Current evidence-based practice guidelines for the management of nonacute persistent and recurring musculoskeletal-related pain have emphasized the use of holistic multidisciplinary approaches including nonpharmacological therapies. Kinesiology taping is a simple, economical, easy-to-apply, nondrug therapeutic technique that is used by health-care professionals for managing and rehabilitating musculoskeletal injuries. High-quality research on kinesiology taping is limited, although recent evidence suggests that kinesiology taping may have a small effect in mitigating pain and may be associated with mild cutaneous side effects. We present a review of the principles of kinesiology taping and an evaluation of research on its efficacy to catalyze discussion among clinicians about the merits of kinesiology taping as an adjunct for pain management.

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Background: Brachial plexus block is a reliable, regional anesthetic technique for upper arm surgeries. Opioid agonist-antagonists are also used as adjuvant to enhance the analgesia of bupivacaine. The present study was aimed to assess the analgesic efficacy and safety of nalbuphine as an adjuvant to 0.5% bupivacaine for brachial plexus block. Patients and Methods: Sixty adult patients of American Society of Anesthesiologists physical status I and II of both genders were randomized into two groups of thirty patients each to receive either 20 mL of 0.5% bupivacaine with 1 mL of normal saline (Group 1) or 20 mL of 0.5% bupivacaine with 1 mL of nalbuphine 10 mg (Group 2) for brachial plexus block under ultrasound guidance. Patients were observed for onset and duration of sensory and motor block with duration of pain relief as primary end points while occurrence of any adverse effect due to technique or nalbuphine was noted as secondary outcome. Results: The ultrasound guided the visualization of the nerves, needle, and spread of local anesthetic at brachial plexus block site. Nalbuphine did not affect the onset time of block but enhanced the duration of sensory and motor block. The duration of postoperative analgesia was 481.53 ± 42.45 min in Group 2 and 341.31 ± 21.42 min in Group 1, with statistically highly significant difference (P < 0.001). There were no hemodynamic variations and no complication of technique or adverse effects due to nalbuphine occurred. Conclusion: Nalbuphine 10 mg has significantly extended the duration of analgesia of brachial plexus block with no adverse effects.

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Background: Fluoroscope guidance method is the gold standard for performing lumbar transforaminal epidural steroid injections (TFESIs), but it is not devoid of adverse effects such as exposure to radiation and need to wear heavy lead aprons. Ultrasound (US)-guided techniques are being evaluated recently but methodological acceptability and reproducibility remain unknown. So after reviewing literatures, studing the us scan of lumber region, we have performed these injection safely and methodologial manner and describing in this study. Duration of Study: The duration of this study was six months, from May 01, 2016, to November 31, 2016. Study Design: This was a prospective, open-label, clinical, pilot study. Materials and Methods: A total of twenty patients with low back pain and radiculopathy were enrolled in this study. A US-guided novel technique was used to perform TFESI. A needle was placed under the guidance of US, and then verified with fluoroscope for dye spread. Then, predecided mixture of drugs were injected. Patients were monitored for number of attempts for localization of transforaminal space, number of adjustment, time taken for needle insertion in transforaminal space, radiation dosage, if the cortex of bone touched by the needle, and whether any complication occurred. Results: The number of attempts for localization of transforaminal space in 85% was one and two in 15% of the patients, number of adjustment per attempt was 5.3, and the average time taken for TFESI in patients in one-attempt group was 973 ± 93 s and 1506 ± 65 s in two-attempt group. Average exposure time of fluoroscope per person was 17.5 ± 2.5 s only. Bone was contacted in 75% of cases and no complications were noted. Conclusion: Lumbar TFESI can be safely and effectively performed under US guidance but fluoroscopic confirmation is required to rule out intravascular and intrathecal spread of the contrast at this stage. However, US guidance has reduced radiation exposure to significant level in this study.

