The present study is a retrospective cohort analysis which sought to examine adherence to medications used in managing painful diabetic peripheral neuropathy (PDPN) and to determine their association with oral antidiabetic (OAD) medication adherence using the Texas Medicaid prescription claims database. The study objectives were to: 1) provide a description of PDPN and OAD medication use among the study subjects; 2) determine if PDPN medication adherence differs among individual PDPN agents (i.e., tricyclic antidepressants, gabapentin, pregabalin and duloxetine); 3) determine if pre-index OAD and post-index OAD medication adherence differs among mono, dual, and triple OAD therapies; and 4) determine if PDPN medication adherence is related to post-index OAD medication adherence while controlling for covariates. Study participants were adult (≥18 years) Medicaid beneficiaries prescribed OAD and PDPN medications. The index date was the first PDPN prescription. Data were extracted from June 1, 2003 to October 31, 2009 and prescription claims were analyzed over an 18-month study period (i.e., 6 months pre-index and 12 months post index period). Medication possession ratio (MPR) was used as a proxy measure of medication adherence. An MPR less than 80 percent was regarded as being non-adherent to prescribed medication, while an MPR greater than or equal to 80 percent was regarded as being adherent to prescribed medication. Objective 1 was addressed using descriptive statistics (i.e., mean, standard deviation, frequency). Univariate analysis (ANOVA) was employed to address Objectives 2 and 3. Multivariate analyses (i.e., multiple linear regression and logistic regression) were conducted to address Objective 4. For the logistic regression MPR was dichotomized at the cut-off value of 80 percent. A total of 4,277 patients met the study’s inclusion criteria. The overall mean MPR (±SD) for PDPN medications was 75.4 percent (±23.9). Mean MPR (±SD) was highest for duloxetine (85.6% ±18.2) and was lowest for pregabalin (69.4% ±24.9). Mean MPR differed significantly among individual PDPN medications (p<0.0001). The overall mean MPR (±SD) for OAD medications in the pre and post-index period was 73.0 percent (±24.3) and 64.5 percent (±25.6) respectively. In both pre and post-index periods, mean MPR differed significantly among mono, dual, and triple OAD therapies (p<0.0001). In the pre-index period, mean MPR (±SD) was highest for monotherapy users (75.4% ±24.7) and was lowest for triple therapy users (63.9% ±22.9). Similarly, mean MPR (±SD) was highest for monotherapy users (69.0% ±26.1) and was lowest for triple therapy users (52.9% ±21.8) in the post-index period. After controlling for the covariates, PDPN adherence (i.e., MPR) was statistically significant (p<0.0001) and positively related to post-index OAD adherence (i.e., MPR). PDPN patients who were non-adherent (i.e., MPR<80%) to their PDPN medications (or neuropathic pain medications), compared to those who were adherent (MPR≥80%), were significantly less likely to be adherent to their OAD medications [Odds Ratio (OR) = 0.626, 95% CI=0.545-0.719]. In addition, post-index OAD adherence (i.e., MPR) did not differ significantly (p>0.05) when pregabalin, duloxetine and gabapentin users were individually compared to tricyclic antidepressants users. In conclusion, PDPN patients who were adherent (i.e., MPR≥80%) to their PDPN medications, compared to those who were not adherent (i.e., MPR<80%), were more adherent to their OAD medications. Also, adherence to OAD medications was independent of the type of PDPN medication used. PDPN patients need to be educated regularly that neuropathic pain medications only relieve the pain associated with the neuropathy but achieving adequate glycemic control remains the only established approach for slowing down the progression of the neuropathy and other complications associated with the diabetes. / text

My PhD research studies, described in this thesis, were designed to document the temporal development of mechanical allodynia, a hallmark symptom of painful diabetic neuropathy (PDN), as well as opioid hyposensitivity using two different rat models of diabetes mellitus (DM). Specifically, the studies were conducted using the streptozotocin (STZ)-diabetic rat model of chemically-induced Type 1 diabetes in two different rat strains, as well as the Zucker Diabetic Fatty (ZDF) rat genetic model of Type 2 diabetes. Additionally, a longitudinal investigation of the effect of basal insulin replacement therapy to restore euglycaemia from 7-days post-STZ administration, on the development of mechanical allodynia in the hindpaws of the STZ-diabetic Wistar rat model of PDN, was