Comparing Analgesia on an As-Needed Basis to Traditional Intravenous Patient-Controlled Analgesia Within Fast-Track Orthopedic Procedures: A Randomized Controlled Trial

BackgroundThe aim was to determine if the use of intravenous patient-controlled analgesia (IVPCA) in a fast-track joint replacement program is associated with increased use of perioperative opioid consumption and increased length of hospital stay.DesignA prospective, double-blind, randomized controlled trial.SettingsAcademic hospital.Participants/SubjectsA total of 80 patients aged 18-85 years, with body mass index (BMI) 18-40, undergoing elective total knee arthroplasty were recruited.MethodsPre-operatively, patients received gabapentin, celecoxib, and acetaminophen. Peri-operatively, patients received spinal anesthesia with morphine and fentanyl, and periarticular local anesthetic administration by the surgeon. Postoperatively, 80 patients were randomized by a computer-generated sequence into IVPCA group (group A, n = 40) and non-IVPCA group (group B, n = 40).ResultsThe primary outcome was 48-hour postoperative opioid consumption and length of hospital stay. Secondary outcomes included side effects of opioids, patient satisfaction, and pain scores. There was no significant difference within 48-hour postoperative opioid consumption (median 61.3 vs. 87.5, p = .181) and length of hospital stay (median 49.8 hours vs. 49.5 hours; p = .89) between the two groups. Also, there was no significant difference in patient satisfaction (median 5 in both groups), pain scores, and opioid-related side effects.ConclusionsIVPCA was associated with nonsignificant reduction in opioid exposure in elective total knee arthroplasty surgery within 48 hours. Neither group was superior in terms of length of hospital stay, opioid related side-effects, pain scores, and patient satisfaction.     

Abdominal Surgical Patients Randomized to Aromatherapy for Pain Management

PurposeEvaluate aromatherapy for postoperative abdominal pain in hospitalized patients.DesignA randomized controlled trial design.MethodsStudy participants (n = 172) were randomized to receive either standard care or standard care and aromatherapy (AT) for postsurgical pain up to 24 hours after admission to a nonintensive care surgical unit. A convenience sample was recruited before surgery and given instructions on self-rating pain intensity. The AT group was topically administered a drop of lavender essential oil after medication and at random for pain. Pain scores and medications data were collected.FindingsOf the evaluable patients (n = 147), demographic data were similar (standard care and AT groups). The use of aromatherapy showed no substantial benefit at improving pain scores or reducing medication use (the primary objectives of the study). A subgroup analysis of patients who received a regional nerve block for pain management, however, showed more than fivefold improvement in pain scores after the use of aromatherapy. The AT group used more medications at baseline (P = .032), whereas 70% less medications were used (P = .031) by 24 hours.ConclusionsAromatherapy aided in control of pain intensity for abdominal surgical patients. In patients who received a regional nerve block, significant improvement in pain level occurred as effects of the block diminished.     

The Effects of Listening to the Qur'an in the Postoperative Management of the Patients Undergoing Laparoscopic Cholecystectomy in the Day Surgery Unit

PurposeTo determine if listening to verses of the Qur'an during the immediate postoperative period has an effect on patients’ anxiety levels, the number of opioids used to control pain, and the length of stay (LOS) in the Post Anesthesia Care Unit (PACU).DesignRandomized Control Trial. Adult Muslim patients who had undergone a laparoscopic cholecystectomy through the Day Surgery Unit were randomly selected using computer-generated sequence into two groups, interventional and control groups.MethodsThe control group listened to the natural environment and received Fentanyl for pain relief, and the interventional group listened to the Qur'an recitation and received Fentanyl for pain relief. A total of 112 (79.4%) participants completed the study. The level of the pain and anxiety was measured using the Wong-Baker Faces pain scale and Spielberger State-Trait Anxiety Inventory, respectively. Statistical analysis was conducted using SAS version 9.3 (Statistical Analysis System, SAS Institute Inc, Cary, North Carolina).FindingsThis study compared the effects of Qur'an audio therapy on patients' anxiety levels, opioid consumption, pain, and LOS in the PACU. The findings showed that by listening to chosen verses from the Qur'an in the recovery period post-anaesthesia, anxiety scores were significantly reduced (P = .0001), opiate use was reduced (P = .0081), and overall PACU LOS was also reduced (P = .0083).ConclusionsAdding the use of listening to the Qur'an as a complementary therapy is a simple and cost-effective measure to reduce the need for narcotics in the PACU, and reduce the overall PACU length of stay. This intervention benefits the patient, the PACU, and reduces health care organization costs.     

Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systematic review

BackgroundThe optimal effective dose of epidural morphine that provides postoperative analgesia after caesarean section with minimal side effects remains debated.AimsWe performed a systematic review to assess the analgesic efficacy and the incidence of adverse effects of epidural morphine after caesarean section compared to systemic analgesia with opioids.MethodsWe searched Medline, Embase and Cochrane Collaboration Library databases. Studies were evaluated with the Modified Oxford Scale. Prospective randomized studies comparing analgesic efficacy and/or adverse effects of a single epidural morphine administration versus systemic opioids after elective caesarean section were included.ResultsTen studies (n = 431) were selected. Epidural morphine increases the time until the first request for a rescue analgesic (Emax, 29.7 h; 95% confidence interval, 25.2–33.9) and decreases pain scores and postoperative morphine request during the first 24 h compared to systemic opioid analgesia. However, epidural morphine increases the incidence of pruritus (relative risk, 2.7; 95% CI, 2.1–3.6) and nausea (relative risk, 2.0; 95% CI, 1.2–3.3).ConclusionsA single bolus of epidural morphine provides better analgesia than parenteral opioids but with an effect limited to the first postoperative day after caesarean section and with an increase in morphine side effects.     

Lidocaine Plus Morphine Versus Lidocaine Plus Paracetamol for Bier Block: A Double-Blind Randomized Controlled Trial

PurposeIntravenous regional anesthesia (Bier block) is widely used as an anesthetic technique for operations of short duration of the distal upper or lower extremities. We compared the efficacy of intravenous regional anesthesia with lidocaine plus paracetamol versus lidocaine plus systemic morphine for short-duration hand and forearm surgeries.DesignA double-blind randomized controlled trial with two parallel arms: lidocaine plus morphine (control) and lidocaine plus paracetamol were carried out at a University hospital.MethodsWe included men and women aged 20 to 70 years scheduled for short surgical procedures (30-60 minutes) distal to the elbow. Intravenous regional anesthesia was carried out by injecting 45 cc lidocaine 0.5% plus 300 mg paracetamol for the paracetamol group; or 45 cc lidocaine 0.5% plus 4 mg intravenous morphine for the control group. The primary outcome was postoperative pain-free period in minutes since deflation of proximal tourniquet. The secondary outcome was the highest intensity of postoperative pain on the visual analog scale within 2 hours after deflating the proximal tourniquet.FindingsThere was no significant difference between morphine and paracetamol in the duration of postoperative pain-free period (P = .078) and the mean intensity for maximum pain (P = .106). However, severe pain was significantly more frequent in the morphine group (P = .001). Paracetamol seemed to be safer than morphine as an adjuvant to lidocaine.ConclusionsWe recommend using 2 cc paracetamol (300 mg Apotel) as the adjuvant to lidocaine for intravenous regional anesthesia.     

