and three quasi-experimental studies. The results based on RCT studies showed RD significantly decreased the dressing pain average when compared to the control group (SMD: −1.61, 95%CI: −2.32 to −0.99, Z = 5.09, I²: 66.2%, P < 0.001). Aromatherapy with lavender decreased the average pain in the interventional group more than in the control group (SMD: −1.78, 95%CI: −3.62 to 0.07, Z = 1.89, I²: 97.2%, P = 0.06). Using aromatherapy with RD and lavender significantly decreased pain average in the interventional group than the control group (SMD: −1.68, 95%CI: −2.64 to −0.72, Z = 3.42, I²: 94.2%, P = 0.001). The results showed RD significantly decreased the anxiety average in the interventional group than the control group (SMD: −2.49, 95%CI: −2.98 to −2.0, Z = 9.94, I²: 51.6%, P < 0.001). Overall, this study showed that aromatherapy with RD decreased pain and anxiety of dressing procedures in burn patients. Although aromatherapy with lavender decreased pain in the patients, it was not statistically significant. More RCTs studies are required to be able to better judge the effects of aromatherapy with RD and lavender on the pain and anxiety of burn patients.     

Sufentanil durante a indução da anestesia intravenosa total à base de remifentanil: ensaio clínico randômico

BackgroundPostoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half‐life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil‐based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil‐based total intravenous anesthesia.MethodsForty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil‐based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient‐controlled analgesia pump. Self‐reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery.ResultsThe mean difference between the sufentanil and control groups regarding morphine consumption in the post‐anesthetic care unit and at 12, 24 and 48 h after surgery were −7.2 mg (95%CI: −12.5 to −2.1, p < 0.001), −3.9 mg (95%CI: −11.9 to 4.7, p = 0.26), −0.6 mg (95%CI: (−12.7 to 12.7, p = 0.80), and −1.8 mg (95%CI: (−11.6 to 15.6, p = 0.94), respectively. Neither self‐reported pain nor the incidence of adverse events were significantly different between groups at any time point.ConclusionOur findings suggest that the administration of sufentanil during induction of remifentanil‐based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.     

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1–32) mg; ilio-inguinal–iliohypogastric 13 (6–19) mg; transversalis fascia 11 (4–26) mg; erector spinae 11 (10–32); transverse abdominis 9 (4–13) mg; wound catheter infusion 8 (2–15) mg; quadratus lumborum 8 (1–15) mg; wound infiltration 8 (2–13) mg; and no intervention −4 (−10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4–6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0–10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2–2.1); erector spinae 1.3 (−0.5 to 3.1); quadratus lumborum 1.0 (0.1–1.8); ilio-inguinal–iliohypogastric 0.6 (−0.5 to 1.8); transverse abdominis 0.6 (−0.1 to 1.2); wound infiltration 0.5 (−0.3 to 1.3); transversalis fascia −0.8 (−3.4 to 1.9); ilio-inguinal −0.9 (−3.6 to 1.7); and no intervention −0.8 (−1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.     

Pregabalin in the treatment of postmastectomy chronic pain: Results of an open label,single‐arm clinical study

Postmastectomy chronic pain (PMCP) is one of the important survivorship issues faced by breast cancer patients. It is a chronic pain which persists for more than 3 months after mastectomy or quadrantectomy and is considered to be neuropathic in nature. An open label, single‐arm, prospective study was conducted to evaluate the efficacy of Pregabalin in relieving clinically significant PMCP (pain score ≥3 on visual analogue scale). Pregabalin brought about significant reductions in pain (visual analogue scale [VAS] Scores; baseline 5.50 ± 1.197, end of 1 month 2.40 ± 1.430, end of 2 months 2.10 ± 1.370) and significant improvement in quality of life.     

Surgical site wound infection and wound pain after video-assisted thoracoscopy in patients with lung cancer: A meta-analysis

A meta-analysis was performed to comprehensively assess the effects of video-assisted thoracoscopy on surgical site wound infection and wound pain in patients with lung cancer. Studies on video-assisted thoracoscopy for lung cancer were collected from PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang database, from inception to January 2023. Two researchers independently screened the literature, extracted the data, and evaluated the quality of the included studies according to the inclusion and exclusion criteria. Meta-analysis was performed using RevMan 5.4 software. Thirty-one articles with a total of 3608 patients were included, with 1809 in the video-assisted thoracoscopy group and 1799 in the control group. Compared with the control group, video-assisted thoracoscopy significantly reduced surgical site wound infection (odds ratio: 0.22, 95% confidence interval [CI]: 0.14–0.33, P < .001) and surgical site wound pain at postoperative day 1 (standardised mean difference [SMD]: −0.90, 95% CI: −1.17 to −0.64, P < .001) and postoperative day 3 (SMD: −1.59, 95% CI: −2.25 to −0.92, P < .001). Thus, these results showed that video-assisted thoracoscopy may have beneficial outcomes by reducing surgical site wound infection and pain. However, owing to the large variation in sample sizes and some methodological shortcomings, further validation is needed in future studies with higher quality and larger sample sizes.     