conducted. The studies herein also included a longitudinal study to document the temporal development of mechanical allodynia and opioid hyposensitivity in the ZDF rat, which also examined the influence of dietary composition on the time course for the development of mechanical allodynia in the hindpaws, together with opioid hyposensitivity in these animals. In the final section of this thesis, the experiments were designed to examine possible mechanisms that may contribute to the development of opioid hyposensitivity in ZDF diabetic rats. These experiments involved the quantification of opioid receptor messenger ribonucleic acid (mRNA) gene expression as well as μ-opioid receptor (MOP-r) functional responses in tissues collected from 29-wk old diabetic ZDF rats relative to 7-wk old pre-diabetic control ZDF animals. In Chapter One, diabetes mellitus and more specifically its longterm complication, PDN, the focus of this doctoral research program, has been reviewed. Specifically, possible pathogenic mechanisms underlying mechanical allodynia, the relevant diabetic rodent models of PDN, use of insulin replacement therapy in diabetic rodents and its impact on hallmark symptoms of PDN, role of opioid pharmacology, the comparative efficacy of opioids in the treatment of PDN, and possible mechanisms that may underpin the development of opioid hyposensitivity in PDN, including the impact of altered excitatory neurotransmitters, have been reviewed. In Chapter Two, a preliminary study was conducted to investigate the efficacy of 4-wks treatment with Linplants (subcutaneous (s.c.) sustained-release bovine insulin implants) alone and in combination with ActRapid® (s.c. human insulin; 0.05 U to 3.5 U/100 g/day) with respect to glycaemic control in STZ-diabetic Wistar rats, and on acute diabetes characteristics for a 5-wk post-STZ administration period. Briefly, STZ-diabetic rats were divided into three groups: (1) rats which received no insulin treatment, (2) rats which were implanted with one s.c. Linplant at Day 7 post-STZ administration, and (3) rats which received one s.c. Linplant plus a once-daily injection of ActRapid® once diabetes was confirmed at 7-days post-STZ administration. The findings were that following implantation of a single Linplant at Day 7 post-STZ administration, euglycaemia was achieved in 50% of STZ-diabetic rats, with glycaemic control maintained for up to 4-wks post-implantation. Furthermore, once-daily injection of ActRapid™ to animals whose blood glucose levels (BGLs) were not well-controlled through use of Linplants alone, failed to achieve euglycaemia. It is possible that the ActRapid™ doses administered were not sufficient to achieve euglycaemia, and that increasing the doses may provide more effective glycaemic control. However, doubling the mean ActRapid™ dose from 1.63 (+ 0.3) U administered at Day 28 to 2.56 (+ 0.6) U administered at Day 34 post-STZ administration effectively only reduced BGLs by 1.3 mM to 11.6 + 1.6 mM. This suggests that although administering additional large doses of ActRapid™ to STZ-diabetic rats may eventually achieve euglycaemia, this method would presumably not be a more efficient method in achieving euglycaemia compared with the use of dosage-adjustable s.c. Linplants. Group (1) STZ-diabetic rats which were not treated with insulin developed diabetic signs including polydipsia, hyperphagia, decreased rate of body weight gain, and mechanical allodynia. Group (2) rats in which insulin treatment from 7-days post-STZ administration restored euglycaemia and reversed polydipsia and hyperphagia, were protected against the development of mechanical allodynia and reduced weight gain for the 5-wk study duration, while rats from Group (3) with incomplete glycaemic control developed levels of polydipsia, hyperphagia, reduced weight gain and mechanical allodynia intermediate between rats in Groups (1) and (2). These findings collectively suggest a direct correlation between the level of glycaemic control and the extent to which mechanical allodynia, a defining symptom of PDN, develops. In Chapter Three, the findings from the preliminary 5-wk study in Chapter Two were used to design a 24-wk longitudinal study of the temporal development of mechanical allodynia and opioid hyposensitivity in STZ-diabetic Wistar rats for comparison with the findings of a similar study previously undertaken by our laboratory using STZ-diabetic Dark Agouti rats (Nielsen et al, 2007). Additionally, this study examined the effects of tight glycaemic control achieved through the use of insulin implants as a means of potentially preventing the development of mechanical allodynia and opioid hyposensitivity for up to 24 weeks