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Comparative efficacy, safety, and tolerability of diclofenac and aceclofenac in musculoskeletal pain management: A systematic review
Faizal Vohra, Asawari Raut
January-April 2016, 30(1):3-6
Diclofenac and aceclofenac are nonsteroidal antiinflammatory drugs (NSAIDs). Diclofenac is advocated for the treatment of painful and inflammatory rheumatic and certain nonrheumatic conditions such as rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, tendinitis, and bursitis, and in other inflammatory or painful conditions such as strains and sprains, dysmenorrhea, back pain, sciatica, and postoperative pain. Aceclofenac provides symptomatic relief in a variety of painful conditions such as joint inflammation, and reduces pain intensity and the duration of morning stiffness in the patients with rheumatoid arthritis, improves spinal mobility in the patients with ankylosing spondylitis. Gastrointestinal (GI) problems are the most frequent effects, which are caused by diclofenac and include dyspepsia and abdominal pain. Aceclofenac also has similar adverse effect but they are mild compared to diclofenac. We have reviewed 9 prospective studies that compared efficacy and safety of diclofenac with those of aceclofenac, 5 studies on osteoarthritis patients, 1 study on rheumatoid arthritis patients, 1 study on overall musculoskeletal disorders, 1 study on lower back pain, and 1 study on postextraction dental pain. Western Ontario and McMaster (WOMAC) universities scores, visual analogue scale (VAS), the Ritchie index, Lequesne OA severity index (OSI) were used in assessing the pain intensity and measuring the efficacy of the drug that proved beneficial in assessing the pain intensity and measuring the efficacy of both the drugs. All the studies came to the conclusion that aceclofenac is a better choice of drug in managing pain in case of all the above conditions with better efficacy and tolerability, patients experienced more number of adverse events (AEs) with diclofenac when compared with aceclofenac.
  48,565 1,498 2
Post-herpetic neuralgia: A review of current management strategies
Saru Singh, Ruchi Gupta, Sukhdeep Kaur, Jasleen Kaur
January-April 2013, 27(1):12-21
Post herpetic neuralgia (PHN) is a chronic neuropathic pain in the region of the herpes zoster (HZ) rash, persisting after the cutaneous lesions have healed. Despite numerous treatment advances, many patients remain refractory to the current therapies and continue to have pain, physical and psychological distress. In this review, we will discuss the current strategies for prevention and management of this disease, as also the insight into the future probabilities.
  18,939 2,062 3
Pre-emptive analgesia: Recent trends and evidences
Amiya K Mishra, Mumtaz Afzal, Siddhartha S Mookerjee, Kasturi H Bandyopadhyay, Abhijit Paul
September-December 2013, 27(3):114-120
Preemptive analgesia, initiated before the surgical procedure to prevent pain in the early postoperative period has the potential to be more effective than a similar analgesic treatment initiated after surgery. This article aims to review all the recent published evidences that assess the efficacy of this enigmatic concept. Materials and Methods: We reviewed original research articles, case-reports, meta-analyses, randomized control trials (RCTs), and reviews based on pain physiology for preemptive analgesia from Medline, Medscape, and PubMed from 1993 to 2013. A broad free-text search in English was undertaken with major keywords "Preemptive analgesia," "postoperative pain," "preoperative," and "preincisional". Results: Review of publications showed that intravenous (IV) nonsteroidal anti-inflammatory drugs (NSAIDs) are quite effective when used alone, as well as with low dose iv ketamine, preemptively to provide adequate postoperative analgesia. However, ketamine has a doubtful role as a standalone agent. Preemptive administration of LA at the incision site reduces postoperative pain, but achieves an analgesic effect similar to that of postincisional anesthetic infiltration as does intraperitoneal administration. Preemptive epidural analgesia has proved its efficacy in controlling perioperative immune function and pain in comparison to parenteral opioids. Gamma-amino butyric acid (GABA) analogues like gabapentin and pregabalin have great potential as preemptive analgesic with the added advantage of its anxiolytic effect. Conclusion: Multimodal approaches that address multiple sites along the pain pathway is necessary to treat pain adequately. However, we need to find an answer to the question of how to obtain the maximal clinical benefits with the use of preemptive analgesia.
