Looking After The Future

Health and Wellness

Journal of Pain

EDITORIAL
Percutaneous vertebroplasty: Current controversy p. 123 Kailash Kothari
DOI :10.4103/ijpn.ijpn_67_18 [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta REVIEW ARTICLES
Full-endoscopic lumbar discectomy for high canal compromised disc at upper lumbar level: A technical review p. 125 Manish Raj, Kailash Kothari, Anurag Agarwal, Hyeun Sung Kim, Pankaj Surange, Kapil Tyagi, Prashant Punia, Palea Ovideu
DOI :10.4103/ijpn.ijpn_51_18 Objective: In this study, we have described the technique to overcome difficulty faced during trans-foraminal endoscopic discectomy for the treatment of lumbar radiculopathy in patients who have herniated discs at the upper lumbar level & thoracolumbar junction. Method: After institutional review board approval, A retrospective analysis of 27 patients operated between March 2013- September 2017, by a single specialist for disc herniation at upper lumbar levels D12-L1, L1-2, L2-3 with or without high canal compromise by outside in technique (using rigid endoscope, sequential reamers) along with detailed description of our technique is the focus of this study. Results: Out of 27 patients there were 11 cases for L1-2 & 16 cases of L2-3 disc herniation respectively. There were 21 cases of broad-based, high canal compromised disc herniation with significant neurological deficit & only 6 cases were of focal herniation type. The average preoperative VAS score of 8.5 (range 6-10) reduced to 4 (range 2-7) immediate postoperatively & it further reduced to 2 (range 0-4) at one month follow up. The average preoperative ODI score of 65 (range 28- 88) reduced to 27 (range 12-40) immediate postoperatively & it further reduced to 10 (range 3- 18) at one month follow up. Post-operative MRI showed that the ruptured disc had been successfully removed. Conclusion: An anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic discectomy for upper lumbar disc herniation. Foraminotomy is recommended for all intra-canalicular herniation. Transforaminal endoscopic discectomy and foraminotomy can be used as a safe yet minimally invasive technique for the treatment of lumbar radiculopathy in the setting of an upper lumbar disc herniation. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Pharmacological management of neuropathic pain in India: A consensus statement from Indian experts p. 132 Ashok Kumar Saxena, Parmanand Jain, Gur Prasad Dureja, Anil Venkitachalam, Subrata Goswami, Hammad Usmani, Shardul Kothari, Dipit Sahu, Baljit Singh, Vandana Trivedi, Gaurav Sharma, Sanjay Kamble, Amit Qamra, Salman Motlekar, Rishi Jain
DOI :10.4103/ijpn.ijpn_47_18 Neuropathic pain (NeP) constitutes a major pain-related disorder, which is often underdiagnosed and undertreated. Adverse physical, psychological, and economic consequences associated with NeP lead to poor quality of life. Burden of NeP in developing countries like India is colossal. Various international guidelines provide effective approaches to diagnose and manage NeP. However, differences in the genetic makeup of Indian population can result in subtle differences in clinical response, considering their low body weight, drug metabolism ability, and pain perception. Similarly, treatment-related adverse effects may also vary. Practice of Indian physicians may also differ for choice of drugs based on their availability and affordability. In the absence of country-specific guidelines, this document could serve as a guiding tool for health-care providers, ensuring uniformity in the treatment of NeP. Thus, applicability of all recommendations from any of these guidelines in Indian setting demands careful evaluation. Clinical experience of Indian physicians suggests that there are lot many challenges (e.g., busy outpatient departments, nonavailability of screening questionnaires in regional languages, and availability and affordability of medications) faced by them when managing NeP. In addition, in India, there are no country-specific guidelines that would help them to address these challenges. The objective for this consensus was to develop an expert opinion guideline to harmonize the management of NeP in India. The expert panel consisted of experts from various specialties such as pain medicine, anesthesiology, diabetology, neurology, and orthopedics. The panel critically reviewed the existing literature evidence and guideline recommendations to provide India-specific consensus on the management of NeP. The final consensus document was reviewed and approved by all the experts. This expert opinion consensus will help health-care professionals as a guiding tool for effective management of NeP in India. Use of Douleur Neuropathique 4 (DN4) questionnaire for NeP screening should be routine in day-to-day clinical practice. For effective utilization of DN4 questionnaire, it should be converted to regional language. If DN4 questionnaire screening fails to identify NeP, it should not be disregarded and should not replace the sound clinical judgment from the treating physician. Diagnostic tests may be considered as a supplement to clinical judgment. Cost-effective treatment should be the initial choice. Dosing should be individualized based on efficacy and tolerability. Tricyclic antidepressants (TCAs), gabapentinoids, and serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered among initial choices. Tramadol can be considered as a second-line add-on treatment for NeP if there is partial response to the first-line agent either alone or in combination. Fixed-dose combination (FDC) of gabapentinoids such as pregabalin (75 mg) with TCA such as nortriptyline (10 mg) is synergistic and improves treatment adherence. Among other treatments, Vitamin B12 (methylcobalamin) can be used either alone or in combination for the management of NeP. Use of Vitamin D and steroids should be limited to specific NeP in individual cases. Referral to pain specialists can be considered if two drugs fail to provide relief in NeP. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta ORIGINAL ARTICLES
Is tactile acuity altered in individuals with acute mechanical neck pain? p. 145 Shobhalakshmi S Holla, Turiya Vats, Pratima Nagpal
