A survey of pain relief clinics in the South Western Region.

All the district general hospitals in the South Western Health Region have a pain relief service in existence or planned for the immediate future. Almost all are recognized by the allocation of anaesthetic consultant sessions. In most cases, this allocation is less than the time required for pain relief. All the consultants concerned work in single disciplinary clinics and accept both in-patient and out-patient referrals. They provide an advisory and therapeutic service to patients in the care of other clinicians and give tuition, mainly to junior anaesthetists. Most also undertake domiciliary assessment and treatment. In most clinics the pain relief Service is hampered by inadequate facilities. The minimum facilities for a basic efficient service are here reviewed.

Lumbar epidural blockade for management of pain in interstitial cystitis.

Thirteen patients with interstitial cystitis (IC), whose predominant symptom was pelvic or urethral pain, were treated with a series of lumbar epidural local anaesthetic blocks over an 18-month period. Response was evaluated by interview and with voiding diaries and visual analogue scales (VAS) for pain. Of the 55 injections given, immediate pain relief (lasting longer than 24 h) was obtained from 41 (75%). The duration of subsequent pain relief varied considerably, ranging from 2 to 75 days (mean 15.1). pain relief was accompanied by significant improvement in sleep habit and quality of life. A good correlation was noted between verbally expressed pain and the recorded VAS pain scores. Urinary frequency and average voided volumes were unaffected by treatment. Two patients failed to obtain any relief. Apart from minor transient backache at the injection site, there were no complications from the procedure. Lumbar sympathetic epidural blockade is an excellent means of providing pain relief in interstitial cystitis.

Palliative radiotherapy of bone metastases: an evaluation of outcome measures.

The objective of this study was to identify and evaluate important patient-based outcomes that are specific to the palliative radiotherapy of bone metastases. We first conducted a literature review to identify and evaluate outcomes that are currently in use. To identify outcomes that are important to patients, in-depth patient interviews were conducted. Finally, issues identified through the interviews were quantified through a prospective survey, in which patients completed a questionnaire prior to commencing radiotherapy and again after 6 weeks. In our literature review, we found that there was no standardized definition of either response to radiotherapy or assessment of pain relief. Pain measurement in many studies was undertaken using very simple measures, which could possibly yield inaccurate results. The vast majority of studies did not include quality of life as an endpoint. The patient interviews and survey showed that chronic pain and associated limitation of movement were the disease symptoms causing the most concern. Having a clear, alert mind and being able in self-care were the aspects of daily living given the highest priority. Sustained pain relief and minimizing the risk of future complications were the main priorities relating to radiotherapy treatment. The practical aspects of treatment (travelling distance, remaining at home and brevity of treatment) were of least importance. This study indicates the complexity of evaluating the outcomes of palliative interventions, and confirms the deficiencies of pain relief as the primary end-point. The patient's quality of life is affected by many factors other than pain (such as limited mobility, reduced performance, side effects and impaired role functioning); hence a wider range of end-points is required. Greater sensitivity is required than in currently used end-points. Concurrent diseases as well as concurrent therapies can make it difficult to attribute effects with precision. Unless such factors are considered in research design, the results may prove unreliable.

Cost-effectiveness of long-term intrathecal morphine therapy for pain associated with failed back surgery syndrome.

A decision analytic study was conducted using computer simulation to project the outcomes in a simulated cohort of patients whose treatment for back surgery had failed. The objective of this study was to estimate the direct cost of intrathecal morphine therapy (IMT) delivered via an implantable pump relative to alternative therapy (medical management) over a 60-month course of treatment. IMT administered by way of an implantable pump can provide effective pain relief for selected patients whose less invasive treatment modalities have failed. Previous research suggested that a pump implant is less costly than alternative methods providing comparable analgesia for treatment exceeding 12 to 18 months. However, those analyses did not include the cost of complications or pump replacement. Scenarios representing the course of IMT, devised by a panel of experts, were represented as treatment pathways in a Monte Carlo simulation. Adverse event rates were drawn from published data supplemented by expert judgment. Direct costs were based on a health insurer paid claims perspective (direct costs) discounted at a 5% annual rate. The cost-effectiveness of IMT was calculated based on a report of 65% to 81% "good to excellent" pain relief relative to alternative (medical) management. With both adverse event probabilities and costs set at most likely (base case) values, the expected total cost of IMT over 60 months was $82,893 (an average of $1382 per month). In a sensitivity analysis, the best case (low adverse event rate, low cost) estimate was $53,468 ($891/mo), whereas the worst case (high adverse event rate, high cost) estimate was $125,102 ($2085/mo). Cost-effectiveness estimates ranged from $7212 (best case) to $12,276 (worst case) per year of pain relief. Results from a computer simulation designed to collect the costs not included in previous empiric research indicate that IMT appears to be cost-effective when compared with alternative (medical) management for selected patients when the duration of therapy exceeds 12 to 22 months.

