Research Database -
International Updates

Pain

Issue 76

KUBSCH and colleagues, University of Wisconsin, Green Bay, WI, USA, KubschM@GBMS01.uwgb.edu, evaluated the effectiveness of cutaneous stimulation (CS) in relieving pain in Emergency Department (ED) patients.
Background: Patients admitted to [hospital] EDs often have to suffer unrelieved pain prior to diagnosis, since analgesics and narcotics may mask the symptoms of the underlying problem (hindering correct diagnosis). CS administered by ED nurses may offer a non-invasive alternative to pharmacological treatments for relieving pain prediagnosis.
Methods: 50 ED patients (38 adults, 12 children) deemed eligible for inclusion in the study were treated with a specific protocol of CS, developed by the researchers, to relieve pain. Effects on blood pressure and heart rate were also measured. Factors that might influence outcome measures were tested: age, gender, educational level, location of pain and site of CS.
Results: CS-treated patients reported significantly reduced pain levels and showed decreases in heart rate and blood pressure. Location of pain significantly influenced heart rate and diastolic blood pressure but not pain level. CS was most effective when applied at the corresponding site on the side of the body opposite to the pain. Effects of CS were not influenced by age, gender or educational level.
Conclusion: In this study, application of Cutaneous Stimulation was effective in reducing pain, heart rate and blood pressure in ED patients. The findings indicate a positive potential for the use of CS. The procedure should be easy to incorporate into standard ED procedures. Further study, however, is needed to eliminate other possible factors that might influence the outcomes measured here, particularly the caring presence of the ED nurse.
Kubsch SM et al. Effect of cutaneous stimulation on pain reduction in emergency department patients. Accident and Emergency Nursing 9 (3): 143-51. Jul 2001.

Issue 51

Issue 44

NICKELSON and colleagues, Department of Psychiatry and Behavioral Sciences, Mercer University School of Medicine, Macon GA 31207, USA write that despite the availability of specialised treatment for chronic pain, including biofeedback training, relaxation training, and hypnotic treatment, most physicians rely upon traditional surgical or drug approaches for control of pain.
Methods and Results: The authors present the case study of a patient with severe and chronic pain who obtained little relief from pain medications which also caused side effects. The patient took the initiative to learn and practise self-hypnosis with good results. Her physician in the resident’s internal medicine clinic support this endeavour and encouraged her to continue self-hypnosis.
Conclusions: This patient’s success demonstrates that self-hypnosis can be a safe and beneficial approach to control or diminish the pain from chronic pain syndrome and can become a useful part of a physician’s therapeutic armamentarium.
Nickelson C et al. What if your patient prefers an alternative pain control method? Self-hypnosis in the control of pain. Southern Medical Journal 92(5): 521-3. May 1999.

LAO and colleagues, Department of Family Medicine, School of Medicine, University of Maryland at Baltimore, 21207-6697 USA. Llao@compmed.ummc.ab.umd.edu write that although acupuncture is increasingly used by the general population is being investigated by conventional medicine, studies regarding its efficacy on pain still lack adequate control procedures.
Methods: The authors conducted a randomised, double-blind, placebo-controlled trial to evaluate: 1) the efficacy of Chinese acupuncture for treating postoperative oral surgical pain ; 2) the validity of a placebo-controlled procedure; and 3) the effects of psychological factors upon outcomes. Participants were 39 healthy subjects, aged 18-40 years, who were randomly assigned to treatment (n = 19) and control (n =20) groups. The main outcome measures were the patients’ self-reports of time until moderate pain, time until medication use, total pain relief, pain half gone and total pain medication consumption.
Results: Compared with the placebo group (93.8 minutes), the mean pain-free postoperative time was significantly longer in the acupuncture group (172.9 minutes), as was the time until moderate pain. The mean number of minutes prior to requesting pain rescue medication was significantly longer in the treatment group (242.1 minutes) than in the placebo group (166.2 minutes), as was the time until medication use. The average pain medication consumption was significantly less in the treatment group (1.1 tablets) than in the placebo group (1.65 tablets). There were no significant between-groups differences regarding total pain relief scores or pain-half-gone scores. About 50% of more of all patients were uncertain of or incorrect regarding their group assignment. The outcomes were not associated with psychological factors.
Conclusions: Acupuncture is superior to placebo in preventing postoperative dental pain and the noninsertion placebo procedure is valid as a control.
Lao L et al. Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial. Archives of Otolaryngology 125(5): 567-72 May 1999.