in STZ-diabetic Wistar rats. Briefly, STZ-diabetic rats were divided into 3 groups: (1) non-insulin treated STZ-diabetic Dark Agouti rats to provide comparison data with our laboratory’s previously published data in this rat strain (Nielsen et al, 2007), (2) non-insulin treated STZ-diabetic Wistar rats to examine possible between-species differences, and (3) STZ-diabetic Wistar rats which were treated with adjustable-dose s.c. Linplants from Day 7 post-STZ administration to maintain euglycaemia for the remainder of the 24-wk study period. In this 24-wk longitudinal study in STZ-diabetic rats, body weight, 24-hr water intake, paw withdrawal thresholds (PWTs) and BGLs were monitored at fortnightly intervals in all animals in order to document possible temporal changes in the development of diabetic signs and mechanical allodynia in the hindpaws respectively. STZ-diabetic rats underwent 6-wkly opioid antinociceptive testing, using single bolus doses of each of morphine and oxycodone with a 2-3 day washout period between individual opioids in order to assess the potential influence of both diabetes and glycaemic control on opioid potency in these animals. The findings demonstrate that non-insulin treated STZ-diabetic rats of both strains exhibited a decreased rate of body weight gain and polydipsia, as well as progressive development of mechanical allodynia in the hindpaws and loss of morphine potency. Importantly, STZ-diabetic Wistar rats which were treated with insulin to maintain euglycaemia from Day 7 post-STZ administration failed to develop these diabetic symptoms for the duration of the 24-wk study period, highlighting the importance of chronic hyperglycaemia in the development of mechanical allodynia and morphine hyposensitivity in the STZ-diabetic rodent model of PDN. The research described in Chapter Four involved a 22-wk longitudinal study of the development of diabetes and its longterm sensory nerve complications, viz mechanical allodynia and opioid hyposensitivity, in the ZDF rodent model of Type 2 diabetes commencing at 7-wks of age. This study also examined the influence of four different diets fed to separate groups of ZDF rats from 7-wks age, on the time course for the development of diabetes, mechanical allodynia in the hindpaws and opioid hyposensitivity in these animals. Briefly, ZDF rats were sub-divided into four dietary groups, each of which was fed one of the four following diets for 22-wks commencing at 7-wks of age, viz: (a) Purina 5008™, (b) a domestically-produced rat chow of similar composition to Purina 5008 (termed Purina Composition diet), (c) a Diabetogenic diet, or (d) Standard Rat Chow. All rats underwent once-fortnightly measurement of BGLs, body weight, 24-hr water intake, and measurement of PWTs in the hindpaws. Additionally, ZDF rats underwent opioid antinociceptive testing, similar to that previously described for STZ-diabetic rats (Chapter Three), to investigate the influence of diabetes and dietary composition on the antinociceptive potency of single bolus doses of morphine and oxycodone administered at 6-weekly intervals over a 22-wk study period. The afore-mentioned data were compared with the respective data obtained from the pre-diabetic control group of ZDF rats that were euthanised at 7-wks of age prior to the development of hyperglycaemia. The results demonstrate that the ZDF rat develops mechanical allodynia in the hindpaws and opioid hyposensitivity in a temporal fashion, in a manner similar to that previously documented for the STZ-diabetic Wistar rat model of Type 1 diabetes (Chapter Three). For the four diets assessed, there did not appear to be significant differences between dietary groups with respect to the time course and extent of development of hyperglycaemia, mechanical allodynia or opioid hyposensitivity in the ZDF rat model of PDN. The study described in Chapter Five investigated the effect of both diabetes and dietary composition on opioid receptor mRNA expression in tissue samples collected from the five groups of ZDF rats used in the behavioural studies described in Chapter Four and outlined above. Briefly, mRNA expression for each of the - (MOP), - (DOP), and - (KOP) receptors were quantified in mid-brain and spinal cord tissues prepared from 29-wk old diabetic ZDF rats maintained on one of four diets from 7-wks age, and compared with the respective expression levels in samples prepared from pre-diabetic ZDF rats euthanised at 7-wks of age. Overall, the findings suggest that diabetes does not alter opioid receptor mRNA expression in the mid-brain or spinal cord of diabetic ZDF rats at 29-wks of age relative to the corresponding levels of mRNA expression in the mid-brain