DOI :10.4103/ijpn.ijpn_20_18 Background: Tactile acuity measured by point discrimination (TPD) refers to the precision by which we can sense touch.An increase in TPD threshold (loss of tactile acuity) is considered suggestive of disruptions to S1 cortical maps of that specific body part. In some chronically painful conditions, reduced tactile acuity is a manifestation of Central sensitization (CS).The other symptoms include hyperalgesia and allodynia due to repeated activation of spinal nociceptors. A recent study has shown that tactile acuity is affected in individuals with chronic neck pain. While there seems to be adequate evidence stating that tactile acuity is reduced in individuals with chronic pain, CS may not be limited to chronic pain states. There is a paucity of literature with respect to the tactile acuity of a person with acute neck pain. A measurement of tactile acuity of the affected body area in acute pain, may suggest the extent of the altered threshold of sensory discriminative aspect of pain experience. Objectives: To compare the two-point discrimination over C7 spinous process between the symptomatic individuals with mechanical neck pain and age matched healthy controls. Methods: 30 individuals with mechanical neck pain & 30 age matched normals were assessed for two point discrimination using mechanical calipers, The two sharp points of the caliper were vertically placed against the skin surface over C7 spinous process, commencing with 5mm, which was stretched out till the subject appreciated the two points. Values were noted down in millimeters. Results: An independent t – test showed a significant difference in the two point discrimination between the 2 groups ( P < 0.000). Conclusion: It can be concluded that individuals with acute mechanical neck pain demonstrated a change in tactile acuity. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block p. 150 Neena Jain, Pooja Rawat Mathur, Veena Patodi, Saurav Singh
DOI :10.4103/ijpn.ijpn_21_18 Context: Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain and shortens the duration of hospital stay. Aims: To compare analgesic efficacy of ultrasound guided femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Settings and Design: It was a prospective, randomized, double blind study. Methods and Material: Group A ( n = 25) received ultrasound guided FNB and Group B ( n = 25) received ultrasound guided FICB using 0.5% ropivacaine. Primary objective was to observe reduction in pain associated with positioning (sitting) for subarachnoid block. Statistical Analysis used: For data analysis t test, Mann Whitney test and Chi-square test were applied. Results: Visual analog scale (VAS) score for pain before giving peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable ( P = 0.302). VAS score for pain in sitting position before giving subarachnoid block was lesser in Group A (1.88 ± 0.83) than in Group B (2.40 ± 0.57) ( P = 0.013). Mean reduction in VAS score for pain was more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) ( P = 0.002). Conclusion: Ultrasound guided FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients undergoing surgery for fracture femur compared to ultrasound guided FICB. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Image guided trans foraminal epidural injection: Is it a viable stopgap therapy for low backache p. 155 Samaresh Sahu, Rochan Pant, Sashank Sharma
DOI :10.4103/ijpn.ijpn_33_18 Aims: 1. Study the change in pain and function in patient with lumbosacral disc disease on MRI using visual analogue scale (VAS) and the revised Oswestry disability index (ODI) for back pain after administration of fluoroscopically guided transforaminal epidural injection. 2. Correlate the response of the patient with the spread of contrast in epidural space. Method: 100 patients with history of low back ache and imaging findings of disc herniation were enrolled based on inclusion criteria. Patients scored their pain on the VAS and functional disability on revised ODI. The patient was evaluated for distribution of pain and was administered a combination of anaesthetic and steroid after confirming the position of the tip of needle using iodinated contrast. Follow up for response to pain and improvement in disability in immediate post procedure done at 3 and 6 months. Result: 102 injections were administered for 100 patients which comprised of n =69 {67.6%} male and 33{32.4%} female and age distribution was 21-79 years. The distribution of indication was disc bulge n =29 (28.4%), extrusion n =12 (11.8%), post operative n =19 (18.6%), protrusion n =42 (41.2%). No significant difference between the VAS scores ( p =0.20) of the individual indication pre procedure. After 3 & 6 months there was statistically significant difference between the mean rank value of population indicating maximum benefit for disc bulge population and least for post operative population at three months follow up. Conclusion: There is statistically proven good results in all cases for 6 months, after which repeat injections may be tried. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Perception, knowledge, and attitudes of first-year postgraduates toward postoperative pain management: A questionnaire-based study p. 163 Pritam B Adsule, Pradnya M Bhalerao, Prakash R Dhumal
DOI :10.4103/ijpn.ijpn_31_18 Context: Inadequately controlled postoperative pain has undesirable physiological and psychological consequences. It increases postoperative morbidity, delays recovery, and hence causes a delayed return to normal daily living. Furthermore, the lack of adequate postoperative pain treatment may lead to persistent pain after surgery, which is often overlooked. Overall, inadequate pain management increases the use of health care resources and health care costs. Aim: To evaluate the knowledge and attitudes of first-year postgraduate students toward postoperative pain. Study Design: This questionnaire-based cross-sectional study was conducted on 42 first-year postgraduate students. Materials and Methods: A 20-point questionnaire was prepared based on the various aspects of postoperative pain services. The students were asked to provide their answers on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." The responses were kept anonymous, and the results were expressed in terms of percentage. Results: Almost 70% of students had a good knowledge of opioids, 52% strongly felt the need for a structured pain curriculum, 76% were well aware of nonpharmacological methods of pain relief, 48% agreed on the need for a pain physician, and 52% were aware of the advantage of postoperative analgesia. Conclusion: This pilot study helped us to evaluate the current understanding of our first-year postgraduate students and further created awareness on the importance of pain relief postoperatively. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Executive function and its clinical correlates among migraineurs p. 167 Ashitha Sreedhar, Suresh M Kumar, Anjali N Shobha
