Placebo Analgesia: Clinical considerations

Pain is the predominant symptom that prompts patients to seek medical advice and treatment from physiotherapists. Various treatment modalities such as heat and cold, electrical stimulation (Cheing and Hui-Chan, 1999), ultrasound, manipulative techniques, massage and laser treatment have been demonstrated in varying degrees to be clinically effective for managing pain of different pathologies. However, all these treatments could be assumed to have some placebo elements (French, 1994).

From a research design perspective, the presence of placebo response is undesirable and must be controlled as it complicates the demonstration of ‘real' treatment effect. From a clinical perspective, it is intriguing to note that the condition of patients in the placebo control groups did improve considerably in many of these validation studies, although in the majority the improvement was not so marked as in the treatment groups. Conspicuously, some neuro-physiological and psychological aspects of the placebo effects may have clinical use in enhancing the effect of pain treatments and their outcomes.

Unfortunately, although placebo response has been a subject of continuing interest among some physiotherapy researchers and clinicians, information about placebo analgesia and its clinical utility is seldom discussed. The purpose of this paper is to provide clinicians with an overview of the construct and research related to placebo analgesia as well as a discussion of the potential clinical use of certain components of placebo analgesia to enhance pain rehabilitation outcomes in physiotherapy practice.     

分娩时局部和全身应用阿片类药物镇痛的系统评价

目的运用Cochrane系统评价的方法，评价分娩时局部和全身应用阿片类药物镇痛的有效性与安全性。方法计算机检索PubMed（1966-2008．1）、EMbase（1980-2008．1）、Cochrane图书馆（2008年第1期）、CBM（1978-2008．1）、CNKI（1979-2008．1），同时筛选纳入研究的参考文献，收集有关比较局部和全身应用阿片类药物镇痛的随机对照试验，由两名评价员独立评价文献质量，并采用RevMan4．2．10软件对纳入研究结果进行Meta分析：结果共纳入12个研究，5909例产妇。Meta分析结果显示，局部和全身应用阿片类药比较进行分晚镇痛．母亲对局部应用阿片类药分娩镇痛疼痛缓解更满意[RR=I．63，95％CI（1．27，2．09）]，两组5min新生儿Apgar评分〈7，差异无统计学意义：RR=0．63，95％CI（0.40，1．01）]：结论现有证据显示，与局部用药比较，全身心用阿片类药物镇痛的母亲对分娩疼痛缓解更满意。但两组均存在对母亲和新生儿的不良影响。因此，要证明哪种途径应用阿片类药进行分娩镇痛更加有效和安全，尚需开展更多高质量的随机对照研究。     

Effects of Adrenaline on maternal and fetal fentanyl absorption in epidural analgesia: A randomized trial

Background

The combination of low‐dose local anesthesia and lipophilic opioids such as fentanyl is established as a standard solution for labor epidural analgesia. Fentanyl increases efficacy, but may have negative effects on the neonate in terms of reduced neonatal neurologic and adaptive capacity scores and breast feeding. We hypothesized that addition of adrenaline 2 μg/mL to a solution of bupivacaine 1 mg/mL and fentanyl 2 μg/mL would reduce the systemic uptake of fentanyl, resulting in reduced serum fentanyl in the fetus at birth.

Methods

Forty‐one nulliparous women requesting epidural analgesia were randomized to epidural analgesia with or without adrenaline. Blood samples were drawn from the mother with regular intervals, and at delivery. An umbilical vein blood sample (used as a proxy for fetal exposure) was drawn after clamping.

Results

There were no significant differences between the groups in fentanyl concentrations in the umbilical vein and maternal serum at birth. There was a significantly lower mean area under the maternal serum‐concentration curve for the first 2 hours of treatment in the adrenaline group (mean difference 0.161 nmol h/L [0.034; 0.289], P = .015), implying slower systemic uptake in the adrenaline group initially. There were no significant differences in treatment duration, motor block, Apgar scores, umbilical pH and base excess, or mode of delivery.

Conclusions

The addition of adrenaline to an epidural solution containing fentanyl lowered maternal systemic serum fentanyl concentration during the first 2 hours, but did not lower serum fentanyl concentration in the umbilical vein and mother at delivery.     