Comparison of Periarticular Injection and Intra-articular Injection for Pain Management After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

PurposeLocal infiltration analgesia, an essential component of multimodal analgesia after total knee arthroplasty (TKA), can be classified into periarticular injection (PAI) and intra-articular injection (IAI) as per administration techniques. Currently, there is no definite answer of the optimal choice between the two techniques. This meta-analysis aims to determine whether PAI provides superiority of pain relief and functional recovery than IAI after TKA.DesignSystematic review and meta-analysis.MethodsComparative studies that compared PAI and IAI in patients after TKA were searched in the Embase, PubMed, MEDLINE, and the Cochrane Library databases. The primary outcomes were visual analog scale scores for pain and opioid consumption. The secondary outcomes were complications, function of recovery, and length of hospital stay.FindingsFour randomized controlled trials and two case-controlled studies with a total of 769 patients were enrolled. There were no significant differences in mean visual analog scale scores at postoperative day 0 (P = .17) and day 1 (P = .27), maximum visual analog scale scores at day 0 (P = .89) and day 1 (P = .82), total opioid consumption at day 1 (P = .96), opioid complications (P = .15), and length of hospital stay (P = .84) between PAI and IAI.ConclusionsBased on the available evidence, PAI does not offer superior effects at pain control and discharge than IAI after TKA. However, owing to the limited sample size and heterogeneity of the included studies, further large well-designed randomized controlled trials are still needed to validate this conclusion.RegistrationThe protocol has been registered in the PROSPERO international database under number CRD42020165138.     

Effects of Transcutaneous Occipital Nerve Stimulation and Instrument-Assisted Soft Tissue Mobilization in Chronic Migraine

ObjectiveThe purpose of this study was to examine the effects of transcutaneous occipital nerve stimulation (TONS) and instrument-assisted soft tissue mobilization (IASTM) on pain, sleep, and quality of life in patients with chronic migraine.MethodsForty-five female patients with chronic migraine were randomly assigned to control (n = 15), IASTM (n = 15), and TONS (n = 15) groups. Neck exercises were given to all groups once per day for 5 weeks. IASTM, using a smooth metal scraping massage tool, was applied to the patients in the IASTM group twice per week for 5 weeks. Patients in the TONS group were treated with transcutaneous electrical nerve stimulation 3 times per week for 5 weeks. The outcome measures were a Numeric Pain Scale, the Headache Impact Test-6, the Pittsburgh Sleep Quality Index, and the Short Form-36.ResultsThe IASTM and TONS groups had significantly lower mean Headache Impact Test-6 scores than the control group in the last measurement (F = 3.908, P = .028). The IASTM and TONS groups had lower mean Numeric Pain Scale scores than the control group (F = 13.861, P = .001). The IASTM group had a lower mean Pittsburgh Sleep Quality Index score in the last measurements than the other 2 groups (F = 6.792, P = .003). There was no difference between the groups in the general health perception scores obtained in the last measurements (F = 1.585, P = .217). In the last measurement, the IASTM and TONS groups had higher mean general health scores than the control group.ConclusionIASTM and TONS applications reduced head and neck pain and improved sleep and quality of life in patients with chronic migraine. Neither had superiority over the other.     

Music Listening as a Postanesthesia Care Unit (PACU) Nursing Intervention for Laparoscopic Radical Prostatectomy Patients: A Randomized Comparative Clinical Trial

PurposeRandomized comparative mixed method approach with qualitative inquiry study's aim sought to determine if there was a difference in pre/post-intervention State-Trait Anxiety Inventory (STAI) scores and postanesthesia pain scores between two music listening groups of laparoscopic radical prostatectomy patients.DesignProspective randomized comparative mixed method approach with a qualitative inquiry.MethodsSample size of 77 male participants assigned by a table of random numbers to Spotify patient-preferred music selection Group I (n = 37) or minimalist hypnotic music with guided relaxation breathing (MHMGRB) instructional narrative Group II (n = 40). Outcome measures used patients’ STAI questionnaire and reported PACU admission and discharge pain scores.ResultsBoth Groups I and II had reduced pain scores at discharge as compared to admission; both groups had a significant reduction (P = .046 Group I, and Group II (P = .002), but changes for comparative groups (I and II) were not significant between the two groups (P = .53).ConclusionsStudy revealed that both patient-preferred selected music and MHMGRB can meaningfully reduce patients’ anxiety and PACU pain scores.     