DOI :10.4103/ijpn.ijpn_38_18 Background: The studies conducted in the field of migraine and its effect on various cognitive functions revealed contradicting results mainly due to the incorporation of patients from varied socioeconomic status, clinical conditions, and the methodology adopted to the study. Methods: The participants of the study consist of 130 migraineurs, selected from the outpatient department of neurology from reputed tertiary centers at Chennai, South India, and controls were picked up from the community. Patients were selected on the basis of clinical examination and screening. The instruments used are Migraine Severity Scale, Headache impact test, hospital anxiety and depression scale (HADS), Wisconsin Card Sorting Test, Trail Making Test, and Controlled Oral word Association Test. Results: The study found that migraine group to have deficits in some aspects of problem-solving and concept formation competencies in comparison with healthy individuals and also found strong and weak correlation with various clinical variables such as its severity, duration, and headache impact indicating the role of migraine on cognitive functioning. Conclusion: The condition of migraine does lead to mild-to-moderate levels of impairment in various frontal lobe-involved cognitive functions such as attention, planning, and problem-solving even in a high-profile samples having higher levels of education and occupation. The relation between the migraine and impairment in cognitive functions are further cemented by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Findings from such a study will also pave new ways and means to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain p. 173 Vrushali P Panhale, Reshma S Gurav, Kartiki Suradkar
DOI :10.4103/ijpn.ijpn_41_18 Background: Fear-Avoidance Beliefs Questionnaire (FABQ) is widely used to assess the fear-avoidance beliefs in patients with low back pain (LBP). However, English serves as a barrier to the population of the state where Marathi is the prime language. Hence, the FABQ needs to be translated into Marathi for the ease of its use. Materials and Methods: FABQ was successfully translated in Marathi using forward-backward translation using recommended guidelines. The final version of FABQ-Marathi version (FABQ-M) was used on 100 patients with chronic nonspecific LBP to assess its reliability and validity. Reliability was assessed by measuring the internal consistency of FABQ-M and its subscales and by checking the test-retest reliability on day 1 and day 2. For the determination of construct validity, convergent and divergent validity was assessed. The floor and ceiling effects were studied. Results: Reliability-internal consistency-Cronbach's alpha for FABQ-M was 0.860 and test–retest: correlation between FABQ-M on day 1 and day 2 were highly significant. The intraclass coefficient was 0.976. There was a high internal consistency between the FABQ-M and its subscales. On assessing convergent validity, there was moderate correlation found between FABQ-M and TSK ( r = 0.52, P = 0.00). Divergent validity showed moderate correlation between FABQ-M and NRS ( r = 0.48, P = 0.00) and between FABQ-M and RMDQ ( r = 0.59, P = 0.00). Conclusion: The translated FABQ-M proved to be acceptable. The results suggest it is a validated, an easy to comprehend, reliable, and valid instrument for the measurement of the fear and avoidance beliefs caused by back disorders in the Marathi-speaking population. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta CASE SERIES
A case series discussing the intrathecal drug delivery system to improve the quality of life in terminal cancer patients p. 179 Joanna Samantha Rodrigues, Preeti Gupta, Shalini Saksena, Manju Butani
DOI :10.4103/ijpn.ijpn_49_18 Cancer is a life changing diagnosis and chronic pain in these terminally ill patients is extremely debilitating. In the present case series, the feasibility of continuous infusion of low dose local anaesthetics and opioids through the intrathecal route has been discussed pertaining to patient selection, technique, drugs used and trouble shooting. The intrathecal catheters were connected through a subcutaneous port to an external ambulatory infusion device (CADD pump) and used on a home care basis. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta CASE REPORTS
Quadratus lumborum: One of the many significant causes of low back pain p. 184 Asha Satish Barge, Satish Mahadeo Barge
DOI :10.4103/ijpn.ijpn_53_18 Quadratus lumborum is one of the common sources of pain and that can be missed or ignored easily. Quadratus lumborum pain syndrome is a myofascial pain syndrome. The pain is due to spasm and stiffness of the muscle. Many a times, weak back muscles are compensated by quadratus lumborum leading to painful spasm. It is diffi cult to differentiate between quadratus lumborum and iliopsoas pain syndrome. Diagnostic quadratus lumborum injection helps differentiate between these two. In this report, we reported a case of quadratus lumborum pain syndrome as a primary diagnosis and iliopsoas pain syndrome as a secondary diagnosis. The diagnosis was confi rmed by fl uoroscopically guided quadratus lumborum injection. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Management of chronic postsurgical pain following cholecystectomy p. 187 Parthasarathy Srinivasan, Gobinath Jayaraman
DOI :10.4103/ijpn.ijpn_36_18 A 50-year-old female presented with severe pain at the cholecystectomy scar site of 4 months' duration. She had an open cholecystectomy done followed by continuous pain from the time of discharge. She was diagnosed as a case of chronic postsurgical pain (CPSP) syndrome. We administered right-sided erector spinae (ES) block by ultrasound guidance depositing 15 ml of 0.25% bupivacaine and 40 mg of methylprednisolone at site of incision. The visual analog score showed significant improvement from 7/10 to 2/10 for the next 2 months of follow-up. We conclude that ultrasonography-guided ES block combined with intralesional steroid is a viable treatment option in cases of CPSP. This is possibly the first case report of postcholecystectomy chronic pain managed with ES block. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Horner syndrome: A hidden benign complication of cervical epidural injection p. 190 Sudheer Dara, Minal Chandra, Rachna Varma
