Showing papers on "Visual analogue scale published in 1999"

Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain.

Abstract: Study Design. A prospective double-blind randomized trial in 31 patients. Objectives. To assess the clinical efficacy of percutaneous radiofrequency denervation of the lumbar zygapophysial joints in reducing pain, functional disability, and physical impairment in patients with back pain originating from the lumbar zygapophysial joints. Summary of Background Data. Chronic low back pain is a major health problem in the industrialized world. A treatment option is percutaneous radiofrequency denervation of the lumbar zygapophysial joints. Its clinical elficacy has never been formally tested in a controlled trial. Methods. Thirty-one patients with a history of at least 1 year of chronic low back pain were selected on the basis of a positive response to a diagnostic nerve blockade and subsequently randomly assigned to one of two treatment groups. Each patient in the radiofreguency treatment group (15 patients) received an 80 C radiofrequency lesion of the dorsal ramus of the segmental nerve roots L3, L4, and L5. Patients in the control group (n = 16) underwent an the same procedure but without use of a radiofrequency current. Both the treating physician and the patients were blinded to the group assignment. Before treatment, physical impairment, rating of pain, the degree of disability, and quality of life were assessed by a blinded investigator. Results. Eight weeks after treatment there were 10 success patients in the radiofrequency group (n = 15) and 6 in the sham group (n = 16), The unadjusted odds ratio was 3.3 (P = 0.05, not significant), and the adjusted odds ratio was 4.8 (P < 0.05, significant). The differences in effect on the visual analog scale scores, global perceived effect, and the Oswestry disability scale were statistically significant. Three, 6, and 12 months after treatment, there were significantly more success patients in the radiofrequency group compared with the sham group. Conclusions. Radiofrequency lumbar zygapophysial joint denervation results in a significant alleviation of pain and functional disability in a select group of patients with chronic low back pain, both on a short-term and a long-term basis.

[The Spanish version of EuroQol: a description and its applications. European Quality of Life scale].

Abstract: Background To introduce the EuroQol 5D (EQ-5D) to health care professionals wishing to use it as a measure of health-related quality of life. Methods This paper is based on a review of studies using the EQ-5D in Spanish populations which include chronic and critical patients, health care users, and random samples of the general population in Navarra and Catalonia. Results Results are presented for three aspects of the EQ-5D: the descriptive system, the visual analogic scale, and the EQ-5D tariff. Presence of problems on the descriptive system and lower scores on the visual analogue scale were positively associated with increasing age, being female, lower educational level and social class, presence of chronic conditions, higher levels of restricted activity, visits to a health care professional in the previous 15 days, and hospitalisation during the previous year. The ability of the descriptive system and the visual analogic scale to discriminate between healthy individuals and critical and chronic patients was good. Social tariffs for EQ-5D health states have been obtained based on self-rated health and the rating of hypothetical health states (health states not experienced by the rater). Tariffs for hypothetical health states have been obtained using visual analogic scale and time trade-off techniques. Tariffs also discriminate between healthy and non-healthy subjects, and are a valid reflection of preferences for health states. Conclusions The Spanish version of the EQ-5D is a simple, valid and practical measure for its use as an outcome variable both in clinical research and in the allocation of health care resources:

Capturing the Patient's View of Change as a Clinical Outcome Measure

Abstract: ContextMeasurement of change in patients' health status is central to both clinical trials and clinical practice. Trials commonly use serial measurements by the patients at 2 points in time while clinicians use the patient's retrospective assessment of change made at 1 point in time. How well these measures correlate is not known.ObjectiveTo compare the 2 methods in measurement of changes in pain and disability.DesignLongitudinal survey of patients starting new therapy for chronic arthritis in 1994 and 1995. Surveys were completed at baseline (before intervention) and at 6 weeks and 4 months.SettingCommunity health education program and university medical and orthopedic services.SubjectsA total of 202 patients undertaking self-management education (n=140), therapy with prednisone or methotrexate (n=34), or arthroplasty of the knee or hip (n=28).Main Outcome MeasuresConcordance between serial (visual analog scale for pain and Health Assessment Questionnaire for disability) and retrospective (7-point Likert scale) measures, sensitivities of these measures, and their correlation with patients' satisfaction with the change (7-point Likert scale).ResultsWhen change was small (education group), serial measures correlated poorly with retrospective assessments (eg, r=0.13-0.21 at 6 weeks). With greater change, correlations improved (eg,r=0.45-0.71 at 6 weeks). Average agreement between all pairs of assessments was 29%. Significant lack of concordance was confirmed in all 12 comparisons by McNemar tests (P=.02 to <.001) and by t tests (P=.03 to <.001). Retrospective measures were more sensitive to change than serial measures and correlated more strongly with patients' satisfaction with change.ConclusionThe 2 methods for measuring health status change did not give concordant results. Including patient retrospective assessments in clinical trials might increase the comprehensiveness of information gained and its accord with clinical practice.

