Local cooling for relieving pain from perineal trauma sustained during childbirth.

BACKGROUND: Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments. OBJECTIVES: To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012), CINAHL (1982 to 10 January 2012), the Australian New Zealand Clinical Trials Register (10 January 2012) and contacted experts in the field. SELECTION CRITERIA: Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed trials for inclusion, assessed trial quality and extracted data. A sub-set of data were double checked for accuracy. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials. MAIN RESULTS: Ten published RCTs were included (involving 1825 women). Comparisons were local cooling treatments (ice packs, cold gel pads (with or without compression) or cold/iced baths) with no treatment, gel pads with compression, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam (Epifoam), oral paracetamol or warm baths. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61; 95% confidence interval (CI) 0.41 to 0.91; one study, n = 208). Women preferred the utility of the gel pads compared with ice packs or no treatment (RR 0.82; 95% CI 0.73, 0.92). Differences detected in a composite of perineal oedema and bruising and overall wound healing were noted in one small study, favouring cold gel pads (n = 37) over ice (n = 35, mean difference (MD) 0.63 on a scale of 0 to 15; 95% CI 0.20 to 1.06) or no treatment (n = 39, MD -2.10; 95% CI -3.80 to -0.40) three to 14 days after giving birth. Women reported more pain (RR 5.60; 95% CI 2.35 to 13.33; one study, 100 women) and used more additional analgesia (RR 4.00; 95% CI 1.44 to 11.13; one study, 100 women) following the application of ice packs compared with PET. AUTHORS' CONCLUSIONS: There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.

Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults.

BACKGROUND: Amputee pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. Phantom pain and stump pain are complex and multidimensional and the underlying pathophysiology remains unclear. The mainstay treatments for phantom pain and stump pain are predominately pharmacological. The condition remains a severe burden for those who are affected by it. There is increasing acknowledgement of the need for non-drug interventions and Transcutaneous Electrical Nerve Stimulation (TENS) may have an important role to play. TENS has been recommended as a treatment option for phantom pain and stump pain. To date there has been no systematic review of available evidence and the effectiveness of TENS for phantom pain and stump pain is currently unknown. OBJECTIVES: To assess the analgesic effectiveness of TENS for the treatment of phantom pain and stump pain following amputation in adults. SEARCH STRATEGY: We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, PsycINFO, AMED, CINAHL, PEDRO and SPORTDiscus (February 2010). SELECTION CRITERIA: Only randomised controlled trials (RCTs) investigating the use of TENS for the management of phantom pain and stump pain following an amputation in adults were included. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. It was planned that where available and appropriate, data from outcome measures were to be pooled and presented as an overall estimate of the effectiveness of TENS. MAIN RESULTS: No RCTs that examined the effectiveness of TENS for the treatment of phantom pain and stump pain in adults were identified by the searches. AUTHORS' CONCLUSIONS: There were no RCTs on which to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigour and robust reporting needed to confidently assess its effectiveness. Further RCT evidence is required before such a judgement can be made.

The effectiveness of walking stick use for neurogenic claudication: results from a randomized trial and the effects on walking tolerance and posture.

UNLABELLED: Comer CM, Johnson MI, Marchant PR, Redmond AC, Bird HA, Conaghan PG. The effectiveness of walking stick use for neurogenic claudication: results from a randomized trial and the effects on walking tolerance and posture. OBJECTIVES: To determine the immediate effects of using a stick on walking tolerance and on the potential explanatory variable of posture, and to provide a preliminary evaluation of the effects of daily walking stick use on symptoms and function for people with neurogenic claudication. DESIGN: A 2-phase study of neurogenic claudication patients comprising a randomized trial of 2 weeks of home use of a walking stick and a crossover study comparing walking tolerance and posture with and without a walking stick. SETTING: A primary care-based musculoskeletal service. PARTICIPANTS: Patients aged 50 years or older with neurogenic claudication symptoms (N=46; 24 women, 22 men, mean age=71.26y) were recruited. INTERVENTION: Walking stick. MAIN OUTCOME MEASURES: Phase 1 of the trial used the Zurich Claudication Questionnaire symptom severity and physical function scores to measure outcome. The total walking distance during a shuttle walking test and the mean lumbar spinal posture (measured by using electronic goniometry) were used as the primary outcome measurements in the second phase. RESULTS: Forty of the participants completed phase 1 of the trial, and 40 completed phase 2. No significant differences in symptom severity or physical function were shown in score improvements for walking stick users (stick user scores - control scores) in the 2-week trial (95% confidence interval [CI], -.24 to .28 and -.10 to .26, respectively). In the second phase of the trial, the ratio of the shuttle walking distance with a stick to without a stick showed no significance (95% CI, .959-1.096) between the groups. Furthermore, the use of a walking stick did not systematically promote spinal flexion; no significant difference was shown for mean lumbar spinal flexion for stick use versus no stick (95% CI, .351 degrees -.836 degrees ). CONCLUSIONS: The prescription of a walking stick does not improve walking tolerance or systematically alter the postural mechanisms associated with symptoms in neurogenic claudication.