  15,921 3,628 2
The art of history taking in patient with pain: An ignored but very important component in making diagnosis
R Gurumoorthi, Gautam Das, Mayank Gupta, Vijay Patil, S Manojkumar, Palak Mehta, Subrata Ray
May-August 2013, 27(2):59-66
History taking in patient suffering from pain is dealt like an art by emphasizing the multimodal experience of pain which is ignored in modern sophisticated investigations era. For clinical diagnosis, we need proper history, targeted clinical examination and support by investigation with or without diagnostic intervention. Ignoring history part in clinical assessment can lead to wrong diagnosis and unnecessary experience and expenses for patient. History part of patient evaluation can be divided into present pain as chief complaint, ruling out red flags or warning signals, past history, personnel history including sleep and bladder and bowel history, treatment history and family history. Present pain history can be divided into quantity assessment, quality assessment, mode of onset and location, duration and chronicity, provocative and relieving factors, special characters, timing of pain, relation to posture and associated features. Quantity and quality of pain can be assessed by different tools with different sensitivity and specificity. These tools give idea about the multimodal experience of pain which cannot be assessed by any physical examination and investigation. This helps us in diagnosing and planning for multimodal approach of pain management. We can conclude that proper history with adequate tools which is supported by physical examination and investigation with or without diagnostic intervention helps in diagnosing exact nature of pain.
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Challenges in pain assessment: Pain intensity scales
Praveen Kumar, Laxmi Tripathi
May-August 2014, 28(2):61-70
Pain assessment remains a challenge to medical professionals and received much attention over the past decade. Effective management of pain remains an important indicator of the quality of care provided to patients. Pain scales are useful for clinically assessing how intensely patients are feeling pain and for monitoring the effectiveness of treatments at different points in time. A number of questionnaires have been developed to assess chronic pain. They are mainly used as research tools to assess the effect of a treatment in a clinical trial but may be used in specialist pain clinics. This review comprises the basic information of pain intensity scales and questionnaires. Various pain assessment tools are summarized. Pain assessment and management protocols are also highlighted.
  14,817 1,465 6
Labor epidural analgesia: Past, present and future
Reena , Kasturi H. Bandyopadhyay, Mumtaz Afzal, Amiya K. Mishra, Abhijit Paul
May-August 2014, 28(2):71-81
One of the most severe pains experienced by a woman is that of childbirth. Providing analgesia for labor has always been a challenge more so because of the myths and controversies surrounding labor. It is imperative to understand the pain transmission during various stages of labor in order to select a proper technique for providing labor analgesia. The adverse effects of labor pain are numerous and affect both the mother as well as the fetus. Currently lumbar epidural is considered to be the gold standard technique for labor analgesia. Local anaesthetics like bupivacaine and ropivacaine are commonly used and adjuvants like clonidine, fentanyl and neostigmine have been extensively studied. However, despite being so popular, epidural analgesia is not without complications, with hypotension being the most common. Other complications include accidental dural puncture, infection, intravascular placement, high block and epidural hematoma. Other neuraxial techniques include continuous caudal analgesia, and combined spinal epidural analgesia. The numerous studies investigating the various aspects of this method have also served to dispel various myths surrounding epidural analgesia like increased incidence of cesarean section and instrumental delivery, prolongation of labor and future back pain. The future of labor analgesia lies in the incorporation of ultrasound in identifying the epidural space helping in proper catheter placement. The keywords "labor epidural" in the PUBMED revealed a total of 5018 articles with 574 review articles and 969 clinical trials. The relevant articles along with their references were extensively studied.