DOI :10.4103/ijpn.ijpn_59_18 Cervical epidural steroid injection is an intervention done for cervical prolapsed intervertebral disc. Cervical epidural steroid injection is done if a patient has not responded to medications and physical therapy. We discuss a case report of the occurrence of Horner's syndrome in the patient with cervical radiculopathy undergoing cervical interlaminar epidural steroid injection which resolved spontaneously without residual side effects. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta

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Journal of Pain

EDITORIAL
Percutaneous vertebroplasty: Current controversy p. 123 Kailash Kothari
DOI :10.4103/ijpn.ijpn_67_18 [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta REVIEW ARTICLES
Full-endoscopic lumbar discectomy for high canal compromised disc at upper lumbar level: A technical review p. 125 Manish Raj, Kailash Kothari, Anurag Agarwal, Hyeun Sung Kim, Pankaj Surange, Kapil Tyagi, Prashant Punia, Palea Ovideu
DOI :10.4103/ijpn.ijpn_51_18 Objective: In this study, we have described the technique to overcome difficulty faced during trans-foraminal endoscopic discectomy for the treatment of lumbar radiculopathy in patients who have herniated discs at the upper lumbar level & thoracolumbar junction. Method: After institutional review board approval, A retrospective analysis of 27 patients operated between March 2013- September 2017, by a single specialist for disc herniation at upper lumbar levels D12-L1, L1-2, L2-3 with or without high canal compromise by outside in technique (using rigid endoscope, sequential reamers) along with detailed description of our technique is the focus of this study. Results: Out of 27 patients there were 11 cases for L1-2 & 16 cases of L2-3 disc herniation respectively. There were 21 cases of broad-based, high canal compromised disc herniation with significant neurological deficit & only 6 cases were of focal herniation type. The average preoperative VAS score of 8.5 (range 6-10) reduced to 4 (range 2-7) immediate postoperatively & it further reduced to 2 (range 0-4) at one month follow up. The average preoperative ODI score of 65 (range 28- 88) reduced to 27 (range 12-40) immediate postoperatively & it further reduced to 10 (range 3- 18) at one month follow up. Post-operative MRI showed that the ruptured disc had been successfully removed. Conclusion: An anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic discectomy for upper lumbar disc herniation. Foraminotomy is recommended for all intra-canalicular herniation. Transforaminal endoscopic discectomy and foraminotomy can be used as a safe yet minimally invasive technique for the treatment of lumbar radiculopathy in the setting of an upper lumbar disc herniation. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Pharmacological management of neuropathic pain in India: A consensus statement from Indian experts p. 132 Ashok Kumar Saxena, Parmanand Jain, Gur Prasad Dureja, Anil Venkitachalam, Subrata Goswami, Hammad Usmani, Shardul Kothari, Dipit Sahu, Baljit Singh, Vandana Trivedi, Gaurav Sharma, Sanjay Kamble, Amit Qamra, Salman Motlekar, Rishi Jain
DOI :10.4103/ijpn.ijpn_47_18 Neuropathic pain (NeP) constitutes a major pain-related disorder, which is often underdiagnosed and undertreated. Adverse physical, psychological, and economic consequences associated with NeP lead to poor quality of life. Burden of NeP in developing countries like India is colossal. Various international guidelines provide effective approaches to diagnose and manage NeP. However, differences in the genetic makeup of Indian population can result in subtle differences in clinical response, considering their low body weight, drug metabolism ability, and pain perception. Similarly, treatment-related adverse effects may also vary. Practice of Indian physicians may also differ for choice of drugs based on their availability and affordability. In the absence of country-specific guidelines, this document could serve as a guiding tool for health-care providers, ensuring uniformity in the treatment of NeP. Thus, applicability of all recommendations from any of these guidelines in Indian setting demands careful evaluation. Clinical experience of Indian physicians suggests that there are lot many challenges (e.g., busy outpatient departments, nonavailability of screening questionnaires in regional languages, and availability and affordability of medications) faced by them when managing NeP. In addition, in India, there are no country-specific guidelines that would help them to address these challenges. The objective for this consensus was to develop an expert opinion guideline to harmonize the management of NeP in India. The expert panel consisted of experts from various specialties such as pain medicine, anesthesiology, diabetology, neurology, and orthopedics. The panel critically reviewed the existing literature evidence and guideline recommendations to provide India-specific consensus on the management of NeP. The final consensus document was reviewed and approved by all the experts. This expert opinion consensus will help health-care professionals as a guiding tool for effective management of NeP in India. Use of Douleur Neuropathique 4 (DN4) questionnaire for NeP screening should be routine in day-to-day clinical practice. For effective utilization of DN4 questionnaire, it should be converted to regional language. If DN4 questionnaire screening fails to identify NeP, it should not be disregarded and should not replace the sound clinical judgment from the treating physician. Diagnostic tests may be considered as a supplement to clinical judgment. Cost-effective treatment should be the initial choice. Dosing should be individualized based on efficacy and tolerability. Tricyclic antidepressants (TCAs), gabapentinoids, and serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered among initial choices. Tramadol can be considered as a second-line add-on treatment for NeP if there is partial response to the first-line agent either alone or in combination. Fixed-dose combination (FDC) of gabapentinoids such as pregabalin (75 mg) with TCA such as nortriptyline (10 mg) is synergistic and improves treatment adherence. Among other treatments, Vitamin B12 (methylcobalamin) can be used either alone or in combination for the management of NeP. Use of Vitamin D and steroids should be limited to specific NeP in individual cases. Referral to pain specialists can be considered if two drugs fail to provide relief in NeP. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta ORIGINAL ARTICLES