LAUNSO and colleagues, Department of Social Pharmacy, royal Danish School of Pharmacy, Copenhagen, Denmark write that headache is the most frequently reported symptom among Danish adults, with migraine headache prevalence rates similar to those in various European countries. The authors conducted a prospective and exploratory study of reflexology treatment for headache from 1993 to 1994 with 220 patients with migraine and/or tension headache, using random sampling to determine which patients with headache sought reflexology treatment, why, what previous medication was used for headache and what outcomes patients experienced from reflexology treatment.
Methods: Headache diaries, registration schemes for practitioners, questionnaires and qualitative interviews were used as data collection methods. Treatment was for a maximum of 6 months by 78 reflexologists systematically drawn from membership lists of 5 associations. A diagnosis of each patient’s type of headache at treatment outset was made by a consulting physician according to the International Headache Society Classification (1988).
Results: At 3-month follow-up, 81% of patients reported that they were helped by the treatments or were cured of their headache problems. Following participation in the study, 19% of those patients who had formerly taken drugs to control their headaches were able to stop medication support.
Conclusions: Reflexology treatment appeared to improve patients’ general well-being, energy level, ability to interpret their own body signals and ability to understand the reasons for headache. These relationships, however, may be due to other factors in the treatment environment, and additional studies are required to determine the proximate cause of the therapeutic benefits of reflexology treatment.
Launso L et al. An exploratory study of reflexological treatment for headache. Alternative Therapies in Health and Medicine 5(3): 57-65. May 1999.

Issue 41

WOOLLAM and JACKSON, Norfolk Hospital Health Care NHS Trust, Norwich UK conducted a survey of acupuncture practice in chronic pain clinics in the UK.
Results: The results of the survey revealed that acupuncture is widely used for the treatment of chronic pain. 84% of respondents stated that acupuncture was available at their clinics. The majority of practitioners had attended a course at an acupuncture school; however, in about one fifth of the clinics, the practitioner had not received any formal training.
Woollam CH and Jackson AO. Acupuncture in the management of chronic pain. Anaesthesia 53(6): 593-5 Jun 1998.

Comments: What a valuable published report this is, demonstrating how a technique such as hypnosis can be applied within an intensive care setting to reduce pain which is not responding to narcotics. I hope that if I were a burn patient, someone in the emergency unit could apply hypnosis to help relieve my suffering.

Issue 40

KAZAK and colleagues, Department of Pediatrics, University of Pennsylvania School of Medicine and Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania 19104—4399 USA compared a combined pharmacologic and psychological intervention (CI) with a pharmacologic-only (PO) approach for reducing child distress for invasive procedures for childhood leukaemia.
Methods: The predictors of child distress included age, group (CI, PO) and procedural variables including medications and dosages, technical difficulty, the number of needles required. The authors conducted a randomised, controlled prospective study which compared the PO (n = 45) and CI arms (n – 47) at 1, 6 and >12 months following diagnosis of childhood leukaemia. The cross-sectional control group consisted of parents of 70 patients in first remission prior to the prospective study. Questionnaires of parents, staff and parent ratings, data regarding medications administered, the technical difficulty of the procedure and needle insertions were obtained for each procedure. This paper reports on the final data for the project at >12 months.
Results: Compared to the PO group, mothers and nurses in the CI reported lower levels of child distress. CI and PO groups showed lower levels of child and parent distress than did the cross-sectional control groups. Distress decreased throughout the period and the age of the child was inversely associated with distress, i.e. younger children experienced more distress, regardless of group. Child distress was associated with staff perceptions of the technical difficulty of the procedure and with the age of the child, but not with the medications administered.
Conclusions: These data demonstrate that pharmacologic and psychological interventions for reducing procedural distress were effective in reducing child and parent distress and support the integration of the two approaches. Younger children experienced more distress and warranted additional consideration. Perceptions of the staff regarding the technical difficulty of procedures were complex and potentially helpful in the design of the intervention protocols.
Kazak AE et al. Pharmacologic and psychologic interventions for procedural pain. Pediatrics 102 (1 Pt 1): 59-66. Jul 1998.

KUZNETSOV and colleagues, Eastern Europe investigated the use of massotherapy for chronic salpingo-oophoritis (inflammation of the ovaries and fallopian tubes, CSO).
Methods: The authors used a variety of massotherapy regimens with 30 patients in remission of chronic salpingo-oophoritis.
Results: The massage produced positive changes in blood coagulation, immune status, regional haemodynamics of the small pelvis, bioelectric activity of the muscles of the anterior abdominal wall and lumbosacral region. There was a strong anaesthetic and anti-inflammatory effect of intensive massage in 78% of the women and recovered reproductive function in 33% of the patients.
Conclusions: The results obtained in this study enable the authors to recommend intensive massage as possible monotherapy of women in remission of CSO.
Kuznetsov OF et al The comparative effect of classic massage of different intensities on patients with chronic salpingo-oophoritis Vopr Kurortol fizioter Lech Fiz Kult 2: 20-3. Mar-Apr 1998.
Comments: I greatly look forward to the availability of ASTM for us non athletes with soft tissue injuries. Perhaps my doddery ankles may yet become fit again for more downhill skiing, although I would probably plump for being able to run and jump again. It is also promising to read the results of massage for burns and salpingo-oophoritis.