and spinal cord of pre-diabetic ZDF rats at 7-wks of age. Hence, the marked reduction in the anti-allodynic potency of morphine and oxycodone observed in diabetic ZDF rats at 29-wks of age relative to that observed in pre-diabetic ZDF rats at 7-wks of age (Chapter Four) does not appear to be associated with a decrease in opioid receptor mRNA expression. In Chapter Six, the effect of both advanced diabetes and dietary composition on opioid-agonist stimulated [35S]GTPγS binding was examined in spinal cord tissue membranes from the ZDF rat. Specifically, [35S]GTPγS binding assays were used to assess the ability of a -opioid ligand (DAMGO) to stimulate -opioid receptor coupling to inhibitory G proteins in homogenates prepared from spinal cord samples of 29-wk old ZDF rats maintained on one of four different diets from 7-wks age (Chapter Four), relative to [35S]GTPγS binding in homogenates prepared from spinal cord samples of pre-diabetic 7-wk old ZDF rats. As specific MOP agonist-stimulated [35S]GTPγS binding was significantly decreased in spinal cord homogenates from diabetic ZDF rats at 29-wks of age relative to that for pre-diabetic ZDF rats (7-wks), this may contribute, at least in part, to the morphine hyposensitivity observed in diabetic ZDF rats at 29-wks of age relative to the pre-diabetic ZDF group. However, closer examination of these data revealed that specific MOP agonist-stimulated [35S]GTPγS binding above basal did not differ significantly between the pre-diabetic group and the longterm diabetic group of ZDF rats. Instead, there was significantly lower basal [35S]GTPγS binding in the spinal cord of ZDF rats at 29-wks c.f. 7-wks of age. Together, the findings suggest that impaired basal G-protein function rather than impaired coupling of MOP-r to its inhibitory G-protein may, at least in part, underpin -opioid agonist hyposensitivity in 29-wk ZDF rats. Finally, Chapter 7 contains a brief description of the main conclusions and discussion of the relevance of this doctoral research project, including potential future research directions.

L'objectif de cette thèse est d'étudier le traitement des expressions faciales de douleur d'un point de vue psychophysique et neurophysiologique. Contrairement aux autres émotions dites de base, la douleur est à la fois une expérience sensorielle et émotionnelle, composantes qui se retrouvent sur l'expression faciale de douleur qui accompagne cette expérience. En ce sens, l'expression faciale de douleur semble être plus riche et complexe que l'expression faciale d'autres émotions, la rendant particulière. Dans une première partie de notre travail, nous avons montré, chez des sujets sains, que l'expression faciale de douleur engendrait un plus haut niveau d'empathie que l'expression faciale d'autres émotions. De plus, une présentation de ces visages masqués à 100 ms était suffisante pour permettre de détecter la douleur sur un visage de façon subliminale alors même que la reconnaissance du genre était impossible dans ces conditions. Dans une seconde partie, nous avons étudié le traitement implicite des expressions faciales de douleur chez des patients souffrant d'épilepsie réfractaire et explorés en stéréotaxie par des électrodes intracérébrales. Pour cela, nous avons détourné leur attention du caractère émotionnel des visages et enregistré des réponses évoquées aux visages expressifs. Les résultats montrent une activation précoce de l'insula antérieure (début de réponse à 131 ms ; pic à 180 ms post-stimulus) suivie d'une activation de l'amygdale (début à 273 ms ; pic à 363 ms). Cependant, ces activations antéro-insulaire et amygdalienne ne sont pas spécifiques de la douleur. L'insula postérieure semble également répondre à la présentation de visages exprimant la douleur mais l'amplitude de cette réponse ne diffère pas de celle de la réponse aux visages neutres. Ainsi, malgré les nombreuses informations que véhicule un visage de douleur, l'être humain est capable de le détecter très rapidement et d'être suffisamment empathique pour prodiguer l'aide appropriée à son prochain. Cette capacité serait permise grâce à l'insula antérieure, relai entre nociception et douleur / The aim of this work is to study painful facial expression processing through psychophysical and neurophysiological approaches. Contrary to the basic emotions, pain is both a sensory and an emotional experience and these two aspects are encoded in the facial expression of pain. In that sense, painful facial expressions are richer and more complex than the facial expression of others emotions. In a first phase, we showed that painful facial expressions trigger more empathy than other emotional facial expressions in healthy