Does changing to brighter road lighting improve road safety? Multilevel longitudinal analysis of road traffic collision frequency during the relighting of a UK city.

BACKGROUND: A step change in the night environment is taking place, with the large-scale installation of bright, broad-spectrum road lighting such as white light-emitting diodes (LEDs). One justification for this is a reduction in road traffic collisions (RTCs). This study aimed to estimate the effect of new lighting on personal injury RTCs within a large UK city. METHODS: We analysed a 9-year time series of weekly RTC personal injury counts in 132 areas of the city using multilevel modelling. The RTC rate over a full 24-hour period was the primary outcome; darkness and daylight RTC rates were secondary. The background change in RTC rate was separated from the change associated with the number of newly installed bright lamps by including a polynomial underlying time trend for the logarithm of the mean number of collisions per week for each area. The study was based on a rigorous, predesigned and archived protocol. RESULTS: Within-area coefficients for the broad lighting effect were positive; as the number of bright lamps in an area increased, so did the RTC rate. The estimate for the increase in the within-area 24-hour RTC rate is 11% (95% CI 2% to 20%). The estimate of darkness-only RTCs is 16% (95% CI 2% to 32%). If the effect of lighting on darkness RTC rate is adjusted by that for daylight, one obtains 4% (95% CI -12% to +23%). CONCLUSION: No evidence was found for bright lamps leading to an improvement in road safety in any of the analyses. For this city, introducing brighter road lighting may have compromised safety rather than reducing harm.

Self-care in primary care: findings from a longitudinal comparison study.

AIM: To examine the effects of self-care training workshops for primary healthcare workers on frequently attending patients. BACKGROUND: Interventions to promote self-care in frequent users of primary care services have had mixed results. This paper reports an evaluation of a self-care initiative that aimed to develop a practice-based strategy to support self-care. METHODS: A 12-month longitudinal-matched comparison study was carried out in seven intervention and four comparison practices. The intervention was a multidisciplinary training package delivered to Primary Care Trusts (PCTs) and practice staff in three workshops, over a three- to six-month period. Twenty-one managers, health professionals and other staff from participating practices and PCTs and 1454 patients were involved in the study. 'Frequently attending' patients were defined as having visited the practice more than eight times in the previous year, and were identified from practice registers and recruited by letter. Three sets of data were obtained: psychometric scores and other data from structured questionnaires; routinely collected data on use of healthcare services; and self-care beliefs and behaviour from qualitative interviews. Findings Study recruitment rate was 20% and retention rate 75%. Of those recruited 66% were female and the majority (94.8%) were White. There was poor uptake of the training programme within the participating practices, with few changes agreed or implemented. Few healthcare professionals consented to take part in the evaluation. No significant changes were seen in patients' use of health services, psychometric scores or self-care beliefs or behaviour. CONCLUSION: The initiative did not show any effects during its pilot phase. Uptake and implementation were adversely affected by competing pressures for time and resources in primary care, coupled with a lack of engagement from primary health care professionals.

Cross-sectional comparisons of BMI and waist circumference in British children: mixed public health messages.

Research suggests that there has been a leveling off in obesity prevalence occurring in the child population. However, a concern with the evidence base is that all of the studies have relied upon the use of BMI. The purpose of this study was to compare waist circumference (WC), BMI, and waist-to-height ratio (WHtR) data in three different sample of children (total number: 14,697) typically aged 11-12 years. Obesity prevalence defined by BMI did not change significantly between measurement years (2005 boys 20.6%, girls 18.0%; 2006 boys 19.3%, girls 17.3%; 2007 boys 19.8%, girls 16.4%). Obesity prevalence defined by WC was considerably higher especially, in girls (2005 boys 26.3%, girls 35.6%; 2006 boys 20.3%, girls 28.2%; 2007 boys 22.1%, girls 30.1%). The prevalence of children defined as "at risk" according to WHtR (2005 boys 23.3%, girls 21.1%; 2006 boys 16.7%, girls 15.6%; 2007 boys 17.6%, girls 17.2%) was found to be between obesity prevalence, estimated using BMI and WC. This data are the most up to date collection that includes BMI and WC in three large samples of children and clearly demonstrates inconsistencies between different measurements based on current classification systems. There is a need to understand the relationship between BMI and WC, with growth and health risk to establish a consistent public health message that is easily understood by the public.

The self-care for people initiative: the outcome evaluation.

AIM: To determine the effects of a community-based training programme in self-care on the lay population. BACKGROUND: Self Care is recognised as being a cornerstone of the populations health, but to date there have been few large-scale studies of its effectiveness on the general public. This paper reports on an evaluation of a self-care skills training course delivered in small group sessions within workplace and parent and toddler group settings to a lay population. METHODS: A quasi-experimental longitudinal study of 12-month duration was conducted in three intervention primary care trusts (PCTs) and two similar comparison PCTs in England. The sample comprised 1568 self-selecting participants: 868 received the intervention and 700 did not. FINDINGS: No changes were seen in usage of General Practitioner services, the primary outcome, however, statistical analysis suggested that being in the intervention group may be associated with increased use of out-of-hours and secondary care services. At six months' follow-up small but statistically significant positive effects of being in the intervention group were seen on self-esteem, well-being and anxiety scores. At 12 months' follow-up small but statistically significant positive effects of being in the intervention group were also seen on recovery locus of control, health literacy and self-esteem scores, and on knowledge of adult cough. The clinical significance of these very small changes is unclear. The training programme had a small but positive effect, which was still evident at 12 months, on individuals' knowledge and confidence levels with regard to managing their own health, but did not lead to reductions in health service use.

