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Biomedical subjects

C E Pither

Publications and source records attributed to C E Pither.

At least 19 recordsLinked to original sources
PubMed1999

Generalizing from a controlled trial: the effects of patient preference versus randomization on the outcome of inpatient versus outpatient chronic pain management.

Patients accepting randomization in a randomized controlled trial (RCT) may not be representative of the clinical population from which they are drawn, calling into question the generalizability of study findings. Comparison of randomized and non-randomized inpatient and outpatient samples at baseline and in treatment outcomes up to one year was made to determine whether the findings of the RCT generalized to non-randomized patients in the same treatment program. One hundred and twenty one patients with intractable pain, randomized between inpatient, outpatient and waiting list control, were compared with 128 who elected for either inpatient or outpatient treatment. Treatment was a group-based multidisciplinary cognitive-behavioral treatment program aimed at enabling patients to return to more normal function despite persistent pain, delivered to mixed groups of randomized and elective patients, and outcome was measured by physical performance, pain impact on function, mood, and drug use. Agreement to randomization was a function of travelling distance from home to hospital. Non-randomized patients largely resembled their randomized counterparts before and after treatment. In order to indicate the clinical significance of results, analyses were conducted using numbers needed to treat (NNTs). NNTs estimate the number of patients required in the treatment condition for one of them to achieve the specified outcome who would not have achieved it in the comparison condition. Across a range of measures at one month follow-up, comparison of inpatients with outpatients gave NNTs between 2.3 and 7.5, and comparison of inpatients with waiting list controls gave NNTs between 2.3 and 3.6. At one year inpatients showed greater likelihood than outpatients of maintaining these treatment gains.

Adult↗
PubMed1997

Medication misuse, abuse and dependence in chronic pain patients.

We report the prevalence of drug use, misuse, abuse, and dependence in 125 chronic pain patients attending specialist pain clinics in South London. A total of 110 patients (88%) were taking medications for their pain problem. Opioid analgesics (69.6%), nonopioids (48%), antidepressants (25%), and benzodiazepines (17.6%) were the drugs most frequently used. Psychoactive substance abuse or dependence (DSM-III-R) was diagnosed in 12%. A total of 9.6% of the patients met the DSM-III-R criteria for substance abuse or dependence in remission. Data are also presented on the misuse and abuse of nonpsychoactive drugs, qualitative information on how patients use drugs, and the information they have received about medication.

Adolescent↗
PubMed1996

Inpatient vs. outpatient pain management: results of a randomised controlled trial.

Inpatient and outpatient cognitive behavioural pain management programmes for mixed chronic pain patients were compared. Patients were randomly allocated to the 4 week inpatient programme or to the 8 half day per week outpatient programme, or to a waiting list control group. Staff, teaching materials, and setting were the same for the two treatment groups. Patients were assessed pre-treatment, and at 1 month after discharge, and treated patients also at 6 months and 1 year after discharge, by assessors blind to treatment group; assessments included physical, functional and psychological measures, and medication use. In total, 121 mixed chronic pain patients (mean age 50 years; mean chronicity 8.1 years) were included in the study, following medical examination to ensure that no further medical treatment was appropriate. There was no change in the control group; inpatients and outpatients, comparable before treatment, both made significant improvements in physical performance and psychological function, and reduced medication use. Inpatients made greater gains, and maintained them better at 1 year; they also used less health care than outpatients. There were no outstanding predictors of improvement other than treatment group.

Ambulatory Care↗
PubMed1993

Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain.

The aim of this prospective longitudinal study was to evaluate an inpatient cognitive behavioural pain management programme for patients with chronic pain. A physical and psychological assessment of patients was carried out before and after treatment, and at one and six months follow up. A total of 212 patients with disabling chronic pain of mean duration 10.5 years, for whom no further medical or psychiatric treatment was appropriate or available, were admitted; their mean age was 50 years and 65% were women. The four week programme was delivered by a multidisciplinary team of two psychologists, a physiotherapist, nurse, occupational therapist and anaesthetist. The main components of therapy included: education, teaching behavioural and cognitive skills, a stretch and exercise programme, medication reduction, goal setting and pacing, and relaxation training. Outcome measures assessed quality of life, physical performance (for example walking speed), pain intensity and distress, depression severity and confidence. Assessment immediately after treatment revealed significant improvements on all measures. Improvements were well maintained at six month follow up. Cognitive behavioural treatment can be of value in improving the day-to-day functioning and quality of life of patients with chronic pain for whom conventional medical treatments have apparently failed.