  13,802 1,883 1
Prolonged knee pain relief by saphenous block (new technique)
Rajeev Harshe
January-April 2013, 27(1):36-40
Pain in the knee joint can be from a variety of reasons. It can be either from the joint itself, it can be myofascial or it can be neuropathy, radicular pain. The myofascial component can be in different forms, namely, collateral ligament pain, bursitis, tendinitis, and so on. This responds well to local injections of steroids. Pain from the joint can be because of osteoarthritis (OA), rheumatoid arthritis or any other variety of arthritis. Among these osteoarthritis is the most common and naturally occurring pain. There are several modalities used for managing pain in the knee joint. They include medicines and physiotherapy, intra-articular steroid injection, intra-articular Hyalgan, Synvisc injection, prolotherapy, genicular nerve block, ablation, intra-articular pulsed radio frequency (PRF) ablation, acupuncture, injection of platelet-rich plasma in the joint, total knee replacement, high tibial osteotomy, arthroscopy and lavage, and so on. All these modalities have their pros and cons. Literature and experience state that the pain relief provided may last for a few months with these modalities except in surgical interventions in advanced OA. The saphenous nerve is termination of femoral nerve and it is essentially sensory nerve. It supplies the medial compartment and some part of the anterior compartment of the knee joint. This nerve has been blocked near the knee joint by way of infiltration by surgeons and anesthetists, for relief of pain after knee surgery, with varying pain relief of postoperative pain. When we block the saphenous in the mid thigh in the sartorial canal, the fluid tends to block the medial branch of the anterior femoral cutaneous nerve also. It is hypothesized that this may give complete medial and anterior knee pain relief and as most of the knee OA patients have medial and anterior knee pain, this may prove useful. Use of ultrasonography helps to locate the nerve better, ensuring perfection. An effort has been made to block this nerve in the sartorial canal with steroid and LA under ultrasonography (USG) guidance and observe the results. Patients have received very good pain relief (95 - 100%) for a substantially long time (up to four years).
  14,446 925 2
MRI in Coccydynia
Kritika Doshi
January-April 2016, 30(1):61-66
Patients who are diagnosed clinically as Coccygodynia often do not get satisfactory relief. The clinical diagnosis is based on various hypotheses that have been proposed to explain the pain of coccydynia - including coccygeal spicules, pain from the pericoccygeal soft tissues, pelvic floor muscle spasm, referred pain from lumbar pathology, arachnoiditis of the lower sacral nerve roots, local posttraumatic lesions, somatization, etc. The diagnosis is difficult and the pathophysiology is poorly understood. Till recently, use of dynamic X-rays and MRI imaging was not considered to diagnose this condition. The author would like to report three patients who presented to the pain clinic with refractory coccygeal pain and underwent dynamic coccyx X-rays and MRI as part of their evaluation. All these patients had positive findings on MRI. These patients were treated satisfactorily as a result of the added diagnostic value of MRI.
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Transcutaneous electrical nerve stimulation (TENS): A potential intervention for pain management in India?
Gourav Banerjee, Mark I Johnson
September-December 2013, 27(3):132-141
Globally, the burden of pain and consequent disability on healthcare and economy is significant. Given the pain prevalence, inconsistent, and inadequate specialist health care services in India, the burden is likely to be magnified. Analgesic medication is the mainstay treatment for most types of pain; however, its side effects and financial costs for prolonged periods of time have resulted in the search for safer, inexpensive treatment options. Transcutaneous Electrical Nerve Stimulation TENS is a non-invasive, self-administered and inexpensive analgesic technique used worldwide to manage pain. Evidence suggests that TENS is effective in relieving acute and chronic pain and can be used as a stand-alone treatment for mild to moderate pain or as an adjunct for moderate to severe pain. The purpose of this study is to overview the principles, techniques, and clinical research evidence when TENS is used to manage pain with reference to health care and research studies conducted in India. A summary of evidence was formed based on Cochrane reviews, systematic reviews and meta-analyses on TENS with respect to pain management.
  11,623 1,027 1
Management of failed back surgery syndrome with transforaminal epidural steroid and epidural saline adhesiolysis
Kalpana Rajendra Kulkarni, Shirish Kumar Talakanti
May-August 2014, 28(2):117-120
Failed back surgery syndrome (FBSS) is a condition of persistent pain following spine surgery as a result of epidural adhesions, nerve root entrapment/inflammation. Transforaminal epidural steroid (TFES), interlaminar/caudal epidural (CE) with local anesthetic, saline, steroid and hyaluronidase are established therapeutic options over re-surgery. We report a 55 years old male patient with FBSS since 10 years. Following informed consent, under fluoroscopy guidance TFES given at L4/5, L5/S1 foramina with 1.5 ml 0.25% bupivacaine + triamcinolone 20 mg. Besides, CE injection of 10 ml 0.25% bupivacaine with 50 mcg fentanyl given using 18 gauge Tuohy's needle. Fifteen minutes later 20 ml of 0.9% cold (2°C) normal saline with hyaluronidase (on day 1) was injected forcefully through epidural catheter, repeated on 2 nd and 3 rd day with triamcenolone 20 mg. 90% pain relief persisted till 8 months with improved quality of life. TFES with successive CE saline can be a good therapeutic option for long term relief in FBSS.
