Approach to headache disorders and the management of migraine: consensus guidelines from the Headache Society of Singapore, first edition (2023).

Headache disorders, particularly migraine, are one of the most common and disabling neurological disorders. There is a need for high-quality, accessible care for patients with headache disorders across all levels of the healthcare system in Singapore. The role of the Headache Society of Singapore is to increase awareness and advance the understanding of these disorders and to advocate for the needs of affected patients. In this first edition of local consensus guidelines, we focus on treatment approaches for headaches and provide consensus recommendations for the management of migraine in adults. The recommendations in these guidelines can be used as a practical tool in routine clinical practice by primary care physicians, neurologists and other healthcare professionals who have a common interest in headache disorders.

Percutaneous t2 and t3 radiofrequency sympathectomy for complex regional pain syndrome secondary to brachial plexus injury: a case series.

Complex regional pain syndrome secondary to brachial plexus injury is often severe, debilitating and difficult to manage. Percuteneous radiofrequency sympathectomy is a relatively new technique, which has shown promising results in various chronic pain disorders. We present four consecutive patients with complex regional pain syndrome secondary to brachial plexus injury for more than 6 months duration, who had undergone percutaneous T2 and T3 radiofrequency sympathectomy after a diagnostic block. All four patients experienced minimal pain relief with conservative treatment and stellate ganglion blockade. An acceptable 6 month pain relief was achieved in all 4 patients where pain score remained less than 50% than that of initial score and all oral analgesics were able to be tapered down. There were no complications attributed to this procedure were reported. From this case series, percutaneous T2 and T3 radiofrequency sympathectomy might play a significant role in multi-modal approach of CRPS management.

Evidence-based guidelines on the use of opioids in chronic non-cancer pain--a consensus statement by the Pain Association of Singapore Task Force.

INTRODUCTION: While opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed. MATERIALS AND METHODS: A multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions. RESULTS: Available data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour. CONCLUSION: Due to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as secondor third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required.

Current considerations for the management of musculoskeletal pain in Asian countries: a special focus on cyclooxygenase-2 inhibitors and non-steroid anti-inflammation drugs.

Chronic pain is a complex problem that eludes precise definition and can be clinically difficult to diagnose and challenging to treat. In the Asia-Pacific region, prevalence estimates that chronic pain ranges from 12% to 45% of the population, with musculoskeletal, rheumatic or osteoarthritis pain making up the majority of the disease burden. Implementation of current management guidelines into routine clinical practice has been challenging and as a result, patients with musculoskeletal pain are often poorly managed. For these reasons, a multidisciplinary Chronic Pain Advisory Board of leading physicians from various Asian countries was convened to explore ways to improve treatment and compliance, especially among patients with osteoarthritis and rheumatoid arthritis. We have identified a number of unmet therapeutic needs and prioritized initiatives with the potential to contribute toward a more integrated approach to chronic pain management. Key priorities included using evidence-based interventions as recommended by current guidelines, particularly those aspects pertinent to addressing treatment priorities in Asia (e.g., patient compliance), and the incorporation of cyclooxygenase-2 inhibitors and non-steroid anti-inflammation drugs into the management algorithms for osteoarthritis and rheumatoid arthritis. Treatment must be individualized for each patient based on efficacy, side-effect profile and drug accessibility. Further studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics and long-term efficacy outcomes. Our increasing understanding of the problem combined with the promise of new therapy options offers hope for improved management of musculoskeletal pain in Asian countries.

Pain prevalence in Singapore.

UNLABELLED: The prevalence of chronic pain is well described in various parts of the world; primarily in Western societies such as Europe, America and Australia. Little is known of the prevalence of chronic pain within Asia or Southeast Asia. In view of the cultural and genetic variation in pain causation, manifestation and reporting, the findings of previous studies cannot be translated to Asian countries. Prevalence studies needed to be carried out to quantify the magnitude and impact of chronic pain within Asian countries to properly allocate precious health funds to deal with this important healthcare issue. We report the findings of the prevalence study within one Asian country: Singapore. OBJECTIVE: To determine the prevalence and impact of chronic pain in adult Singaporeans. MATERIALS AND METHODS: Two sets of questionnaires were designed. The first, a screening questionnaire, to identify the prevalence of chronic pain, and should there be chronic pain; the second, a detailed questionnaire was administered, to characterise the features and the impact of pain. A cross-sectional sampling of Singapore adults were achieved using a computer-based multi-step random sampling of listed telephones numbers. The questionnaires were administered via telephone by a trained interviewer with the aid of a computer-assisted telephone interview system. RESULTS: A total of 4141 screening and 400 detailed questionnaires were completed. The prevalence of chronic pain, defined as pain of at least 3 months' duration over the last 6 months was 8.7% (n = 359). There was a higher prevalence in females (10.9%) and with increasing age. In particular, pain prevalence increased steeply beyond the age of 65 years old. There was a significant impact on work and daily function of those with chronic pain. CONCLUSION: Though the prevalence of chronic pain was marginally lower compared other studies, the impact of pain was just as significant. In a rapidly ageing population such as Singapore, chronic pain is an important emerging healthcare problem which will likely exert increasing toll on the existing social infrastructure within the next 5 to 10 years.

Continuous femoral nerve block in total knee arthroplasty: immediate and two-year outcomes.

We conducted a prospective study to investigate the immediate and 2-year outcomes of total knee arthroplasty patients who received continuous femoral nerve block (FNB) for analgesia. Sixty patients undergoing unilateral total knee arthroplasty were randomized into 3 groups and received high-dose continuous FNB, low-dose continuous FNB, or no FNB. In the immediate postoperative period, we studied their pain scores, cumulative morphine use, any FNB-related complications, time of first ambulation, and patient satisfaction. At 2 years, we assessed their functional outcomes with Oxford knee questionnaire and Knee Society clinical rating system. Immediately after surgery, there was less pain, higher satisfaction, and lower morphine use among patients on continuous FNB regardless of ropivacaine dosage used. At 2 years, there were no significant differences in functional outcomes.

Piriformis muscle injection using ultrasonography and motor stimulation--report of a technique.

The piriformis muscle syndrome has been described in the literature since 1947 and accounts for 6-8% of patients presenting with buttock pain, which may variably be associated with sciatica. Through the years, there have been attempts to find safe and effective ways of managing this condition, whether through conservative treatment or with the use of interventional procedures. Several authors have reported injection techniques using the following: nerve stimulation; fluoroscopy with electromyography; and fluoroscopy with muscle stimulation. We aim to describe an injection method which is effective, simple, reproducible, easily available, and safe. This is the first report on the combined use of ultrasonography and motor stimulation in performing piriformis muscle injection. Our technique offers advantages such as: markedly decreased radiation exposure for both patient and doctor; improved visualization of sciatic nerve and surrounding muscles; improved portability; the possibility of being performed as an office-based procedure; and allows for an accurate confirmation of pain in the piriformis muscle with stimulation.