Is tactile acuity altered in individuals with acute mechanical neck pain? p. 145 Shobhalakshmi S Holla, Turiya Vats, Pratima Nagpal
DOI :10.4103/ijpn.ijpn_20_18 Background: Tactile acuity measured by point discrimination (TPD) refers to the precision by which we can sense touch.An increase in TPD threshold (loss of tactile acuity) is considered suggestive of disruptions to S1 cortical maps of that specific body part. In some chronically painful conditions, reduced tactile acuity is a manifestation of Central sensitization (CS).The other symptoms include hyperalgesia and allodynia due to repeated activation of spinal nociceptors. A recent study has shown that tactile acuity is affected in individuals with chronic neck pain. While there seems to be adequate evidence stating that tactile acuity is reduced in individuals with chronic pain, CS may not be limited to chronic pain states. There is a paucity of literature with respect to the tactile acuity of a person with acute neck pain. A measurement of tactile acuity of the affected body area in acute pain, may suggest the extent of the altered threshold of sensory discriminative aspect of pain experience. Objectives: To compare the two-point discrimination over C7 spinous process between the symptomatic individuals with mechanical neck pain and age matched healthy controls. Methods: 30 individuals with mechanical neck pain & 30 age matched normals were assessed for two point discrimination using mechanical calipers, The two sharp points of the caliper were vertically placed against the skin surface over C7 spinous process, commencing with 5mm, which was stretched out till the subject appreciated the two points. Values were noted down in millimeters. Results: An independent t – test showed a significant difference in the two point discrimination between the 2 groups ( P < 0.000). Conclusion: It can be concluded that individuals with acute mechanical neck pain demonstrated a change in tactile acuity. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block p. 150 Neena Jain, Pooja Rawat Mathur, Veena Patodi, Saurav Singh
DOI :10.4103/ijpn.ijpn_21_18 Context: Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain and shortens the duration of hospital stay. Aims: To compare analgesic efficacy of ultrasound guided femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Settings and Design: It was a prospective, randomized, double blind study. Methods and Material: Group A ( n = 25) received ultrasound guided FNB and Group B ( n = 25) received ultrasound guided FICB using 0.5% ropivacaine. Primary objective was to observe reduction in pain associated with positioning (sitting) for subarachnoid block. Statistical Analysis used: For data analysis t test, Mann Whitney test and Chi-square test were applied. Results: Visual analog scale (VAS) score for pain before giving peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable ( P = 0.302). VAS score for pain in sitting position before giving subarachnoid block was lesser in Group A (1.88 ± 0.83) than in Group B (2.40 ± 0.57) ( P = 0.013). Mean reduction in VAS score for pain was more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) ( P = 0.002). Conclusion: Ultrasound guided FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients undergoing surgery for fracture femur compared to ultrasound guided FICB. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Image guided trans foraminal epidural injection: Is it a viable stopgap therapy for low backache p. 155 Samaresh Sahu, Rochan Pant, Sashank Sharma
DOI :10.4103/ijpn.ijpn_33_18 Aims: 1. Study the change in pain and function in patient with lumbosacral disc disease on MRI using visual analogue scale (VAS) and the revised Oswestry disability index (ODI) for back pain after administration of fluoroscopically guided transforaminal epidural injection. 2. Correlate the response of the patient with the spread of contrast in epidural space. Method: 100 patients with history of low back ache and imaging findings of disc herniation were enrolled based on inclusion criteria. Patients scored their pain on the VAS and functional disability on revised ODI. The patient was evaluated for distribution of pain and was administered a combination of anaesthetic and steroid after confirming the position of the tip of needle using iodinated contrast. Follow up for response to pain and improvement in disability in immediate post procedure done at 3 and 6 months. Result: 102 injections were administered for 100 patients which comprised of n =69 {67.6%} male and 33{32.4%} female and age distribution was 21-79 years. The distribution of indication was disc bulge n =29 (28.4%), extrusion n =12 (11.8%), post operative n =19 (18.6%), protrusion n =42 (41.2%). No significant difference between the VAS scores ( p =0.20) of the individual indication pre procedure. After 3 & 6 months there was statistically significant difference between the mean rank value of population indicating maximum benefit for disc bulge population and least for post operative population at three months follow up. Conclusion: There is statistically proven good results in all cases for 6 months, after which repeat injections may be tried. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Perception, knowledge, and attitudes of first-year postgraduates toward postoperative pain management: A questionnaire-based study p. 163 Pritam B Adsule, Pradnya M Bhalerao, Prakash R Dhumal