  9,913 392 -
Prevalence of low back pain and its relation to quality of life and disability among women in rural area of Puducherry, India
Guna Sankar Ahdhi, Revathi Subramanian, Ganesh Kumar Saya, Thiruvanthipuram Venkatesan Yamuna
May-August 2016, 30(2):111-115
Background: The level of quality of life (QOL) and disability among women with low back pain is an important health issue at global level. Objective: To find out the prevalence of low back pain and to assess the relationship of low back pain with disability and QOL among women. Materials and Methods: A community-based cross-sectional study was conducted among 250 women in age group of 30-65 years residing in field practice area of a Tertiary Care Medical Institution, Puducherry. Severity of the pain was assessed using Numerical Pain Scale. Modified Oswestry Low Back Pain Disability Questionnaire was used to measure the disability level and WHO-BREF scale to assess the QOL among women with low back pain. Results: Overall, the prevalence of low back pain was found to be 42%. The majority of women (60.9%) with low back pain experienced moderate disability. Almost 72% of women with low back pain perceived their QOL as good and overall mean QOL score was 88.41 (standard deviation = 12.9). The low back pain was influenced by the demographic variables that include age, marital status, illiteracy, total family income, type of delivery, number of children and household chores, menopausal status, and chronic illness (P < 0.05). Disability was influenced by age, education, and occupation, whereas QOL was influenced by education of the women with low back pain (P < 0.05). Conclusions: Prevalence of low back pain among women was comparatively more than other studies in India. Although moderate disability was more among those with low back pain, overall QOL was good.
  8,405 809 2
Chronic low back pain and treatment with microwave diathermy
Sheikh Javeed Ahmad, Velayat N Buchh, Ajaz Nabi Koul, Abdul Hamid Rather
January-April 2013, 27(1):22-25
Clinical trial of 100 patients of chronic low back ache was conducted in the Department of Physical Medicine and Rehabilitation (PMR) at Sher-i-Kashmir Institute of Medical Sciences Soura a Tertiary care hospital for period of two year from January 2010 to January 2012 to find out effect of Microwave diathermy (MWD). All patients were treated with Microwave diathermy along with conventional treatment. The results were compared and student's 't' test was applied to see the level of significance. A significant improvement after treatment (P=0.000) was found. The present study suggests that short wave diathermy is effective for the treatment of patients with chronic low back pain.
  7,897 820 1
A case of peripheral neuropathy due to hypothyroidism misdiagnosed as lumbar radiculopathy: A case report
Raj Bahadur Singh, Arindam Sarkar, Mohd Meesam Rizvi, Mohmmad A Rasheed
September-December 2015, 29(3):181-184
Peripheral neuropathy is a group of disorders in which the peripheral nervous system gets damaged due to conditions such as diabetes, shingles, vitamin deficiency, acquired immune deficiency syndrome (AIDS), spinal cord disorder, poisoning by heavy metals, alchohol, etc. Patients with peripheral neuropathy usually present with symptoms such as numbness, tingling, paresthesia, and weakness of the involved limb. Here, we have discussed a case of a 34-year-old male who had tingling and numbness of the right leg and right foot. However, initially, he was treated as a case of lumbar radiculopathy but was finally managed with tablets oxcarbazepine and Pregabalin in due course of time to which he responded well.
