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   2013| May-August  | Volume 27 | Issue 2  
    Online since October 4, 2013

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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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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.
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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.
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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.
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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.
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A difficult case of subacromial bursitis in diabetes treated by steroid injection and physiotherapy combined with yoga
Vijay Pratap Singh, Bidita Khandelwal, Namgyal T Sherpa
May-August 2013, 27(2):98-102
Subacromial injections of steroid when given accurately to the subacromial space followed by appropriate physiotherapy and yoga resulted in significantly reduced pain and increased functional outcomes in subacromial bursitis in a type II diabetes patient. Steroidal injections wherever indicated and if injected correctly into the subacromial space under proper sterile condition leads to enhanced healing, reduced pain, improved range of motion, and increased functional ability and return to work. In situations of doubt, ultrasonography (USG) or magnetic resonance imaging (MRI) can provide better insight to its pathology and site which in turn helps the clinician to take correct decisions about injection therapy, drug, and approach to be used. Inaccurately administered injections may delay the healing process and burden the patient further to undergo surgical intervention. It is better to use physiotherapy exercises and yoga asanas as adjuvant to enhance recovery and functions after injection therapy.
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Long-term safety and efficacy of intralesional injection of triamcinolone acetonide for sternal keloid pain and pruritis: A double-blind comparison of two concentrations
Babita Ghai, Dipika Bansal, Shyam KS Thingnam
May-August 2013, 27(2):86-91
Background: Intralesional injection of triamcinolone acetonide (TAC) is the most frequently used treatment modality for keloids or hypertrophic scars. However, 20 mg/mL, triamcinolone is reported to have 50% incidence of adverse sequelae. We compared the long-term safety and efficacy of 10 mg/mL with 20 mg/mL intralesional injection of TAC on sternal keloid pain. Methods: Thirty adult patients presenting with pain and/or pruritis at sternal keloid site were randomized into one of the two groups. In group T20 patient received 1 mL of 20 mg/mL TAC, whereas in group T10 patients received 1 mL of 10 mg/mL of TAC intralesional every 2 weeks for a total of 3-4 treatments. Visual analog scale (VAS) scores for pain and pruritis, keloid/scar height, and any adverse sequelae were recorded at 2 weeks interval till 2 months and then at 6, 12, and 15 months. Primary outcome of the study was the percentage of patient developing side effects. Secondary outcome measures were VAS score for pain and itching, keloid height, and recurrence rate of pain or itching. Results: There was a significant decrease in VAS score for pain, pruritis, and keloid height after drug administration in both groups. Side effects was observed in 6 (40%) patients in group T20 and 1 (6.7%) patients in group T10 (P = 0.04). Two patients (13.3%) in group T20 and one in group T10 (6.7%) did not have any improvement in their pain/pruritis scores. Recurrence rate was 13.3% (2 patients) in T20 group compared with 20% (3 patients) in group T10 at 15 months after initial response. Conclusion: Intralesional injection of TAC in concentration of 10 mg/mL is as efficacious as 20 mg/mL for sternal keloid pain but is associated with significantly less side effects.
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Response of therapeutic exercise and patellar taping on patella position and pain control in the Patellofemoral pain syndrome
Mohammad Hassan Manzer, Kalpana Zutshi, Pratip Mandal
May-August 2013, 27(2):75-79
Objective: To evaluate the effect of multiple applications of patellar taping over a longer period of time, alone and along with the application of therapeutic exercise on patella position and pain control in Patellofemoral Pain Syndrome (PFPS). Study Design: A different subject pretest-post test, experimental group design. Materials and Methods: Twenty-one subjects participated in the study. The subjects were randomly assigned to one of the three groups: Patellar taping combined with Close Kinetic Chain (CKC) exercise, Patellar taping only, and CKC exercise only (n = 7 in each group). Taping was applied and exercise was performed on a daily basis for three weeks. The measures were obtained on the Visual Analog Scale (VAS) for pain and lateral patellar displacement for patella position. Results: The paired t-test was used for within-group comparison of pre-test and post test measurement and Analysis of Variance (ANOVA) was used for between-group comparisons of the three groups. The result of the study showed that the group receiving patellar taping and CKC exercise had better pain relief (p < .05) than the patellar taping only and CKC exercise only groups. There were no significant differences in terms of patella position in any of the group (p > .05). Conclusion: The combination of daily patella taping along with CKC exercise program for three weeks has been seen to be more effective than only patella taping and only the CKC exercise program, in reducing pain in patients with PFPS. Patella taping alone or in conjunction with CKC exercises is not able to bring any significant change in the patella position in patients with PFPS.
