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   Table of Contents - Current issue
Coverpage
January-April 2018
Volume 32 | Issue 1
Page Nos. 1-55

Online since Monday, April 30, 2018

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EDITORIAL  

Pain and psychology: Do we need to change the way we treat patient? p. 1
Kailash M Kothari, Khushali Tilvawala
DOI:10.4103/ijpn.ijpn_24_18  
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REVIEW ARTICLES Top

Sacroiliac joint: A review p. 4
Khushali Tilvawala, Kailash Kothari, Rupal Patel
DOI:10.4103/ijpn.ijpn_18_18  
Sacroiliac joint (SIJ) pain is one of the common but underdiagnosed source of mechanical low back pain. The incidence is estimated to be in the range of 15%–30% in patients with nonradicular low back pain. The signs and symptoms of SIJ pain mimic pain arising from other causes of low back pain. There is no single symptom or physical examination finding that can firmly diagnose SIJ as a source of patient's pain. There is good evidence suggesting that a combination of three or more positive provocative tests strongly suggests SIJ dysfunction. Intra-articular injection with local anesthetic is considered the gold standard for diagnosis of SIJ pain. Many treatment modalities are available for SIJ pain, ranging from conservative management to surgical interventions. This review article covers all the aspects of SIJ pain, with treatment section mainly covering evidence-based interventional procedures.
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Aflapin®: A novel and selective 5-lipoxygenase inhibitor for arthritis management p. 16
Manoj A Suva, Dharmesh B Kheni, Varun P Sureja
DOI:10.4103/ijpn.ijpn_71_17  
Osteoarthritis (OA) is the most common form of arthritis characterized by progressive destruction of joint cartilage tissue, pain and inflammation, stiffness, and impaired physical activity. It is the most prevalent and leading cause of pain and disability across the globe. During the pain and inflammatory process, 5-lipoxygenase (5-LOX) pathway is also involved, which generates leukotrienes (LTs), namely LTB4 and cysteinyl LTs. Osteoblasts also synthesize LTs, which stimulate and enhance the production of interleukin 1, tumor necrosis factor α, and various other cytokines that are potent inflammatory mediators. LT formation leads to cartilage degradation and compensates chondrocyte-mediated cartilage repair mechanism. Current therapies include nonsteroidal anti-inflammatory drugs, analgesics, and disease-modifying agents, but do not affect 5-LOX pathway. Boswellia serrata extract–derived boswellic acids are specific, non-redox inhibitors of 5-LOX, and 3-O-acetyl-11-keto-β-boswellic acid (AKBA) possesses the most potent 5-LOX inhibitory activity. B. serrata extracts have shown significant efficacy and safety in the treatment of various inflammatory disorders such as OA, rheumatoid arthritis, asthma, and inflammatory bowel diseases. Aflapin® is a novel synergistic composition containing B. serrata extract selectively enriched with 20% AKBA and B. serrata nonvolatile oil. Aflapin® is a patented, selective, and most potent 5-LOX inhibitor, which significantly reduces joint pain, inflammation, stiffness, and improves physical function compared to placebo and other B. serrata extract. Aflapin® also significantly reduces matrix metalloproteinase levels, enhances chondrocytes proliferation, and increases glycosaminoglycans levels, thereby providing cartilage protection in arthritis. Numerous in vitro studies, preclinical studies, and clinical studies suggest the potential of Aflapin® as a useful therapeutic intervention for the management of arthritis.
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Plantar fasciitis: A review p. 24
Nitin Ajitkumar Menon, Jitendra Jain
DOI:10.4103/ijpn.ijpn_3_18  
Plantar fasciitis, though a common condition seen by pain specialists, occasionally presents diagnostic dilemmas and very often the management of this condition suffers from lack of awareness of the varied treatment modalities and progressive escalation of treatment options. For this purpose, we searched through all articles with key words of plantar fasciitis or heel pain in the last ten years for which full text was available and compiled a narrative review to guide clinical decision making. An appreciation of pathomechanics of involved structures, possible differential diagnoses and a review of all treatment modalities presented in this article may perhaps help in simplifying matters. Treatment options consist of non-invasive physical therapy modalities, footwear modification, exercise program and newer modalities like shock-wave therapy, minimally invasive treatments like steroid or platelet-rich plasma injections and surgery in recalcitrant cases. Resorting to combining treatment modalities, step-wise escalation of treatment depending on duration of the condition and using our suggested step-ladder approach maybe an appropriate way of treating this condition.
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ORIGINAL ARTICLES Top