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Background: Transversus abdominis plane (TAP) block is a regional anesthesia technique whose efficacy has been proven for postoperative pain relief after cesarean section (CS). Dexamethasone, a glucocorticoid, is now emerging as a new adjunct to local anesthetics for prolonging the duration of action and has been studied in different brachial plexus blocks. The primary outcome was to study the effect of dexamethasone as additive to ropivacaine on the duration of TAP block as assessed by time to first analgesic (TFA) . The secondary outcome was total postoperative analgesic consumption, postoperative nausea and vomiting, and patient satisfaction. Method: This RCT was conducted on seventy American Society of Anesthesiology Grade I and II patients undergoing CS under subarachnoid block. Patients were randomly allocated to two groups comprising 35 patients each. Patients in Group I received ultrasound-guided bilateral TAP block at the end of surgery using 40 ml ropivacaine 0.2% and 2 ml saline, and patients in Group II received the block using 40 ml ropivacaine 0.2% and 2 ml (8 mg) dexamethasone. Result: TFA was significantly longer in Group II (5.92 ± 1.02 vs. 3.11 ± 0.82 h, P = 0). Group II also had decreased tramadol requirement postoperatively (100.00 ± 0.00 vs. 140.00 ± 50.26 mg, P = 0.046). The incidence of nausea and vomiting was also lower (82.86% vs. 97.14%, P = 0.02318). The patient satisfaction with regard to pain relief was more (57.14% vs. 25.71%, P = 0.038). Conclusion: Addition of dexamethasone to ropivacaine in TAP block prolonged the duration of the block. There was no complication seen with TAP block in any of the patients.

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Background: Myofascial pain syndrome (MPS) is described as sensory symptoms, sometimes with motor and autonomic symptoms caused by myofascial trigger points (TPs). Injection at TPs is most likely to benefit patients with such disorder. The identification of TPs is usually clinical. However, in sites where there are major vital structures, ultrasound guidance and real-time visualization may help in decreasing complications. Methodology: Twenty patients who presented to pain clinic with classic symptoms of MPS in the neck and shoulder area with clinically detectable TPs were selected. The points were imaged with ultrasound to find correlation with clinical positions. They were injected with a mixture of local anesthetic and steroid on TPs with real-time ultrasound guidance and needle visualization. Pretreatment visual analog scale (VAS) scores and posttreatment (immediate and after 1 month) were noted. The mean reduction in VAS scores was analyzed with paired Student's t-test. Any side effect was observed and managed. Results: Clinically detectable TPs coincided with an echogenic point on the undersurface of the trapezius. There was a significant reduction in pain scores at both times. The needle sign was positive in all the cases. There were no major complications. Conclusion: The clinically identified TPs in trapezius muscle coincided well with ultrasound imaged echogenic structure in the muscle in all the cases. Ultrasound-assisted injections also produced the needle sign in all the cases. The achieved analgesia both immediately after the injection and a month later was satisfactory in the majority of cases. The echogenic mass corresponding to the TP is found to be on the undersurface of the muscle rather than inside the mass of the muscle.

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Background: Stellate ganglion block (SGB) is a well-established treatment option for CRPS (complex regional pain syndrome) type I. However, no studies have been conducted to study its efficacy in patients with CRPS-not otherwise specified (NOS). We conducted a study to evaluate the efficacy of SGB in decreasing pain and improving the functional use of the upper limb in patients with CRPS-NOS. Materials and Methods: We performed SGB on 24 patients with a diagnosis of CRPS-NOS at weekly intervals until 50% relief in pain and functional activity of the limb was achieved. Pain and functional ability of the limb were assessed by visual analog scale (VAS) disabilities of the arm, shoulder, and hand (DASH) scores, respectively. VAS and DASH scores were recorded before and 1 week after the procedure and the results were compared using appropriate statistical tests. The number of blocks required to achieve the desired effect was also noted in all the patients. Results: All the patients in our study showed significant improvement in VAS (P = 0.001) and DASH scores (P < 0.001). It was noted that the number of blocks required to achieve the desired relief was lower in patients with shorter duration of symptoms (<12 weeks) than those with longer duration of symptoms (>12 weeks). This finding was statistically significant (P = 0.047). Conclusion: SGB used early in the course of disease improves pain and functional ability of the limb in patients with CRPS-NOS. We also presume that CRPS-NOS might be an initial stage of the full blown CRPS and hence can serve as a window period in identifying and treating patients early in the course of the disease. However, this finding needs to be substantiated by further studies.

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Abdominal sympathetic blockade is a safe, minimally invasive and proven measure for pain control in intra-abdominal malignancies. Hereby, we report a case of severe abdominal and back pain due to advanced carcinoma gall bladder refractory to oral and transdermal medications, managed successfully by bilateral splanchnic neurolysis using 50% alcohol under fluoroscopy. Pain was significantly relieved immediately after the procedure with a gradual reduction in analgesics consumption. The effect was sustained during follow-up with improved quality of life.