DOI :10.4103/ijpn.ijpn_31_18 Context: Inadequately controlled postoperative pain has undesirable physiological and psychological consequences. It increases postoperative morbidity, delays recovery, and hence causes a delayed return to normal daily living. Furthermore, the lack of adequate postoperative pain treatment may lead to persistent pain after surgery, which is often overlooked. Overall, inadequate pain management increases the use of health care resources and health care costs. Aim: To evaluate the knowledge and attitudes of first-year postgraduate students toward postoperative pain. Study Design: This questionnaire-based cross-sectional study was conducted on 42 first-year postgraduate students. Materials and Methods: A 20-point questionnaire was prepared based on the various aspects of postoperative pain services. The students were asked to provide their answers on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." The responses were kept anonymous, and the results were expressed in terms of percentage. Results: Almost 70% of students had a good knowledge of opioids, 52% strongly felt the need for a structured pain curriculum, 76% were well aware of nonpharmacological methods of pain relief, 48% agreed on the need for a pain physician, and 52% were aware of the advantage of postoperative analgesia. Conclusion: This pilot study helped us to evaluate the current understanding of our first-year postgraduate students and further created awareness on the importance of pain relief postoperatively. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Executive function and its clinical correlates among migraineurs p. 167 Ashitha Sreedhar, Suresh M Kumar, Anjali N Shobha
DOI :10.4103/ijpn.ijpn_38_18 Background: The studies conducted in the field of migraine and its effect on various cognitive functions revealed contradicting results mainly due to the incorporation of patients from varied socioeconomic status, clinical conditions, and the methodology adopted to the study. Methods: The participants of the study consist of 130 migraineurs, selected from the outpatient department of neurology from reputed tertiary centers at Chennai, South India, and controls were picked up from the community. Patients were selected on the basis of clinical examination and screening. The instruments used are Migraine Severity Scale, Headache impact test, hospital anxiety and depression scale (HADS), Wisconsin Card Sorting Test, Trail Making Test, and Controlled Oral word Association Test. Results: The study found that migraine group to have deficits in some aspects of problem-solving and concept formation competencies in comparison with healthy individuals and also found strong and weak correlation with various clinical variables such as its severity, duration, and headache impact indicating the role of migraine on cognitive functioning. Conclusion: The condition of migraine does lead to mild-to-moderate levels of impairment in various frontal lobe-involved cognitive functions such as attention, planning, and problem-solving even in a high-profile samples having higher levels of education and occupation. The relation between the migraine and impairment in cognitive functions are further cemented by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Findings from such a study will also pave new ways and means to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain p. 173 Vrushali P Panhale, Reshma S Gurav, Kartiki Suradkar
DOI :10.4103/ijpn.ijpn_41_18 Background: Fear-Avoidance Beliefs Questionnaire (FABQ) is widely used to assess the fear-avoidance beliefs in patients with low back pain (LBP). However, English serves as a barrier to the population of the state where Marathi is the prime language. Hence, the FABQ needs to be translated into Marathi for the ease of its use. Materials and Methods: FABQ was successfully translated in Marathi using forward-backward translation using recommended guidelines. The final version of FABQ-Marathi version (FABQ-M) was used on 100 patients with chronic nonspecific LBP to assess its reliability and validity. Reliability was assessed by measuring the internal consistency of FABQ-M and its subscales and by checking the test-retest reliability on day 1 and day 2. For the determination of construct validity, convergent and divergent validity was assessed. The floor and ceiling effects were studied. Results: Reliability-internal consistency-Cronbach's alpha for FABQ-M was 0.860 and test–retest: correlation between FABQ-M on day 1 and day 2 were highly significant. The intraclass coefficient was 0.976. There was a high internal consistency between the FABQ-M and its subscales. On assessing convergent validity, there was moderate correlation found between FABQ-M and TSK ( r = 0.52, P = 0.00). Divergent validity showed moderate correlation between FABQ-M and NRS ( r = 0.48, P = 0.00) and between FABQ-M and RMDQ ( r = 0.59, P = 0.00). Conclusion: The translated FABQ-M proved to be acceptable. The results suggest it is a validated, an easy to comprehend, reliable, and valid instrument for the measurement of the fear and avoidance beliefs caused by back disorders in the Marathi-speaking population. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta CASE SERIES
A case series discussing the intrathecal drug delivery system to improve the quality of life in terminal cancer patients p. 179 Joanna Samantha Rodrigues, Preeti Gupta, Shalini Saksena, Manju Butani
DOI :10.4103/ijpn.ijpn_49_18 Cancer is a life changing diagnosis and chronic pain in these terminally ill patients is extremely debilitating. In the present case series, the feasibility of continuous infusion of low dose local anaesthetics and opioids through the intrathecal route has been discussed pertaining to patient selection, technique, drugs used and trouble shooting. The intrathecal catheters were connected through a subcutaneous port to an external ambulatory infusion device (CADD pump) and used on a home care basis. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta CASE REPORTS
Quadratus lumborum: One of the many significant causes of low back pain p. 184 Asha Satish Barge, Satish Mahadeo Barge
