No abstract

ObjectiveIncreasing evidence purports exercise as a first-line therapeutic for the treatment of nearly all forms of chronic pain. However, knowledge of efficacious dosing respective to treatment modality and pain condition is virtually absent in the literature. The purpose of this analysis was to calculate the extent to which exercise treatment shows dose-dependent effects similar to what is seen with pharmacological treatments.MethodsA recently published comprehensive review of exercise and physical activity for chronic pain in adults was identified in May 2017. This report reviewed different physical activity and exercise interventions and their effectiveness in reducing pain severity and found overall modest effects of exercise in the treatment of pain. We analyzed this existing data set, focusing specifically on the dose of exercise intervention in these studies. We re-analyzed data from 75 studies looking at benefits of time of exercising per week, frequency of exercise per week, duration of intervention (in weeks), and estimated intensity of exercise.ResultsAnalysis revealed a significant positive correlation with exercise duration and analgesic effect on neck pain. Multiple linear regression modeling of these data predicted that increasing the frequency of exercise sessions per week is most likely to have a positive effect on chronic pain patients.DiscussionModest effects were observed with one significant correlation between duration and pain effect for neck pain. Overall, these results provide insufficient evidence to conclude the presence of a strong dose effect of exercise in pain, but our modeling data provide tes predictions that can be used to design future studies to explicitly test the question of dose in specific patient populations.

A lthough epidural analgesia is used widely for pain relief during labor, the failure rate ranges from 1.5% to 20%. This prospective, randomized, nonblinded study investigated whether ultrasound measurement of the depth from the skin to the epidural space before epidural placement decreases the failure rate of labor analgesia. The second objective of the study was to correlate the ultrasoundmeasured depth to the epidural space with the actual depth of the needle when the epidural space is reached.A total of 370 laboring parturients were randomized to undergo epidural placement by first-year anesthesia residents with or without prior ultrasound measurement of the depth to the epidural space. Patients in the ultrasound group underwent ultrasound visualization of the epidural space in the longitudinal median and transverse planes while in the sitting position. The ultrasound measurements were used to estimate the distance from the skin to the ligamentum flavum before the epidural catheter was inserted. The epidural was performed in both groups using the midline approach at the L3-4 or L4-5 vertebral interspace using a loss of resistance to saline technique. All patients received a 10 mL bolus of ropivacaine 0.1% + 100 mcg fentanyl and were then placed on a continuous maintenance epidural infusion of ropivacaine 0.1% and fentanyl 2 mcg/ mL. Outcomes measured included the incidence of epidural catheter replacement for failed analgesia, the number of epidural attempts, and the number of accidental dural punctures.The 189 patients in the ultrasound group and 181 in the control group did not differ significantly in age, height, weight, body mass index, gestation, or parity. The groups did not differ in cervical dilation, station at epidural placement, and initial visual analog score for pain. The use of ultrasound, undertaken by an investigator skilled in ultrasound epidural placement (not the learner), added 60 ± 15 seconds to the mean preparation time. The epidural block failed in 3 and 10 patients in the ultrasound and control groups, respectively, with one in the ultrasound and 6 in the control group considered early failures (within the first 90 min after placement), P = NS. Patients in the control group had more initial placement attempts (2 vs. 1), but the need for staff intervention was not significantly different. The ultrasoundestimated mean epidural depth was 4.6 ± 0.9 cm when measured in the longitudinal plane and 4.7 ± 1.0 cm as measured in the transverse plane showed a strong correlation with the actual clinical depth of the epidural space. No significant differences in staff interventions, need for additional top-ups, or delivery outcomes were determined.In conclusion, the investigators determined that the use of ultrasound to measure the depth of the epidural space before an epidural catheter is inserted for labor analgesia is an excellent teaching tool for neophyte learners of the clinical skill set necessary to locate the epidural space.

Therapeutic, II.