The Effect of a Cartoon and an Information Video About Intravenous Insertion on Pain and Fear in Children Aged 6 to 12 Years in the Pediatric Emergency Unit: A Randomized Controlled Trial

IntroductionIntravenous insertion is the most common invasive procedure made for administering intravascular fluid and medicine. Peripheral venous catheterization may cause pain, fear, and stress in children. This study aimed to compare the effects of watching a cartoon and an information video about intravenous insertion on the pain and fear levels of children aged 6-12 years.MethodsThe study was an experimental, randomized controlled clinical trial. It was conducted with 477 children aged 6-12 years randomized into 3 groups: the informative animated video group, the cartoon group, and the control group. Fear and pain perception were evaluated on the basis of the feedback from the child, observer nurse, and parents. The Children’s Fear Scale was used to evaluate the fear level and the Wong-Baker FACES Scale was used to assess pain levels. Data were analyzed using one-way analysis of variance, the chi-square test, and the intraclass correlation coefficient test.ResultsThe children who watched the information video before the intravenous insertion procedure and those who watched a cartoon during the procedure had lower mean pain and fear scores as evaluated by the child (pain: F = 278.67, P = 0.001; fear: F = 294.88, P = 0.001), parent (pain: F = 279.53, P = 0.001; fear: F = 294.47, P = 0.001), and nurse (pain: F = 286.88, P = 0.001; fear: F = 300.81, P = 0.001) than children in the control group.DiscussionThis study showed that watching an animation video or a cartoon was effective in lowering children’s perceived level of pain and fear during an intravenous insertion intervention.     

Evaluation of Efficacy of Valsalva Maneuver During Peripheral Intravenous Cannulation on Pain

BackgroundAimsThe aim of this study was to examine the effects of the Valsalva maneuver during peripheral intravenous catheter (PIVC) insertion on procedure-related pain.DesignThis work was a prospective randomized controlled study.SettingsStudy was conducted in the orthopedics clinic of a university hospital.Participants/SubjectsMethodsThe sample of patients (N = 110) was allocated to the Valsalva maneuver group (n = 55) and control group (n = 55) by using blocked randomization to reduce bias and achieve balance according to age and gender. Pain was evaluated by using Numerical Rating Scale. Systolic/diastolic blood pressure and heart rate before and after the PIVC placement was recorded.ResultsThe patients in the intervention group had less severe pain during the PIVC insertion than the patients in the control group (p ? .001). After PIVC placement, systolic blood pressure was significantly reduced in both groups (p = .008), no other variables changed significantly. No clinical complication related to the Valsalva maneuver occurred in the intervention group.ConclusionValsalva maneuver can be used as a non-pharmacologic method to reduce pain during PIVC placement.     

The Effect of Preoperative Oral Versus Parenteral Dextrose Supplementation on Pain,Nausea, and Quality of Recovery After Laparoscopic Cholecystectomy

PurposeEarlier studies suggest that carbohydrate loading is effective in reducing preoperative nausea. This study was conducted to investigate the effect of preoperative oral versus parenteral carbohydrate loading on the postoperative pain, nausea, and quality of recovery (QoR).DesignThree-arm randomized, single-blind clinical trial.MethodsIn this study, 95 adult patients scheduled for elective laparoscopic cholecystectomy were randomly assigned into three groups of preoperative intravenous dextrose 10% infusion, oral carbohydrate (OCH)–rich drink, and control. The pain and nausea severity scores were measured during recovery, 6 hours, and 24 hours thereafter. The 40-item QoR score was evaluated the day after surgery.FindingsIn recovery, nausea severity was comparable among three groups, whereas pain score in the OCH group was significantly less than the controls (P = .009). Pain score in patients who received intravenous dextrose was mediocre and not statistically different from two other groups. Six and 24 hours after surgery, nausea and pain scores in OCH and dextrose infusion groups were significantly lower than the control group (P < .05). The 40-item QoR score was significantly higher in intervention groups than control participants (P < .05). Blood glucose levels were comparable in three groups before and after surgery.ConclusionsPreoperative carbohydrate loading significantly improves the QoR after laparoscopic cholecystectomy without significant effect on blood glucose levels. Oral route more effectively controls nausea and pain than parenteral dextrose administration.     