Issue 38

TURP and colleagues, Department of Biologic and Materials Sciences, School of Dentistry, University of Michigan, Ann Arbor 48109-1078 USA write that knowledge regarding differing treatments for nonmalignant musculoskeletal facial pain is limited.
Methods: The authors conducted a study with 206 consecutive patients referred to a university-based tertiary care clinic for persistent facial pain, to obtain information regarding the number and speciality of providers consulted for these conditions and to follow the underlying treatment-seeking patterns.
Results: On average 4.88 providers from 44 different therapeutic categories were consulted. 70% of patients visited a dentist or a dental specialist. For those patients whose first provider was a dentist, the most likely subsequent provider was another dentist. Conversely, if the first provider had been a physician, the chances were higher that the subsequent provider was a physician rather than a dentist. From the nondental therapies, physical therapy was the most frequently chosen therapy (42.2%). Greater than 60% of patients had at least one nondental treatment, and the majority of these patients had two or more different types of therapies e.g. chiropractic, osteopathy, relaxation training. Patients' satisfaction with their care and treatment was moderate: only 18.5% of the patients were very satisfied; 27.7% were dissatisfied or very dissatisfied.
Conclusions: The results of this study, which corroborate a recent study from Kansas City Missouri, suggest that patients with persistent facial pain visit a large number of different providers and that nonmedical/nondental treatment approaches are common. The merely moderate satisfaction shown with all the therapies indicates that much needs to be improved before this patient population is satisfactorily served.
Turp JC et al. Treatment-seeking patterns of facial pain patients: many possibilities, limited satisfaction. J Orofac Pain 12(1): 61-6 Winter 1998.

WIDERSTROM-NOGA and colleagues, Department of Physiology, Goteborg University, Sweden.investigated the influence of trait anxiety and mood variables upon change in the threshold of tooth pain.
Methods: The authors used 2 similar methods of stimulation, manual acupuncture and low-frequency transcutaneous electrical nerve stimulation (low-TENS). Selected for the study were 21 acupuncture responders who had been treated for long-lasting orofacial muscular pain and naïve to low-TENS. Acupuncture and low-TENS were randomly given during 2 periods separated by a rest interval. Tooth pain thresholds (PT) were measured prior to and following stimulation, using a computerised electrical pulp tester. Trait anxiety and depression were assessed using psychometric forms prior to the experimental session with all patients, and momentary mood was assessed in 10 patients randomly selected using visual analogue scales during and following the two types of stimulation.
Results: Following acupuncture, the group average PT increased significantly, whereas no significant change occurred following low-TENS. Higher trait anxiety scores correlated significantly with low PT increase following low-TENS; higher stress ratings correlated significantly with a low PT increase following acupuncture.
Conclusions: The results of this study suggest that the magnitude of pain-relief induced by acupuncture and low-TENS may be subject to modification by psychological factors including anxiety and stress.
Widerstrom-Noga et al. Pain threshold responses to two different modes of sensory stimulation in patients with orofacial muscular pain: psychological considerations. J Orofac Pain 12(1): 27-34 Winter 1998.

McMILLAN and colleagues, Department of Restorative Dentistry, University of Newcastle, Newcastle upon Tyne, United Kingdom write that painful trigger points are often treated with dry needling and local anaesthetic injections; however, the therapeutic efficacy of these treatments has not been well quantified and the mechanism poorly understood. The authors conducted a randomised, double-blind, double- placeboclinical trial to compare the therapeutic efficacy of dry needling and local anaesthetic injections for myofascial pain in the jaw muscles.
Methods: The authors measured pain-pressure thresholds in the masseter and temporalis muscles prior to and following a series of dry needling treatments, local anaesthetic injections and simulated dry needling and local anaesthetic treatments. 30 individuals, aged 23-53 years were divided into 3 treatment groups: A - Procaine + stimulated dry needling; B - dry needling + simulated local anaesthetic; C - simulated local anaesthetic + simulated dry needling. The subjects rated pain intensity and unpleasantness using visual analogue scales.
Results: Pain intensity and unpleasantness scores decreased significantly following treatment in all the groups. There were no statistically significant differences at the end of treatment between the groups regarding pain pressure thresholds and visual analogue scale scores.
Conclusions: These results suggest that the general improvement in pain symptoms resulted from non-specific, placebo-related factors rather than from a true treatment effect. Therefore, the therapeutic value of dry needling and Procaine for the management of myofascial pain in the jaw muscles is questionable.
McMillan AS et al. The efficacy of dry needling and procaine in the treatment of myofascial pain in the jaw muscles. J Orofac Pain 11(4): 307-14 Fall 1997.

BLANCHARD and colleagues, Center for Stress and Anxiety Disorders, University at Albany-SUNY, New York 12203 USA tested for the specific therapeutic effects of thermal biofeedback (TBF) for hand warming upon vascular headache (HA).
Methods: 70 patients suffering from chronic vascular HA were assigned randomly to TBF for hand warming, TBF for hand cooling, TBF for stabilisation of hand temperature, or biofeedback to suppress alpha in the EEG. Patients with each condition had high initial levels of expectation of the therapeutic benefit and found the treatment rationales highly credible. Each participant received 12 treatment sessions twice weekly. A daily HA diary was kept for 4 weeks prior to treatment and 4 weeks following treatment.
Results: Based upon the diary data, the HA index was significantly reduced, as was HA medication used. There were no differential reductions in HA Index or Medication Index among the 4 conditions. Global self-reports of improvement gathered at the conclusion of the post-treatment monitoring period did not differ among the 4 conditions.
Conclusions: The authors were unable to demonstrate a specific effect of TBF for hand warming upon vascular HA activity.
Blanchard EB et al. Direction of temperature control in the thermal biofeedback treatment of vascular headache. Appl Psychophysiol Biofeedback 22(4): 227-45 Dec 1997.