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Introduction: The temporomandibular disorders (TMDs) include a heterogeneous group of clinical conditions affecting the stomatognathic system and its related structures. It is characterized by pain specific to the maxillofacial region, and these disorders are the main cause of chronic facial pain and disability. Management of TMDs is challenging due to the unknown etiology and complex anatomy of the temporomandibular joint region. Aim and Objectives: To evaluate the effect of botulinum toxin type-A (BTX-A) on pain and day to day functional and social activities of myofascial pain with or without TMDs, and to compare the effectiveness of BTX-A with a placebo group with the aid of EMG and a Behavioural Questionnaire. Materials and Methods: The study was done on 24 patients randomly divided into two groups and each group contains 12 participants. The study group showed a statistically significant decrease in the muscle activity after 14 days, and the patients responded that there was a significant reduction in the pain and improvement in their day-to-day functional as well as social activities after BTX-A treatment with 8 months follow-up. Conclusion: BTX-A has been proven to have positive desired effects on patients with TMDs.

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Context: Spinal anesthesia is a time-tested method for orthopedic surgeries of the lower limb while peripheral nerve block is a comparatively newer method and still under controversy. Aims: The aim of this study was to compare efficacy of spinal bupivacaine and fentanyl with combined lumbar plexus and sciatic nerve block in lower limb orthopedic procedures. Settings and Design: A randomized single-blinded prospective study conducted at orthopedic operation theater and perioperative area. Subjects and Methods: Sixty patients were randomly allocated into two groups, Group A received spinal anesthesia with 12.5 mg bupivacaine and 25 μg fentanyl, Group B received lumbar plexus block with 30 ml (0.25%) bupivacaine and sciatic nerve block with 25 ml (0.25%) bupivacaine. In Group B, three patients were converted to general anesthesia due to failure of development of block. In postoperative period, visual analog scale (VAS) score was assessed, and pethidine was used as rescue analgesic. Statistical Analysis Used: IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY, USA). Results: Faster onset of sensory and motor block was found in Group A. In the intraoperative period, incidence of hypotension and bradycardia was found to be higher in Group A although statistically insignificant. In the postoperative period, the VAS score difference between the two groups was found to be significantly higher in Group B till 6 h postoperative. The total duration of analgesia was significantly higher in Group B (690.00 ± 108.344 min) than in Group A (264.67 ± 25.962 min). The total dose of analgesic required in first 24 h was significantly less in Group B (200.00 ± 57.17 mg) than in Group A (371.67 ± 28.416 mg). Conclusion: Combination of lumbar plexus and sciatic nerve block provided effective unilateral analgesia for a prolonged time into the postoperative period.

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Background: Dexamethasone, a long-acting glucocorticoid is used as an additive along with local anesthetics perineurally to prolong the duration of neuraxial blocks. The aim of this prospective, randomized, double-blind study was to evaluate the efficacy of low-dose intravenous (IV) dexamethasone (2 mg) along with bupivacaine for prolongation of supraclavicular block in patients undergoing upper limb surgeries. Materials and Methods: Sixty American Society of Anaesthesiologists 1 and 2 patients, aged between 18 and 60 years were included in this study and randomized into two groups: Group D (dexamethasone group) and Group C (control group). Ultrasound-guided supraclavicular block was performed and patients belonging to Group D received 25 ml of 0.5% bupivacaine and 2 mg (1 ml) dexamethasone intravenously while patients belonging to Group C received 25 ml of 0.5% bupivacaine and 1 ml of normal saline intravenously. Duration of analgesia, motor blockade, and requirement of rescue analgesic were recorded. Results were analyzed using unpaired Student's t-test and Chi-squared test. P <0.05 was considered statistically significant. Results: Duration of analgesia in Group D was 11.88 ± 1.31 h as compared to 6.47 ± 0.93 in Group C (P < 0.05). Rescue analgesic requirement was significantly less in Group D (38.00 ± 20.51) as compared to Group C (173.33 ± 34.07). Patient satisfaction and quality of sleep was better in patients belonging to Group D. Conclusion: We conclude that low dose IV dexamethasone significantly prolongs the duration of analgesia and reduces analgesic requirements without producing any significant side effects.

