BACKGROUND: Acupuncture has been shown to be effective in pain relief and anesthesia, and has been suggested for treating various kinds of functional disabilities in traditional Chinese medicine, including knee osteoarthritis (OA). The study aimed to investigate the immediate effects of acupuncture on gait patterns in patients with knee OA. METHODS: Twenty patients with bilateral medial knee OA were assigned evenly and randomly to a sham group and an experimental group. During the experiment, the experimental group underwent a 30-minute formula electro-acupuncture treatment while the sham group received a sham treatment. Before and after treatment, each subject was evaluated for their knee pain using visual analog scales (VAS) and then their performance of level walking using gait analysis. For all the obtained variables, the independent t-test was used for between-group comparisons, while paired t-test was used to investigate the before and after changes. RESULTS: All the measured data before acupuncture treatment between the groups were not significantly different. The VAS scores were decreased significantly after acupuncture in both groups, and the mean change of the VAS values of the experiment group was 2 times greater than that of the sham group. After formula acupuncture stimulation, while no significant changes were found in all the gait variables in the sham group, the experimental group had significant increases in the gait speed, step length, as well as in several components of the joint angles and moments. CONCLUSIONS: The results of the study suggest that significantly improved gait performance in the experimental group may be associated with pain relief after treatment, but the relatively small decrease of pain in the sham group was not enough to induce significant improvements in gait patterns. Gait analysis combined with the VAS can be useful for the evaluation of the effect of acupuncture treatment for patients with neuromusculoskeletal diseases and movement disorder.

PURPOSE: Women with breast cancer (BC) treated with aromatase inhibitors (AIs) may experience joint symptoms that can lead to discontinuation of effective therapy. We examined whether acupuncture improves AI-induced arthralgias in women with early-stage BC. METHODS: We conducted a randomized, controlled, blinded study comparing true acupuncture (TA) versus sham acupuncture (SA) twice weekly for 6 weeks in postmenopuasal women with BC who had self-reported musculoskeletal pain related to AIs. TA included full body/auricular acupuncture and joint-specific point prescriptions, whereas SA involved superficial needle insertion at nonacupoint locations. Outcome measures included the Brief Pain Inventory-Short Form (BPI-SF), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Modified Score for the Assessment of Chronic Rheumatoid Affections of the Hands (M-SACRAH) obtained at baseline and at 3 and 6 weeks. RESULTS: Of 51 women enrolled, 43 women were randomly assigned and 38 were evaluable. Baseline characteristics were comparable between the two groups. Our primary end point was the difference in mean BPI-SF worst pain scores at 6 weeks, which was lower for TA compared with SA (3.0 v 5.5; P <.001). We also found differences between TA and SA in pain severity (2.6 v 4.5; P =.003) and pain-related interference (2.5 v 4.5; P =.002) at 6 weeks. Similar findings were seen for the WOMAC and M-SACRAH scores. The acupuncture intervention was well-tolerated. CONCLUSION: Women with AI-induced arthralgias treated with TA had significant improvement of joint pain and stiffness, which was not seen with SA. Acupuncture is an effective and well-tolerated strategy for managing this common treatment-related side effect.

Neurobiological mechanisms invoking the release of endogenous opioids and depression of stress hormone release are believed to be the basis of acupuncture analgesia. This study compared plasma beta-endorphin and cortisol levels with self assessment scores of intensity of pain, before and after 10 days of electro-acupuncture treatment in patients suffering from chronic pain as a result of osteoarthritis knees. Forty patients of either sex over 40years with primary osteoarthritis knee were recruited into a single-blinded, sham-controlled study. For electro-acupuncture group the points were selected according to the Traditional Chinese Medicine Meridian Theory. In the sham group needles were inserted at random points away from true acupoints and no current was passed. Both groups were treated for 10days with one session every day lasting for 20-25min. Pre- and post-treatment Western Ontario and McMaster Universities (WOMAC) index of osteoarthritis knee and Visual Analogue Scale (VAS) for pain were recorded and blood samples were taken for the measurement of plasma cortisol and beta-endorphin levels. Following electro-acupuncture treatment there was a significant improvement in WOMAC index and VAS (p=0.001), a significant rise in plasma beta-endorphin (p=0.001), and a significant fall in plasma cortisol (p=0.016). In conclusion electro-acupuncture resulted in an improvement in pain, stiffness and disability. Of clinical importance is that an improvement in objective measures of pain and stress/pain associated biomarkers was shown above that of a sham treatment; hence demonstrating acupuncture associated physiological changes beyond that of the placebo effects.