  8,353 265 -
Neurolytic celiac plexus block for pancreatic cancer pain: A review of literature
Sankalp Sehgal, Ahmed Ghaleb
September-December 2013, 27(3):121-131
The effective management of pancreatic cancer pain continues to be a major challenge for patients and clinicians. Up to 80% of patients with advanced pancreatic cancer present with the symptoms of severe pain. One of the most important goals in their management is achieving the highest quality of life throughout the course of disease with effective palliation of pain. Majority of the current data supports the use Neurolytic celiac plexus block (NCPB) and has been shown to be more effective in reducing pain compared with standard pharmacotherapy. NCPBs have led to decreased opioid requirements and related side effects, thus preventing deterioration in quality of life. In this article, we discuss the treatment of pancreatic cancer pain and the advances in techniques of performing NCPB. We also analyzed the incidence of complications and the quality of pain relief with the use of NCPB. NCPB is effective, has a low incidence of complications, and should be used more often in patients with pancreatic cancer pain.
  7,387 893 5
Lateral atlanto-axial joint block for cervical headache
Shantanu P Mallick
May-August 2013, 27(2):103-107
The patient is a 32-year-old car mechanic, having chronic headache for three years affecting the left upper lateral part of the neck, suboccipital region, and scalp (VAS: 8/10), having a history of whiplash injury from a car accident three years ago, with a deep cut injury on the scalp. He was complaining of neck stiffness and pain during all neck movements and a burning pain in the entire left side of the neck and scalp. He was treated, using conservative methods, by Orthopedists, Neurologists, as well as Psychiatrists, and all investigations including computed tomography (CT) of the brain, X-ray cervical spine, and all related blood reports were within normal limits. He was sent to the Pain Clinic for further assessment. Suspecting sympathetic mediated pain on the left side and upper cervical facet pain, he was given a diagnostic Stellate Ganglion Block, a Third Occipital Nerve block, and a fourth cervical medial branch block (MBB), which gave him good relief; by this the visual analog scale (VAS) score reduced to 3/10. Yet, he was complaining of pain on a focal area on the left upper cervical spine corresponding to the C1-2 joint with lateral rotation on the left side. Subsequently it was decided that a diagnostic Atlanto-axial joint block under fluoroscopy would be carried out. This gave him very good relief from the cervicogenic headache.
  7,313 445 -
Prolotherapy: A new hope for temporomandibular joint pain
A Vijay Kumar, HP Jaishankar, AP Kavitha, Purnachandra Rao Naik
May-August 2013, 27(2):49-52
The most common cause of orofacial pain is the Temporomandibular Joint Disorder (TMD), a collective term used to describe a group of medical disorders causing temporomandibular joint (TMJ) pain and dysfunction. As the causes of TMD are varied and run the gamut from mechanical issues, such as disc degeneration and dislocation or erosion of the fibrocartilaginous surfaces of the condyle, fossa, and articular eminence, the treatment approaches for the chronic TMJ case are also quite varied. As surgery is considered a last resort for TMD, it is common for sufferers to seek out alternatives and one of the alternative treatments is 'Prolotherapy,' which is also known as Regenerative Injection Therapy. This article provides an overview of this new alternative therapy.
  6,058 886 -
Chronic female pelvic pain
Gaurab Maitra, Subhabrata Pal, Subrata Ray, Amitava Rudra
May-August 2013, 27(2):53-58
Chronic pelvic pain (CPP) is defined as nonmalignant pain perceived in the structures related to the pelvis that has been present for more than 6 months or a non acute pain mechanism of shorter duration. Pain in the pelvic region can arise from musculoskeletal, gynaecological, urologic, gastrointestinal and or neurologic conditions. Key gynaecological conditions that contribute to CPP include pelvic inflammatory disease (PID), endometriosis, adnexa pathologies (ovarian cysts, ovarian remnant syndrome), uterine pathologies (leiomyoma, adenomyosis) and pelvic girdle pain associated with pregnancy. Several major and minor sexually transmitted diseases (STD) can cause pelvic and vulvar pain. A common painful condition of the urinary system is Interstitial cystitis(IC. A second urologic condition that can lead to development of CPP is urethral syndrome. Irritable bowel syndrome (IBS) is associated with dysmenorrhoea in 60% of cases. Other bowel conditions contributing to pelvic pain include diverticular disease,Crohn's disease ulcerative colitis and chronic appendicitis. Musculoskeletal pathologies that can cause pelvic pain include sacroiliac joint (SIJ) dysfunction, symphysis pubis and sacro-coccygeal joint dysfunction, coccyx injury or malposition and neuropathic structures in the lower thoracic, lumbar and sacral plexus. Prolonged pelvic girdle pain, lasting more than 6 months postpartum is estimated in 3% to 30% of women. Nerve irritation or entrapment as a cause of pelvic pain can be related to injury of the upper lumbar segments giving rise to irritation of the sensory nerves to the ventral trunk or from direct trauma from abdominal incisions or retractors used during abdominal surgical procedures. Afflictions of the iliohypogastric, ilioinguinal, genitofemoral, pudendal and obturator nerves are of greatest concern in patients with pelvic pain. Patient education about the disease and treatment involved is paramount. A knowledge of the differential diagnosis of the pain generators leads to a diagnosis specific management of the pain condition. Using a multidisciplinary approach can improve outcomes for patients suffering from the condition and minimize the associated disability.
