Measurement of pain.

Visual analogue scales (VAS) of sensory intensity and affective magnitude were validated as ratio scale measures for both chronic and experimental pain. Chronic pain patients and healthy volunteers made VAS sensory and affective responses to 6 noxious thermal stimuli (43, 45, 47, 48, 49 and 51 degrees C) applied for 5 sec to the forearm by a contact thermode. Sensory VAS and affective VAS responses to these temperatures yielded power functions with exponents 2.1 and 3.8, respectively; these functions were similar for pain patients and for volunteers. The power functions were predictive of estimated ratios of sensation or affect produced by pairs of standard temperatures (e.g. 47 and 49 degrees C), thereby providing direct evidence for ratio scaling properties of VAS. Vas sensory intensity responses to experimental pain, VAS sensory intensity responses to different levels of chronic pain, and direct temperature (experimental pain) matches to 3 levels of chronic pain were all internally consistent, thereby demonstrating the valid use of VAS for the measurement of and comparison between chronic pain and experimental heat pain.

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The validation of visual analogue scales as ratio scale measures for chronic and experimental pain

Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronicconditions,frailty, anddisability. However, in geriatricmedicine,there isagrowingconsensusthatthese are distinct clinical entities that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions,including theirclinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state of published knowledge is supplemented by targeted analysesin selectedareas where no current publisheddataexists. Overall,the goalof this articleis to providea basis fordistinguishingbetweenthesethreeimportantclinicalconditionsinolderadultsandshowinghowuseofseparate, distinct definitions of each can improve our understanding of the problems affecting older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this area.

/pdf/untangling-the-concepts-of-disability-frailty-and-3jhe15an05.pdf

Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care

Of the various methods for measuring pain the visual analogue scale seems to be the most sensitive. For assessing response to treatment a pain-relief scale has advantages over a pain scale. Pain cannot be said to have been relieved unless pain or pain relief has been directly measured.

The measurement of subjective pain intensity continues to be important to both researchers and clinicians. Although several scales are currently used to assess the intensity construct, it remains unclear which of these provides the most precise, replicable, and predictively valid measure. Five criteria for judging intensity scales have been considered in previous research: ease of administration of scoring; relative rates of incorrect responding; sensitivity as defined by the number of available response categories; sensitivity as defined by statistical power; and the magnitude of the relationship between each scale and a linear combination of pain intensity indices. In order to judge commonly used pain intensity measures, 75 chronic pain patients were asked to rate 4 kinds of pain (present, least, most, and average) using 6 scales. The utility and validity of the scales was judged using the criteria listed above. The results indicate that, for the present sample, the scales yield similar results in terms of the number of subjects who respond correctly to them and their predictive validity. However, when considering the remaining 3 criteria, the 101-point numerical rating scale appears to be the most practical index.

The measurement of clinical pain intensity: a comparison of six methods.

Of the different types of visual analogue and graphic rating scales tested in a series of experiments, only two were satisfactory: these were the visual analogue scale and the graphic rating scales used horizontally with the words spread out along the whole length of the line. Other types of scale used gave distributions of results which were not uniform. Unusual distribution of results occurred when patients selected a position adjacent either to descriptive terms or preferred numbers. In some experiments, the distribution of results was determined by the nature of the experiment. Alternation of the ends of a scale did not affect the results. The behaviour of the graphic rating scale was different in patients accustomed to completing it and in those not so accustomed. The results of pain severity measured by these methods showed a very good correlation with pain severity measured by the simple descriptive pain scale. Changes in visual analogue scores also correlated well with changes in simple descriptive pain scores. The visual analogue and graphic rating scales were more sensitive than the traditional simple descriptive pain scale. Most patients could readily use visual analogue and graphic rating scales despite having no previous experience. The failure rate was slightly lower with the graphic rating method. Use of these scales is the best available method for measuring pain or pain relief.

Graphic representation of pain.

Aspirin (acetylsalicylic acid), the first of the NSAIDs (introduced in 1899), was initially never referred to as an anti-inflammatory agent. It was the advent of cortisone in 1949 that demonstrated dramatically that corticosteroids had anti-inflammatory properties and the term ‘non-steroidal anti-inflammatory drug’ was first used when phenylbutazone was introduced 3 years later. Since then, the NSAIDs have proliferated. There is to date no good evidence that they halt progression of rheumatoid disease, but by easing pain and diminishing swelling they make life much easier in osteoarthrosis, rheumatoid arthritis and many other types of arthritis, and are the drugs of first choice in acute gout. Their mode (or modes) of action are obscure and though inhibition of cyclo-oxygenase (prostaglandin synthetase) is clearly important, other mechanisms are also involved. The assessment of the anti-inflammatory action of these agents has received considerable attention in clinical trials because, whatever their action may be in experimental animal models, their action in inflamed joints in human patients must be ascertained, since there may be little parallel between the two. Different experimental animal models give different results with various agents and often bear little relation to their therapeutic action in man. No attempt has been made here to review in depth all the NSAIDs that have appeared since 1952. All have anti-inflammatory and analgesic activity and all can cause gastrointestinal side effects, though effectiveness and toxicity vary from drug to drug and patient to patient, there being very great interpatient variability. Non-reactors, patients who apparently fail to respond to certain agents, need further study, for it seems that these subjects may metabolise these agents differently from others. Considerable ingenuity has been shown not only in evolving new NSAIDs but in finding new ways of administering them. The number and variety of NSAIDs in their various forms varies greatly from country to country, depending largely on the regulatory bodies of those countries. In the meantime, the search for a better, less toxic compound continues with the hope that one may be found which has a deeper and more basic action on the underlying disease process.