A retrospective analysis of neurolytic celiac plexus block for nonpancreatic intra-abdominal cancer pain.

Neurolytic celiac plexus block (NCPB) has been reported to be an effective method for pain relief for a variety of intra-abdominal malignancies, especially pancreatic. In spite of this, few data exist concerning efficacy of the block for pain related to other intraabdominal tumors. The author analyzed the quality of pain relief obtained and complications during the use of NCPB in 66 patients with nonpancreatic intraabdominal malignancies. Seventy-three percent of the patients with nonpancreatic cancer pain had good pain relief, which in 59% of cases lasted through the remaining life of the patients. The incidence of neurologic injury (footdrop) was less than 0.5%. This therapy deserves more widespread use in patients with abdominal pain secondary to a variety of other malignancies, in addition to that of the pancreas.

Bilateral chronic proximal plantar fasciopathy: treatment with electrohydraulic orthotripsy.

BACKGROUND: Patients presenting for treatment of chronic plantar fasciopathy often have bilateral involvement. When various nonoperative treatments fail, subsequent intervention may be problematic, especially since bilateral surgery (bilateral fascial release) may not be realistic because of variable, frequently restrictive postoperative weightbearing limitations. METHODS: Twenty-three patients (46 heels) were treated with electrohydraulic high-energy orthotripsy to the plantar entheses of both feet while under the same anesthesia (conscious sedation). Following orthotripsy, all patients immediately were fully weightbearing and resumed normal activities of daily living and work, usually within 24 hours. Progressive return to athletic activities was allowed. Patients were assessed by three outcome parameters: (1) pain measured objectively by a dolorimeter combined with the patient's subjective evaluation of the level of pain; (2) pain after 5 minutes of walking upon arising; and (3) pain with daily activities. All pain measurements were done by the visual analog scale. RESULTS: Patients initially experienced varied pain relief responses. This included earlier pain relief in one heel compared to the other, as well as better pain relief in one heel than the other at the 6- and 12-week evaluations, but with much less variance at the 1-year evaluation. By 3 months following orthotripsy, 28 heels (61%) had good or excellent results. These results were maintained or improved at 1 year. In 18 heels (39%), the outcome was fair or poor. Nineteen heels received a second orthotripsy application; one patient requested a second orthotripsy treatment of only one heel, while nine patients requested a second treatment of both heels. The outcome showed further improvement following the second application of orthotripsy. At 1 year after one or two orthotripsy applications, 19 patients (38 heels) were satisfied with the results in both heels (83%), while four patients (eight heels) still had an unsatisfactory outcome (17%). CONCLUSION: Electrohydraulic high-energy orthotripsy is a reasonable nonincisional method for treating patients with bilateral chronic proximal plantar fasciopathy under a single anesthetic without the prolonged nonweightbearing status often recommended for patients following unilateral open or endoscopic fascial release.

pain relief with morphine, intrathecally or peridurally?

We investigated pain relief following 1-2 mg morphine intrathecally applied in 7 patients with cancer pains and in 5 patients with multiple rib fractures (group 1). For postoperative pain relief (group 2) we applied 1-2 mg morphine intrathecally in 26 patients immediately before the induction of the anaesthesia. In 30 patients we applied 4 mg morphine epidurally in 10-20 ml saline solution for postoperative pain relief (group 3). In the first group the duration of the pain relief was 25,2 hours, in the second group 31 hours and in the third group 15,7 hours. In the second group a respiratory depression occurred in 3 cases and was successfully treated with naloxon. In the third group a bladder disorder occurred in two cases. Because of the risk of respiratory depression following intrathecally applied morphine, we recommend the epidural way of application.