Virtual reality for the treatment of neuropathic pain in people with spinal cord injuries: A scoping review

Context: Virtual and augmented imagery are emerging technologies with potential to reduce the severity and impact of neuropathic pain in people with spinal cord injury (SCI).Objective: We aimed to identify and discuss studies using virtual and augmented reality applications for the management of neuropathic pain in people with spinal cord injury.Methods (data sources, data extraction): A systematic literature search was conducted using PRISMA scoping review guidelines. Articles were searched in PubMed, Embase and Web of Science databases using search terms relating to SCI, virtual and augmented reality and neuropathic pain. With no strong evidence for visual imagery in the treatment of pain in SCI patients, we selected exploratory, feasibility and more rigorous methodologies such as randomized controlled trials and case-control studies. We only selected studies evaluating the effects of visual imagery on neuropathic pain at or below the spinal cord injury level.Results: Of 60 articles located, we included nine articles involving 207 participants. All studies were exploratory using head-mounted devices or 3D and 2D screens with virtual walking or limb movement imagery. Outcomes included pain sensitivity, motor function and body ownership. Eight of the nine studies reported significant reductions in neuropathic pain intensity. However, given small sample sizes in all studies, results may be unreliable.Conclusion: Although the number of studies and individual sample sizes are small, these initial findings are promising. Given the limited options available for the effective treatment of neuropathic SCI pain and early evidence of efficacy, they provide valuable incentive for further research.     

A double‐blinded randomised controlled study of the value of sequential intravenous and oral magnesium therapy in patients with chronic low back pain with a neuropathic component

Persistent mechanical irritation of the nerve root sets up a series of events mediating sensitisation of the dorsal roots and dorsal horns in the spinal cord. Current evidence supports the role of magnesium in blocking central sensitisation through its effect on N‐methyl–d ‐aspartate receptors. We studied the role of sequential intravenous and oral magnesium infusion in patients with chronic low back pain with a neuropathic component. We recruited a cohort of 80 patients with chronic low back pain with a Leeds Assessment of Neuropathic Signs and Symptoms pain scale score ≥ 12, who were receiving a physical therapy programme. All patients were treated with anticonvulsants, antidepressants and simple analgesics; in addition 40 patients received placebo for 6 weeks (control group), while the other 40 patients received an intravenous magnesium infusion for 2 weeks followed by oral magnesium capsules for another 4 weeks (magnesium group). Patients were asked to rate their pain using a numerical rating scale. Lumbar spine range of motion was also determined using a long‐arm goniometer. In the magnesium group, the patients’ numerical rating scales revealed a significant reduction in pain intensity. The mean (SD) pre‐treatment value was 7.5 (2.2) compared with 4.7 (1.8) at 6 months (p = 0.034). The reduction in pain intensity was accompanied by significant improvement in lumbar spine range of motion during the follow‐up period. The mean (SD) values of flexion, extension and lateral flexion movements before treatment and at 6‐month follow up were 22.2 (8.4) vs 34.7 (11.5) (p = 0.018), 11.8 (3.4) vs 16.9 (3.5) (p = 0.039), 11.4 (3.6) vs 17.2 (4.4) (p = 0.035), respectively. Our findings show that a 2‐week intravenous magnesium infusion followed by 4 weeks of oral magnesium supplementation can reduce pain intensity and improve lumbar spine mobility during a 6‐month period in patients with refractory chronic low back pain with a neuropathic component.     

Application of behavioral economic strategies to enhance recruitment into a pediatric randomized clinical trial for postoperative pain relief: A randomized clinical trial

Introduction

A major challenge in conducting clinical trials is recruitment. Trial under-enrollment leads to underpowered studies. Behavioral economics offers strategies that may enhance trial recruitment. This study assessed the impact of behavioral economic strategies versus a standard biological approach to recruit children into a randomized clinical trial assessing a biofeedback-based virtual reality intervention for postoperative pain management. We hypothesized the behavioral economics-informed approach would increase enrollment into the future trial, intention to adhere to therapy, acceptability of the intervention, and perceived efficacy while decreasing perception of treatment burden and risk.

Methods

This single-center, prospective, randomized trial recruited patients 12-18 years old undergoing surgery requiring postoperative admission and narcotic administration. Patient-parent dyads were randomized to watch a behavioral economics-informed (n = 64) or standard biological (n = 66) recruitment video about a study designed to assess impact of a virtual reality pain management intervention.

