Relaxation and music to reduce postsurgical pain.

AIMS: We investigated the effects of relaxation, music, and the combination of relaxation and music on postoperative pain, across and between two days and two activities (ambulation and rest) and across ambulation each day. This secondary analysis of a randomized controlled trial was conducted from 1995 to 1997. BACKGROUND: After surgery, patients do not always receive sufficient relief from opioids and may have undesired side-effects. More complete relief (10-30%) was found recently with adjuvant interventions of relaxation, music, and their combination. Comparison of effects between days and treatments have not been examined longitudinally. METHODS: With a repeated measures design, abdominal surgery patients (n = 468) in five US hospitals were assigned randomly to one of four groups; relaxation, music, their combination, and control. With institutional approval and written informed consent, subjects were interviewed and taught interventions preoperatively. Postoperative testing was at ambulation and rest on days 1 and 2 using visual analogue (VAS) sensation and distress of pain scales. RESULTS: Multivariate analysis indicated that although pain decreased by day 2, interventions were not different between days and activities. They were effective for pain across ambulation on each day, across ambulation and across rest over both days (all P < 0.001), and had similar effects by day and by activity. CONCLUSION: Nurses can safely recommend any of these interventions for pain on both postoperative days and at both ambulation and rest.

Relief of postoperative pain with jaw relaxation, music and their combination.

The aim of this randomized controlled trial was to determine the effect of jaw relaxation, music and the combination of relaxation and music on postoperative pain after major abdominal surgery during ambulation and rest on postoperative days 1 and 2. Opioid medication provided for pain, following abdominal surgery, does not always give sufficient relief and can cause undesired side effects. Thus, additional interventions such as music and relaxation may provide more complete relief. Previous studies have found mixed results due to small sample sizes and other methodological problems. In a rigorous experimental design, 500 subjects aged 18-70 in five Midwestern hospitals were randomly assigned by minimization to a relaxation, music, relaxation plus music, or control group. Interventions were taught preoperatively and tested postoperatively. The same amount of time was spent with subjects in the control group. Pain was measured with the visual analogue sensation and distress of pain scales. Demographic and surgical variables, and milligrams of parenteral or oral opioids in effect at the time of testing were not significantly different between the groups, nor did they correlate with pain scores. Controlling for pretest sensation and distress, orthogonal a priori contrasts and multivariate analysis of covariance indicated that the three treatment groups had significantly less pain than the controls, (P = 0.028-0.000) which was confirmed by the univariate analysis of covariance (P = 0.018-0.000). Post hoc multivariate analysis revealed that the combination group had significantly less sensation and distress of pain than the control group on all post-tests (P = 0.035-0.000), and the relaxation and music groups had significantly less on all tests (P = 0.022-0.000) except after ambulation. At post ambulation those using relaxation did not have significantly less pain than the controls on both days and those using music did not on day 1, although there were some univariate effects. A corresponding significant decrease in mastery of the interventions from pre to post ambulation suggests the need for reminders to focus on the intervention during this increased activity. Physicians and nurses preparing patients for surgery and caring for them afterward, should encourage patients to use relaxation and music as adjuvants to medication for postoperative pain.

Stimulation of the central and peripheral nervous system for the control of pain.

After suffering some setbacks since its introduction in 1967, stimulation of the spinal and peripheral nervous systems has undergone rapid development in the last ten years. Based on principles enunciated in the Gate Control Hypothesis that was published in 1968, stimulation-produced analgesia [SPA] has been subjected to intensive laboratory and clinical investigation. Historically, most new clinical ideas in medicine have tended to follow a three-tiered course. Initial enthusiasm gives way to a reappraisal of the treatment or modality as side-effects or unanticipated problems arise. The last and third phase proceeds at a more measured pace as the treatment is refined by experience. This review is divided into three parts as it traces the progress of spinal cord stimulation [SCS] and peripheral nerve stimulation [PNS]. The review commences with a discussion of the theory of SCS and PNS, and is followed by early reports during which it became apparent that the modality is essentially only effective in the treatment of neuropathic pain. The last section describes the modern experience including efficacy in specific types of pain and concludes with recent accomplishments that dramatize the relief of pain which can be achieved in nonoperable peripheral vascular disease or myocardial ischemia. Over the years, a search for those transmitters that might be influenced by spinal cord stimulation focused on somatostatin, cholecystokinin (CCK), vasoactive intestinal polypeptide (VIP), neurotensin and other amines, although only substance "P" was implicated. More recently, in animal studies, evidence that GABA-ergic systems are affected may explain the frequent successful suppression of allodynia that follows spinal cord stimulation. During the past eight years, much attention has been directed to studies that use a chronic neuropathic pain model. While PNS held significant promise as a pain relieving modality, early electrode systems and their surgical implantation yielded variable results due to evolving technical and surgical skills. These results dramatically reduced the continued development of PNS, which then gave way to a preoccupation with SCS. Modern development of SCS with outcome studies, particularly in relation to failed back surgery syndrome [FBSS] and the outcome of peripheral nerve surgery for chronic regional pain syndromes, has earned both modalities a place in the ongoing management of patients with intractable neuropathic pain. The last section, dealing with pain of peripheral vascular and myocardial ischemia, is perhaps one of the more exciting developments in stimulation produced analgesia and as the papers discussed demonstrate, can provide a level of analgesia and efficacy that is unattainable by other treatment modalities. SCS and PNS has an important role to play in the management of conditions that are otherwise refractory to conservative or other conventional management.