Integrative medicine has emerged as a potential solution to the American healthcare crisis. It provides care that is patient centered, healing oriented, emphasizes the therapeutic relationship, and uses therapeutic approaches originating from conventional and alternative medicine. Initially driven by consumer demand, the attention integrative medicine places on understanding whole persons and assisting with lifestyle change is now being recognized as a strategy to address the epidemic of chronic diseases bankrupting our economy. This paper defines integrative medicine and its principles, describes the history of complementary and alternative medicine (CAM) in American healthcare, and discusses the current state and desired future of integrative medical practice. The importance of patient-centered care, patient empowerment, behavior change, continuity of care, outcomes research, and the challenges to successful integration are discussed. The authors suggest a model for an integrative healthcare system grounded in team-based care. A primary health partner who knows the patient well, is able to addresses mind, body, and spiritual needs, and coordinates care with the help of a team of practitioners is at the centerpiece. Collectively, the team can meet all the health needs of the particular patient and forms the patient-centered medical home. The paper culminates with 10 recommendations directed to key actors to facilitate the systemic changes needed for a functional healthcare delivery system. Recommendations include creating financial incentives aligned with health promotion and prevention. Insurers are requested to consider the total costs of care, the potential cost effectiveness of lifestyle approaches and CAM modalities, and the value of longer office visits to develop a therapeutic relationship and stimulate behavioral change. Outcomes research to track the effectiveness of integrative models must be funded, as well as feedback and dissemination strategies. Additional competencies for primary health partners, including CAM and conventional medical providers, will need to be developed to foster successful integrative practices. Skills include learning to develop appropriate healthcare teams that function well in a medical home, developing an understanding of the diverse healing traditions, and enhancing communication skills. For integrative medicine to flourish in the United States, new providers, new provider models, and a realignment of incentives and a commitment to health promotion and disease management will be required.

OBJECTIVE: To investigate the remote effect of acupuncture on the pain intensity and the endplate noise (EPN) recorded from a myofascial trigger point (MTrP) of the upper trapezius muscle. DESIGN: Randomized controlled trial. SETTING: University hospital. PARTICIPANTS: Patients (N = 20) with active MTrPs in upper trapezius muscles and no experience in acupuncture therapy. INTERVENTIONS: Patients were divided into 2 groups. Those in the control group received sham acupuncture, and those in the acupuncture group received modified acupuncture therapy with needle insertion into multiple loci to elicit local twitch responses. The acupuncture points of Wai-guan and Qu-chi were treated. MAIN OUTCOME MEASURES: Subjective pain intensity (numerical pain rating scale) and mean EPN amplitude in the MTrP of the upper trapezius muscle. RESULTS: The pain intensity in the MTrP was significantly reduced after remote acupuncture (from 7.4 +/- 0.8 to 3.3 +/- 1.1; P <.001), but not after sham acupuncture (from 7.4 +/- 0.8 to 7.1 +/- 0.9; P >.05). The mean EPN amplitude was significantly lower than the pretreatment level after acupuncture treatment (from 21.3 +/- 9.5 microV to 9.5 +/- 3.5 microV; P <.01), but not after sham acupuncture treatment (from 19.6 +/- 7.6 microV to 19.3 +/- 7.8 microV; P >.05). The change in the pain intensity was significantly correlated with the change of EPN amplitude (r = 0.685). CONCLUSIONS: Both subjective changes in the pain intensity and objective changes of the EPN amplitude in the MTrP region of the upper trapezius muscle were found during and after acupuncture treatment at the remote ipsilateral acupuncture points. This study may further clarify the physiological basis of the remote effectiveness of acupuncture therapy for pain control.