  5,972 468 -
Aflapin®: A novel and selective 5-lipoxygenase inhibitor for arthritis management
Manoj A Suva, Dharmesh B Kheni, Varun P Sureja
January-April 2018, 32(1):16-23
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.
  5,878 432 -
Analgesic effect of ethanolic leaf extract of moringa oleifera on albino mice
Ayon Bhattacharya, Divya Agrawal, Pratap Kumar Sahu, Sanjay Kumar, Sudhanshu Sekhar Mishra, Shantilata Patnaik
May-August 2014, 28(2):89-94
Objectives: Moringa oleifera is a highly valued plant distributed in many countries of the tropic and subtropics. Moringa oleifera leaves are a potential source of phytochemical ingredients claimed to have analgesic property. Pain is an unpleasant sensation, which in many cases represents the only symptom for the diagnosis of several diseases. Therefore analgesic drugs lacking the side effect as alternative to nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates are in demand by the society. The present study is undertaken to evaluate the analgesic activity of Moringa oleifera using acetic acid induced writhing test and Eddy's hot plate test. Materials and Methods: It is a randomized control study. The present study was done using two experimental models. The albino mice were divided into six groups, each group consisting of 6 mice. A total of 36 mice were used in each of the two experimental models. Group I: Control (normal saline given orally at 2 ml/kg body weight); Group II: Standard (diclofenac 10 mg/kg i.p/ morphine 1 mg/kg i.p); Group III, IV, V, VI (ethanolic extract of Moringa oleifera (EMO) 50, 100, 200, 400 mg/kg, respectively). The EMO leaves were administered at 50, 100, 200, 400 mg/kg doses orally 1 hour before the experiments. For peripheral analgesic effect, acetic acid induced writhing test was used. The central analgesic effect was screened using Eddy's hot plate method. The standard drug used in acetic acid induced writhing test was diclofenac and in Eddy's hot plate test was morphine. Results: The EMO leaf showed significant (P < 0.01) analgesic activity at 100, 200, 400 mg/kg in the acetic acid induced writhing test showing 32.21%, 59.71% and 78.61% inhibition of writhes, respectively in comparison with the control. In the Eddy's hot plate test EMO at 400 mg/kg showed significant (P < 0.01) analgesic activity from 15 min to 90 min with a mean rank ranging from 28.92 to 26.00, second mean rank following morphine in comparison with control. In both the tests, EMO showed significant (P < 0.01) analgesic activity in a dose-dependent manner. Conclusion: The ethanolic leaf extract of Moringa oleifera exhibited analgesic activity in both models showing its both central and peripheral analgesic actions.
  5,534 594 1
Sacroiliac joint: A review
Khushali Tilvawala, Kailash Kothari, Rupal Patel
January-April 2018, 32(1):4-15
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.