Determinants of pain severity in knee osteoarthritis: effect of demographic and psychosocial variables using 3 pain measures.

Abstract: Objectives Why some patients with knee osteoarthritis (OA) report greater pain severity than others is unclear. We examined the demographic variables, psychosocial variables, and physical findings that predict severity of pain in patients with symptomatic knee OA comparing 3 different pain scales. Methods Pain severity was measured in 68 outpatients with knee OA using the WOMAC OA Index, the McGill Pain Questionnaire (MPQ), and a 0-100 visual analog scale (VAS). Depression, anxiety, fatigue, helplessness, self-efficacy, and quality of life were measured using standard instruments. Pain threshold was measured by dolorimetry and a standard knee examination performed. Radiographs were viewed when available. Results Significant correlations (r = 0.39-0.61) were found between pain measures. In unadjusted analysis, BMI and helplessness correlated with all 3 scales; race, education, female sex, and osteophyte score also correlated with at least one instrument. Depression, anxiety, and fatigue correlated only with the MPQ. Age, duration, and quality of life were not related to pain severity. After adjusted analysis the following variables remained: education, helplessness, and osteophyte score (WOMAC); BMI and helplessness (MPQ); duration, education, helplessness, and osteophyte score (VAS). "Sitting pain" and "night pain" had different associations from pain on walking, standing, or using stairs. Conclusion Different pain scales measure different facets of the pain experience in knee OA and cannot be used interchangeably. The WOMAC pain scale has advantages over other instruments. Helplessness, education, and BMI appear to be important, potentially treatable, factors in determining self-reported pain severity in knee OA: other associations vary with both the pain scale used and the situation in which pain occurs, supporting the hypothesis that pain in knee OA is heterogeneous.

The pain visual analog scale: is it linear or nonlinear?

Abstract: The visual analog scale (VAS) is a tool widely used to measure pain, yet controversy surrounds whether the VAS score is ratio or ordinal data. We studied 52 postoperative patients and measured their pain intensity using the VAS. We then asked them to consider different amounts of pain (conceptually twice as much and then half as much) and asked them to repeat their VAS rating after each consideration (VAS2 and VAS3, respectively). Patients with unrelieved pain had their pain treated with IV fentanyl and were then asked to rate their pain intensity when they considered they had half as much pain. We compared the baseline VAS (VAS1) with VAS2 and VAS3. The mean (95% confidence interval) for VAS2:1 was 2.12 (1.81‐2.43) and VAS3:1 was 0.45 (0.38 ‐ 0.52). We conclude that the VAS is linear for mild-to-moderate pain, and the VAS score can be treated as ratio data. Implications: A change in the visual analog scale score represents a relative change in the magnitude of pain sensation. Use of the VAS in comparative analgesic trials can now meaningfully quantify differences in potency and efficacy. (Anesth Analg 1999;89:1517‐20)

The efficacy of active rehabilitation in chronic low back pain. Effect on pain intensity, self-experienced disability, and lumbar fatigability.