BACKGROUND: Although substantial data have supported the effectiveness of acupuncture for treating knee osteoarthritis (OA), the number of points used has varied. The objective of this study was to compare the effectiveness of six and two acupuncture points in the treatment of knee OA. METHODS: A randomised trial of knee OA patients was conducted. Patients were randomly allocated into two groups of 35. The "six point group" received treatment at six acupuncture points, ST35, EX-LE4 (Neixiyan), ST36, SP9, SP10 and ST34, while the "two point group" received treatment at just the first pair of points, ST35 and EX-LE4. Both groups received twice weekly electroacupuncture on 10 occasions. Electrical stimulation was carried out at low-frequency of 3 Hz to all points, with the intensity as high as tolerable. Both groups were allowed to take a 200 mg celecoxib capsule per day for intolerable pain. Patients were assessed at baseline, week 5, week 9 and week 13, using a Thai language version of the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Global assessment of change after 10 treatments was also recorded. RESULTS: Acupuncture at both six and two acupuncture points was associated with significant improvement. Mean total WOMAC score at weeks 5 and 13 of patients in both groups showed no significant difference statistically (p = 0.75 and p = 0.51). Moreover, the number of celecoxib capsules taken, global assessment of global change and body weight change of both groups also showed no statistical difference. CONCLUSION: This evidence suggests that electroacupuncture to two local points may be sufficient to treat knee OA, but in view of some limitations to this study further research is necessary before this can be stated conclusively.

INTRODUCTION: Aromatase inhibitors (AIs) have become the standard of care for the adjuvant treatment of postmenopausal, hormone-sensitive breast cancer. However, patients receiving AIs may experience joint symptoms, which may lead to early discontinuation of this effective therapy. We hypothesize that acupuncture is a safe and effective treatment for AI-induced arthralgias. METHODS: Postmenopausal women with early-stage breast cancer who had self-reported musculoskeletal pain related to adjuvant AI therapy were randomized in a crossover study to receive acupuncture twice weekly for 6 weeks followed by observation or vice-versa. The intervention included full body and auricular acupuncture, and a joint-specific point prescription. Outcome measures included the Brief Pain Inventory-Short Form (BPI-SF), Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, the Functional Assessment of Cancer Therapy-General (FACT-G) quality of life measure, and serum levels of inflammatory markers, IL-1 beta and TNF-alpha. RESULTS: Twenty-one women were enrolled and two discontinued early. From baseline to the end of treatment, patients reported improvement in the mean BPI-SF worst pain scores (5.3 to 3.3, p = 0.01), pain severity (3.7 to 2.5, p = 0.02), and pain-related functional interference (3.1 to 1.7, p = 0.02), as well as the WOMAC function subscale and FACT-G physical well-being (p = 0.02 and 0.04, respectively). No adverse events were reported. DISCUSSION/CONCLUSIONS: In this pilot study, acupuncture reduced AI-related joint symptoms and improved functional ability and was well-tolerated. IMPLICATIONS FOR CANCER SURVIVORS: Musculoskeletal side effects are common among breast cancer survivors on adjuvant AI therapy, therefore, effective treatments are needed for symptom relief and to improve adherence to these life-saving medications.

Objectives To compare the effect of acupuncture (manual and electroacupuncture) with that of a non-penetrating sham ('placebo' needle) in patients with osteoarthritic knee pain and disability who are blind to the treatment allocation. Methods Acupuncture na patients with symptomatic and radiological evidence of osteoarthritis of the knee were randomly allocated to a course of either acupuncture or non-penetrating sham acupuncture using a sheathed 'placebo' needle system. Acupuncture points for pain and stiffness were selected according to acupuncture theory for treating Bi syndrome. Both manual and electrical stimulation were used. Response was assessed using the WOMAC index for osteoarthritis of the knee, self reported pain scale, the EuroQol score and plasma b-endorphin. The effectiveness of blinding was assessed. Results There were 34 patients in each group. The primary end point was the change in WOMAC pain score after the course of treatment. Comparison between the two treatment groups found a significantly greater improvement with acupuncture (mean difference 60, 95% CI 5 to 116, P= 0.035) than with sham. Within the acupuncture group there was a significant improvement in pain (baseline 294, mean change 95, 95% CI 60 to 130, P<0.001) which was not seen by those who had sham acupuncture (baseline 261, mean change 35, 95% CI -10 to 80, P=0.12). Similar effects within group, but not between groups, were seen with the secondary end points of WOMAC stiffness, WOMAC function, and self reported pain. One month after treatment the between group pain difference had been lost (mean difference 46; 95% CI -9 to 100, P=0.10) although the acupuncture group was still benefiting compared to baseline (mean difference 59; 95% CI 16 to 102, P=0.009). The EuroQol score, a generic measure of health related quality of life, was not altered by the treatments. A minority of patients correctly guessed their treatment group (41% in the acupuncture group and 44% in the control group). Plasma b-endorphin levels were not affected by either treatment. Conclusions Acupuncture gives symptomatic improvement for patients with osteoarthritis of the knee, and is significantly superior to non-penetrating sham acupuncture. The study did not confirm earlier reports of release of plasma b-endorphin during acupuncture.