subjects. Moreover, a 100ms-masked presentation of faces is enough to subliminally detect pain but not gender. In a second phase, we studied pre-conscious processing of painful facial expressions in patients suffering from refractory epilepsy having intracranial electrodes implanted in the insular cortex and amygdala for stereotaxic exploration of epilepsy. To this purpose, we diverted the patients' attention from the emotional aspects of the faces by asking them to focus on the gender and we recorded evoked potentials to pain and other emotional faces. Results showed an early activation in the anterior part of the insula (onset latency around 131ms, peak latency 180ms post stimulus) followed by an amygdala response (onset latency around 273ms, peak latency 363ms post stimulus). Response to pain faces is larger than that to other emotional faces in anterior insula but anterior-insula and amygdala activations are not pain specific. Posterior part of the insula also responds to painful faces but the amplitude of the evoked potentials do not differ from that of potentials evoked by neutral faces. In this way, even if the pain face contains a great amount of information, the human- being is able to rapidly detect it and to be empathic enough to provide the help needed for others in pain. This ability would be possible through anterior insula activation, thought to be a relay between nociception and emotional reaction to pain

M.Tech. / aim of this unblinded randomized control study was to compare Chiropractic Adjustive Therapy (CAT) to Interferential Current Therapy (IFC) as treatment for Painful Minor Intervertebral Dysfunction (PMID) in the lumbar spine. The effects of CAT and IFC on lumbar spine range of motion (ROM) and pain relief from PMID were also examined. The participants of the trials were treated at the Chiropractic Day Clinic at the University of Johannesburg. Thirty participants presenting with Low Back Pain (LBP) and PMID on segmental intervertebral examination were used for this study and divided into two groups of fifteen. Group A participants were treated with CAT applied to the painful intervertebral segment. Group B participants were treated with IFC over the painful intervertebral segment. The objective data for this research was recorded by the readings obtained from the application of transverse pressure by a Pressure Algometer to the lateral aspect of a painful spinous process. Further objective readings were taken using a Digital Inclinometer to measure the participants Range of Motion (ROM). Subjective data was obtained by an Oswestry Pain and Disability Index (ODI). The subjective and the objective data were both recorded at the first, fourth and seventh visit which took place over a three week period. The results of the study showed that Group A had a statistically significant decrease in Pressure Algometer Readings and ODI scores. Group A also showed a statistically significant improvement in ROM readings for Left Lateral Flexion, Left Rotation and Right Rotation. Group B did not show any statistical significance in either the subjective or objective data. Importantly, an Inter-group comparison for the Pressure Algometer Readings also revealed an increasing statistically significant difference between Group A and Group B from the first to the fourth and seventh visit. The pain elicited by transverse pressure to a spinous process is core to the diagnosis of PMID, which can result in many pain syndromes of vertebral origin (Maigne, 2006). This research provides evidence that CAT is more beneficial than IFC for the treatment of PMID in the lumbar spine over a short and longer period of time.

No description available.

Bakgrund: Lustgas har konstaterats vara ett mycket bra alternativ för smärtlindring av barn vid kortvarig procedurrelaterad smärta. Lustgasen har snabbt insättande effekt och biverkningar av lustgas är få eller av mild karaktär. Lustgas påverkar miljön negativt men en del av detta kan avhjälpas med effektiva ventilationssystem. Sjukvårdspersonal som exponeras för lustgas regelbundet utsätts för hälsorisker, dessa risker är dock inte helt kartlagda i nuläget. Sjuksköterskor som administrerar lustgas ställs inför en komplex situation med många faktorer att ta hänsyn till. Lustgasens betydelse i vården har studerats ur ett patient-, hälso- och miljöperspektiv. Enligt vår kännedom saknas studier som fokuserat på specialistsjuksköterskans eller blivande specialistsjuksköterskors upplevelser av lustgasadministrering till barn. Syfte: Att undersöka specialistsjuksköterskors och sjuksköterskor under pågående specialistutbildnings upplevelser av att administrera lustgas till barn i samband med procedursmärta på