Non-steroidal anti-inflammatory drugs. Current status and rational therapeutic use.

Objectives. We examined the eYcacy, safety and patient satisfaction of intra-articular hyaluronic acid (HA) in patients with osteoarthritis of the knee. Methods. One hundred patients with mild to moderate osteoarthritis of the knee entered a randomized blind-observer trial of 6 months HA vs placebo. Primary eYcacy criteria were pain on walking, measured with a visual analogue scale, and the Lequesne Index. Results. For pain on walking, a significant diVerence in favour of HA was found for completed patients at week 5, the end of the course of injections, and at month 6, the end of the study (P= 0.0087 and P= 0.0049, respectively). Further analysis using the Last Observation Carried Forward (LOCF ) also showed a significant benefit favouring HA at month 6 (P= 0.0010). For the Lequesne Index, a significant diVerence in favour of HA was found at week 5 (P= 0.030) and at month 2 (P= 0.0431), but this was only of borderline significance at month 4 (P= 0.0528). Patients’ global assessment of eYcacy favoured HA at month 6 (P= 0.012). Improvement in other secondary criteria was generally superior in the HA group compared to placebo both at week 5 and month 6. Adverse events, mainly local injection site reactions, occurred in both groups with equal frequency. Conclusions. The study demonstrated that five weekly intra-articular injections of sodium hyaluronate (HyalganA) were superior to placebo and well tolerated in patients with osteoarthritis of the knee with a symptomatic benefit which persisted for 6 months. Osteoarthritis (OA) of the knee is very common and toms in patients with OA of the knee [3‐5]. This type very important. Population surveys have shown that of action is characteristic of a group of compounds radiographically determined OA of the knee is present called ‘slow acting symptomatic drug for osteoarthritis’ in between 15 and 30% of subjects aged over 45 yr, and [6 ] to distinguish them from NSAIDs. thereafter increases steadily with age [1, 2]. Current HyalganA, used in this study, is a highly purified, treatment is usually disappointing and most rheuma- concentrated (10 mg/ml ), viscous solution of natural tologists do not follow-up patients once the diag- HA with a molecular weight in the range of 500‐ nosis is made. Non-steroidal anti-inflammatory drugs 730 kDa, extracted from rooster combs. In studies (NSAIDs) have been the mainstay of drug treatment in reported to date [3‐5], HyalganA has been very well knee OA, as in other types of arthritis, but have obvious tolerated with no significant side-eVects apart from the limitations. The elderly are most at risk from serious possibility of transient localized pain after the injection. adverse eVects of these drugs, particularly peptic ulcer- While most studies have found HyalganA to be eVective, ation, bleeding or perforation. Intra-articular steroids Henderson et al. [7] failed to show a diVerence in a are used in OA, but their long-term eYcacy is not well placebo-controlled study. This 6 month study of 91 established. patients had a high percentage of withdrawals (38%) Intra-articular sodium hyaluronate (hyaluronic acid; and local adverse eVects (pain and/or swelling: 47% in HA) oVers the prospect of another approach to the the HA group and 22% with placebo). This may have treatment of OA. Studies have shown that a course of resulted in an insuYcient power to detect a diVerence five injections of HA provides prolonged relief of symp- in the completed patients. The question, therefore,

Hyaluronic acid in the treatment of osteoarthritis of the knee.

Ninety patients with rheumatoid arthritis completed a double-blind crossover trial comparing fenoprofen, ibuprofen, ketoprofen, and naproxen. Fenoprofen and naproxen were slightly more effective than the other two drugs but there were striking individual variations in response. Groups of patients could be identified who preferred each of the four drugs. The commonest side effects were those related to the upper gastrointestinal tract; these showed individual variation and seldom occurred with more than one or two of the drugs. Side effects were least common with ibuprofen and naproxen.Since naproxen combined greater effectiveness with a lower incidence of side effects it must be regarded as the first choice among these drugs. It may be necessary to try several drugs before finding the right one for a particular patient.

https://www.bmj.com/content/bmj/1/6017/1048.full.pdf

Four new anti-inflammatory drugs: responses and variations.

An articular index was devised for the sequential assessment of patients with osteoarthritis (OA). Forty-eight joint units, chosen to reflect the characteristic pattern of the disease, were scored for tenderness on pressure or movement on a 4-point scale. Four observers examined patients to assess inter- and intraobserver error. The index was highly reproducible both within and between observers; intraobserver error was, however, significantly smaller. In a double-blind, cross-over trial the index was sufficiently sensitive to detect a statistically significant difference between the responses of patients with OA to an anti-inflammatory agent and to a simple analgesic. It is likely to be a useful addition to current methods of measurement in osteoarthritis.

https://ard.bmj.com/content/annrheumdis/40/1/75.full.pdf

E. C. Huskisson

Papers

Graphic representation of pain.

Non-steroidal anti-inflammatory drugs. Current status and rational therapeutic use.

Hyaluronic acid in the treatment of osteoarthritis of the knee.

Four new anti-inflammatory drugs: responses and variations.

An articular index for the assessment of osteoarthritis.