DOI :10.4103/ijpn.ijpn_53_18 Quadratus lumborum is one of the common sources of pain and that can be missed or ignored easily. Quadratus lumborum pain syndrome is a myofascial pain syndrome. The pain is due to spasm and stiffness of the muscle. Many a times, weak back muscles are compensated by quadratus lumborum leading to painful spasm. It is diffi cult to differentiate between quadratus lumborum and iliopsoas pain syndrome. Diagnostic quadratus lumborum injection helps differentiate between these two. In this report, we reported a case of quadratus lumborum pain syndrome as a primary diagnosis and iliopsoas pain syndrome as a secondary diagnosis. The diagnosis was confi rmed by fl uoroscopically guided quadratus lumborum injection. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Management of chronic postsurgical pain following cholecystectomy p. 187 Parthasarathy Srinivasan, Gobinath Jayaraman
DOI :10.4103/ijpn.ijpn_36_18 A 50-year-old female presented with severe pain at the cholecystectomy scar site of 4 months' duration. She had an open cholecystectomy done followed by continuous pain from the time of discharge. She was diagnosed as a case of chronic postsurgical pain (CPSP) syndrome. We administered right-sided erector spinae (ES) block by ultrasound guidance depositing 15 ml of 0.25% bupivacaine and 40 mg of methylprednisolone at site of incision. The visual analog score showed significant improvement from 7/10 to 2/10 for the next 2 months of follow-up. We conclude that ultrasonography-guided ES block combined with intralesional steroid is a viable treatment option in cases of CPSP. This is possibly the first case report of postcholecystectomy chronic pain managed with ES block. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta
Horner syndrome: A hidden benign complication of cervical epidural injection p. 190 Sudheer Dara, Minal Chandra, Rachna Varma
DOI :10.4103/ijpn.ijpn_59_18 Cervical epidural steroid injection is an intervention done for cervical prolapsed intervertebral disc. Cervical epidural steroid injection is done if a patient has not responded to medications and physical therapy. We discuss a case report of the occurrence of Horner's syndrome in the patient with cervical radiculopathy undergoing cervical interlaminar epidural steroid injection which resolved spontaneously without residual side effects. [ABSTRACT] [HTML Full text] [PDF] [Mobile Full text] [EPub] [Sword Plugin for Repository] Beta

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Forget GlaxoSmithKline, Eli Lilly Is a Better Big Pharma Stock

GlaxoSmithKline (NYSE: GSK) has popped up on plenty of radar screens following some bold, unexpected moves. Investors will finally get the consumer healthcare spinoff they’ve been asking for through a recently formed joint venture with Pfizer (NYSE: PFE) . The British pharma giant also dived back into the lucrative oncology space with a $5 billion biotech acquisition in early December.
Although Glaxo’s taken some important steps toward building a product lineup full of new blockbuster drugs, it isn’t there yet. While some eyes were on Glaxo, Eli Lilly (NYSE: LLY) has successfully assembled one of the most impressive new-product lineups in the business.
Image source: Getty Images.
Here’s what you need to know about Eli Lilly and the growth drivers that could help it achieve rapid sales growth.
9 big drug launches in just 5 years In five short years, Eli Lilly has launched nine new drugs with blockbuster potential, some of which already add more than $1 billion annually to total revenue. Trulicity is a weekly injection for type-2 diabetes that racked up $2.3 billion during the first nine months of 2018, a 65% gain versus the prior-year period. The Centers for Disease Control and Prevention (CDC) thinks there are around 29 million type-2 diabetics in the U.S. alone, which means Trulicity sales could climb much further.
Taltz is a psoriasis treatment that grew sales a stunning 74% in the third quarter, achieving an annualized run rate of $1.1 billion. That’s impressive for a treatment that launched a couple of years ago into a competitive market. Recent psoriatic arthritis results that significantly outperformed the megablockbuster Humira could help Taltz sales continue rocketing.
Image source: Getty Images.
Headache relief In September, the Food and Drug Administration approved Emgality to help prevent migraine headaches for an enormous group of patients — those who suffer from regular migraines. Emgality is one of three new monthly injections proven to reduce migraine frequency, and they all work essentially the same way.
In 2019, investors will want to keep an eye on total prescriptions compared with Aimovig from Amgen (NASDAQ: AMGN) and Ajovy from Teva Pharmaceuticals (NYSE: TEVA) . Lilly and its peers are currently offering deep discounts to spark awareness of their new treatment options and gain a leading share of this potentially lucrative market. With an estimated 30 million migraine sufferers in the U.S. alone, analysts will be shocked if annual Emgality sales don’t pass the $1 billion mark by 2022.
Although Eli Lilly will compete with Teva Pharmaceuticals and Amgen for migraine patients seeking preventive therapy, Lilly could sew up the market for acute relief with lasmiditan. If the FDA approves an application Lilly submitted in November, lasmiditan could become the first new acute treatment for migraines in decades. During a study underpinning lasmiditan’s application, patients were 110% more likely to report feeling headache-free two hours after taking the experimental pain reliever than patients given a placebo.
Image source: Getty Images.
A cancer drug relaunch to watch Eli Lilly launched a new breast cancer tablet called Verzenio in late 2017 that didn’t begin gaining traction until the FDA expanded its addressable-patient population to include newly diagnosed breast cancer patients in February 2018. Verzenio is similar to Ibrance, a blockbuster Pfizer launched in 2015 that racked up an astounding $3 billion in sales during the first nine months of 2018.
During a clinical trial that supported Ibrance’s approval for newly diagnosed patients, adding the capsules to standard care reduced their risk of disease progression or death by 42.4%, compared with standard treatment on its own. Eli Lilly hasn’t tested Verzenio head-to-head against Ibrance, so comparisons need to be taken with a grain of salt. In a similar study, adding Verzenio to standard care led to a slightly better than 46% reduction in patients’ risk of disease progression or death.
A majority of patients given Verzenio still hadn’t shown signs of disease progression 28.2 months after starting treatment, and long treatment durations could drive sales to similar heights as Ibrance in the years ahead.