Evaluation of knowledge, attitude, and practices of nurses regarding pain management in tertiary care hospitals of Pune, India p. 30
Madhuri A Lokapur, Poonam P Vasani, Nivedita D Page
DOI:10.4103/ijpn.ijpn_65_17  
Aim: Nurses are the point of contact for patients admitted in hospital wards. Nurse's deal with all complaints of the patients, most common being pain. Hospitalised patients can suffer from pain due to various causes like post-operative, infection, malignancy, trauma, iatrogenic causes like i.v. cannulation, catheters etc. Proper management of pain in such patients improves patient experience and doctor-patient relationship. The knowledge and attitude of nurses regarding pain management affects the overall patient experience in hospital. We conducted a survey among nurses of tertiary care hospital (including government and private hospitals) in Pune regarding their knowledge, attitude and practices in pain management. Our questionnaire consisted of 20 questions relating to knowledge, attitude and practices of nurses in pain management. Material and Method: A survey was conducted among 248 nurses of tertiary care hospital (including government and private hospitals) in Pune regarding their knowledge (6 questions), attitude (5 questions) and practices (7 questions) in pain management using a questionnaire. Statistical Analysis: Questionnaire comprised all categorical answers hence descriptive statistics (percentage values) of all the individual categories was calculated. Results: Our survey revealed deficiency in nowledge, attitude and practices of nurses regarding basics of pain management, especially cancer pain and opioid use. Conclusion: This study has brought to light the deficiency in nursing curriculum or training regarding basics of pain management specifically cancer pain and opioid use.
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Intra-Articular hyaluronic acid injection versus RF ablation of genicular nerve for knee osteoarthritis pain: A randomized, open-label, clinical study p. 36
Debanjali Ray, Subrata Goswami, Santi R Dasgupta, Subrata Ray, Sagarmay Basu
DOI:10.4103/ijpn.ijpn_2_18  
Background: Chronic knee osteoarthritis (OA) is one of the most common diseases of advanced age. Available therapies have insufficient evidence and adverse effects. Hyaluronic acid (HA) injection reduces knee pain in certain patients only for short duration. Radiofrequency (RF) neurotomy of genicular nerve branches has been tried recently. Comparison of these two modalities is lacking. The aim of this study was to compare pain relief and daily activities by visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between intra-articular HA injection and RF neurotomy of genicular nerves. Materials and Methods: Patients were treated with intra-articular HA injection and RF neurotomy of genicular nerves 12 in each group (n = 12). Pain relief and day-to-day activity were compared. Results: There was statistically significant difference and lower VAS and WOMAC scores in the RF group compared to HA group after treatment. Conclusion: As compared to intra-articular HA injection, RF neurotomy of genicular nerves appears to be a promising and more effective therapeutic procedure for patients with chronic knee OA.
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Pregabalin versus oxcarbazepine in painful diabetic neuropathy in elderly population: Efficacy and safety in terms of pain relief, cognitive function, and overall quality of life p. 40
Syed H Amir, Farah Nasreen, Hammad Usmani, Sheelu S Siddiqi, Muazzam Hasan, Nazia Tauheed
DOI:10.4103/ijpn.ijpn_76_17  
Background and Aims: The treatment of painful diabetic neuropathy (PDN) in elderly patients is challenging considering the adverse effects associated with long term use of drugs. Pregabalin has been recommended as the first line therapy for relief of neuropathic pain in such patients. However, the occurrence of side effects especially cognitive dysfunction and peripheral edema raised concerns during long term therapy in elderly population. Recently, few studies have highlighted the role of oxcarbazepine, a second generation antiepileptic, in PDN. This prospective, randomized, single-blind, parallel-group study was done to compare pregabaline and oxcarbazepine monotherapy in patients