Pain practice : the official journal of World Institute of Pain
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Nonsteroidal anti-inflammatory drugs (NSAIDs) play an important role in multimodal pain management. In patients with a contraindication for NSAIDs, pain management is challenging. A recent Dutch anesthesiology guideline propagates the use of metamizole (dipyrone) in these patients. Metamizole is a controversial drug, its use being previously discouraged because of the risk for agranulocytosis. We discuss whether metamizole could be an alternative to classical NSAIDs and opioids in postoperative pain management despite this drawback. ⋯ Although firm evidence is lacking, metamizole may be safer for the upper intestinal tract and kidneys than other NSAIDs, and could alternatively be used in patients with an increased risk for stomach or renal problems. Hereby, improved postoperative pain relief can potentially be achieved. The risk for metamizole-induced agranulocytosis is judged to be acceptable.
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Shoulder pain is a common health problem in which changes in shoulder structure cannot always explain the patient's perceived pain. Central sensitization (CS) might play a role in a subgroup of these patients. ⋯ This review has shown that great progress has been made toward a better understanding of neurophysiologic pain mechanisms in patients with shoulder pain. The presence of generalized mechanical hyperalgesia, allodynia, and impaired conditioned pain modulation in patients with MSK shoulder pain indicates the involvement of the central nervous system. Widespread somatosensory abnormalities observed in patients with HSP could suggest a central origin for their shoulder pain and predispose patients with HSP to develop CS, although results are inconsistent. Additional research is required adopting different assessment methods (especially dynamic methods) to establish the role of CS in patients with shoulder pain.
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Review Meta Analysis
Nervous System Sensitization as a Predictor of Outcome in the Treatment of Peripheral Musculoskeletal Conditions: A Systematic Review.
Research suggests that peripheral and central nervous system sensitization can contribute to the overall pain experience in peripheral musculoskeletal (MSK) conditions. It is unclear, however, whether sensitization of the nervous system results in poorer outcomes following the treatment. This systematic review investigated whether nervous system sensitization in peripheral MSK conditions predicts poorer clinical outcomes in response to a surgical or conservative intervention. ⋯ This systematic review found insufficient evidence to support an independent predictive relationship between QST measures of nervous system sensitization and treatment outcome. Self-report measures demonstrated better predictive ability. Further high-quality prognostic research is warranted.
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Postoperative pain management protocols that use patient-controlled analgesia (PCA) can hinder mobility due to attached machinery and tubing. Immobility in the postoperative setting can increase complications, length of stay (LOS), and costs. Early and enhanced mobilization can reduce the cost of care while improving patient outcomes. A needle-free, compact, patient-activated, and portable fentanyl iontophoretic transdermal system (fentanyl ITS, IONSYS; The Medicines Company, Parsippany NJ) has been shown to provide comparable efficacy and tolerability to intravenous (IV) PCA morphine that promotes improved mobility. ⋯ Due to improved mobility with fentanyl ITS, complications are expected to be less frequent than with IV PCA and epidural PCA. Incorporation of this strategy into postoperative pain management protocols may reduce LOS and total hospital costs.
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Musculoskeletal pain has major public health implications, but the theoretical framework remains unclear. It is hypothesized that sensorimotor incongruence (SMI) might be a cause of long-lasting pain sensations in people with chronic musculoskeletal pain. Research data about experimental SMI triggering pain has been equivocal, making the relation between SMI and pain elusive. The aim of this study was to systematically review the studies on experimental SMI in people with musculoskeletal pain and healthy individuals. ⋯ Based on the current evidence and despite some methodological issues, there is no evidence that experimental SMI triggers pain in healthy individuals and in people with chronic musculoskeletal pain. However, people with chronic musculoskeletal pain report more sensory disturbances and pain during the experimental conditions, indicating that visual manipulation influences pain outcomes in this population.