Issue 36

LONGWORTH and McCARTHY, East Finchley Clinic, London UK write that the association between acupuncture (AP) and pain relief is so strong that is has tended to obscure other clinically significant results. The authors review (77 references) the literature regarding acupuncture treatment for the range of low back syndromes.
Methods: the review covers various aspects of AP treatment for low back syndromes related to lumbar intervertebral disk prolapse (PID). The volume of research is considerable, although the quality of research is variable, particularly regarding design, consistency and follow-up.
Results: Despite the variable quality of the research, there are a large number of patients who appear to have been successfully treated and who have received symptomatic relief from AP treatment. These results are further supported by studies with patients previously unsuccessfully treated with other conventional methods. The role envisaged for AP for lumbar PID and sciatica is as a supplementary therapy which could reduce the requirement of more invasive treatments. This role might not be the case for all conditions, such as cauda equina compression, where surgery must remain the treatment of choice.
Conclusions: AP needs to be explored more fully, using appropriately designed research, to enable this discipline to achieve its full therapeutic potential.
Longworth W and McCarthy PW. A review of research on acupuncture for the treatment of lumbar disk protrusions and associated neurological symptomatology. J Altern Complement Med 3(1): 55-76. Spring 1997.

JIN and colleagues, Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China studied the analgesia efficacy of drugs combined with acupuncture to treat pain for women in labour.
Methods: 462 normal pregnancy women were observed. Several pain relief methods were used during the latent phase in labour, including acupuncture, analgesia, analgesics, magnetotherapy, auricular acupressure and TENS combined with dihydroetorphine. The intrauterine pressure and the peripheral content of beta-EP were measured during labour; experiments of SEPS were also performed on healthy adults to demonstrate the efficacy of these pain relief methods.
Results: The combination of drugs with acupuncture was an excellent method for painless labour without any complications. All mothers and babies were safe, with an effectiveness was 97.5%.
Conclusions: These data demonstrate that the mechanism of pain relief efficacy needs to regulate the incoordinate uterine action and improve the hypertonic uterine status, but also decrease the pain threshold and elevate the tolerance of uterine contractions during labour.
Jin Y et al. Clinical study on painless labor under drugs combined with acupuncture analgesia. Chen Tzu Yen Chiu 21(30: 9-17. 1996.

Issue 29

PATTERSON and colleagues, University of Washington School of Medicine, Seattle USA write in their review (96 references) that there has been strong anecdotal support from case reports regarding the use of hypnosis for treating pain from severe burn injuries, but that controlled studies provide less dramatic but empirically sound support for the use of hypnosis for burn pain. They write that the mechanisms underlying hypnotic analgesia for burn pain are poorly understood as they are with pain in general. It is likely that patients with burn injuries are more receptive to hypnosis than the general population. The authors postulate variables which may account for this enhanced receptivity, including motivation, hypnotisability, dissociation and regression.
Patterson DR et al. Factors predicting hypnotic analgesia in clinical burn pain. Int J Clin Exp Hypn 45(4): 377-95. Oct 1997.

CHAVES and DWORKIN, Indiana University School of Dentistry, Indianapolis 46202-5186 USA write in this review (108 references) that hypnotic analgesia has a pivotal place in experimental and clinical hypnosis, since its emergence during the 19th century when effective clinical pain management techniques were not developed and when relief of pain and suffering were not even well-defined goals. The acceptance of hypnosis for pain relief was complicated by political struggles encompassing the humanitarian transformation of medicine and the redefinition of the doctor-patient relationship which wrested control from the patient. Acceptance of hypnosis by professional organisations, won after long debate within the professional community, has endured alternating periods of interest and indifference. Scientific information regarding hypnotic analgesia has grown substantially since the mid-20th century and has significantly influenced strategies for acute and chronic pain management. The success of the wider application of hypnosis in pain management will need more data from clinical populations and a balanced and scientifically prudent approach by advocates.
Chaves JF and Dworkin SF. Hypnotic control of pain: historical perspectives and future prospects. Int J Clin Exp Hypn. 45(4): 356-76. Oct 1997.