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Background: Nalbuphine is a synthetic opioid with mixed agonist-antagonist action, used as an adjuvant with intrathecal bupivacaine to prolong postoperative analgesia. However, only a few studies so far have quantified the optimal intrathecal nalbuphine dose. Our aim was to compare the relative effectiveness of three doses of intrathecal nalbuphine to determine the optimum dose which prolonged analgesia with minimal side effects. Settings and Design: This was a prospective, randomized, double-blind study. Subjects and Methods: Eighty American Society of Anesthesiologists I and II patients undergoing elective lower abdominal and lower limb surgeries under subarachnoid block were randomly allocated to four groups (A, B, C, and D of twenty patients each) to receive 0.5 ml normal saline or 0.8, 1.2, and 1.6 mg nalbuphine added to 0.5% hyperbaric bupivacaine 15 mg. The onset of sensory and motor blockade, two-segment regression time of sensory blockade, duration of motor blockade, duration of analgesia, visual analog scale pain score, and side effects were compared between these groups. Results: Two-segment regression time of sensory blockade and duration of effective analgesia were prolonged in both Group C (1.2 mg nalbuphine) and Group D (1.6 mg nalbuphine) compared to Groups A and B (P < 0.05), but the incidence of side effects was significantly higher in Group D (P < 0.05). Conclusion: Nalbuphine 1.2 mg is the optimum intrathecal dose which prolongs postoperative analgesia without increased side effects.

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Persistent idiopathic facial pain is a facial pain disorder without any identifiable cause. A patient has persistent facial pain without any objective sign on clinical examination or investigations. There are associated psychological problems such as depression and anxiety. This condition is poorly responsive to therapy with anticonvulsants or analgesics. Stellate ganglion block interrupts the sympathetic supply to head, neck, and upper extremities. This block can be used to alleviate pain of sympathetic origin in head and neck region as well as upper extremities. We report a case of a middle-aged female with persistent idiopathic facial pain on the right side of face with no response to analgesics and anticonvulsants. Her pain was provoked by exposure to cold weather or wind. Assuming a sympathetic component to her pain, we did a right-sided stellate ganglion block for her with local anesthetic and steroid. The patient had significant pain relief (>80%) after the block. This indicates that the sympathetic nervous system plays a major role in initiation and perpetuation of this pain condition. Stellate ganglion block can be done early in such patients both as a diagnostic and therapeutic modality.

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Introduction: Regional anaesthesia (RA) and its accompanying range of central and peripheral nerve blocks (PNB) have fast become a sophisticated and relatively safe mode of sole and adjunct anaesthetic technique in the past decade. Our aims were to retrospectively survey the one year neurological outcomes of regional anaesthesia in our center. We specifically wished to assess the incidence of residual pain as well as sensory and motor loss at one year after receiving regional anaesthesia. Methods: Our design is a telephone survey of all patients included in the study. Usual RA blocks done in our center include central neuraxial blocks as well as all upper limb, lower limb or abdominal wall blocks. Results: When looking at the neurological outcomes, 27% (22 patients) complained of residual pain at the site of the operation; 23% (19 patients) claimed they experienced numbness or paresthesias and 20% (17 patients) reported residual motor weakness. Only 2% of these patients received any further intervention and some stated they have reported their residual pain or sensory/ motor loss to their primary physicians or GPs. Majority of the symptoms was mild in nature (89%). Almost none returned to the chronic pain clinic for assessment. Conclusions: Our study shows a higher than expected incidence of neurological sequelae of this type of anaesthesia. This study highlights the need for careful assessment of RA outcomes and perhaps following these patients more closely at regular intervals during the year, a thorough interval neurological assessment with proper referrals and opening avenues for seeking help or giving feedback for the patients.

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A 68 year old female with carcinoma vulva, presented with severe unrelenting, burning pain in the vulval region. The pain was not controlled by dispersible Morphine 20 mg q4h, and a dose of 25 mg q4h produced intolerable side effects like nausea, vomiting and drowsiness, without additional pain relief. A ganglion impar could not be done due to altered anatomy. A lumbar epidural block with a catheter to deliver a continuous infusion of 0.125% bupivacaine at 2.0 ml/hour was initiated. She had excellent analgesia and she could be taken off morphine. Her epidural catheter dislodged in 3 days and could not be reinserted immediately. When we started her on morphine, her pain was well controlled with Morphine 5 mg q4h. We propose this increase in sensitivity to morphine to be due to breaking of the pain cycle with the epidural block.

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