Comparing the analgesic effect of intravenous paracetamol with morphine on patients with renal colic pain: A meta-analysis of randomized controlled studies

IntroductionThe choice of intravenous paracetamol or morphine for the pain control of renal colic remains controversial. We conduct a systematic review and meta-analysis to compare the analgesic efficacy and safety of intravenous paracetamol with morphine for renal colic pain.MethodsWe search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2019 for randomized controlled trials (RCTs) assessing the analgesic efficacy and safety of intravenous paracetamol versus morphine for renal colic pain. This meta-analysis is performed using the random-effect model.ResultsFive RCTs are included in the meta-analysis. Intravenous paracetamol can lead to significantly lower pain scores at 30 min (standard mean difference (Std. MD) = −0.40; 95% confidence interval (CI) = −0.68 to −0.12; P = 0.005) and incidence of dizziness (risk ratio (RR) = 0.06; 95% CI = 0.01 to 0.48; P = 0.007) than morphine for renal colic pain. There is no statistical difference of pain scores at 15 min (Std. MD = −0.80; 95% CI = −1.84 to 0.24; P = 0.13), analgesic rescue (RR = 0.73; 95% CI = 0.45 to 1.19; P = 0.21), the incidence of adverse events (RR = 0.60; 95% CI = 0.35 to 1.03; P = 0.06), nausea or vomiting (RR = 0.61; 95% CI = 0.20 to 1.87; P = 0.38) between two groups.ConclusionsIntravenous paracetamol may result in lower pain scores at 30 min than morphine for renal colic pain, and more studies should be conducted to compare their analgesic efficacy.     

Virtual reality distraction during pediatric intravenous line placement in the emergency department: A prospective randomized comparison study

ObjectiveTo evaluate the efficacy of virtual reality distraction (VR) during intravenous line (IV) placement in a pediatric emergency department to increase first-attempt IV success. Secondary endpoints included median time to successful IV placement, patient pain and anxiety scores, and an evaluation of characteristics of patients in whom VR is well tolerated.Study designThis was a randomized controlled trial at a tertiary pediatric emergency department, enrolling patients aged 4–17 years who required IV placement. Patients were enrolled only when child life specialists were unavailable. The primary endpoint was first attempt IV success.ResultsA total of 116 subjects were enrolled, 58 were randomly assigned to the VR group and 58 were assigned to the standard of care (SOC) group. 115 subjects completed the trial and were analyzed. First attempt IV success rates were similar between the groups (VR = 81%, standard = 84.2%, p = .65). Number of IV attempts and changes in pain and anxiety scores were also similar between the groups. The median time to successful IV placement was shorter in the VR group (78 vs 104 seconds) but this difference was not statistically significant (p = .21). Overall the VR headset was tolerated by 79% of subjects assigned to that group. The only significant predictor of headset tolerance was older age (P = .02).ConclusionsVR distraction for IV placement in the Pediatric Emergency Department shows similar efficacy to standard distraction techniques and appears to be well tolerated.     