BARRY and VON BAEYER, Department of Psychology, University of Saskatchewan, Saskatoon, Canada assessed the effectiveness of an abbreviated cognitive therapy group programme to treat headaches in children. METHODS: The authors conducted a randomised study with 36 children, aged 7-12 years of age, randomly assigned either to the treatment group, in which small groups of 5-8 children were taught relaxation, distraction, visualisation and stress management skills in two 90-minute sessions, or to a waiting list control group. Parent groups were seen concurrently, reviewed the children's programme and addressed parenting strategies. The waiting list control groups were treated 5 weeks later. Headache frequency, intensity, duration and five other variables, were rated by children and kept in a diary for 3 weeks prior to and 3 weeks following treatment. Parent measures were taken one prior to treatment and once at 3-month follow-up. RESULTS: Children in the control group showed a significant reduction in self-rated headache frequency, while the treatment group did not show any such reduction in frequency. In all the other self-reported variables, there were no significant differences between the control and treatment conditions. Two children in each group achieved a 50% or greater reduction in the self-rating headache index. In follow-up ratings, obtained by telephone from parents following the treatment of children in both groups, showed that the children in both groups had experienced reduced intensity, frequency and duration of headaches and that 82% of the children were using the techniques taught in the programme. 14 children achieved 50% or greater reduction in the headache index based upon parent rating. CONCLUSIONS: Despite the enthusiasm of the parents for the effectiveness of this programme, the results for children's self-rating do not support the use of this highly abbreviated treatment technique.
Barry J and von-Baeyer CL. Brief cognitive-behavioral group treatment for children's headache. Clin J Pain. 13(3): 215-20. Sep 1997.

COMMENTS: How disappointing and how counter-intuitive are these results, which illustrates how important it is to do good clinical research. If the hypothesis was that children's headaches are partly due to stress, then presumably such a programme of relaxation and stress reduction would help reduce headache frequency, intensity and duration. But the control group had the significant reduction in headache frequency and no significant differences in the other headache parameters. Back to the drawing board!

ROKICKI and colleagues, Department of Psychology, Ohio University, Athens Georgia USA studied the use of combined relaxation and biofeedback therapy for tension headaches. METHODS: Therapeutic mechanisms used included: 1) changes in electromyographic (EMG) activity in frontal and trapezii muscles 2) changes in central pain modulation as measured by duration of the second exteroceptive silent period (ES2) and 3) changes in headache locus of control and self-efficacy. 44 young adults suffering with chronic tension-type headaches were assigned either to 6 relaxation sessions and EMG biofeedback training (n=30) or to an assessment only control group (n=14) requiring 3 assessment sessions. Self-efficacy and locus of control measures were taken prior to and following treatment and ES2 was evaluated at the beginning and end of the first, third and last session. EMG was monitored prior to, during and following training trials. RESULTS: Relaxation/EMG Biofeedback training reduced headache activity effectively. Compared to the control group who failed to improve on any measure, 51.7% of participants receiving relaxation/ biofeedback therapy achieved at least a 50% reduction in headache activity following treatment. CONCLUSIONS: These results support the hypothesis that cognitive changes underlie the effectiveness of relaxation and biofeedback therapies for young adults suffering tension-type headache.
Rokicki LA et al. Change mechanisms associated with combined relaxation/EMG biofeedback training for chronic tension headache. Appl Psychophysiol Biofeedback. 22(1): 21-41. Mar 1997.

COMMENTS: Quite a difference in the results of this study to the one prior which used only relaxation and stress management techniques for children. Perhaps the addition of biofeedback therapy is the added strategy which contributed to the success.

WHITMARSH and colleagues, Princess Margaret Migraine Clinic, Charing Cross Hospital, London UK write that homoeopathic remedies for migraine are widely available over the counter are statutorily provided by the national health service in the UK and are apparently popular with migraine sufferers. The authors studied the use of homoeopathic remedies for migraine. METHODS: 63 outpatient migraine sufferers with or without aura participated in a 4-month randomised placebo-controlled, double-blind parallel groups trial of individualised homoeopathic remedies, the first month the baseline, with all patients being given placebos. 3 patients in each group dropped out, leaving 30 per treatment group. RESULTS: At baseline, there were chance differences in attack frequency and severity between groups attacks were more frequent but less severe in the placebo group. Both groups improved with therapy, but neither to a great extent regarding the primary outcome measure of frequency of attack - verum: -19% placebo: -16%. In the placebo group, reduction was mostly in mild attacks in the homoeopathy group the reduction was more in moderate and severe attacks. There were few adverse events reported. Overall, there was no significant benefit of homoeopathic treatment over placebo. The course of change differed between the groups and suggested that improvement reversed in the last month of placebo treatment. CONCLUSIONS: On the basis of these results, the authors cannot recommend homoeopathy for migraine relief, but they cannot conclude that it is without effect.
Whitmarsh TE et al. Double-blind randomised placebo- controlled study of homoeopathic prophylaxis of migraine. Cephalagia. 17(5): 600-4 Aug 1997.

COMMENTS: Not being a homoeopath and therefore not privy to the "nitty gritty" of the materia medica, these results would seem to suggest that homoeopathic treatment appeared to have some effect. Probably migraine is of multi-factorial origin, involving allergies, stress and endocrine factors. Hence, it is difficult to imagine that homoeopathic treatment alone would succeed in the absence of other causes being addressed. Please, homoeopaths, write in with your comments.