Image source: Getty Images.
The attraction in the numbers GlaxoSmithKline shareholders have suffered a declining dividend for years, but Eli Lilly has raised its payout every year since 2014. Lilly shares offer a decent 2.3% yield at recent prices following a big 15% payout bump that the company committed to in December.
At recent prices, investors can scoop up shares of Lilly for just 18.3 times management’s earnings estimates for 2019. At the moment, the average stock in the S&P 500 trades at 15.1 times forward estimates, but Lilly’s growth story will probably be far more exciting than most stocks in the benchmark index. The average Wall Street analyst following Lilly expects its bottom line to grow by 13.9% annually over the next five years.
Verzenio’s success in a space dominated by Ibrance isn’t certain, and blockbuster migraine sales could fail to materialize. But at recent share prices, those look like risks well worth taking.
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Why Essential Oils Need to be In Your Survival Kit

Natural News
Essential oils are concentrated plant extracts which are used for various purposes. You might not think of them as necessary additions to your survival kit, but they can come in handy if ever SHTF. Here are a few good reasons why you should pack essential oils in your survival kit. (h/t to BackdoorSurvival.com ) Disinfects and treats wounds
Certain essential oils can be used to clean minor injuries and accelerate their healing process. According to research, lavender essential oil can promote the formation of new cell tissue, speeding up the wound recovery. You can also use tea tree oil to make your own antibiotic ointment for the treatment of minor cuts, due to its antibacterial, antiviral and antifungal properties. (Related: How to use essential oils to increase your odds of survival in almost any situation .) Relieves headaches
Lavender and peppermint essential oils are useful for alleviating headaches and migraines that are caused by stress and other environmental factors. If you have a severe migraine, you can reduce its severity by inhaling the aroma of diffused lavender oil for 15 minutes. Rosemary oil can help relieve headaches and mental fatigue. Fights bacterial infections
Oregano oil is a highly potent essential oil for fighting yeast and bacterial infections. It can also be used to treat inflammation and gastrointestinal problems. Due to the strength of oregano oil, it should first be diluted in a carrier oil before being used. Alleviates sunburns
Soothe your inflamed sunburns with anti-inflammatory essential oils, such as peppermint and eucalyptus oils. The cooling and refreshing sensation these oils provide can bring immediate relief to the affected skin. Other useful essential oils for treating sunburns include lavender, tea tree, chamomile, and geranium oils.
100% organic essential oil sets now available for your home and personal care, including Rosemary, Oregano, Eucalyptus, Tea Tree, Clary Sage and more, all 100% organic and laboratory tested for safety. A multitude of uses, from stress reduction to topical first aid. See the complete listing here , and help support this news site. Relieves toothaches
Clove oil can alleviate pain due to toothaches and other dental issues, by numbing the nerves around the affected area in your mouth. However, it must be used sparingly due to its highly concentrated potency. Soothes nausea
Peppermint oil is a truly versatile essential oil, as it can also be utilized for the treatment of nausea. The health benefits it provides are seemingly endless as it can also be used to promote proper digestion. Repels insects
Protect yourself from bugs and pests with the help of essential oils. Diluted citronella oil can effectively repel mosquitoes if you apply it on your skin once every 30 to 60 minutes. If you want to keep insects from a certain area, you can spray that area with a mixture of water and either peppermint oil or tea tree oil. Other useful natural repellents include lemongrass, lavender, and cinnamon oils. Promotes restful sleep
Some calming essential oils may also have sleep-inducing properties to help you manage your insomnia or other sleep-related issues. Lavender oil is one of these natural sleep aids. Enhances mood
Stay calm and collected even in the most stressful situations with the help of essential oils . You can use them every day to remain confident and to reduce restlessness and anxiety. Lemon oil is particularly useful for promoting focus and relieving feelings of anxiety. You can induce positive feelings by inhaling diffused bergamot essential oil for 15 minutes. Research suggests that a three percent concentration of lavender oil is sufficient for reducing work-related stress. Other popular essential oils that can help reduce levels of stress and anxiety include lemongrass, ylang-ylang, orange, and frankincense. Disinfects utensils
Some essential oils possess antibacterial, antifungal, and antiviral properties. In a pinch, you can use them for cleaning purposes. Some examples of antiseptic essential oils include tea tree, oregano, thyme, and lemon oils.
If you want to learn about the survival uses of essential oils, you can read more articles by going to EssentialOils.news .
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There are numerous type of frustrations, consisting of stress, migraine headache, sinus, collection and also menstruation frustrations, each showing differing signs and symptoms as well as levels of extent. Determine various kinds of headaches with guidance from a board-certified neurologist in this totally free video clip on frustrations.

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Call: www.nyheadache.com
Bio: Dr. Alexander Mauskop, MD FAAN, is the director and owner of the New York Headache Center in New York City.
Filmmaker: Paul Muller

Headache getting the best of me

I’m seriously struggling with headaches. I’m 15w5d and have had a nasty headache for the last 3 days now. I would get migraines prior to pregnancy so bad headaches are not foreign to me. I have tried just about everything: Tylenol, hot and cold packs, caffeine, extra hydrating, acupuncture and going to the chiropractor even today.
I’m not getting any relief, even broke down crying today because of it. I am waiting to hear back from my doctor about anything else I can do, but anyone else have any home remedies they have found too help? Or just other sob stories so I don’t feel so alone. I’m a FTM (first time mom) so this is all still new and hard for me.

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