Osteoarthritis of the knee is a major cause of disability among adults. Treatment is focused on symptom management, with nonpharmacologic therapies being the preferred first line of treatment. Acupuncture is considered a potentially useful treatment for osteoarthritis. The objective of this article is to review the English-language articles, indexed in MEDLINE or CINAHL, describing randomized, controlled trials of the effects of needle or electroacupuncture on knee osteoarthritis. Ten trials representing 1456 participants met the inclusion criteria and were analyzed. These studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with osteoarthritis of the knee.

The primary objective of this double-blind, randomised, controlled trial was to determine if implanting gold beads at five acupuncture points around the knee joint improves 1-year outcomes for patients with osteoarthritis (OA) of the knee. Participants were 43 adults aged 18-80 years with pain and stiffness from non-specific OA of the knee for over a year. The intervention was blinded implantation of gold beads at five acupuncture points around the affected knee through a hypodermic needle, or needle insertion alone. Primary outcome measures were knee pain, stiffness and function assessed by the patient at 0, 1, 3, 6, 9 and 12 months and knee score and knee function assessed by an orthopaedic surgeon at 0, 6 and 12 months. Within the first month, three patients dropped out. The remaining 21/19 patients in the intervention/control groups generally improved, but there was no statistically significant difference between the groups. The improvement was shown in the patients' self-assessment scores that decreased from randomisation until 1 year later (intervention/control group, medians): pain -1.92/-2.18 (P = 0.95, F test, general linear mixed model); stiffness -0.93/-0.43 (P = 0.11); function -7.23/-3.36 (P = 0.63). The surgeon's scores also generally improved, i.e. increased: knee score +16.4/+8.2 (P = 0.65); knee function +10.5/+5.8 (P = 0.79). In the protocol-based subgroup analysis, the 15 intervention patients of the 32 patients who had a positive response to the initial conventional acupuncture had greater relative improvements in self-assessed outcomes. The treatment was well tolerated. This 1-year pilot study indicates that extraarticular gold bead implantation is a promising treatment modality for patients with OA of the knee. The new treatment should be tested in a larger trial including only patients who respond positively to initial conventional acupuncture.

To evaluate if it is possible to predict the outcome of acupuncture treatment in patients with knee osteoarthrosis, six treatments were given during a 3 week period. Follow-up time was 9-17 weeks. Seven parameters were evaluated to examine if they had any influence on the outcome of treatment: Age, duration of disease, pain, range of knee movement, analgesic consumption, knee score (an objective and subjective evaluation of the knees) and x-ray changes. Twenty-nine patients were included with a total of 42 osteoarthritic knees waiting for a total knee replacement. The median age was 69.2 years, and median duration of disease was 4.2 years. 85% of the participants reported a subjective effect, and in 88% an objective effect was found. Although there were some significant differences when you looked at the 7 parameters above, the pattern was not a consistent one. Follow up results also indicated that those with the best immediate results, not necessarily were the ones with the best long-term effect. It is not possible to predict the outcome of acupuncture treatment of osteoarthritic knees. Immediate results are not a guide-line for long-term results, which indicate that acupuncture research must include a follow-up period.

The purpose of this study was to examine acupuncture treatment of patients with osteoarthrosis of the knee. Twenty-nine patients with a total of 42 osteoarthritic knees were randomized to two groups. Group A was treated while group B served as a no treatment control group for nine weeks. Analgesic consumption, pain and objective measurements were registered. In the second part of the study 17 patients (26 knees) continued with treatments once a months. Registrations were continued for a total study period of 49 weeks. Comparing group A with B, there was a significant reduction in pain, analgesic consumption and in most objective measures. In group A + B combined there was an 80% subjective improvement, and a significantly increased range of movement of the knee. Results were significantly better in those who had not been ill for a long time. The second part of the study showed that it was possible to maintain the improvements.