Issue 28

KOTANI and colleagues, Department of Anesthesiology, University of Hirosaki School of Medicine, Japan evaluated the analgaesic (pain-relieving) effect of Toki-shakyuaku-san (TSS), a herb used in Chinese Medicine in women suffering from dysmenorrhoea. METHODS: Women with a combination of “Yin deficiency”, “cold” and “stagnated blood” syndromes, determined using a diagnostic scoring system, and who were suffering from dysmenorrhea were treated either with TSS or placebo during 2 menstrual cycles double-blind and were followed for an additional 2 cycles. RESULTS: Compared to women treated with placebo, women treated with TSS experienced a significant alleviation of dysmenorrhoea. CONCLUSIONS: These results suggest that TSS is effective the treatment of dysmenorrhea in women with the above-named syndromes.
Kotani N et al. Analgesic effect of a herbal medicine for treatment of primary dysmenorrhea - a double-blind study. Am J Chin Med. 25(2): 205-12. 1997.

TANAKA and colleagues, Pacific Wellness Institute, Toronto, Ontario Canada studied the physiological effect of superficial acupuncture stimulation during a patient’s exhalation phase in a sitting position (SES). METHODS: The response to SES was compared to stimulation applied continuously without considering the respiratory phase (CONT). The study evaluated the chronic tension-type headache patient’s electromyographic (EMG) activity, pain response, heart rate, pulse height and skin conductance level. RESULTS: Compared to CONT stimulation, SES stimulation significantly decreased headache intensity and showed a strong trend towards decreasing static EMG activity. CONCLUSIONS: Acupuncture, applied to the same point and at the same depth, produced varying physiological effects, depending upon whether the stimulation was applied during exhalation alone, or continuously applied. This result suggests that the effect of acupuncture derives not only from point selection matching symptoms, but also from the consideration and use of the patient’s respiratory phase during stimulation.
Tanaka TH et al. The physiological responses induced by superficial acupuncture: a comparative study of acupuncture stimulation during exhalation phase and continuous stimulation. Int J Neurosci 90(1-2): 45-58. Jun 1997.

COTTINGHAM and MAITLAND, Christie Clinic Association, Department of Sports Medicine and Physical Therapy, Rantoul, IL USA write that it is not common for physical therapists to have difficulty in treating certain people with chronic idiopathic low back pain. The authors present a 3-paradigm model of intervention for adaptation to the treatment of difficult low back pain cases. METHODS: The model is composed of: 1) relaxation paradigm with pain modulation procedures 2) corrective paradigm with manual techniques and exercise to correct faulty biomechanical alignment(s) such as pelvic asymmetry and 3) integrative paradigm, with guided movement/mobilisation techniques for improving overall posture and movement patterns. In order to illustrate the 3-paradigm approach, the case study is presented of a young adult with chronic low back pain correlated with unilateral innominate bone rotation. The patient received a corrective (sessions 1-3) and integrative treatment protocol (sessions 4-6) composed of Rolf’s method of soft tissue mobilisation and Alexander system of guided movement awareness techniques. Prior to and following each session and following a 4-week follow-up, the patient was assessed for sacroiliac joint pain using compression, anterior ration of the innominate bones, pelvic angle while standing and vagal tone. Both the subject’s self-reports of pain and the therapist’s visual analysis of sit-to-stand movement were noted. RESULTS: The corrective paradigm protocol of soft tissue mobilisation and exercise was unsuccessful in eliminating the individual’s assessed anterior rotation of the innominate bone and associated low back pain for more than 1 or 2 days following treatment. It was only following the implementation of a third paradigm movement/mobilisation protocol did the person begin to show sustained improvement through a 4-week follow-up. CONCLUSIONS: The authors discuss interpretations of the results, appropriate corrective and integrative protocols and physiological mechanisms.
Cottingham JT and Maitland J. A three-paradigm treatment model using soft tissue mobilisation and guided movement-awareness techniques for a patient with chronic low back pain: a case study. J Orthop Sports Phys Ther 26(3): 155-67. Sep 1997.

COMMENTS: In view of the generalised and miserable epidemic of back pain amongst the majority of adults in developed countries, the above report demonstrates how important re-education and mobilisation are in successful therapeutic treatment. Please, therapists, write in with your results.

Issue 23

ENQVIST and FISCHER, Eastman Dental Centre, Stockholm, Sweden conducted a study to evaluate the effects of preoperative hypnotic techniques used by patients having surgical removal of their third mandibular molar. METHODS: patients were randomly assigned either to an experimental (n = 33) - hypnotic techniques - or a control (36) 2 no hypnotic techniques - group. The week prior to the surgery, the experimental group listened to an audiotape which contained a hypnotic relaxation induction, posthypnotic suggestions of healing and recovery as well as advice regarding ways to achieve control over stress and pain. The control group had no hypnotic intervention. One surgeon, who did not know the patient group assignments, performed all the operations. RESULTS: In the control group, anxiety prior to the operation increased significantly, whereas anxiety remained at baseline level in the hypnosis group. Additionally, compared to the control group, postoperative consumption of analgesics in the hypnosis group was significantly reduced.
Enqvist B and Fischer K. Preoperative hypnotic techniques reduce consumption of analgesics after surgical removal of third mandibular molars: a brief communication. Int J Clin Exp Hypn 45(2): 102-8. Apr 1997.