Abstract: Study Design. A randomized study comparing the results of active rehabilitation and passive control treatment in patients with chronic low back pain with follow-up at 6 months and 1 year. Objectives. To study the efficacy of active rehabilitation on pain, self-experienced disability, and lumbar fatigability. of Background Data. Exercises in an outpatient setting are widely used for the treatment of chronic low back pain. The efficacy of the active rehabilitation approach has been documented in randomized control studies, but these studies have seldom been focused on lumbar fatigability, which is now recognized as a frequent problem among patients with chronic low back pain. Methods. Fifty-nine middle-aged patients (37 men and 22 women) with nonspecific chronic low back pain were randomly assigned to 12 weeks' active rehabilitation or to a passive control treatment (massage, thermal therapy). Pain and disability index, low back pain intensity (visual analog scale, 100 mmi, and the objectively assessed lumbar muscle fatigability (spectral electromyogram, mean power frequency slope [MPF SLOPE ]) in a new 90-second submaximal isoinertial back endurance test were recorded before and after the interventions and at 6-month and 1-year follow-up visits. Results. Results of repeated measures multivariate analysis of variance indicated that back pain intensity (visual analog scale) and functional disability (pain and disability index score) decreased, and lumbar endurance (MPF SLOPE ) improved significantly more (P < 0.05) in the active rehabilitation group than in the passive control treatment group, when measured at a 1-year follow-up examination. The group difference in visual analog scale and pain and disability index changes became even more significant at the end of 1 year. The change in lumbar endurance was significantly greater in the active rehabilitation group than in the passive control treatment group at the 6-month follow-up, but not at the 1-year follow-up. Conclusions. The active progressive treatment program was more successful in reducing pain and self-experienced disability and also in improving lumbar endurance than was the passive control treatment. However, the group difference in lumbar endurance tended to diminish at the 1-year follow-up.

Development of the Neck Pain and Disability Scale. Item analysis, face, and criterion-related validity.

Abstract: Study design The development and testing of a new comprehensive measure of neck pain and disability, the Neck Pain and Disability Scale. Objectives To provide an initial evaluation of the Neck Pain and Disability Scale's reliability and validity. Summary of background data Although several measures exist for generalized pain and disability, none is specific for neck pain. More specific measurements should improve assessment of treatments and clinical research aimed at cervical pain syndromes. Methods The Neck Pain and Disability Scale was designed using the Million Visual Analogue Scale as a template and consists of 20 items that assess neck pain. In this study, 100 patients with neck pain, 52 patients with lower back and leg pain, and 27 pain-free volunteers were rated by the Neck Pain and Disability Scale. In addition, a subset of the 47 patients with neck pain were rated by several other established psychometric instruments. Results An item analysis showed a high degree of internal consistency among the 20 items on the Neck Pain and Disability Scale (r = 0.93), and face validity was established by comparing patients who had neck pain as well as lower back and leg pain with a pain-free group. The Neck Pain and Disability Scale scores correlated with the Oswestry Disability Questionnaire, the Pain Disability Index, and psychological measures of depression and neuroticism. Conclusions The results suggest a highly reliable instrument for evaluating neck pain with at least four underlying dimensions. Further work to address the predictive validity of this new tool are under way.

Determinants of WOMAC function, pain and stiffness scores: evidence for the role of low back pain, symptom counts, fatigue and depression in osteoarthritis, rheumatoid arthritis and fibromyalgia.

Abstract: Objectives. The Western Ontario MacMaster ( WOMAC ) is a validated instrument designed specifically for the assessment of lower extremity pain and function in osteoarthritis (OA) of the knee or hip. In the clinic, however, we have noted that OA patients frequently have other musculoskeletal and non-musculoskeletal problems that might contribute to the total level of pain and functional abnormality that is measured by the WOMAC. In this report, we investigated back pain and non-articular factors that might explain WOMAC scores in patients with OA, rheumatoid arthritis (RA) and fibromyalgia (FM ) in order to understand the specificity of this instrument. Methods. RA, OA and FM patients participating in long-term outcomes studies completed the WOMAC and were assessed for low back pain, fatigue, depression and rheumatic disease symptoms by mailed questionnaires. Results. Regardless of diagnosis, WOMAC functional and pain scores were very much higher (abnormal ) among those complaining of back pain. On average, WOMAC scores for back pain (+) patients exceeded those of back pain (’) patients by ~65%, and 52% of OA patients reported back pain. In regression analyses, study symptom variables explained 42, 44 and 38% of the variance in WOMAC function, pain and stiVness scores, respectively. In the subset of OA patients, radiographic scores added little to the explained variance. The strongest predictor of WOMAC abnormality in bivariate and multivariate analyses was the fatigue score, with correlations of 0.58, 0.60 and 0.53 with WOMAC function, pain and stiVness, respectively. The WOMAC performed well in RA and FM, and correlated strongly with the Health Assessment Questionnaire (HAQ) disability scale and a visual analogue scale ( VAS) pain scale. Conclusion. The WOMAC captures more than just knee or hip pain and dysfunction, and is clearly influenced by the presence of fatigue, symptom counts, depression and low back pain. WOMAC scores also appear to reflect psychological and constitutional status. These observations suggest the need for care in interpreting WOMAC scores as just a measure of function, pain or stiVness, and indicate the considerable importance of psychological factors in rheumatic disease and rheumatic disease assessments.

