An alternative for pain control after knee replacement surgery

Orthopedics_Anesthesiology

It’s estimated that more than half of adults in the United States diagnosed with knee osteoarthritis will undergo knee replacement surgery. While improvements in implantable devices and surgical technique has made the procedure highly effective, pain control after surgery remains a common but persistent side effect for patients.

A Henry Ford Hospital study, presented recently at the American Association of Hip and Knee Surgeons meeting in Dallas, found that injecting a newer long-acting numbing medicine called liposomal bupivacaine into the tissue surrounding the knee during surgery may provide a faster recovery and higher patient satisfaction.

“The pain scores for this injection technique averaged about 3/10, which is similar to the pain scores seen with our traditional method,” says Jason Davis, M.D., a Henry Ford West Bloomfield Hospital joint replacement surgeon and the study’s senior author. “Patients had pain relief for up to two days after surgery and better knee function compared with the traditional method.”

It is estimated that the number of total knee replacement surgeries has more than tripled from 1993 to 2009. Arthritisis the most common cause of chronic knee pain and disability. However, a June 2014 study found that 95 percent of knee surgeries are attributed to the epidemic of overweight and obesity in the United States.

During the two-hour knee replacement procedure, the orthopedic surgeon removes the damaged cartilage and bone, and inserts a knee implant to restore the alignment and function of the knee. More than 90 percent of knee replacements are functioning 15 years after surgery, according to the American Academy of Orthopaedic Surgeons.

In the Henry Ford study, 216 patients were evaluated for pain control the first two days after surgery from October 2012 to September 2013. Half of the patients received the traditional pain control method with continuous femoral nerve blockade, in which common numbing medicine is injected into the groin area, blunting the main nerve down the front of the knee. This method uses a pain pump to extend pain control for two days but causes some leg weakness. “Pain control came at the price of weakness and made patients somewhat tentative when walking during their hospital stay,” Dr. Davis says.

The other half of patients received the liposomal bupivacaine injection at the site of the surgery.

Dr. Davis says many patients were able to walk comfortably within hours after surgery.

Dr. Davis says the injection around the knee itself “optimizes pain control early on” without the side effects of the traditional technique. “Function-wise, it was a lot easier for patients to move around more confidently,” he says. “In the past decade, we’ve made major advancements in pain control for knee replacement surgery. This option is a promising, viable one for our patients.”

Adapted by MNT from original media release

http://www.medicalnewstoday.com/releases/287423.php

 

 

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The difficulties of treating shoulder pain in baseball pitchers

Anesthesiology

Results of treating shoulder pain in baseball pitchers and other throwing athletes are not as predictable as doctors, patients and coaches would like to think, according to a report in the journal Physical Medicine and Rehabilitation Clinics of North America.

Nickolas Garbis, MD, an orthopedic surgeon who specializes in shoulder and elbow injuries at Loyola University Medical Center, is the primary author.

Shoulder pain occurs in athletes who play sports that require rapid acceleration and deceleration of the throwing arm. They include baseball pitchers, tennis players, softball pitchers and javelin throwers, as well as athletes who play handball and water polo.

Overhead throwing generates a large amount of stress on the shoulder, which is one of the most mobile joints in the body. This makes it vulnerable to injury.

It is difficult to diagnose the cause of shoulder pain. The shoulder is comprised of four joints, and a problem with any of them can cause pain and affect performance. Moreover, many of these structures are deep in the shoulder and therefore difficult to examine by touch. Also, the same kind of pain can be due to multiple causes. For example, pain in the front of the shoulder can be due to rotator cuff tendinitis, rotator cuff tears, biceps tendinitis, shoulder instability, shoulder stiffness and several other causes.

“A systemic approach, and some experience, can help the clinician become more familiar with which constellation of findings in these athletes is not normal,” Dr. Garbis and co-author Edward McFarland, MD, write.

Shoulder problems can begin during adolescence. Little League shoulder, an injury to the growth plate in the shoulder, is one of the most common. Adolescent pitchers most at risk for injuries are those who compete on traveling teams. Overuse injuries can lead to more serious mechanical injuries. Adhering to pitch counts should reduce injuries and decrease fatigue.

Treatment should be primarily nonsurgical. Nonsurgical options include icing the shoulder and judicial use of nonsteroidal anti-inflammatory medications such as ibuprofen and naproxen. Rehabilitation can restore a normal muscular balance. Rest can help, but it should not be prolonged, because the shoulder could become deconditioned.

If nonsurgical options fail, arthroscopic surgery can be considered. For example, surgical repair or trimming of partial rotator cuff tears can be highly successful, returning as many as 89 percent of college and professional pitchers back to play. However, the type of surgery needed depends upon the patient’s shoulder problem.

http://www.medicalnewstoday.com/releases/286793.php

 

 

 

Pain relief for kids in the ER without a needle

Emergency Medicine_Pediatrics_Orthopedic Surgery_Anesthesiology

Children in emergency departments can safely be treated for pain from limb injuries using intranasal ketamine, a drug more typically used for sedation, according to the results of the first randomized, controlled trial comparing intranasal analgesics in children in the emergency department. The study was published online recently in Annals of Emergency Medicine (“The PICHFORK (Pain in Children Fentanyl OR Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children with Limb Injuries”).