Use of Scheduled Nonopioid Analgesia to Decrease Inpatient Opioid Consumption After Scheduled Cesarean Birth

ObjectiveTo compare opioid use and pain scores in women who had scheduled cesarean birth before and after implementing a scheduled nonopioid analgesia practice guideline.DesignQuality improvement project with a comparison of pre-/postintervention.Setting/Local ProblemA 170-bed community hospital where the administration of postcesarean pain medications was unstandardized.ParticipantsConvenience sample of 175 individuals who were scheduled for cesarean birth (106 in preintervention group and 69 in postimplementation group).Intervention/MeasurementsAll participants had received a dose of 150 mcg of intrathecal morphine intraoperatively. Care of participants in the postimplementation group included a new practice guideline using preoperative oral acetaminophen 1 g and postoperative intravenous ketorolac 30 mg that transitioned to ibuprofen 600 mg orally every 6 hours until discharge. Acetaminophen 1 g every 6 hours also continued until discharge. For breakthrough pain, oxycodone 5 mg to 10 mg was available.ResultsResults were analyzed using the chi-square and t test. There was a statistical difference in the mean milligram morphine equivalent consumed after scheduled cesarean birth (preintervention = 21.15 vs. postintervention = 3.91, p < .001). Postimplementation, 84.1% of participants did not consume any opioids beyond the intrathecal dose compared to 47.2% of participants preintervention. Mean pain scores decreased from 2.49 to 1.62 (p < .001), and there was an observed decrease of the highest reported pain score from 5.39 to 4.03 (p < .001).ConclusionThe results of this project support the current literature indicating that the administration of a scheduled nonopioid multimodal analgesia regimen to individuals with scheduled cesarean birth is an effective postoperative pain management strategy. This approach to managing surgical birth pain can decrease subjective reports of pain and overall opioid consumption during the hospital stay.     

Intravenous magnesium sulfate vs. morphine sulfate in relieving renal colic: A randomized clinical trial

ObjectiveRenal colic emerging from renal stone is virtually the most severe pain which is experienced. Intravenous infusion of morphine sulfate is known as a usual treatment for the disease. This study was designed to compare the efficacy of magnesium sulfate vs morphine sulfate in renal colic relief as for analgesic effect as well as lack of morphine sulfate side effects when using magnesium sulfate.MethodsWe conducted a double-blind randomized clinical trial in renal colic patients who had referred to the emergency department of Shahid Sadoughi Hospital in Yazd, Iran. A total of 80 eligible patients were selected and randomly assigned into two groups; patients in the case group received 50 mg/kg intravenous magnesium sulfate, and those in the control group 0.1 mg/kg intravenous morphine. The primary outcome was the pain score measured on a numerical rating scale at 0, 10 and 20 minutes after infusion. Data were analyzed using SPSS₁₆.ResultsThe two groups were similar in terms of demographic features and pain intensity at the time of referral (P <.0001). Ten minutes after drug administration, the pain mean score in the morphine group leveled at 4.88, and in the magnesium group 5.70, which proved to be greater in the morphine group (P- = 0.06). However, the pain mean score turned out to be 3.65 in the morphine group and 3.20 in the magnesium group thus significantly indifferent (P = .48).ConclusionsIn this study, we concluded that administration of intravenous 50 mg/kg magnesium sulfate could be as effective as morphine in reducing renal colic without any further complications.     

Association Between Pain Intensity and Discontinuing Opioid Therapy or Transitioning to Intermittent Opioid Therapy After Initial Long-Term Opioid Therapy: A Retrospective Cohort Study