心外科术后吗啡与芬太尼患者自控镇痛效果观察

目的观察吗啡和芬太尼患者自控镇痛 (PCIA)用于心外科术后疼痛康复的疗效和安全性。方法将 70例心脏手术患者随机分为吗啡组和芬太尼组 ,术后在ICU病房用PCIA进行疼痛康复 ,观察镇痛起效时间、效果及满意率 ,以及 2 4h、48h和 72h生命体征及恶心、呕吐等副作用。结果两组患者的镇痛效果及满意率无显著性差异 ,生命体征均平稳 ,但芬太尼组的起效时间明显短于吗啡组 (P <0 .0 5 ) ,患者的恶心、呕吐次数明显少于吗啡组 (P <0 .0 5 )。结论吗啡和芬太尼PCIA均能安全地用于心外科术后患者急性疼痛的康复治疗 ,但芬太尼PCIA明显比吗啡PCIA起效快 ,恶心、呕吐副作用少。     

氯胺酮在吗啡急性耐受大鼠的外周镇痛作用

我们产证明氯胺酮引起的外周镇痛作用与阿片受体的激活有关。本实验旨在建立吗啡外周镇痛耐受的大鼠模型，进一步观察氯胺酮的外周镇痛作用与阿片受体的关系。外周感受野局部皮下注射５μｌ吗啡（１０μｇ／μｌ）明显的抑制伤害性肌电反应。随吗啡注射次数的增加，伤害性反应的抑制逐渐减弱，一般于第五次注射，吗啡不再产生抑制，出现外周镇痛的急性耐受。但是，在耐受动物的同一部位注射０μｌ氯胺酮（５０μｇ／μｌ），仍产生很     

1例宫内孕合并反流性食管炎自然分娩的护理

目的探讨反流性食管炎、慢性浅表性胃炎伴糜烂,合并宫内孕自然分娩的护理。方法患者因呕吐咖啡色呕吐物数次,不能进食,低钾血症,予止吐,营养支持治疗及应用胃黏膜保护治疗。结果患者经补钾、补钠及静点奥美拉唑及硫酸镁保胎治疗,最后至妊娠足月。结论由于医疗和护理工作到位使患者足月自然产,母子平安。     

N-乙酰-5-甲氧色胺镇痛作用的实验研究

目的为了寻找新型镇痛药物,对N-乙酰-5-甲氧色胺(Mel)的镇痛作用及其与哌替啶(Pt)的协同作用进行探索性研究。方法采用小鼠热板法及冰乙酸致小鼠扭体为疼痛模型,观察Mel对痛阈的影响。结果Mel30,60,120mg/kg剂量依赖性地增加小鼠痛阈,且于给药后1h达高峰,持续至2h仍有效。此外,无镇痛效应的Mel(10mg/kg)与哌替啶(10mg/kg)合用,能明显提高小鼠痛阈。结论Mel具有良好的镇痛作用,增大剂量完全能达到哌替啶的镇痛效应,且与哌替啶有明显协同效应。     

疼痛的评估与护理进展

介绍了疼痛的定义、对机体的危害性、评估方法以及疼痛病人的护理对策，提出充分了解疼痛控制不足的原因，可以提高护士自身的认知能力，提高控制疼痛的水平。     

Dor radicular causada por nódulo de Schmorl: relato de caso

Schmörl's node is focal herniation of intervertebral disc through the end plate into the vertebral body. Most of the established Schmörl's nodes are quiescent. However, disc herniation into the vertebral marrow can cause low back pain by irritating a nociceptive system. Schmörl's node induced radicular pain is very rare condition. Some cases of Schmörl's node which generated low back pain or radicular pain were treated by surgical methods. In this article, authors reported a rare case of a patient with radicular pain cause by Schmörl's node located inferior surface of the 5 th lumbar spine. The radicular pain was alleviated by serial 5 th lumbar transforamnial epidural blocks. Transforamnial epidural block is suggested as first conservative option to treat radicular pain due to herniation of intervertebral disc. Therefore, non‐surgical treatment such as transforamnial epidural block can be considered first treatment option of radicular pain caused by Schmörl's node.