“This is great news for emergency physicians and their young patients, especially those who may not tolerate other intranasal pain medications such as fentanyl,” said lead study author Professor Andis Graudins, MD, of Monash University in Clayton, Victoria, Australia. “For children in pain and distress, the option of treating their pain without a needle is a huge benefit as well. The intranasal option using fentanyl is accepted already for children, but the safe use of ketamine is new.”

Researchers compared pain relief resulting from ketamine and fentanyl, both delivered intranasally, for children 3 to 13 years old whose pain from isolated limb injuries registered seven or higher on a 10 point scale. Median baseline pain rating was eight out of ten. After 30 minutes, the median reductions in pain for ketamine were 4.45 and for fentanyl were 4.0. The pain reduction was maintained in both groups at 60 minutes. Satisfaction for ketamine was slightly higher at 83 percent. Fentanyl had a 72 percent satisfaction rating.

Adverse events were reported more frequently for ketamine (78 percent of patient) than for fentanyl (40 percent of patients), but they were all mild (dizziness or drowsiness were common).

“Ketamine is a great alternative for injured children in the ER who may not be able to tolerate opiates, like fentanyl,” said Prof. Graudins. “And being able to deliver pain-relief with minimal upset, such as that triggered in some children by even the sight of needles, is a great boon to our youngest patients.”

http://www.medicalnewstoday.com/releases/286526.php

 

 

New clue to how anesthesia works

Anesthesiology_Thoracic Surgery_Neurosurgery

Anesthesia, long considered a blessing to patients and surgeons, has been a mystery for much of its 160-plus-year history in the operating room.

No one could figure out how these drugs interact with the brain to block pain and induce a coma-like, memory-free state. The debate has divided the anesthesia research community into two camps: one that believes anesthetics primarily act on the cell membrane (the lipid bilayer) of nerve cells, perhaps altering it to the point that embedded proteins cannot function normally. The other says the membrane proteins themselves are altered directly by anesthetics.

Now there is new evidence supporting the latter position. A team of researchers from Weill Cornell Medical College has found that it is the proteins that are affected by commonly used anesthesia. Specifically, activity of ion channel proteins that are important for cell-to-cell communication is markedly reduced when anesthetics are applied, the researchers report in The Journal of General Physiology.

“This is, to our knowledge, the first demonstration that anesthetics alter the function of relevant ion channels without altering properties of the cell membranes,” says the study’s lead investigator, Dr. Hugh C. Hemmings, Jr., professor and chair of anesthesiology at Weill Cornell, who worked in close collaboration with Dr. Olaf S. Andersen, a lipid bilayer expert and professor of physiology and biophysics at Weill Cornell, who has developed methods to quantify the membrane-perturbing effects of drugs and other molecules.

Importantly, Drs. Hemmings and Andersen note, the studies tested clinically relevant concentrations of isoflurane, a widely used anesthetic. Previous studies that found the membrane was altered used much higher doses of isoflurane–concentrations that would never be used in patients.

The distinction matters, says first author Dr. Karl Herold, a research associate in the Department of Anesthesiology who performed and analyzed the experiments.

“Drugs are not perfect–they always have side effects,” Dr. Herold says. “You can only improve drugs if you know how they work, which means that you need to know when drugs have non-specific or undesired membrane effects,” Dr. Andersen adds.

“Now that we have a basic understanding of how anesthetics affect cells in the central nervous system, we have knowledge to improve them,” he says. “In the future, we may be able to design anesthetics that do just what we want them to do, and not what we don’t.”

http://www.medicalnewstoday.com/releases/285514.php

 

 

Pain and anxiety relief for cancer inpatients

Anesthesiology_Pain Management

Pain is a common symptom of cancer and side effect of cancer treatment, and treating cancer-related pain is often a challenge for health care providers.

The Penny George Institute for Health and Healing researchers found that integrative medicine therapies can substantially decrease pain and anxiety for hospitalized cancer patients. Their findings are published in the current issue of the Journal of the National Cancer Institute Monographs.

“Following Integrative medicine interventions, such as medical massage, acupuncture, guided imagery or relaxation response intervention, cancer patients experienced a reduction in pain by an average of 47 percent and anxiety by 56 percent,” said Jill Johnson, Ph.D., M.P.H., lead author and Senior Scientific Advisor at the Penny George Institute.

“The size of these reductions is clinically important, because theoretically, these therapies can be as effective as medications, which is the next step of our research,” said Jeffery Dusek, Ph.D., senior author and Research Director for the Penny George Institute.

The Penny George Institute receives funding from the National Center of Alternative and Complementary Medicine of the National Institutes of Health to study the impact of integrative therapies on pain over many hours as well as over the course of a patient’s entire hospital stay.

“The overall goal of this research is to determine how integrative services can be used with or instead of narcotic medications to control pain,” Johnson said.