akutmottagning. Metod: En kvalitativ deskriptiv intervjustudie med induktiv design tillämpades. Strukturerade intervjuer genomfördes med tio specialistsjuksköterskor och blivande specialistsjuksköterskor på ett medelstort sjukhus i Sverige. Intervjuerna transkriberades och analyserades därefter genom kvalitativ innehållsanalys. Resultat: Analysen resulterade i tre huvudkategorier; Sjuksköterskans strategier vid lustgasadministrering, Utmaningar i samband med lustgasadministrering och Lustgasens begränsningar och möjligheter. Vidare abstraherades 11 underkategorier. Övervägande positiva erfarenheter av lustgasadministrering till barn framkom under intervjuerna. I resultaten framkom att sjuksköterskan behöver kunna anpassa sig efter barnets förutsättningar. Även betydelsen av ett välfungerande teamarbete, hur arbetsmiljön påverkar lustgasadministrering och betydelsen av tydliga riktlinjer framträdde. Upplevelser av trötthet och det känslomässiga engagemanget vid lustgasadministrering beskrevs. Diskussion: Teamarbetets framgång kopplas till god kommunikation. Resultaten tyder på att hög arbetsbelastning påverkar hur väl riktlinjer följs och i förlängningen skulle detta kunna innebära att patientsäkerheten påverkas negativt. Lokala skillnader kan ha gått förlorade då studien utgår från ett sjukhus, skillnader mellan olika verksamheter skulle kunna ha bidragit med viktig information. För att belysa sjuksköterskors personliga erfarenheter användes strukturerade intervjuer. Det är möjligt att frågorna styrt svaren och att ämnen som inte togs upp kunnat ge värdefullt information. Slutsats: Sjuksköterskors upplevelser av att administrera lustgas är övervägande positiva och det finns en önskan om att utöka användandet av lustgas inom barnsjukvård. Välfungerande teamarbete och tydliga riktlinjer framträder som väsentligt för att framgångsrikt kunna administrera lustgas till barn inom akutsjukvård. Vidare forskning bör inkludera flera sjukhus för att identifiera viktig information om likheter och skillnader i användandet av lustgas samt jämföra upplevelserna hos dem som administrerar lustgasen.

Bakgrund: Barns smärtfysiologi och deras reaktioner på smärta skiljer sig från vuxnas. De har inte lika välutvecklad smärtreglering och smärtan är närmare associerad med emotionella upplevelser. Smärta hos barn kan leda till negativa följder och har ett samband med stress, oro och rädsla. Syfte: Att beskriva sjuksköterskans möjligheter att lindra smärta i samband med procedurer hos barn 6-12 år. Metod: En litteraturstudie med systematisk ansats där sökningar gjordes i Cinahl, PubMed och Scopus. Sökorden som användes var: ”treatment related pain”, ”procedural pain”, ”procedure pain”, ”child*” och ”nurs*”. Utvalda artiklar kvalitetsgranskades och analyserades genom kvalitativ innehållsanalys. Resultat: Sjuksköterskan har stora möjligheter att lindra smärtan i samband med procedurer. Resultatet grundas på 18 artiklar med olika ansatser och behandlas i sju teman: avledningsmetoder, avslappning, farmakologisk smärtlindring, ålders inverkan på barns smärtupplevelse, att använda avledning, sjuksköterskans betydelse och delaktighet. Konklusion: Sjuksköterskans bemötande och förhållningsätt spelar stor roll i mötet med barnet och denne kan använda sig själv som ett verktyg för att främja barnets känsla av trygghet och använda sig av avledningsmetoder anpassade till barnets förutsättningar. / Background: Children's physiology of pain, as well as their reaction to it, differs from that of an adult. Their pain modulation is not as developed and pain is more closely associated with emotional experiences. Pain in children can lead to negative consequences and is linked to stress, anxiety and fear. Aim: To describe the nurse’s opportunities to alleviate pain in procedures in children 6-12 years. Method: A literature review with a systematic approach where searches were made in Cinahl, PubMed and Scopus. The search terms used were: ”treatment related pain”, ”procedural pain”, ”procedure pain”, ”child*” and ”nurs*”. Selected articles were examined regarding quality and analysed through qualitative content analysis. Results: The nurse has many opportunities to alleviate pain in procedures. The result is based on 18 articles with different approaches and presented in seven themes: distraction methods, relaxation, pharmacological pain relief, influence of age in children's experience of pain, to use distraction, the importance of the nurse and participation. Conclusion: The nurse's approach makes a difference in the encounter with the child and they can use themselves as a tool to promote the child's feeling of security, aswell as use distraction methods adapted to the child.