The purpose of this study was to evaluate changes in pain intensity among Veterans transitioning from long-term opioid therapy (LTOT) to either intermittent therapy or discontinuation compared to continued LTOT. Pain intensity was assessed using the Numeric Rating Scale in 90-day increments starting in the 90-day period prior to potential opioid transitions and the two ensuing 90-day periods after transition. Primary analyses used a 1:1 greedy propensity matched sample. A total of 29,293 Veterans switching to intermittent opioids and 5,972 discontinuing opioids were matched to Veterans continuing LTOT. Covariates were well balanced after matching except minor differences in baseline mean pain scores. Pain scores were lower in the follow up periods for those switching to intermittent opioids and discontinuing opioids compared to those continuing LTOT (0–90 days: Intermittent: 3.79, 95%CI: 3.76, 3.82; LTOT: 4.09, 95%CI: 4.06, 4.12, P < .0001; Discontinuation: 3.06, 95%CI: 2.99, 3.13; LTOT: 3.86, 95%CI: 3.79, 3.94, P = <.0001; 91–180 days: Intermittent: 3.76, 95%CI: 3.73, 3.79; LTOT: 3.99, 95%CI: 3.96, 4.02, P < .0001; Discontinuation: 3.01, 95%CI: 2.94, 3.09; LTOT: 3.80, 95%CI: 3.73, 3.87, P = <.0001). Sensitivity analyses found similar results. Discontinuing opioid therapy or switching to intermittent opioid therapy was not associated with increased pain intensity.PerspectiveThis article evaluates the association of switching to intermittent opioid therapy or discontinuing opioids with pain intensity after using opioids long-term. Pain intensity decreased after switching to intermittent therapy or discontinuing opioids, but remained relatively stable for those continuing long-term opioid therapy. Switching to intermittent opioids or discontinuing opioids was not associated with increased pain intensity.     

Biological Correlates of the Effects of Auricular Point Acupressure on Pain

BackgroundTo identify candidate inflammatory biomarkers for the underlying mechanism of auricular point acupressure (APA) on pain relief and examine the correlations among pain intensity, interference, and inflammatory biomarkers.DesignThis is a secondary data analysis.MethodsData on inflammatory biomarkers collected via blood samples and patient self-reported pain intensity and interference from three pilot studies (chronic low back pain, n = 61; arthralgia related to aromatase inhibitors, n = 20; and chemotherapy-induced neuropathy, n = 15) were integrated and analyzed. This paper reports the results based on within-subject treatment effects (change in scores from pre- to post-APA intervention) for each study group (chronic low back pain, cancer pain), between-group differences (changes in scores from pre- to post-intervention between targeted-point APA [T-APA] and non-targeted-point APA [NT-APA]), and correlations among pain intensity, interference, and biomarkers.ResultsWithin-group analysis (the change score from pre- to post-APA) revealed statistically significant changes in three biomarkers: TNF-α (cancer pain in the APA group, p = .03), β-endorphin (back pain in the APA group, p = .04), and IL-2 (back pain in the NT-APA group, p = .002). Based on between-group analysis in patients with chronic low back pain (T-APA vs NT-APA), IL-4 had the largest effect size (0.35), followed by TNF-α (0.29). A strong positive monotonic relationship between IL-1β and IL-2 was detected.ConclusionsThe current findings further support the potential role of inflammatory biomarkers in the analgesic effects of APA. More work is needed to gain a comprehensive understanding of the underlying mechanisms of APA on chronic pain. Because it is simple, inexpensive, and has no negative side effects, APA can be widely disseminated as an alternative to opioids.     

Masseter Muscle Thickness And Elasticity in Bruxism After Exercise Treatment: A Comparison Trial

ObjectiveThe purpose of this study was to evaluate the effects of Rocabado's 6 × 6 exercises on masseter muscle thickness, muscle elasticity, and pain scores in patients with bruxism.MethodsA total of 58 participants with bruxism were divided into 2 groups as the exercise group (EG) and control group (CG). A self-care program was applied for the participants in the CG. For those in the EG, in addition to the self-care program, an exercise treatment was performed for 6 days per week for a total of 8 weeks. Using ultrasonography, bilateral masseter muscle thickness and elasticity were assessed before and after treatment. Pain was measured using a visual analog scale. Changes over time within the groups and group–time interactions for continuous variables were assessed using mixed 2-way repeated measures analysis of variance.ResultsThe improvement in muscle elasticity (P = .015; P = .004) and pain values (P = .049; P = .040) were greater in the EG compared with the CG. There was no significant difference between the 2 groups for masseter muscle thickness (P > .05).ConclusionThis study suggests that Rocabado's 6 × 6 exercises are effective in the treatment of muscle elasticity and pain values in participants with bruxism.