Conventional versus acupuncture-like transcutaneous electrical nerve stimulation on cold-induced pain in healthy human participants: effects during stimulation.

OBJECTIVES: To compare the hypoalgesic effects of conventional transcutaneous electrical nerve stimulation (TENS) (high frequency, low intensity) and acupuncture-like TENS (AL-TENS, low frequency, high intensity) on cold-induced pain. DESIGN: Randomized controlled parallel group study comparing the effects of strong non-painful AL-TENS, conventional TENS and placebo (no current) TENS on cold-pressor pain threshold (CPT) and pain intensity. Two baseline (pre-intervention) measures and three during intervention measures of CPT and cold pain intensity (four point category scale) were recorded. SETTING: Physiology laboratory in Leeds Metropolitan University. PARTICIPANTS: One hundred and twenty-one healthy participants. INTERVENTIONS: Each participant received one of three TENS interventions over their flexor digitorum profundus: (i) high pulse rate TENS with a strong non-painful paraesthesia (conventional), (ii) low-rate burst mode TENS that caused strong non-painful phasic muscle twitching (acupuncture like) or (iii) no current (placebo) TENS. MAIN OUTCOME MEASURE: Difference between conventional TENS and AL-TENS in cold pain threshold relative to pre-TENS baseline after 25 min of stimulation. RESULTS: No differences were detected for CPT or cold pain intensity during conventional TENS compared with AL-TENS. When compared with placebo TENS, the confidence intervals for the ratio of intervention CPT to baseline CPT, for both AL-TENS (0·966, 1·424) and conventional TENS (0·948, 1·401), were close to the positive side of one, although neither reached statistical significance. CONCLUSIONS: Unlike some previous studies, the present study detected no differences in hypoalgesia between AL-TENS, conventional TENS and placebo (no current) TENS during stimulation.

Comparison of post-treatment effects of conventional and acupuncture-like transcutaneous electrical nerve stimulation (TENS): A randomised placebo-controlled study using cold-induced pain and healthy human participants.

TENS can be administered in conventional (high frequency, low intensity) or acupuncture-like (AL-TENS: low frequency, high intensity) formats. It is claimed that AL-TENS produces stronger and longer-lasting hypoalgesia than conventional TENS, although evidence is lacking. This randomised controlled parallel group study compared the effects of 30 minutes of AL-TENS, conventional TENS, and placebo (no current) TENS, on cold-pressor pain threshold (CPT), in 43 healthy participants. Results showed a greater increase in mean log(e) cold-pressor pain threshold relative to baseline for both AL-TENS and conventional TENS vs. placebo TENS, and for AL-TENS vs. placebo 5 and 15 minutes after TENS was switched off. There were no statistically significant differences between conventional TENS vs. placebo or between AL-TENS vs. conventional TENS at 5 or 15 minutes after TENS was switched off. In conclusion, AL-TENS but not conventional TENS prolonged post-stimulation hypoalgesia compared to placebo TENS. However, no differences between AL-TENS and conventional TENS were detected in head-to-head comparisons.

A preliminary investigation into the effect of coffee on hypolagesia associated with transcutaneous electrical nerve stimulation.

Transcutaneous electrical nerve stimulation (TENS) is a non-invasive, inexpensive analgesic technique used to relieve pain. It has been suggested that caffeine, an adenosine antagonist, may interfere with TENS action. This double-blind controlled pilot study investigated the effect of coffee on response to TENS in healthy human participants experiencing experimentally induced pain. Twelve participants (7 female, age range = 20-41 years) took part in two experiments separated by 24 h. Each experiment lasted 80 min and consisted of 3 x 15 min cycles: pre-TENS, during TENS predrink and during TENS postdrink [coffee (100 mg caffeine) or decaffeinated coffee randomized across experiments]. During each cycle, thresholds for electrical (EPT), mechanical (MPT) and cold pressor (CPT) pain were recorded. The statistical analysis modelled the responses for the coffee and decaffeinated coffee conditions during TENS (i.e. as a standard crossover) and detected no statistically significant effects between coffee and decaffeinated drinks for the natural logarithm (ln) transformed values of electrical pain threshold [ln EPT Coffee-ln EPT Decaffeinated coffee mean (standard error) = 0.0147 (0.2159)], mechanical pain threshold [ln MPT Coffee-ln MPT Decaffeinated coffee mean (standard error) = 0.1296 (0.0816)] and cold pain threshold [ln CPT Coffee-ln CPT Decaffeinated coffee mean (standard error) = 0.0793 (0.1139)]. We conclude that a single cup of coffee (100 mg caffeine) had no detectable effect on TENS outcome. Reasons why coffee did not produce a detectable effect on pain threshold are discussed.