Title Evaluation of the effect of physiotherapeutic approaches in painful conditions of the cervical spine. Objectives The aim of this thesis is to find out, which physiotherapy methods and techniques are used for pain of cervical spine, and to evaluate their effect. The study also aims to summarize current knowledge on this issue. Methods The thesis is processed through the method of literature review and is of analytical and descriptive nature. The used studies meet all pre-determined criteria. The thesis is divided into several parts. The first part, general information, describes mainly the physiotherapy methods and techniques that are used for treatment of pain in cervical spine. The second part, results, summarizes these physiotherapy approaches and evaluates their effect. The study concludes with a discussion that is focused on the two main questions of the thesis. Results A total of 25 studies met the criteria for inclusion in this thesis. These studies show that the physiotherapy methods and techniques currently used in painful conditions of cervical spine, include: mobilization and manipulation of cervical, possibly thoracic spine, therapeutic exercise, massage, McKenzie therapy, transcutaneous electrical nerve stimulation, conservative interventions, and educational and physical programs....

Chronische Schmerzerkrankungen beeinflussen die Arbeitsfähigkeit deutlich. Ziel dieser systematischen Übersichtsarbeit ist es, arbeitsbezogene Studienendpunkte in randomisierten, placebokontrollierten Studien zu chronischen Schmerzerkrankungen und schmerzhaften rheumatologischen Erkrankungen zu analysieren. Datenbanktreffer einer Literaturrecherche in Medline (Pubmed) wurden als Abstracts gesichtet und potentiell relevante Studien danach im Volltext beurteilt. Die methodologische Studienqualität wurde mit der Oxford Quality Scale (OQS) bewertet. Verfügbare arbeitsbezogene und schmerzbezogene Endpunkte wurden in Meta-Analysen mit Hilfe von einem „fixed effect model“ oder einem „random effects model“ zusammengefasst. Lineare Regressionen zwischen arbeitsbezogenen Endpunkten und schmerzbezogenen Endpunkten wurden durchgeführt. Insgesamt 31 Publikationen mit einer Gesamtzahl von 11434 Patienten berichten über arbeitsbezogene Studienendpunkte; dies waren nur ungefähr 0,23% aller relevanten Publikationen. Eine Meta-Analyse aller arbeitsbezogenen Endpunkte, ohne Unterteilung nach vorgenommener Behandlung und der spezifischen vorliegenden Erkrankung, konnte einen allgemeinen Behandlungserfolg von 0,35, ausgedrückt als standardisierte Mittelwertsdifferenz (SMD), mit einem 95%-Konfidenzintervall (95%-KI) von 0,21 bis 0,50 beschreiben. Eine umfassende Meta-Analyse der Schmerzendpunkte derselben Studien ergab eine allgemeine Verbesserung bezüglich schmerzbezogener Endpunkte von 0,40, ausgedrückt als SMD (95%-KI: 0,25; 0,55). Weitere Meta-Analysen zeigten statistisch signifikante Verbesserungen in den Behandlungsgruppen für die folgenden Parameter: Beeinträchtigungen bei der Arbeit (0,62 Punkte auf einer 0- bis 10-Punkte-Skala; 95%-KI: 0,45; 0,79), Arbeitsproduktivität (SMD 0,53; 95%-KI: 0,18; 0,88), 30%ige Schmerzverbesserung relativ zu Studienbeginn (ausgedrückt als Verbesserung des relativen Risikos (RR) von 33%; 95%-KI: 15%; 53%) und 50%ige Schmerzverbesserung relativ zu Studienbeginn (RR 46%; 95%-KI: 22%; 74%), 20%iges (RR 184%; 95%-KI: 86%; 334%), 50%iges (RR 237%; 95%-KI: 84%; 715%) und 70%iges (RR 232%; 95%-KI: 65%; 571%) Ansprechen der Patienten bezogen auf die Kriterien des „American College of Rheumatology“ (ACR). Ergebnisse Arbeitsfehlzeiten und Beschäftigungsverhältnisse betreffend waren heterogen und nicht aussagekräftig. Lineare Regressionensanalysen von sowohl kontinuierlichen arbeitsbezogenen mit kontinuierlichen schmerzbezogenen Endpunkten, als auch von kontinuierlichen arbeitsbezogenen Endpunkten mit kategorischen schmerzbezogenen Ansprechraten, belegten einen statistisch signifikanten Zusammenhang. Abschließend kann berichtet werden, dass arbeitsbezogene Endpunkte nur sehr selten in placebokontrollierten Studien zu chronischen Schmerzerkrankungen untersucht wurden, und dass, wenn sie berichtet wurden, die Endpunkte und Berichterstattung heterogen waren. Es konnten wiederholt statistisch signifikante Behandlungseffekte für verschiedene arbeitsbezogene Endpunkte nachgewiesen werden. Weiterhin konnte gezeigt werden, dass eine starke lineare Relation zwischen arbeitsbezogenen Endpunkten und schmerzbezogenen Endpunkten vorliegt.