WENNEBERG and colleagues, Maharishi University of Management, Fairfield, Iowa USA studied the relationships between increased platelet aggregability and the psychological traits hostility and anger. METHODS: This study was part of a larger intervention study investigating the potential efficacy of stress reduction techniques. Study participants performed 6-minute mental arithmetic tests under time pressure. Blood was taken during the first minute and whole blood platelet aggregation measured. Anger and hostility were assessed using Spielberger's State-Trait Anger, Anger Expression and Cook-Medley Hostility scales. RESULTS: There were positive correlations between collagen-induced platelet aggregation and outwardly expressed anger, as measured by the Anger Expression Scale. These results suggested that modes of anger expression may be association with increased platelet aggregation. CONCLUSIONS: These findings may provide a mechanism for the putative connection between anger/hostility and coronary heart disease.
Wenneberg et al. Anger expression correlates with platelet aggregation. Behav Med 22(4): 174-7. Winter 1997.

BRAUCHLI and ZEIER, Institut fur Verhaltenswissenschaft ETH Zurich, Switzerland studied whether there is a relationship between subjective well-being and change in immune markers in HIV-infected people. METHODS: 21 HIV-infected people completed questionnaires. CD4-percentage and CD4/CD8-ratio immune markers were measured at the beginning of the study, after 8 months and after 15 months. RESULTS: Baseline values of immune markers explained most of the variance observed of the immune markers following 8 and 15 months. After including several control variables in the hierarchical multiple regression model, Values for depression and values on the symptom checklist explained an additional variance increment of both immune markers after 8 months. CONCLUSIONS: The results of this study suggest that predominantly depressive feelings co-determine immune status in HIV-infected people.
Brauchli P and Zeier H. Depressive affect and surrogate markers in HIV infected patients. Psychother Psychosom Med Psychol 47(1): 34-40. Jan 1997.

TELLES and colleagues, Vivekananda Kendra Yoga Research Foundation, Bangalore India recorded heart rate, breathing rate and skin resistance in 20 community home girls (Home group) and in 20 age-matched girls from a regular school (School group). The Home group had a significantly higher rate of breathing and a more irregular breath pattern, which is correlated with high fear and anxiety, than the School group. Skin resistance was significantly lower in the School group, which may be suggestive of greater arousal. METHODS: 28 girls from the Home group formed 14 pairs, matched for age and duration of stay in the home. Girls within a pair were randomly assigned to either yoga or games groups. With the yoga group, emphasis was on relaxation and awareness, for the games group emphasis was on increasing physical activity. RESULTS: After one hour daily for six months, both groups showed a significant decrease in the resting heart rate compared to initial values and the yoga group showed a significant decrease in breath rate, which was more regular, but no significant increase in skin resistance. CONCLUSIONS: These results suggest that a yoga programme including relaxation, awareness and graded physician activity is a useful addition to the routine of community home children.
Telles S et al. Comparison of changes in autonomic and respiratory parameters of girls after yoga and games at a community home. Percept Mot Skills 84(1): 251-7. Feb 1997.

CADY and JONES, Department of Management, Bowling Green State University, Ohio 43403-0270, USA evaluated the effectiveness of a 15 minute on-site massage while seated in a chair upon reducing stress, as indicated by blood pressure. METHODS: 52 employed participants' blood pressures were measured prior to and following a 15-minute massage at work. RESULTS: There was a significant reduction in systolic and diastolic blood pressure after receiving massage, although there was no control group.
Cady SH and Jones GD. Massage therapy as a workplace intervention for reduction of stress. Percept Mot Skills 84(1): 157-8 Feb 1997.

PAGE and BEN-ELIYAHU, College of Nursing, Ohio State University, Columbia Ohio USA review (50 references) the evidence that the immune system plays a role in controlling the spread of cancer, and that perioperative pain relief improves immune status and health outcome. METHODS: Reviewed were research studies and articles pertaining to immunity, immune function, stress and the immune-suppressive nature of pain. RESULTS and CONCLUSIONS: Pain not only results in suffering but is itself a pathogen, capable of facilitating the progression of metastatic disease. Adequate pain relief decreases these risks. IMPLICATIONS FOR NURSING PRACTICE: Adequate pain relief is not only a primary concern in caring for people in pain but may also be a physiological necessity, in light of studies revealing the immune-suppressive nature of pain.
Page GG and Ben-Eliyahu S. The immune-suppressive nature of pain. Semin Oncol Nurs 13(1): 10-5 Feb 1997.