The kappa opioid nalbuphine produces gender- and dose-dependent analgesia and antianalgesia in patients with postoperative pain

Abstract: Nalbuphine, pentazocine, and butorphanol, mixed agonist/antagonist opioids that induce analgesia by acting predominantly at kappa opioid receptors, have recently been shown in single-dose studies to have greater analgesic efficacy in women than in men. In the current experiments, the first placebo controlled dose response study of opioid analgesic efficacy that examines for gender differences, nalbuphine (5, 10, or 20 mg) and placebo were evaluated in 62 men and 69 women for the treatment of moderate to severe postoperative pain following extraction of impacted wisdom teeth. In a randomized, open injection, double blind experimental design, pain intensity was recorded on a 10 cm visual analog scale (VAS) immediately prior to drug administration (baseline) and at 20 min intervals thereafter. Although responses to placebo were similar in men and women, for all doses of nalbuphine women exhibited significantly greater analgesic response than men, compatible with our previous results. Unexpectedly, men receiving the 5 mg dose of nalbuphine experienced significantly greater pain than those receiving placebo; only the 20 mg dose of nalbuphine in men produced significant analgesia compared to placebo. While a similar antianalgesic effect was not observed in women, only the 10 mg dose of nalbuphine produced significant analgesia compared to placebo. These results suggest that the optimal analgesic dose of nalbuphine for women is lower than the highest dose that can be safely administered. In contrast, the antianalgesic effect of nalbuphine suggests avoidance of its routine use for postoperative analgesia in men until further studies clarify this issue. Because gender differences in other mixed kappa agonists/antagonists (i.e. pentazocine and butorphanol) have previously been shown, these results may generally apply to this class of opioid analgesics.

A prospective study of long-term intrathecal morphine in the management of chronic nonmalignant pain.

Abstract: Objective To examine in a prospective manner the long-term safety and efficacy of chronic intrathecal morphine in patients with severe, nonmalignant pain refractory to less invasive modalities Methods Forty patients with severe, chronic nonmalignant pain poorly managed by systemic medications were identified as candidates for intraspinal trial of morphine Thirty participants reported successful pain relief during trial and were implanted with an intraspinal delivery system Standardized measures of pain and functional status were assessed before treatment was begun and at defined intervals during the subsequent 24 months Intrathecal opioid use and pharmacological and device-related complications were also monitored Results The participants had a mean age of 58 +/- 13 years and a mean pain duration of 8 +/- 9 years Fifty-three percent of the study participants were women Pain type was characterized as mixed neuropathic-nociceptive (15 of 30 patients, 50%), peripheral neuropathic (10 of 30 patients, 33%), deafferentation (4 of 30 patients, 13%), or nociceptive (1 of 30 patients, 3%) Forty-seven percent of the patients were diagnosed with failed back surgery syndrome Significant improvement over baseline levels of visual analog scale pain was measured at each follow-up examination after implant Overall, 50% (11 of 22 patients) of the population reported at least a 25% reduction in visual analog scale pain after 24 months of treatment In addition, the McGill Pain Questionnaire, visual analog scale measures of functional improvement and pain coping, and several subscales of the Chronic Illness Problem Inventory showed improvement throughout the follow-up period Pharmacological side effects were managed medically by morphine dose reduction, addition of bupivacaine, or replacement of morphine with hydromorphone Device-related complications requiring repeat operations were experienced by 20% of the patients Conclusion Continuous intrathecal morphine can be a safe, effective therapy for the management of severe, nonmalignant pain among a carefully selected patient population and can result in long-term improvement in several areas of daily function

Epidural block with mepivacaine before surgery reduces long-term post-thoracotomy pain.

Abstract: To examine the effect of continuous epidural block initiated before thoracic surgery upon early and long-term postoperative pain. In a double-blind study, 70 patients scheduled for thoracic surgery under general anesthesia were assigned randomly to receive continuous epidural block with mepivacaine 1.5% initiated either 20 min before surgical incision (Pre group) or at completion of surgery (Post group). In both groups the initial dose was 4 ml, followed by a continuous infusion at 4 ml·hr−1 until 72 hr after operation. Indomethadn suppositories, 50 mg, were administered on request as supplementary analgesics. Visual analogue scale at rest was assessed four hours after operation, and then every 24 hr after operation on postoperative days 1 through 7, and also days 14 and 30. At three and six months after operation, all patients were interviewed by telephone with respect to postoperative pain. The most severe pain was assessed using modified numerical rating scale. By a visual analogue scale, postoperative pain was less in the Pre group than in the Post group at four hours, two and three days after operation (P < 0.05). By a numerical rating scale six months after operation, pain was less in the Pre group than in the Post group (P = 0.015). The percentage of pain-free patients was higher in the Pre group than in the Post group at three (P = 0.035) and six (P = 0.0086) months after operation. Continuous epidural block initiated prior to surgery may reduce long-term post-thoracotomy pain.

Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction

Abstract: The aim of this study was to evaluate the long-term outcome of an outpatient pulmonary rehabilitation programme (PRP) in patients with chronic airway obstruction (CAO). In 61 CAO patients (35 asthmatics and 26 chronic obstructive pulmonary disease (COPD)) lung and respiratory muscle function, exercise tolerance (by symptom limited cycloergometer and walking tests), dyspnoea (Borg scale, visual analogue scale (VAS), baseline and transitional dyspnoea index (BDI and TDI, respectively)) and quality of life (St George's Respiratory Questionnaire (SGRQ)) were assessed at baseline (to), at discharge (t1) and 12 months postdischarge (t2). Preprogramme and post-programme hospital admissions and exacerbations of disease were also recorded. In comparison with baseline, no significant change was observed in lung function tests in either diagnostic group, either at t1 or at t2. In both groups improvements in respiratory muscle strength, exercise tolerance, Borg scale and VAS reported at t1 were partially reduced at t2. Analysis of variance showed that these changes over time were similar in the two groups. Mean values of SGRQ and BDI/TDI improved at t1, and, unlike exercise tolerance, did not worsen at t2. However, a clinically relevant difference in SGRQ between t2 and to was reported only in 56% of asthmatics and 52% of COPD patients. Compared with the preceding 2 yrs, in the year following PRP, hospital admissions and disease exacerbations decreased significantly in both diagnostic groups. Regardless of diagnosis, patients with chronic airway obstruction who underwent an outpatient pulmonary rehabilitation programme maintained an improved quality of life 12 months postdischarge despite a partial loss of the improvement in exercise tolerance.

Radiofrequency tongue base reduction in sleep-disordered breathing: A pilot study.

Abstract: Objective: This pilot study investigates the new technology of radiofrequency energy (RFe), as applied to the tongue base, for the purpose of assessing feasibility, safety, and possible efficacy in the treatment of sleep-disordered breathing (SDB). Methods: Eighteen patients with SDB, in whom at least palatopharyngoplasty had failed, were entered in this study. The mean respiratory disturbance index was 39.6, with a mean nadir oxygen (SaO2) of 81.9%. A radiofrequency electrode delivered energy to the subsurface tongue base with local anesthetic. Polysomnography, quantitative speech and swallowing studies, questionnaires, and visual analog scales were used to assess outcomes. MRI assessed changes in tongue volume. Results: Separate RFe treatments (mean 5.5) at 4-week intervals were given (mean 1543 J for 9 minutes at 80°C), for a mean energy total of 8490 J per patient. The posttreatment mean respiratory disturbance index was 17.8, and the SaO2 nadir was 88.3%. Weight increased slightly; speech and swallowing did not change. Questionnaires and visual analog scale scores showed improvement in study variables. Tongue volume was reduced by a mean of 17%. Pain was controlled by hydrocodone for 3 to 4 days. One infection was seen and resolved with incision and drainage. Conclusion: This pilot study demonstrates feasibility, safety, and efficacy in reducing tongue volume using RFe. Additional cumulative energy may improve the cure rate for SDB. (Otolaryngol Head Neck Surg 1999;120:656-64.)

Percutaneous electrical nerve stimulation for low back pain: A randomized crossover study