Long-term pain relief during spinal cord stimulation. The effect of patient selection.

We reviewed our experience with spinal cord stimulation (SCS) in treating 116 patients with pain in one or both legs. All these patients were selected for an initial week of trial stimulation by the criteria: pain due to a known benign organic cause, failure of conventional pain control methods and absence of major personality disorders. Selected patients included 78 with the Failed Back Surgery Syndrome (FBSS), in whom proven correlation existed between the clinical picture and the neuroradiological and electromyogram abnormalities. Eighty-four out of 116 selected patients underwent definitive SCS implantation after 1 week of trial stimulation with excellent results (more than 75% pain relief). They were followed clinically every 3 months for a mean follow-up period of 47 months. Forty-five patients (54%) continued to experience at least 50% of pain relief at the latest follow up. Seventy-seven patients (91%) were able to reduce their medication intake and 50 patients (60%) reported an improvement in lifestyle. FBSS patients responded more positively to the trial stimulation than the other patients. However, the later outcome was not affected by patient selection as long-term benefit was similar in all definitive SCS patients irrespective of aetiology.

Thermoradiotherapy for local control of chest wall invasion in patients with advanced non-small cell lung cancer.

BACKGROUND: We tested the feasibility of hyperthermia combined with concurrent radiotherapy (thermoradiotherapy) for pain relief and local control of non-small cell lung cancer (NSCLC) invading to the chest wall. METHODS: Thirteen patients with advanced NSCLC (eight stage IIIB and five stage IV) and severe pain caused by chest wall invasion of tumor were treated with thermoradiotherapy. During the conventional fractionated radiotherapy period, 8-MHz radiofrequency capacitive hyperthermia was administered once or twice per week for a total of three to nine treatment sessions. pain relief, objective tumor response, thermometry, and toxicity were evaluated. RESULTS: Twelve of the 13 patients (92%) experienced satisfactory pain relief, and objective tumor shrinkage was observed in 11 of the 13 patients (85%), including complete regression in two. The thermometry parameters of minimum and maximum intratumor temperatures, mean of all intratumor temperatures, and rate of the time during which intratumor temperature was 41 degrees C or higher were 37.6 +/- 0.8 degrees C, 42.4 +/- 0.7 degrees C, 40.3 +/- 0.3 degrees C, and 80.1 +/- 8.6%, respectively. Adverse reactions included local transient skin pain in three patients, but no major toxicity was observed. CONCLUSION: Concurrent thermoradiotherapy for chest wall invasion by advanced NSCLC was feasible, with tolerable toxicity, and it may be effective for pain relief and local tumor control. Further studies comparing thermoradiotherapy and radiotherapy alone for such patient populations are warranted.

Brain stimulation.

Electrical stimulation in the PAG has been shown to elicit profound analgesia in experimental animals that is at least in part due to the release of endogenous opioid substances. Electrical stimulation in the thalamic nuclei VPL and VPM inhibits the activation of spinal dorsal horn neurons by noxious stimuli. Acute electrical stimulation in these two targets relieves chronic pain in about 80% of patients. Chronic electrical stimulation by permanently implanted electrodes relieves pain in about 70% of patients with pain of peripheral or nociceptive origin but in only about 50% of patients with central pain resulting from deafferentation. Stimulating electrodes are implanted stereotactically by a burr hole under local anesthesia. Transient complications occur in 15% to 25% of patients and include infections, malfunctions of the stimulating hardware, pain at the implant sites, and mild temporary neurologic deficits. Permanent complications, including hemiparesis, intracranial hemorrhage, and death, occur in 1% to 2% of patients. Brain stimulation is recommended for the treatment of chronic pain in patients in whom other forms of treatment have failed. The technique is reasonably safe and provides pain relief for a group of patients who have exhausted all other therapeutic modalities. Unfortunately, not all patients receive effective pain relief with brain stimulation. Other stimulation targets such as the K-F nucleus in the parabrachial region of the brain stem are currently being explored in an attempt to provide pain relief to a greater proportion of patients. In addition, improvements in stimulation hardware have made the technique easier and more effective.