Results

There was no difference in rates of intention to enroll in the study between groups (behavioral economics: 75%, control: 79%, p = 0.744) or in median response scores to questions regarding intention to adhere to therapy (4.0 [3.0, 4.0] vs. 4.0 [3.0, 4.0], p=0.084), acceptability of therapy (4.0 [3.0, 4.0] vs. 4.0 [3.0, 4.0], p = 0.376), perceptions of treatment burden (3.0 [3.0, 4.0] vs. 4.0 [3.0, 4.0], p=0.251), and efficacy (3.0 [3.0, 4.0] vs. 3.0 [3.0, 4.0], p = 0.914). Patients in the behavioral economics group were less likely to perceive risk associated with virtual reality versus the control group (behavioral economics: 2.0 [1.0, 2.0], control: 2.0 [2.0, 3.0], p = 0.023).

Discussion

A behavioral economics-informed video did not increase patients’ intentions to enroll into a clinical trial assessing the impact of virtual reality intervention for postoperative pain management.

Conclusion

Either approach would be sufficient for patient recruitment for this type of clinical trial since the overall intention to enroll rate was 77%.     

Pregabalin, celecoxib, and their combination for treatment of chronic low-back pain

Background  

The efficacy and safety of the association of celecoxib [a selective cyclooxygenase-2 (COX-2) inhibitor] and pregabalin (commonly used to control neuropathic pain), compared with monotherapy of each, were evaluated for the treatment of chronic low-back pain, a condition known to be due to neuropathic as well as nociceptive pain mechanisms.     

Ultrasound-guided genicular nerves block vs. local infiltration analgesia for total knee arthroplasty: a randomised controlled non-inferiority trial

Genicular nerves block is a promising technique to treat acute postoperative pain in total knee arthroplasty. Similar to surgeon-administered local infiltration analgesia, it targets sensory branches from the knee capsule, but through a selective ultrasound-guided injection that reduces local anaesthetic dose (150 ml ropivacaine 0.2% with local infiltration analgesia vs. 20 ml with genicular nerves block). This randomised non-inferiority trial compared the analgesic efficacy of genicular nerves block vs. local infiltration analgesia in the first 24 h following total knee arthroplasty. Sixty patients were randomly allocated to receive either ultrasound-guided block of five genicular nerves or local infiltration analgesia. The primary outcome was rest pain numeric rating scale (0–10) at 24 h. Secondary outcomes included pain numeric rating scale (rest and movement) and cumulative opioid consumption during the first 24 h. We analysed 29 patients in the genicular nerves block group and 30 in the local infiltration analgesia group. We found that the median difference (95%CI) in postoperative rest pain at 24 h (non-inferiority criteria, Δ = 1) was −1.0 (−2.0 to 1.0, p < 0.001). Median difference in cumulative opioid consumption was 0.0 mg (−3.0–5.0, p < 0.001) meeting the non-inferiority criteria, Δ = 23 mg. We conclude that genicular nerves block of five nerves provides non-inferior analgesia in the first 24 h following surgery compared with local infiltration analgesia, but with a considerable reduction in the local anaesthetic dose.     

Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burns dressings changes

BackgroundPain arising in burns sufferers is often severe and protracted. The prospect of a dressing change can heighten existing pain by impacting both physically and psychologically. In this trial we examined whether pre-procedural virtual reality guided relaxation added to patient controlled analgesia with morphine reduced pain severity during awake dressings changes in burns patients.MethodsWe conducted a prospective randomized clinical trial in all patients with burns necessitating admission to a tertiary burns referral centre. Eligible patients requiring awake dressings changes were randomly allocated to single use virtual reality relaxation plus intravenous morphine patient controlled analgesia (PCA) infusion or to intravenous morphine patient controlled analgesia infusion alone. Patients rated their worst pain intensity during the dressing change using a visual analogue scale. The primary outcome measure was presence of 30% or greater difference in pain intensity ratings between the groups in estimation of worst pain during the dressing change.FindingsOf 88 eligible and consenting patients having awake dressings changes, 43 were assigned to virtual reality relaxation plus intravenous morphine PCA infusion and 43 to morphine PCA infusion alone. The group receiving virtual reality relaxation plus morphine PCA infusion reported significantly higher pain intensities during the dressing change (mean = 7.3) compared with patients receiving morphine PCA alone (mean = 5.3) (p = 0.003) (95% CI 0.6–2.8).InterpretationThe addition of virtual reality guided relaxation to morphine PCA infusion in burns patients resulted in a significant increase in pain experienced during awake dressings changes. In the absence of a validated predictor for responsiveness to virtual reality relaxation such a therapy cannot be recommended for general use in burns patients having awake dressings changes.