Abstract: ContextLow back pain (LBP) contributes to considerable disability and lost wages in the United States. Commonly used opioid and nonopioid analgesic drugs produce adverse effects and are of limited long-term benefit in the management of this patient population.ObjectiveTo compare the effectiveness of a novel nonpharmacologic pain therapy, percutaneous electrical nerve stimulation (PENS), with transcutaneous electrical nerve stimulation (TENS) and flexion-extension exercise therapies in patients with long-term LBP.DesignA randomized, single-blinded, sham-controlled, crossover study from March 1997 to December 1997.SettingAn ambulatory pain management center at a university medical center.PatientsTwenty-nine men and 31 women with LBP secondary to degenerative disk disease.InterventionsFour therapeutic modalities (sham-PENS, PENS, TENS, and exercise therapies) were each administered for a period of 30 minutes 3 times a week for 3 weeks.Main Outcome MeasuresPretreatment and posttreatment visual analog scale (VAS) scores for pain, physical activity, and quality of sleep; daily analgesic medication usage; a global patient assessment questionnaire; and Health Status Survey Short Form (SF-36).ResultsPENS was significantly more effective in decreasing VAS pain scores after each treatment than sham-PENS, TENS, and exercise therapies (after-treatment mean ± SD VAS for pain, 3.4 ± 1.4 cm, 5.5 ± 1.9 cm, 5.6 ± 1.9 cm, and 6.4 ± 1.9 cm, respectively). The average ± SD daily oral intake of nonopioid analgesics (2.6±1.4 pills per day) was decreased to 1.3±1.0 pills per day with PENS (P<.008) compared with 2.5±1.1, 2.2±1.0, and 2.6±1.2 pills per day with sham-PENS, TENS, and exercise, respectively. Compared with the other 3 modalities, 91% of the patients reported that PENS was the most effective in decreasing their LBP. The PENS therapy was also significantly more effective in improving physical activity, quality of sleep, and sense of well-being (P<.05 for each). The SF-36 survey confirmed that PENS improved posttreatment function more than sham-PENS, TENS, and exercise.ConclusionsIn this sham-controlled study, PENS was more effective than TENS or exercise therapy in providing short-term pain relief and improved physical function in patients with long-term LBP.

The Effects of High-Intensity and Low-Intensity Cycle Ergometry in Older Adults With Knee Osteoarthritis

Abstract: Background People with osteoarthritis (OA) of the knee experience pain and deconditioning that lead to disability. This study challenged the clinical belief that repetitive lower extremity exercise is not indicated in persons with knee OA. The effects of high-intensity and low-intensity stationary cycling on functional status, gait, overall and acute pain, and aerobic capacity were examined. Methods Thirty-nine adults (71+/-6.9 years old) with complaints of knee pain and diagnosis of OA were randomized to either a high-intensity (70% heart rate reserve [HRR]) or low-intensity (40% HRR) exercise group for 10 weeks of stationary cycling. Participants cycled for 25 minutes, 3 times per week. Before and after the exercise intervention they completed the Arthritis Impact Measurement Scale 2 for overall pain assessment, underwent timed chair rise, 6-minute walk test, gait, and graded exercise treadmill tests. Acute pain was reported daily with a visual analog scale and the Western Ontario and McMaster Universities Osteoarthritis Index scale. Results Analysis of variance revealed that participants in both groups significantly improved in the timed chair rise, in the 6-minute walk test, in the range of walking speeds, in the amount of overall pain relief, and in aerobic capacity. No differences between groups were found. Daily pain reports suggested that cycling did not increase acute pain in either group. Conclusions Cycling may be considered as an alternative exercise modality for patients with knee OA. Low-intensity cycling was as effective as high-intensity cycling in improving function and gait, decreasing pain, and increasing aerobic capacity.

Steroid injection for heel pain: evidence of short-term effectiveness. A randomized controlled trial

Abstract: Objectives. To compare the effectiveness of a steroid injection (25 mg/ml prednisolone acetate) with a local anaesthetic control in the treatment of heel pain and to determine any advantage for patients' comfort of using a posterior tibial nerve block to anaesthetize the heel prior to infiltration. Methods. A double-blind randomized controlled trial using a 2 x 2 design in a hospital-based rheumatology clinic. Subjects comprised 106 patients with heel pain referred by general practitioners and other rheumatologists working in Camden and Islington Health Authority. Main outcome measures: heel pain reduction at 1, 3 and 6 months, and patient comfort at the time of injection. All outcomes were measured using a 10 cm visual analogue scale. Results. A statistically significant reduction in pain was detected at 1 month (P = 0.02) in favour of steroid injection, but thereafter no differences could be detected. Patient comfort was not significantly affected by anaesthesia of the heel (P = 0.5). Conclusions. A steroid injection can provide relief from heel pain in the short term. There appears to be no increase in patient comfort from anaesthetizing the heel prior to infiltration.