In this prospective, consecutive study, 191 patients were interviewed before and after surgery (orthopaedic, gynaecological, abdominal and urological operations) about their attitude to and the quality of received pain relief, respectively. In addition, nurses working in the surgical units involved in the study were asked to answer a questionnaire covering attitudes to postoperative pain and pain treatment. Of the patients, 47% were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all and 15% had received less than prescribed. In 36% of the cases there was a discrepancy between the amount of analgesic prescribed by the surgeon and the amount prescribed by the anaesthetist. In 80% of the patients the pain outlasted the first postoperative day, but only 64% would always tell the staff if they had pain. Seventeen per cent of the patients had never been asked about their postoperative pain status. Preoperative pain had a significant correlation to postoperative pain. Although the results are not impressive, they do constitute some improvement compared to previously published studies. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward. Conclusion: Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

One hundred and ninety-one patients were interviewed before and after surgery about their attitude toward and the quality of received pain relief. The nurses working in the same surgical units answered a questionnaire covering attitudes to postoperative pain and pain treatment. Forty-seven percent of the patients were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all, and 15% had received less than prescribed. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward. Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

The aim of this study was to evaluate the efficacy and safety of intramuscular (IM) administration of botulinum toxin type A (Dysport((R)), Ipsen Biopharm Ltd.) for the treatment of cervical dystonia (CD) and the long-term safety and efficacy of repeated treatments. During the randomized, double-blind, placebo-controlled phase patients were randomized to 500 units Dysport (n = 55) or placebo (n = 61). Efficacy assessments included the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total and subscale scores, visual analogue scale (VAS) for pain, subject/investigator's VAS for symptom assessments. Patients completing the double-blind treatment could enter an open-label extension phase and receive up to 4 additional Dysport treatments. Dysport produced a significant decrease from baseline in mean (+/-SE) TWSTRS total scores compared with placebo at Week 4 (primary efficacy endpoint;-15.6 +/- 2.0 vs.-6.7 +/- 2.0; p < 0.001) with significant improvements sustained to Week 12 (p = 0.019). Dysport also produced significant improvements in TWSTRS subscale scores, VAS pain scores, and subject/investigator's VAS symptom assessments compared to placebo. The mean duration of open-label study participation was 51.9 weeks (range 3.9-94.0 weeks). During open-label treatment, all treatment cycles resulted in improvements in mean TWSTRS total and subscale scores at Week 4 post-treatment; greatest improvement was seen in cycle 1. The mean duration between treatment cycles was 15-17 weeks. Dysport demonstrated a good long-term safety profile; most adverse events were mild or moderate and typical of the known safety profile of Dysport in this indication. These results confirm that Dysport (500 units) is safe, effective, and well-tolerated in patients with CD.

BACKGROUND: The objective of this study was to assess repeated needle acupuncture in the treatment of postoperative pain and nausea after visceral surgery. MATERIAL AND METHODS: Sixty-six patients undergoing visceral surgery (hysterectomy, cholecystectomy) were randomly assigned to group A (three sessions of needle acupuncture, n=21), group M (3x1000 mg metamizole, n=20), or group K (control, n=25). All patients received patient-controlled analgesia (PCA) using piritramide. To adjust for nonspecific effects due to physician-patient interaction during acupuncture sessions in group A, patients in groups M and K also received three standardized visits. Primary outcome parameters were defined as pain intensity, analgesic consumption, and frequency of nausea and vomiting in a period up to the morning of the second postoperative day. RESULTS: Patients in group A reported significant less pain, nausea, and vomiting compared to patients in group K. Mean cumulative piritramide consumption was significantly lower in group A (25.0 mg) than in group M (34.5 mg) and group K (55.2 mg). CONCLUSION: Repeated needle acupuncture may be effective in postoperative pain relief and the treatment of nausea and vomiting in the postoperative period. These effects seem not to be due solely to interaction between the acupuncturist and the patient.