  5,480 530 -
A comparison of analgesic effect of different doses of intrathecal nalbuphine hydrochloride with bupivacaine and bupivacaine alone for lower abdominal and orthopedic surgeries
B Jyothi, Shruthi Gowda, Safiya I Shaikh
January-April 2014, 28(1):18-23
Background: Nalbuphine is a synthetic opioid with mixed agonist-antagonist action, when added as adjuvant to intrathecal bupivacaine acts on kappa receptors in the dorsal horn of the spinal cord producing analgesia. Aim: To evaluate the onset of sensory block, hemodynamic changes, duration and quality of analgesia, and adverse effects of different doses of nalbuphine with bupivacaine for spinal anesthesia. Materials and Methods: Randomized double blind study done on 100 patients undergoing lower abdominal and lower limb orthopedic surgeries under subarachnoid block. Patients were randomly allocated to four groups receiving either intrathecal 15 mg of bupivacaine + 0.5 mL normal saline alone or 15 mg of bupivacaine with either of nalbuphine 0.8, 1.6, and 2.5 mg + 0.5 mL normal saline. Results: The mean visual analogue scale score in group A is 4.08 ± 0.5 and in groups B, C, and D are 3.4 ± 0.4, 3.5 ± 0.5, and 3.5 ± 0.5, respectively. The duration of analgesia in group A is 190.4 ± 20.0 and in groups B, C, and D were 322.4 ± 31.1, 319 ± 39.8 and 317.8 ± 47.5. The quality of analgesia was good in 72%-76% and excellent in 16%-28% in groups B, C, and D and poor 28% to satisfactory 72% in group A. Conclusion: Addition of 0.8 mg of nalbuphine to 0.5% bupivacaine for subarachnoid block provides excellent analgesia with longer duration of action compared with 1.6 and 2.4 mg of nalbuphine.
  5,164 739 3
Epidural clonidine for postoperative pain after lower abdominal surgery: A dose - response study
Jyothi Jain, Anjum Khan Joad, Vinita Jain
May-August 2013, 27(2):67-74
Background: Patient controlled epidural analgesia with local anesthetic and opioid is an effective technique for postoperative analgesia after abdominal surgery. Clonidine has a synergistic effect on epidural local anesthetics. The purpose of this study was to determine the optimal epidural clonidine dose to be added to a solution of bupivacaine and morphine for patient controlled epidural analgesia to deliver an optimal balance of analgesia and side effects. Methods: Sixty patients were randomly assigned to three study groups (C0, C1, C2) of 20 patients each. Before the induction of general anesthesia, epidural anesthesia was induced using 10 mL of 1% lidocaine and epinephrine (1:200,000) and was maintained with a continuous infusion of the lidocaine - epinephrine solution until the completion of surgery. After surgery, groups CO, C1, and C2 received patient controlled epidural analgesia (PCEA) with morphine (0.1 mg/mL) in 0.1% bupivacaine. Group C1 and C2 also received epidural clonidine (1 and 2 mcg/mL, respectively). Pain was assessed at rest, cough, and on movement at 1, 2, 4, 8, 12 h after surgery and on day 1, 2, and 3. Differences in the mean postoperative Numerical Rating Scale (NRS) score and analgesic consumption were assessed by one-way analysis of variance and multiple comparisons. Result: Patients in all the groups experienced adequate pain relief during the 72-h period after surgery. There was no statistically significant difference between the mean NRS scores and CRS scores for pain at rest, cough, or during mobilization between the three groups. The cumulative volumes of analgesic solution were C0, 131 ± 21.285 mL; C1, 89.9 ± 18.44 mL; and C2, 80.1 ± 21.32 mL. There was no significant difference in the PCEA analgesic consumption between group C1 and C2 (P = 0.128). Groups C1 and C2 required lower volume of analgesic solution (P < 0.001) than group C0. Also, the number of rescue doses consumed by clonidine group were less (P < 0.001). Conclusion: The optimal epidural clonidine concentration in a morphine (0.1 mg/mL) and bupivacaine (0.1%) solution after lower abdominal surgery is 1.0 μg/ml. The combination of bupivacaine (0.1 %), morphine (0.1%), and clonidine (both 1 and 2 μg/mL) resulted in excellent pain relief in the 72 hour period after surgery and was not accompanied by significant hypotension, sedation, sensory blockade, or motor blockade.