Oral Ketamine and Transdermal Nitroglycerin as Analgesic Adjuvants to Oral Morphine Therapy for Cancer Pain Management

Abstract: BACKGROUND: Guidelines for cancer pain management include nonsteroidal antiinflammatory drugs with opioids administered in a time-contingent manner. This study was designed to evaluate the role of oral ketamine or transdermal nitroglycerin polymer, a nitric oxide donor, as coadjuvants to oral morphine in cancer pain therapy. METHODS: After institutional approval and informed patient consent were obtained, 60 patients with cancer pain were randomized to one of four groups (n = 15) and studied prospectively to evaluate analgesia and any adverse effects. A visual analog scale that consisted of a 10-cm line with 0 representing "no pain at all" and 10 representing "the worst possible pain" was introduced. All patients were regularly taking oral amitriptyline 50 mg at bedtime. The morphine regimen was adjusted individually to a maximal oral dose of 80-90 mg/day to keep the visual analog scale score less than 4. When patients reported pain (visual analog scale of 4 or more), despite taking 80-90 mg oral morphine daily, the test drug was added as follows: the control group (CG) received an additional 20 mg oral morphine (10 mg at 12-h intervals); the nitroglycerin group (NG) received a 5-mg nitroglycerin patch daily; the ketamine group (KG) received 0.5 mg/kg oral ketamine at 12-h intervals; and the dipyrone group (DG) received 500 mg oral dipyrone at 6-h intervals. Patients were free to manipulate their daily morphine consumption when the test drug was introduced to keep their visual analog scale score less than 4. RESULTS: The groups were similar with respect to demographic data and visual analog scale pain scores before treatment. The visual analog scale scores after the test drug was introduced were similar among the groups. The daily consumption of oral morphine was as follows: on day 15: CG = DG = NG (P > 0.05), CG > KG (P = 0.036); on day 20: CG > NG = KG (P KG, P NG, P KG (P KG = NG (P < 0.05). Patients in the CG and DG groups reported somnolence, but patients in the NG and KG groups did not. CONCLUSIONS: Low-dose ketamine and transdermal nitroglycerin were effective coadjuvant analgesics. In conjunction with their opioid tolerance-sparing function, joint delivery of ketamine or nitric oxide donors with opiates may be of significant benefit in cancer pain management.

Quality of life, health-state utilities and willingness to pay in patients with psoriasis and atopic eczema.

Abstract: Skin diseases have been shown to have a significant adverse impact on the health-related quality of life of patients that may be underestimated by objective assessments of clinical severity. The main aim of this study was to measure the health-state utilities on a scale between 0 (dead) and 1 (full health) of patients with psoriasis and atopic eczema, and to measure the willingness to pay for a cure for psoriasis and atopic eczema. A second aim was to analyse how these measures are related to different dimensions of health-related quality of life, as measured by general and disease-specific quality of life instruments and a subjective measure of disability activity. This study was based on data from a questionnaire administered to, and interviews conducted with, 366 patients with psoriasis and atopic eczema aged 17-73 years, attending the dermatology outpatient clinic in Uppsala, Sweden from November 1996 to December 1997. The survey included: a rating scale question, a time trade-off question, a standard gamble question, a dichotomous choice willingness to pay question, a bidding-game willingness to pay question, a generic quality of life instrument (SF-36), a disease-specific quality of life instrument (the Dermatology Life Quality Index) and a subjective measure of disease activity (on a visual analogue scale). The mean health-state utility was 0.69 (rating scale), 0.88 (time trade-off) and 0.97 (standard gamble) for patients with psoriasis. The corresponding health-state utilities for patients with atopic eczema were 0.73, 0.93 and 0.98. On average, patients were willing to pay between 1253 and 1956 Swedish crowns (SEK) per month for a psoriasis cure and between SEK 960 and 1083 per month for an atopic eczema cure ($1 = SEK 8.25 and pound1 = SEK 13.23). The health-state utilities were related to SF-36, the Dermatology Life Quality Index and disease activity in the expected direction and the correlations were strongest for rating scale and weakest for standard gamble. The willingness to pay was correlated with the Dermatology Life Quality Index and disease activity, but not with SF-36. The study indicates that it is feasible to measure health-state utilities and willingness to pay in this patient population, and the sizeable willingness to pay suggests that skin diseases are associated with substantial reductions in quality of life.