Adult↗
PubMed1991

Psychological approaches in chronic pain management.

Psychological factors are contributory to the genesis and maintenance of many chronic pain syndromes. Treatment can be delivered either as one component of multimodal therapy or as the sole approach in a pain management programme. This distinction is important as it has a bearing on the goals of treatment, which in the latter situation is to improve management of the pain and encourage the patient to take more responsibility for their treatment, rather than cure the illness. Treatment typically comprises elements of operant conditioning, where activity and performance can be substantially improved, and cognitive therapy where the thoughts and emotions associated with the pain are tackled, leading to diminution of distress. Relaxation training is also of benefit. The documented success of these techniques in various settings suggests that psychological treatment should be considered a necessary component of any multidisciplinary clinic offering therapies to chronic pain sufferers.

Behavior Therapy↗
PubMed1991

Plasma concentrations of bupivacaine after supraclavicular brachial plexus blockade in patients with chronic renal failure.

The plasma concentrations of bupivacaine and the latency and duration of anaesthesia after supraclavicular block with 30 ml of 0.5% bupivacaine were measured in 10 patients with chronic renal failure and in 10 patients with normal renal function. No significant difference was found between the two groups in respect of pharmacokinetic parameters, or in block latency or duration.

Adult↗
PubMed1991

The effect of a priming epidural injection of adrenaline on epidural blockade with bupivacaine.

Twenty-four patients receiving epidural anaesthesia were studied to test the hypothesis that 1:200,000 adrenaline administered into the epidural space 5 minutes before 20 ml bupivacaine 0.5% would improve nerve block and delay systemic absorption of the local anaesthetic. Group A/B received 20 ml adrenaline 1:200,000 5 minutes before 20 ml bupivacaine 0.5%, group S/BA 20 ml saline followed by 20 ml bupivacaine 0.5% with 100 micrograms adrenaline, and group S/B saline 20 ml followed by 20 ml plain bupivacaine 0.5%. Mean maximum plasma concentrations of bupivacaine tended to be lower in the adrenaline groups. A delay in the time to peak plasma concentration of bupivacaine was noted in the A/B group; this indicated that priming with adrenaline may be effective at delaying early systemic uptake of the local anaesthetic. In both adrenaline groups a more prolonged epidural block and increased efficacy were noted, although this was only significant for the duration of block at T6 (p = 0.023) and duration of motor block at Bromage level 1 (p = 0.016) in group A/B. There seems little clinical advantage in administering adrenaline 5 minutes before bupivacaine.

Anesthesia, Epidural↗
PubMed1990

A comparison of three methods of axillary brachial plexus anaesthesia.

One hundred patients scheduled for elective outpatient hand surgery had blockade of the axillary brachial plexus by one of three techniques; insertion of a catheter into the brachial plexus sheath (n = 25), use of paraesthesia (n = 50) or use of the nerve stimulator (n = 25) to localise the plexus. Only two patients required general anaesthesia for the planned surgery. Assessment of the dermatomes blocked did not demonstrate a statistical difference between the success rates of the three groups. The more nerves detected in the paraesthesia and the nerve stimulator groups before injection of local anaesthetic the higher the success rate of the block. We advocate use of the nerve stimulator technique in view of the possible risk of neurological damage associated with paraesthesia and the technical difficulties with the catheter technique, for routine brachial plexus blockade.

Axilla↗
PubMed1989

The significance of needle placement site in acupuncture.