BACKGROUND: Proponents of minimally invasive total knee arthroplasty claim that patellar eversion and anterior tibial translation during total knee arthroplasty have a deleterious effect on early patient rehabilitation and the early clinical outcome. Our purpose was to identify differences in knee preference and clinical outcome measures in a series of patients who had undergone bilateral total knee arthroplasty with each knee randomized to one of two different surgical approaches: patellar eversion and anterior tibial translation, or patellar subluxation and no tibial translation. METHODS: The knees of forty patients were prospectively randomized to one of two treatment groups, patellar eversion or patellar subluxation, with each patient having one knee treated with each type of approach. Three patients were withdrawn, leaving a final study group of thirty-seven patients. The patients and physical therapists were blinded to the type of treatment. Clinical outcomes, including the Knee Society scores, range of motion, quadriceps strength as tested with a dynamometer, and the patient's preferred knee on the basis of pain, motion, and strength, were collected preoperatively and at six weeks, twelve weeks, and six months postoperatively and were analyzed. RESULTS: At six weeks after the surgery, there were no significant differences between the two groups with regard to the range of motion, quadriceps strength, or Knee Society scores. With regard to the patient's knee preference at six weeks, the two knees were rated as being the same in terms of pain, whereas a higher percentage preferred the knee treated with eversion in terms of motion (43% compared with 35% who preferred the knee treated with subluxation) and strength (43% compared with 22%). The mean arc of motion in both groups was approximately 113 degrees. At twelve weeks and six months after the surgery, we found no significant differences between the treatment groups in terms of the range of motion, quadriceps strength, or Knee Society scores, and there was no difference with regard to the patient's knee preference. CONCLUSIONS: We found no significant differences between the two treatment groups (patellar eversion and anterior tibial translation compared with patellar subluxation and no tibial translation) at six weeks, twelve weeks, or six months after the surgery. We concluded that patellar eversion and anterior tibial translation appear to have no adverse effects on the range of motion, quadriceps strength, or patient's knee preference during the early postoperative recovery period after total knee arthroplasty.

Snoring is a common complaint, especially among the elderly individuals. In the treatment of snoring, many options, surgical or nonsurgical, are available. In this randomized study, we used a modified technique including some components of radiofrequency-assisted uvulopalatoplasty (RAUP) and Uvulopalatopharyngoplasty UPPP (modified-RAUP, MRAUP) and RAUP in a control group. A total of 60 patients (58 male and 2 female), 30 in each group (MRAUP and RAUP groups), with an average age of 38 +/- 9 years were included in the study. In the MRAUP group, in addition to the modified surgery, preoperative steroid injection was used as a preemptive analgesic and pre-incisional steroid injection and closure of the edges of the incision were performed to achieve better relief of pain. Snoring score, pain at rest and during swallowing, analgesic consumption and speech score were evaluated using standard 10 cm visual analog scales (VAS). Operation time and other complications were recorded. The patients in the MRAUP group had better pain scores, both at rest and during swallowing, and less analgesic consumption. Although operation time was longer in the MRAUP group compared to that of the RAUP group, snoring score, evaluated from day 1 to the 6th month after operation, was significantly better in the MRAUP group. Postoperative speech scores at each visit were similar in both groups. In the MRAUP group, 87% of the patients (26 patients) had a final VAS for snoring below 3, while in the RAUP group 63% of the patients (19 patients) were below 3 on the scale (P < 0.05). Thus, MRAUP seems to be a promising technique for surgery as a treatment for snoring.

