Potential advantages of an additional forearm rubber tourniquet in intravenous regional anesthesia: a randomized clinical trial.

OBJECTIVE: Although the usefulness of an additional forearm tourniquet to conventional intravenous regional anesthesia (IVRA) has been reported, the forearm cuff may disturb the surgical field to some degree, especially in wrist surgery. In the present study, we assessed the clinical efficacy of a temporary additional forearm rubber tourniquet to the conventional upper arm tourniquet on the quality of IVRA. METHODS: The study included 32 ASA physical status I and II adult patients undergoing elective hand surgery who were randomly allocated to either an additional forearm tourniquet group (Group F) or to a conventional upper arm tourniquet group (Group C). Upper arm tourniquet IVRA was established using 40 mL of 0.5 % lidocaine in Group C. Hypothetically enhanced forearm tourniquet IVRA was established using 10 mL of 0.5 % lidocaine with an additional forearm rubber tourniquet and then administering 30 mL of 0.25 % lidocaine after removing the forearm tourniquet in Group F. The sensory and motor block onset and recovery times, onset time of tourniquet pain, intraoperative fentanyl consumption, and incidence of local anesthetic toxicity were recorded. The numerical rating score (NRS) of perioperative and postoperative pain and quality of anesthesia were also assessed. RESULTS: Although the total dose of lidocaine in Group F was less and the sensory and motor block onset times were significantly shorter in Group F than those in Group C (P < 0.05), there was no difference regarding sensory and motor block recovery times, onset time of tourniquet pain, intraoperative fentanyl consumption, NRS of perioperative and postoperative pain, and the quality of anesthesia in the two groups (P > 0.05). Compared with Group C, the incidence of local anesthetic toxicity (i.e., dizziness, 43.8 vs 6.2 %, P = 0.02) was significantly decreased in Group F. CONCLUSIONS: The combination of the additional forearm and upper arm tourniquets with a smaller amount of local anesthetic achieved more rapid onset of sensory and motor block, a similar quality of anesthesia and a lower incidence of local anesthetic toxicity compared with the conventional technique.

Do outcomes of acupuncture for back pain differ according to varying sociocultural contexts? The view from China.

OBJECTIVES: What are the outcomes of acupuncture for back pain? According to well-regarded trials, acupuncture is little better for back pain than biomedicine, and active acupuncture is no better than sham acupuncture. These trials occurred in the West. Patients are inside the clinic a miniscule amount of time in relation to the time they are outside the clinic and enmeshed in the wider sociocultural context. Nevertheless, trials have largely overlooked potential effects of sociocultural context. The main objective of this article is to draw attention to designated features of sociocultural context that, as compared with outcomes obtained in the West, may enhance outcomes of acupuncture for back pain in China. Additional objectives of the article are to reconceptualize "sociocultural context" so that it is measurable, and to measure pre-existing acquaintance with acupuncture and other forms of Traditional Chinese Medicine (TCM) within the sociocultural context of China. DESIGN/SETTING/SUBJECTS: Back pain patients (N=86) were recruited from the Acupuncture Clinic and Pain Clinic of West China Hospital (Chengdu, Sichuan Province). Patients completed questionnaires on their use of TCM before they came to the Acupuncture Clinic and their families' use of TCM. RESULTS: Most patients had used TCM, and those who did so likely used it repeatedly, which indicated substantial acquaintance with TCM beliefs in the cultural context. Patients whose families used TCM were also likely to use it themselves, which indicated that TCM use was anchored in the social context of the family. CONCLUSIONS: Although multiple studies substantiate biologic mechanisms of acupuncture, there is not necessarily a fixed relationship between those mechanisms and people's experience of them. Rather, sociocultural context may interact with biologic mechanisms and mediate this experience. The theory proposed here explains why outcomes of acupuncture for back pain will potentially be more pronounced in the sociocultural context of China than in the West.

Opioid pharmacotherapy for chronic non-cancer pain in the United States: a research guideline for developing an evidence-base.

UNLABELLED: This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence. PERSPECTIVE: Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP.

Speech motor control and chronic back pain: a preliminary investigation.

OBJECTIVES: Chronic back pain and its sequelae can influence cognitive, affective, and neuromuscular functioning. Speech production--a complex sensorimotor activity--integrates shared cognitive, neuromuscular, and musculoskeletal resources, and therefore could be altered by chronic pain. The purpose of this preliminary investigation was twofold: 1) to determine whether speech alternating motion rates (i.e., speech AMRs) which require rapid, reciprocally coordinated articulatory movements were associated with chronic back pain; and 2) to identify factors that might mediate any observed alterations. DESIGN: Fifty participants, fully or partially disabled by chronic back pain, completed standardized protocols related to pain, depression, disability, medications, as well as speech AMRs. RESULTS: Higher levels of back pain were significantly associated with slower speech AMRs. Stepwise multiple regression assessed the unique and cumulative effects of specific variables such as degree of back pain, depression, level of disability, and medication use on speech motor performance. Speech motor slowness was uniquely related to back pain and the use of nonprescription pain medications, but not to level of depression or disability. CONCLUSIONS: Chronic back pain independently influences speech motor rates. Several explanatory models are proposed including pain-induced centrally mediated motor retardation/inhibition, reduced selective attention, and peripherally based "bracing/holding" of shared musculoskeletal environments.