Traditional acupuncturists claim that correct needling of classical acupuncture loci is associated with a characteristic set of sensations usually referred to as 'Teh Chi'. The studies reported here examine this claim. In the first a multiple adjective sensation rating scale was developed and administered to 125 patients receiving acupuncture treatment. The results were subjected to principal components analysis and the first factor to emerge provided some support for the constellation of sensations corresponding to Teh Chi. In the second study the scale was used in a randomised controlled mixed single/double blind experiment in which 65 volunteers were stimulated at three classical and three non-classical (sham) needling sites by either a trained acupuncturist (single blind) or an anaesthetist (double blind). The results of the second study did not support the contention that the sensations of Teh Chi occur more frequently at classical acupuncture needling sites. The implications of the results for the practice of acupuncture are discussed.

Acupuncture Therapy↗
PubMed1989

Paravertebral somatic nerve block: a clinical, radiographic, and computed tomographic study in chronic pain patients.

The spread of solution after a standardized paravertebral injection was studied to determine the precision and predictability of paravertebral spread. The spread of 5 ml of a solution of radiological contrast medium (sodium iothalamate) and local anesthetic mixture after 45 (34 thoracic, 11 lumbar) paravertebral injections was studied in 31 patients by radiography and computed tomography and correlated with the clinical effects. Spread confined to the paravertebral area occurred after only eight (18%) injections. Spread was epidural after 31 (70%) injections and exclusively so in 14 (31%) injections. Mean sensory loss was greater after epidural spread, but a wide range of sensation loss was observed with all patterns of spread. Intrapleural spread occurred after three injections, as did spread into the psoas muscle. In addition, measurements were made of 114 paravertebral spaces in 20 patients by means of computed tomography. Dimensional factors identified as possibly leading to complications of a paravertebral injection included narrow width of the thoracic transverse processes (mean, 3.18 cm; range, 2.1-4.2 cm) and the wide range in paravertebral dimensions. The distance from bony landmarks to pleura frequently fell outside the limits recommended by many standard texts. We conclude that the spread of a small volume of solution after paravertebral injection is imprecise and unpredictable. Neurolytic and diagnostic paravertebral injections performed without the aid of radiological imaging and contrast media should be regarded as hazardous and interpreted with extreme caution.

Analgesia, Epidural↗
PubMed1988

Preoperative intercostal nerve block: effect on the endocrine metabolic response to surgery.

The plasma cortisol and glucose responses to cholecystectomy were studied in 20 healthy patients. Ten patients received preoperative intercostal nerve blocks of the 6th to 12th nerves bilaterally using 0.5% bupivacaine with adrenaline 250 micrograms. The control group had the same quantity of adrenaline infiltrated into the intercostal space. Both groups had general anaesthesia with endotracheal intubation and controlled ventilation. In the non-blocked group, the mean cortisol concentration increased from a control value of 182.5 nmol litre-1 to a peak of 686.2 nmol litre-1 at 5.5 h after incision. In the blocked group the baseline serum cortisol concentration was 283.8 nmol litre-1 and it increased to a similar peak at 5.5 h. There were no significant differences between groups. The baseline plasma glucose concentration was also higher in the blocked group (4.45 mmol litre-1 compared with 3.94 mmol litre-1), but after a brief increase following the performance of the block decreased to only 14% above control values. The unblocked group exhibited substantial increase following the start of the surgery which continued for the duration of the study period to end at a mean of 6.48 mmol litre-1. These differences were significant (P less than 0.001). It is concluded that bilateral intercostal blocks may inhibit the glucose response to surgery, but have no effect on the cortisol response.

Anesthesia, General↗
PubMed1987

Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery.

Continuous bupivacaine epidural analgesia was compared with conventional methods of systemic analgesic administration in the management of postoperative pain in 30 patients for 3 days following total knee replacement surgery. Patients given continuous epidural analgesia had significantly better pain relief (visual analogue scale, global evaluation), needed significantly fewer supplementary analgesics, and had significantly fewer side effects. In the epidural group, sensory block averaged six dermatomes on day 1 and four dermatomes on day 3. The number of patients with complete (or almost complete) motor block of the lower limbs decreased from eight on day 1 to five on day 3. The mean dosage of bupivacaine decreased from 21.0 +/- 5.7 (SD) mg/hr on day 1 to 15.1 +/- 8.5 mg/hr on day 3. No signs of accumulation of or toxic reactions to bupivacaine were seen.

Adolescent↗