of PDN. Materials and Methods: 150 elderly patients of painful diabetic neuropathy, for at least 6 months of duration with an average baseline pain score ≥ 4 on 11 point numeric rating scale (NRS), were divided into two groups to receive either pregabalin 150 mg/day or oxcarbazepine 600 mg/day. Assessment of pain scores, cognitive functions and quality of life were performed at different time intervals during the course of treatment. Results: Patients in both the study groups showed significant reduction in pain scores from the baseline; however no significant differences in pain scores were noted between the two groups during the course of treatment. The incidence of cognitive dysfunction as measured by BCRS score was significantly more in pregabalin group while no significant changes were noted in oxcarbazepine group. The overall quality of life as demonstrated by SF12 scores was significantly better in both the study groups as compared to baseline. Conclusion: Oxcarbazepine can be used as an alternative to pregabalin in elderly patients with PDN considering the similar degree of pain relief and better cognitive profile.
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Comparison of efficacy and safety of transdermal buprenorphine patch applied 48 versus 72 hours preoperatively in providing adequate postoperative analgesia following major abdominal surgeries p. 46
Dilesh Kadapamannil, Sunil Rajan, Pulak Tosh, Lakshmi Kumar
DOI:10.4103/ijpn.ijpn_4_18  
Introduction: A transdermal drug delivery system provides steady and continuous drug delivery. As the onset of action is delayed, it has to be applied preoperatively to provide optimal postoperative analgesia. Aim: To compare the efficacy and safety of transdermal buprenorphine patches applied 48 and 72 h preoperatively in providing adequate postoperative analgesia following major abdominal surgeries and the incidence of side effects. Materials and Methods: This prospective randomized, double-blinded study was conducted in a tertiary care institution. Thirty patients undergoing laparotomy were recruited. Group A (n = 15) received a transdermal buprenorphine 10 mg patch with a delivery rate of 10 μg/h, which was applied approximately 48 h before surgery, whereas in group B (n = 15) buprenorphine 10 mg patch was applied 72 h preoperatively. All patients received general anesthesia following standardized protocol. Postoperative pain was assessed using numerical rating scale (NRS). The Mann–Whitney U test and independent t-test were used for statistical analysis. Results: NRS was significantly high in group A for up to 30 h postoperatively as compared to group B. From 36 to 48 h, it was comparable. The need for rescue analgesia was significantly high in group A as compared to group B. Significant number of patients in group B experienced nausea and vomiting (53.33% vs. 26.67%) and sedation (20% vs. 13.33%) in the preoperative period. Conclusion: Transdermal buprenorphine patch applied 72 h preoperatively provided better analgesia than the one applied 48 h before surgery. However, its preoperative use in patients without painful conditions predisposes them to develop side effects.
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CASE REPORT Top

Chronic pain, substance abuse and depression: Unfolding the common linkage p. 51
Supriya Agarwal, Kaveri Saxena, Malvika Dahuja, Sandeep Choudhary
DOI:10.4103/ijpn.ijpn_78_17  
The population bears a huge psychological, social and financial burden due to chronic pain and with its comorbidities it further adds to this burden. There are high rates of co-occurrence of depression and substance abuse, which are often overlooked. Therefore, patients presenting with pain or depression or substance abuse or a combination of these need to be evaluated thoroughly for the presence of the others. We report a case of a patient with primary complaints of pain and depressive symptoms with opioid and benzodiazepine abuse for over 16-18 years and discuss the neurobiological linkage between the three comorbid conditions.
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LETTER TO THE EDITOR Top

Intrathecal morphine: Present status p. 54
Abhijit Sukumaran Nair, Basanth Kumar Rayani
DOI:10.4103/ijpn.ijpn_16_18  
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