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Efficacy and safety of combined spinal: Epidural versus epidural technique for labor analgesia in parturients with rheumatic valvular heart disease
Babita Ghai, Ram Krishnamoorthy, Dipika Bansal, Vanita Suri, Rajesh Vijayvergiya, Jyotsna Wig
May-August 2013, 27(2):80-85
Background: Hemodynamic changes induced by labor pain and apprehension in addition to physiological changes may pose risk to parturients with rheumatic heart disease (RHD). Therefore, it is important to provide adequate pain relief during labor in these patients. We planned this study to compare the efficacy and safety of epidural (E) versus combined spinal - epidural (CSE) for labor analgesia in parturients with rheumatic valvular heart disease. Methods: Twenty-five parturients with RHD included in this study were randomized to one of the two groups - E group (n = 12), received 6 mL of 0.0625% bupivacaine with 25 μg fentanyl or CSE group (n = 13), received 25 μg of fentanyl with 1.25 mg bupivacaine diluted to 1 mL in subarachnoid space. Afterward, a continuous infusion of 0.1% bupivacaine with 2 μg/mL fentanyl was started at 6-8 mL/h. Primary outcome, analgesic efficacy, was assessed by visual analog scale (VAS) for pain. VAS ≤ 3 was considered as effective analgesia. Rescue analgesia in the form of epidural bolus was given if VAS > 3. Results: Demographic characteristics of the patients were comparable. Mitral stenosis was the predominant valvular lesion. The VAS at which the parturients received analgesia was comparable. The mean time to achieve effective analgesia was significantly faster in CSE group (4.46 ± 0.87 min) compared with group E (15.09 ± 5.7 min) (P < 0.001). Significantly lower median pain scores were recorded until the initial 15 min in CSE group. Afterward, median VAS for pain was comparable between the groups. VAS for pain was significantly low at all time intervals than baseline in both the groups. Maternal satisfaction and incidence of cesarean rate and complication were comparable between the groups. Conclusion: Both epidural and CSE are equally effective and safe for labor analgesia in parturients with rheumatic valvular heart disease. However, CSE technique provides a faster onset of analgesia.
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Impact of socio-demographic factors on quality of life of primary chronic daily headache patients
Supriya Vaish, Bharat Singh Shekhawat
May-August 2013, 27(2):92-97
Primary chronic daily headaches (CDHs) have a considerable negative impact on patients. It leads to poor quality of life (QOL) and diminished ability to function in day-to-day life, in spite of this sufficient work has not been done in this area in India. The purpose of this study was to determine influence of sociodemographic variables on QOL of primary daily headache patients. A prospective study was carried out on 50 consecutive primary CDH patients attending psychiatry and neurology outpatient unit, diagnosed as per IHC 2003 criteria. They were evaluated using a specially designed proforma and QOL was evaluated using the WHOQOL-Brief (Hindi) instrument. Statistical analysis was done on SPSS version 10. Results revealed that old age patients had poor QOL in environmental domain. Female patients had poorer QOL in social relationship and environmental domains. Married patients had poorer QOL in physical, environmental domain, and their total QOL was also poor. There was a significant positive correlation with education status of patients, that is, higher educated patients had better QOL in environmental domain and negative correlation with family size, that is, more the number of family members poorer was the QOL in social relationship domain. Thus, to conclude many sociodemographic factors in the patients suffering from primary CDH have significant negative impact on QOL of patients. Among sociodemographic variables age, gender, marital status, and family size were the important factors that influence QOL of patients.
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History taking in evaluation of chronic pain
Gautam Das, Mayank Gupta
May-August 2013, 27(2):47-48
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Transient asystole after mandibular nerve block
Sujoy Banik, Arvind Chaturvedi, Ashish Bindra, Renu Bala
May-August 2013, 27(2):108-110
Blockade of the trigeminal nerve and its branches at various locations is a well-established procedure to treat intractable pain syndromes in the distribution of the nerve. Mandibular nerve block is a commonly performed procedure by anesthesiologists, pain physicians, as well as dental practitioners. As it is considered to be a safe procedure, it is usually performed in an outpatient setting with or without monitoring. The complications associated with mandibular nerve block include intravascular injection, hypoesthesia, dysesthesia, sensory loss in mandibular nerve distribution, facial swelling, weakness of the masseter muscle, and injury to the auditory tube leading to severe vertigo. Here, we present an uncommon complication during mandibular nerve block with lignocaine in a patient of trigeminal neuralgia who suffered transient asystole during the procedure. The case highlights the importance of monitoring and emphasizes the need for additional precautions to be taken during pain procedures particularly in high-risk populations such as geriatric patients.
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