COMMENTS: All of the above research studies demonstrate the powerful links that exist between the mind, pain, stress and the immune system. We all know that pain, anger and stress can have negative or even destructive effects upon our health; the challenge is to apply what we know to enable us to relax more.

Issue 22

LEQUANG and colleagues, Departement d'Anesthesia-Reanimation, CHU Hopital Nord, Amiens France write that they use auriculotherapy based upon traditional Chinese cartography, for pain relief following laparoscopic cholecystectomy (gall bladder removal). The technique consists of palpating and pricking well defined ear points corresponding to the surgical site. Pain relief is quickly obtained and compares favourably with minor parenteral (intervenous) analgaesics.
Lequang T et al. Postoperative analgesia by auriculotherapy during laparoscopic cholecystectomy. Cah Anesthesiol 44(4): 289-92. 1996.

FELHENDLER and LISANDER, Department of Anesthesiology, Faculty of Health Sciences, Linkoping, Sweden studied the analgaesic effect of acupoint pressure upon postoperative pain in a controlled single-blind study. METHODS: 40 patients undergoing knee arthroscopy were randomised to receive either an active stimulation (AS) or a placebo stimulation (PS) 30 minutes following awakening from anaesthesia. The authors stimulated 15 classical acupoints in the AS group, on the side opposite to surgery using firm pressure and a gliding movement across the acupoint. For the PS group, 15 nonacupoints were subjected to light pressure in the same areas as the acupoints in the AS group. Pain was assessed with a visual analog scale (VAS) prior to sensory stimulation, after 30 and 60 minutes and following 24 hours. Heart rate, systolic arterial pressure and skin temperature were monitored prior to stimulation and following 30 and 60 minuts. Skin blood flow was assessed using laser Doppler before stimulation and after 1 and 30 minutes. RESULTS: VAS pain scores were lower than in the placebo group 60 minutes and 24 hours following AS and there were no significant changes in the autonomic variables. CONCLUSIONS: Pressure on acupoints can decrease postoperative pain.
Felhendler D and Lisander B. Pressure on acupoints decreases postoperative pain. Clin J Pain 12(4): 326-9. Dec 1996.

LOGAN and colleagues, Department of Preventive and Community Dentistry, University of Iowa, Iowa City USA write that stress has long been viewed as a contributor to pain experienced by chronic pain patients. The authors studied the relationship between anticipated and experienced stress and anticipated and experienced pain levels in three groups of patients. METHODS: The three patient groups were chronic pain patients, patients about to undergo molar extraction (acute pain group) and a no-pain control group. RESULTS: Although the chronic pain patients anticipated significantly more stress than did the acute and non-pain patient groups, they reported non-significant differences in the actual levels of stress experienced. Cognitive factors studied which may contribute to increased anticipatory stress were similar to those previously reported by chronic headache sufferers. The chronic pain group had significantly higher scores than the other two groups regarding the stress they anticipated from matters related both to practical considerations and health. The authors discuss strategies the dentist can use in combination with dental therapy to reduce cognitive-based anticipatory stress as well as collaborative strategies for patients and mental health therapists.
Logan HL et al. Anticipatory stress reduction among chronic pain pataients. Spec Care Dentist 16(1): 8-14. Jan-Feb 1996.

HART and colleagues, Department of Medicine, University of Southampton, UK conducted a double-blind, placebo-controlled randomised clinical trial with arnica C30 for pain and postoperative recovery following total abdominal hysterectomy. METHODS: Of the 93 women recruited into the study, 20 failed to complete protocol treatment (9 in the arnica group; 11 in the placebo group), 9 failed to comply with the protocol, 9 had their operations cancelled or changed within 24 hours and 2 had to be withdrawn due to recurrence of previously chronic painful conditions. 73 women completed the study - 38 received arnica C30 and 35 received placebo. RESULTS: Although the placebo group had a greater median age and the arnica group had slightly longer operations, there were no significant differences between the two groups. CONCLUSIONS: Arnica in homoeopathic potency had no effect upon postoperative recovery in the context of this study.
Hart O et al. Double-blind, placebo-controlled, randomised clinical trial of homoeopathic arnica c30 for pain and infection after total abdominal hysterectomy. J R Soc Med 90(2): 73-8. Feb 1997.

AUSTRAN and colleagues, UMDNJ School of Health Related Professions USA studied the use of verbal expectancy to reduce pain. METHODS: 25 hospitalised patients receiving arteriotomies were given one of two verbal instructions one hour apart prior to each incision. For the first arteriotomy, the right radial artery was prepped with alcohol without mention and administered non-expectancy instruction A "You may or may not feel pain. Everyone is different." After one hour, prior to the second incision, prepping the left radial artery with alcohol was brought to the patient's attention while providing expectancy instruction B "Notice how cool this feels, it's interesting how coldness numbs the skin." RESULTS: The administration of expectancy instruction B significantly reduced pain associated with arteriotomies.
Austan F et al. The use of verbal expectancy in reducing pain associated with arteriotomies. Am J Clin Hypn 39(3): 182-6. Jan 1997.