Long-term results of peripheral nerve stimulation for reflex sympathetic dystrophy.

This prospective, consecutive series describes peripheral nerve stimulation (PNS) for treatment of severe reflex sympathetic dystrophy (RSD) or complex regional pain syndrome, in patients with symptoms entirely or mainly in the distribution of one major peripheral nerve. Plate-type electrodes were placed surgically on affected nerves and tested for 2 to 4 days. Programmable generators were implanted if 50% or more pain reduction and objective improvement in physical changes were achieved. Patients were followed for 2 to 4 years and a disinterested third-party interviewer performed final patient evaluations. Of 32 patients tested, 30 (94%) underwent permanent PNS placement. Long-term good or fair relief was experienced in 19 (63%) of 30 patients. In successfully treated patients, allodynic and spontaneous pain was reduced on a scale of 10 from 8.3 +/- 0.3 preimplantation to 3.5 +/- 0.4 (mean +/- standard error of the mean) at latest follow up (p<0.001). Changes in vasomotor tone and patient activity levels were markedly improved but motor weakness and trophic changes showed less improvement. Six (20%) of the 30 patients undergoing PNS placement returned to part-time or full-time work after being unemployed prestimulator implantation. Initial involvement of more than one major peripheral nerve correlated with a poor or no relief rating (p<0.01). Operative modifications that minimize technical complications are described. This study indicates that PNS can provide good relief for RSD that is limited to the distribution of one major nerve.

Spinal cord stimulation versus spinal infusion for low back and leg pain.

The relative roles of spinal cord stimulation and the spinal infusion of opioids in the treatment of chronic, non-cancer lower body pain remains unclear. This report contains a retrospective analysis of patients with chronic lower body, neuropathic pain and treated over a 5 year period. Unilateral leg and/or buttock pain was treated initially with spinal stimulation and bilateral leg or mainly low back pain was treated initially with spinal infusions. 26 patients received spinal stimulation. Pain relief was > or = 50% in 16 (62%) with increased activity levels. Stimulator coverage was most difficult or failed in patients with buttock pain. 16 patients received long-term spinal infusions. Pain relief was > or = 50% in 2 (13%) but 25-49% in another 8 (50%) with stable infusion doses and was best in patients requiring low-dose (< 1 mg/h morphine intrathecal) infusions in the trial period. The review indicates that spinal infusions may be best for bilateral or axial pain that has not responded to spinal stimulation. Clonidine appears to be an alternative in high-dose morphine patients. New diamond-shaped electrode and dual quadripolar arrays appear to be very helpful for back, buttock, and/or bilateral leg pain patterns.

Exogenous and endogenous plasma levels of epinephrine during dental treatment under local anesthesia.

BACKGROUND AND OBJECTIVES: To determine serum levels of catecholamines after local anesthesia for dental treatment, we used tritium-labeled epinephrine as a vasoconstrictor for dental local anesthesia. METHODS: Twenty healthy male outpatients undergoing standardized dental treatment (deep scaling) were studied. In all patients, only one quadrant was anesthetized even though the treatment was performed on all teeth. Two milliliters of articaine 4% (amide anesthetic) with 20 micrograms epinephrine was used as local anesthetic. Of the total epinephrine administered, 1.2% (100 microCi) consisted of tritium-labeled epinephrine. Blood samples were drawn through a central venous catheter before and at frequent intervals after the local anesthetic solution was administered. RESULTS: A dramatic increase in exogenous epinephrine was observed in four patients during injection (up to 6937 pg/mL). The other 16 patients demonstrated a continuous increase in applied epinephrine that peaked on average at the 7th minute (631.5 +/- 41.4 pg/mL). A second increase occurred after the beginning of the dental procedure. The mean total epinephrine levels were always higher than those of the applied epinephrine. Extrasystoles were observed in two of four and tachycardia in three of four patients with high plasma levels of applied epinephrine. Increases in total epinephrine were associated with exogenous catecholamine administration, whereas the dental treatment did not significantly influence the plasma levels. CONCLUSION: Despite aspiration in 20% of the patients, an unintended intravascular injection occurred. Although healthy young men tolerated large increases in central plasma epinephrine levels surprisingly well, this may not be the case in patients with concurrent cardiovascular disease. Patients at cardiovascular risk should be under continuous monitoring when an epinephrine-containing solution is applied.