Abstract Study Objectives. To compare opioid requirements in opioid-tolerant and opioid-naïve patients after total knee arthroplasty, and to compare pain scores, sedation scores, and adverse effects between the groups. Design. Prospective, observational study. Setting. Academic medical center. Patients. Twenty-nine patients aged 18 years or older who underwent elective total knee arthroplasty between October 1, 2005, and June 31, 2007. Measurements and Main Results. Patients were classified on the basis of their daily opioid consumption during the week before surgery: those who required 10 mg or less of oral morphine equivalent were considered opioid naïve (20 patients), and those who required at least 30 mg of oral morphine equivalent were opioid tolerant (nine patients). Postoperative opioid consumption, pain scores, sedation scores, and adverse effects were compared between the two groups up to 48 hours after discharge from the postanesthesia care unit (PACU). Postoperative opioid consumption (in intravenous morphine equivalents) was significantly greater in the opioid-tolerant group than in the opioid-naïve group in the PACU (median 56 vs 8.2 mg, p=0.0013), during the first 24 hours after discharge from the PACU (108 vs 20.5 mg, p=0.0004), and 24-48 hours after discharge from the PACU (152.3 vs 25 mg, p=0.0001). Pain scores, assessed by using a verbal numeric scale from 0-10, were significantly greater in the opioid-tolerant group than in the opioid-naïve group during the first 24 hours after discharge from the PACU (5.9 vs 4.1, p=0.03). We observed no significant difference in pain scores during the other time periods studied. Sedation scores and adverse effects were similar between groups. Conclusion. After total knee arthroplasty, patients tolerant to opioids required significantly more opioids in the PACU and up to 48 hours after discharge from the PACU than did opioid-naïve patients. Opioid-tolerant patients also experienced greater pain during the first 24 hours after discharge from the PACU; however, sedation scores and adverse effects did not appear to be significantly different at any of the time periods studied. Clinicians need to be aggressive with pain management immediately after surgery and ensure that patients restart any opioid treatment at home as soon as possible.

ABSTRACT Objective: The aim of this study was to reveal the efficacy of mud pack treatment in patients with knee osteoarthritis and to find the contribution of chemical factors to the build up of these effects. Methods: Sixty patients were randomly assigned to directly applied mud pack (study) group or to nylon-covered mud pack (control) group. Thirty patients in the study group had mud application 15 times to both knees: heated mud, up to 43 degrees C, was applied to skin directly for 30 minutes. Thirty patients in the control group had the same treatment as the study group except heated mud was applied over an impermeable nylon pack. Primary outcome measures of the study were the Western Ontario and McMaster Universities (WOMAC) index, pain intensity on a visual analog scale (VAS), patient's assessment of disease severity index, physician's assessment of disease severity index, and analgesic consumption. The patients were evaluated before and after (end of 15th application) the intervention and followed up for 24 weeks at 4-week intervals. The results were assessed on an intent-to-treat basis. Results: As compared to the baseline, significant decreases were observed in WOMAC, pain intensity, disease severity index scores, and analgesic consumption in both groups after the intervention. Observed improvements in the study group were found to be superior to the control during the whole postintervention follow-up, except for analgesic consumption in the third week. A significant number of patients in the study group showed minimal clinically important improvement as compared to the control group. Conclusion: Mud pack treatment significantly improved the pain and functional status of patients with knee osteoarthritis, whether applied directly or coated with nylon. Direct application was found to be superior, which implies chemical properties of the mud contribute to the build up of therapeutic effect.

We studied the effect of preoperative 3-in-1 block for total hip replacement surgery on postoperative pain and tramadol consumption during patient-controlled analgesia. Thirty ASA I-II patients undergoing elective total hip arthroplasty (THA) were included in the study. Patients were randomly divided into 2 groups; Group I: Patients who received 3-in-1 block with 40 ml of 0.25% bupivacaine 30-minutes before surgery and later received general anesthesia, Group II: Patients who received only a simple needle puncture at the operation site 30-minutes before surgery and later received general anesthesia. All patients received intravenous tramadol at the end of surgery via a PCA device. Pain was evaluated at 0,1/2,1,4,8,12,24 and 48h at rest and on movement of the hip, using a 10cm VAS. The average intraoperative fentanyl consumption was lower in Group I than in Group II. VAS scores were significantly lower in group I, both at rest and during movement at all timepoints over in the first postoperative 12h and also during movement 24h postoperatively. However differences in VAS scores weren't clinically significant after 4 hours. In the recovery room, Group I VAS scores were only a third of Group II, both at rest and movement (p=0.0001). Total tramadol consumption was lower in GroupI (633.0+/-119.3 mg) than in GroupII (991.1+/-41.0 mg). Patient satisfaction scores were higher in GroupI than in GroupII. We concluded that preoperative 3-in-1 block with 40 ml-0,25% bupivacaine provides effective postoperative pain relief for elective THA, reducing intra-and postoperative analgesic consumption without increase in side effects.