Fatigue, Pain, and Depression in Pre‐Autotransplant Breast Cancer Patients

Abstract: objectives: The purpose of this study was to determine the influence of fatigue, pain, and depression on health status in breast cancer patients who had completed adjuvant chemotherapy and were scheduled for autologous bone marrow/peripheral blood stem cell transplant (AT). materials and methods: A predictive, correlational design was used. A convenience sample of 127 women with stages II, III, and IV breast cancer was recruited. The setting was an urban National Cancer Institute-designated comprehensive cancer center located in the Eastern United States. Standardized questionnaires and the Gaston-Johansson Painometer (POM) were used to measure the variables. The subjects completed questionnaires in the outpatient clinic. Relationships between the multiple dimensions of fatigue and pain, depression, and health status were examined. Hierarchical regression techniques were used to determine the variance in health status accounted for by fatigue, pain, and depression. results: The subjects were age 22 to 60 years (Mean = 45; SD = 7.6), and primarily were married, white, Protestant, college educated, employed in a professional position, and had an average yearly household income of equal to or greater than $50,000. All subjects had previously received surgery and chemotherapy. Ninety-one percent of the participants reported fatigue as measured by the Fatigue Visual Analogue Scale. Forty-seven percent of the participants reported pain as measured by the Gaston-Johansson POM visual analogue scale. Fifty-four percent of the participants reported depression, ranging from mild to severe/high. Subjects reported a mean total perceived health status rating of 50.73 (SD 10.79). Fatigue, pain, and depression were all significantly correlated to each other and to total health status. Depression (P < .001) and pain (P < .01) significantly accounted for 64% (adjusted R2 = .60) of the variance in total health status. Fatigue (P < .05) and depression (P < .001) accounted for 42% (adjusted R2 = .36) of the variance in the perception of health status. conclusions: Women with breast cancer previously treated with chemotherapy and awaiting AT may experience fatigue, pain, depression, and alterations in health status. Pain and depression had a significant impact on a woman's total health status, whereas depression and fatigue had an influence on perceived health status. Of the different dimensions of health status, one's perceptions of health status had the strongest correlation to total health status (r = .84, P < .001). Healthcare professionals need to be aware of the effects of multiple symptoms on health status and to provide appropriate care to alleviate them.

Glucosamine, chondroitin, and manganese ascorbate for degenerative joint disease of the knee or low back: a randomized, double-blind, placebo-controlled pilot study.

Abstract: Objective A 16-week randomized, double-blind, placebo-controlled crossover trial of a combination of glucosamine HCl (1,500 mg/day), chondroitin sulfate (1,200 mg/day), and manganese ascorbate (228 mg/day) in degenerative joint disease (DJD) of the knee or low back was conducted. Methods Thirty-four males from the U.S. Navy diving and special warfare community with chronic pain and radiographic DJD of the knee or low back were randomized. A summary disease score incorporated results of pain and functional questionnaires, physical examination scores, and running times. Changes were presented as a percentage of the patient's average score. Results Knee osteoarthritis symptoms were relieved as demonstrated by the summary disease score (-16.3%; p = 0.05), patient assessment of treatment effect (p = 0.02), visual analog scale for pain recorded at clinic visits (-26.6%; p = 0.05) and in a diary (-28.6%; p = 0.02), and physical examination score (-43.3%; p = 0.01). Running times did not change. The study neither demonstrated, nor excluded, a benefit for spinal DJD. Side effect frequency was similar to that at baseline. There were no hematologic effects. Conclusions The combination therapy relieves symptoms of knee osteoarthritis. A larger data set is needed to determine the value of this therapy for spinal DJD. Short-term combination therapy appears safe in this setting.

Fear of falling in patients with stroke: a reliability study

Abstract: Objective: To examine the scaling properties and test–retest reliability of an expanded version of the Falls Efficacy Scale (FES) and to compare group differences in the scores. The expanded version focuses on more basic, primary activities of daily living (ADL), which makes the scale more suitable for subjects with moderate to low functional ability, e.g. patients with stroke.Design: A test–retest reliability study with one group convenience sample.Setting: Two day-care units: a rehabilitation unit and a geriatric rehabilitation unit.Subjects: A volunteer sample of 30 patients (mean age 65 years, SD 11 years) who had sustained stroke between 5 and 84 months prior to the investigation.Main outcome measure: A 13-activity questionnaire (the Swedish modification of the Falls Efficacy Scale (FES(S)) comprising the 10 activities of the original FES and three additional activities was used. Falls efficacy was rated on a 10-point visual analogue scale for each activity on two occasions, 5–22 (mean 10, Md 7) days...