Researchers looked at electronic medical records from admissions at Abbott Northwestern Hospital between July 1, 2009 and December 31, 2012. From more than ten thousand admissions, researchers identified 1,833 in which cancer patients received integrative medicine services.

Patients were asked to report their pain and anxiety before and just after the integrative medicine intervention, which averaged 30 minutes in duration.

Patients being treated for lung, bronchus, and trachea cancers showed the largest percentage decrease in pain (51 percent). Patients with prostate cancer reported the largest percentage decrease in anxiety (64 percent).

Adapted by MNT from original media release

http://www.medicalnewstoday.com/releases/285107.php

Picture courtesy of millcityfarmersmarket.org

 

Number of Patients Experiencing Postsurgical Pain Reduced by 24% in Last Decade

Anesthesiology

 

The number of patients reporting moderate to severe pain two weeks after surgery has decreased by 24% in the last decade, a new study found.

Researchers surveyed 441 patients before they were discharged from the hospital, and then at one, two and three weeks after surgery. Patients were asked to rate their pain intensity and satisfaction with the pain medicine they were given. The results were then compared to a similar study conducted from 1998 to 2002.

The investigators found that 39% of patients experienced moderate to severe pain two weeks after surgery compared with 63% in the previous study.

“During the last 10 years there have been significant changes in hospitals to support better pain management post-surgery,” said lead study author Asokumar Buvanendran, MD, director of orthopedic anesthesia at Rush University Medical Center in Chicago, in a press release. “Our study shows that health care providers are implementing better pain protocols and heading in the right direction.”

The number of patients who reported no pain remained at 22%. And patients continued to be satisfied with their pain management.

Increased measures put in place by hospitals and the involvement of physician anesthesiologists have also contributed to this decrease, according to Dr. Buvanendran.

“Greater awareness among health care providers and the implementation of advanced pain measures have led to great improvements. We are moving forward, but there is still plenty to be done to improve pain management and the quality of health care,” he said.

The findings were presented at American Society of Anesthesiologists’ (ASA) annual meeting in New Orleans.

Based on a press release from the ASA.

http://www.anesthesiologynews.com/ViewArticle.aspx?d=Web%2bExclusives&d_id=175&i=October+2014&i_id=1107&a_id=28573

 

 

Fibromyalgia linked to decreased brain connectivity

Anesthesiology

New study from Sweden finds fibromyalgia is linked to abnormal activity in parts of the brain that process pain signals and link them to other regions.

Dr. Pär Flodin and colleagues, from the Karolinska Institute in Stockholm, report their findings in the journal Brain Connectivity.

Fibromyalgia syndrome is a common and chronic condition of unknown cause that mostly strikes in middle age, although symptoms can often present earlier. Sufferers typically experience fatigue with long-term pain in several areas of the body, plus tenderness in soft tissues such as the muscles, joints and tendons.

We don’t know why, but while men and children can also have it, the vast majority of those diagnosed with fibromyalgia are women.

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, scientists estimate that fibromyalgia affects 5 million adult Americans.

Decreased brain connectivity in fibromyalgia patients

For their study, the Karolinska researchers compared brain activity in women with and without fibromyalgia. In fibromyalgia patients, they found decreased connectivity between brain areas that process pain and sensorimotor signals.

 

They suggest their findings show reduced brain connectivity may contribute to deficient pain regulation in people with fibromyalgia.

The results build on previous studies that have linked abnormal brain activity to poor pain inhibition.

For the study, 22 healthy women and 16 with fibromyalgia underwent functional magnetic resonance imaging (fMRI) brain scans while experiencing different levels of pain by having pressure applied to the thumb.

The day before the scans, the women completed tests to calibrate their pain sensitivity. A computer-controlled pressure stimulator applied pressure to their left thumb, while they rated the sensitivity. Pressure intensities derived from these ratings were then delivered in a random order as the women underwent the brain scans.

The participants had to refrain from taking pain medication and sedatives 48 hours before the assessment of pain and 72 hours before the fMRI scans. Altogether, each received 15 stimuli lasting 2.5 seconds each, at half-minute intervals.

Reduction in brain connectivity could impair pain perception

The results showed that the fibromyalgia participants had significantly increased pain sensitivity compared with the control group.

When they analyzed the brain scans, the team found differences in brain patterns between the healthy participants and those with fibromyalgia. The fibromyalgia participants showed “functional decoupling” between areas of the brain that process pain signals and other parts, including those that control sensorimotor activity.

The authors suggest this reduction in brain connectivity could impair pain perception.

The co-editor-in-chief of the journal, Dr. Christopher Pawela, an assistant professor at the Medical College of Wisconsin in the US, describes the study as “an important first step” in understanding how the brain affects widespread pain perception, which is a known characteristic of fibromyalgia.

In February 2014, Medical News Today learned of a UK study that found poor sleep is tied to widespread pain and fibromyalgia.

Written by Catharine Paddock PhD

http://www.medicalnewstoday.com/articles/283346.php