Preemptive analgesia aims to prevent the sensitization of central nervous system, hence the development of pathologic pain after tissular injury. The aim of the study was to assess the effect of preincisional clonidine treatment on analgesic consumption and hemodynamic stability compared to clonidine administered at the end of the operation and control group. Ninety-one patients undergoing elective colorectal surgery were randomly assigned to four groups: peroral clonidine before operation, epidural clonidine before operation, epidural clonidine at the end of operation, and epidural saline before operation as a control group. After the operation, patient-controlled analgesia with epidural morphine was instituted. Analgesic consumption, blood pressure and heart rate were obtained at 1, 2, 6 and 24 h postoperatively, and the cumulative consumption of analgesics was assessed at the end of the study period. Significant differences (p < 0.05) in postoperative systolic blood pressure, with highest hemodynamic stability was observed at 1 h and 6 h in the group of patients administered epidural clonidine before operation. In this group of patients we found significant reduction in analgesic consumption during the study period (p < 0.05), compared to other groups. The cumulative consumption of analgesics assessed at the end of the study period was significantly reduced (p < 0.05) in the group of patients administered epidural clonidine before operation (8.40 +/- 3.74, respectively) as compared with the peroral clonidine before operation (16.79 +/- 5.75, respectively), epidural clonidine at the end of the operation (11.11 +/- 4.24, respectively) and control group of patients (18.00 +/- 6.45, respectively). Preincisional administration of epidural clonidine was associated with a significantly lower analgesic use, lower cumulative analgesic consumption and greater hemodynamic stability, in comparison with other groups.

Objective. To evaluate the effects of standardized western acupuncture and physiotherapy on pain and functional ability in patients with severe osteoarthritic knee pain awaiting knee arthroplasty. Methods. Three-arm, assessor-blind, randomized controlled trial. Participants: 181 patients awaiting knee arthroplasty. Interventions: acupuncture for 6 weeks; physiotherapy for 6 weeks; standardized advice. Main outcome measures: Oxford Knee Score questionnaire (OKS)(primary); 50 m timed walk, and duration of hospital stay following knee arthroplasty. Results. There was no baseline difference between groups. At 7 weeks, there was a 10% reduction in OKS in the acupuncture group which was a significant difference between the acupuncture and the control group: Mean (s.d.) acupuncture 36.8 (7.20); physiotherapy 39.2 (8.22); control 40.3 (8.48)(P = 0.0497). These effects were no longer present at 12 weeks. There was a trend (P = 0.0984) towards a shorter in-patient stay of 1 day for the physiotherapy group [mean 6.50 days (s.d. 2.0)] compared with the acupuncture group [mean 7.77 days (s.d. 3.96)]. Conclusions. We have demonstrated that patients with severe knee osteoarthritis can achieve a short-term reduction in OKS when treated with acupuncture. However, we failed to demonstrate any other clinically or statically significant effects between the groups. Both interventions can be delivered effectively in an out-patient group setting at a district general hospital. Further study is needed to evaluate the combined effects of these treatments.

We recruited 114 patients (56 with chronic nonspecific low back pain, 37 with osteoarthritic knee and 21 with osteoarthritic hip pain) into a surveillance of the effects of taking Doloteffin((R)) at a dose providing 60mg harpagoside per day for up to 54 weeks. Their symptoms and well-being were monitored at 4-6 week intervals by disease-specific and generic outcome measures, and the patients also kept a diary of their pain and requirement for rescue medication. The principal analyses were on the basis of Intention to Treat (ITT) with Last Value Carried Forward (LOCF). A Multivariate Analysis of Variance (MANOVA) indicated an appreciable overall improvement during the surveillance, similar in the Back, Knee and Hip groups. In separate ANOVAs, most of the individual outcome scores decreased significantly over time. Multiple regression analyses indicated that changes from baseline were independent of patients' characteristics. Additional analgesic requirements (which were very modest) declined during the year of surveillance."Response during treatment", assessed according to criteria adapted from joint proposals of the Outcome Measures in Rheumatoid Arthritis Clinical Trials group and the Osteoarthritis Research Society International group, was achieved in 75% of patients, and was reflected in the percentages who rated the treatment as "good" or "very good". Adverse events were few and none were serious.