  5,144 469 -
Intrathecal clonidine for perioperative pain relief in abdominal hysterectomy
Debjyoti Dutta, Chhandasi Naskar, Rita Wahal, VK Bhatia, Vinita Singh
January-April 2013, 27(1):26-32
Background: Two different doses of intrathecal clonidine with hyperbaric bupivacaine fentanyl combination is compared in women undergoing abdominal hysterectomy to get best beneficial effects with minimal incidence of side effects/complications. Methods: 90 patients undergoing abdominal hysterectomy under spinal anesthesia, were randomized to 3 groups, BFC0: received 3 ml hyperbaric bupivacaine 0.5% + 25μg fentanyl, BFC30: received 3 ml hyperbaric bupivacaine 0.5% + 25μg fentanyl + 30μgm clonidine and BFC60: received 3 ml hyperbaric bupivacaine 0.5% + 25μg fentanyl + 60μgm clonidine. Time to reach peak sensory levels, sensory and motor regression times, intraoperative pain score and time for first analgesic requirement, hemodynamic changes, fluid and vasopressor requirement were recorded. Results: Addition of clonidine has not increased the rapidity of spread of sensory block to T4. Duration of motor block and time to regression to L1 is significantly less in BFC0, (167.78±25.09min and 213.59±22.99min respectively) compared to BFC30 (248.33±26.07 min and 297.33±25.96 min respectively) and BFC60 (260.18 ± 47.64min and 306.43±44.76min respectively). In patients of BFC0 intraoperative vas score (1.3±1.2) was significantly higher and demanded analgesics earlier (241.3 ± 27.76 min) compared to others. Fall in BP was observed in a dose dependent manner. Conclusions: Adding small doses of clonidine to bupivacaine-fentanyl combination improves the quality of perioperative analgesia in a dose dependent manner. However, 60μg clonidine shows significant hemodynamic changes. Hence, 30μg of intrathecal clonidine added to bupivacaine (15mg) fentanyl (25μg) combination is the preferred choice.
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Ameliorative effect of ethyl pyruvate in neuropathic pain induced by chronic constriction injury of sciatic nerve
Varsha J. Bansode, Neeraj S. Vyawahare, Neeraj B. Munjal, Pradip N. Gore, Pushpendra S. Amrutkar, Snehashree R. Sontakke
May-August 2014, 28(2):82-88
Objective: The present study was designed to investigate the ameliorative effects of ethyl pyruvate (EP) in chronic constriction injury (CCI)-induced painful neuropathy in rats. Materials and Methods: EP 50 and 100 mg/kg was administered for 21 consecutive days starting from the day of surgery. The effects of EP in the paw pressure, acetone drop, and tail heat immersion tests were assessed, reflecting the degree of mechanical hyperalgesia, cold allodynia, and spinal thermal sensation, respectively. Axonal degeneration of the sciatic nerve was assessed histopathologically. The levels of thiobarbituric acid reactive species, reduced glutathione (GSH), catalase (CAT), and superoxide dismutase (SOD) were determined to assess oxidative stress. Key Findings: Administration of 50 and 100 mg/kg EP attenuated the reduction of nociceptive threshold in the paw pressure, acetone drop, and tail heat immersion tests. EP 100 mg/kg significantly attenuated reactive changes in histopathology and increase in oxidative stress. Conclusion: EP 100 mg/kg showed beneficial activity against nerve trauma-induced neuropathy. Hence, it can be used as a better treatment option in neuropathic pain (NP). The observed antinociceptive effects of EP may possibly be attributed to its antioxidant and anti-inflammatory activity.
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Pain after craniotomy: A time for reappraisal?
Pradipta Saha, Suman Chattopadhyay, A Rudra, Sourabh Roy
January-April 2013, 27(1):7-11
Until recently, perioperative pain management in neurosurgical patients has been inconsistently recognized and inadequately treated. An increased awareness of pain management in general along with advances in the understanding of pain modulation and pathophysiology, has led to improved practice and perioperative care of patients following craniotomy. Otherwise, severe postoperative pain impairs the quality of recovery and causes emotional distress with the possibility of inducing chronic pain and lasting functional deficits. The greatest challenge in managing neurosurgical patients is the need to assess the neurological function while providing superior analgesia with minimal side effects. To achieve this goal, a multimodal approach to analgesia, using various drugs and techniques, is advocated. There still remains a need, however, to conduct further randomized, controlled trials, to determine the best combination of drugs or techniques for treating perioperative pain in this patient population. Improved awareness, assessment, and treatment of pain result in better care and overall patient outcome.
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