Introdução: a ausência de extensão completa do joelho é uma condição limitante que algumas vezes precisa ser tratada invasivamente através da realização da capsulotomia posterior do joelho, uma vez que medidas conservadoras tenham sido esgotadas previamente. No entanto, mesmo com a literatura vigente, ainda não está claro se o procedimento para aquisição de extensão do membro inferior está associado á melhora funcional de pacientes com contratura em flexão do joelho e queixas de dor anterior, bem como se este ganho de extensão pode ser mantido ao longo do tempo. Métodos: nós conduzimos um estudo de coorte retrospectivo de 21 pacientes com contratura em flexão mínima do joelho os quais foram submetidos à capsulotomia posterior do joelho por técnica aberta entre 1990 e 2010. Após 9.19 ± 6.68 anos de follow-up, os níveis funcionais do joelho e média de ângulo de contratura em flexão foram comparados com os dados pré-operatórios e a taxa de recorrência pôde ser estimada. Complicações investigadas incluíram instabilidade do joelho secundária ao procedimento e danos neurovasculares. Resultados: pré-operatoriamente, todos os pacientes (100%) apresentavam scores funcionais de Lysholm classificados como regular ou ruim (média absoluta do score 58.66 ± 13.87, 95%CI 52.35–64.98), e 15 pacientes (72%) apresentaram melhora funcional, com scores bom ou excelente (média de score de Lysholm 87.61 ± 8.81, 95%CI 83.60–91.63) após o período de follow-up. A média pré-operatória do ângulo de flexão do joelho foi de 25.04 ± 9.15 graus (95%CI 20.88–29.21) e diminuiu para 4.28 ± 4.18 graus (95CI% 2.38 – 6.19). Nenhum paciente apresentou complicações relacionadas ao procedimento Conclusão: baseado em nossos resultados, nós concluímos que a capsulotomia posterior do joelho parece ser um procedimento seguro e efetivo para tratar adequadamente pacientes com joelhos dolorosos secundários a contraturas em flexão, com uma baixa taxa de recorrência mesmo após 9.19 anos em média de seguimento. / Background: lack of full extension of the knee is a disabling condition that sometimes needs to be treated invasively by a posterior capsulotomy of the knee, since conservative treatments have been exhaustively attempted. However, it is not clear if the procedure is able to improve anterior symptoms on the knee of patients with flexion contracture and if the full extension acquired can be kept throughout long-time follow-up. Methods: we conducted a retrospective cohort study of 21 patients diagnosed with minimal flexion contracture of the knee who underwent open posterior capsulotomy between 1990 and 2010. After 9.19 ± 6.68 years of follow-up, knee function and mean angle of fixed knee flexion were compared to baseline data and the recurrence rate was estimated. Complications investigated included knee instability and neurovascular damages. Results: all patients (100%) presented with a preoperative Lysholm score classified as poor or fair (mean, 58.66 ± 13.87, 95%CI 52.35–64.98), but 15 patients (72%) experienced an improvement to good or excellent scores (mean, 87.61 ± 8.81, 95%CI 83.60–91.63) after long-time follow-up. The mean preoperative angle of fixed flexion was 25.04 ± 9.15 degrees (95%CI 20.88–29.21) and it decreased to 4.28 ± 4.18 degrees (95CI% 2.38 – 6.19, after the follow-up. Conclusion: Based on these results, we conclude that posterior capsulotomy of the knee proved to be a safe and effective procedure to treat properly patients with painful knees secondary to lack of full extension with a low rate of recurrence even after a long-term follow-up.