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PubMed1998

The urodynamic effects of intravenous opioids and ketoprofen in humans.

UNLABELLED: We used a double-blind design to study urodynamic changes induced by mu-agonists (fentanyl, morphine), a partial mu-agonist antagonist (buprenorphine), a putative mu-antagonist, kappa-agonist (nalbuphine), and ketoprofen, an injectable nonsteroidal antiinflammatory drug. Men (20-55 yr old) were randomly assigned to receive one of the following i.v. before anesthesia for endoscopic extraction of a ureteral stone: 10 mg of morphine, 0.3 mg of buprenorphine, 0.35 mg of fentanyl, 20 mg of nalbuphine, 100 mg of ketoprofen, or 10 mL of 0.9% sodium chloride. The urodynamic study consisted of cystometry followed by urethral pressure profile. Measurements were taken before the i.v. infusion of drugs and 15 min thereafter. Statistical comparisons were performed by using analysis of variance with repeated measurements (P < 0.05). Ketoprofen and saline did not induce any urodynamic changes. Opioids altered bladder sensations, and the residual volume after voiding increased, except after morphine. Detrusor contraction decreased only after the administration of fentanyl and buprenorphine. Some patients could not micturate after receiving morphine, fentanyl, and buprenorphine. Compliance and urethral pressures did not change with any drug. This study suggests that ketoprofen and nalbuphine are useful analgesics in terms of their urodynamics. IMPLICATIONS: We compared the urodynamic effects of opioids and ketoprofen used as analgesics in surgical patients. In contrast to ketoprofen, opioids altered urodynamics. The opioid nalbuphine had no effect on detrusor contraction. This study suggests that ketoprofen and nalbuphine are useful analgesics in terms of their urodynamics.

Adult↗

PubMed2000

Intrathecal anesthesia: ropivacaine versus bupivacaine.

We compared intrathecal ropivacaine to bupivacaine in patients scheduled for transurethral resection of bladder or prostate. Doses of ropivacaine and bupivacaine were chosen according to a 3:2 ratio found to be equipotent in orthopedic surgery. One hundred patients were randomly assigned to blindly receive either 10 mg of isobaric bupivacaine (0.2%, n = 50) or 15 mg of isobaric ropivacaine (0.3%, n = 50) over 30 s through a 27-gauge Quincke needle at the L2-3 level in the sitting position. Onset and offset times for sensory and motor blockades and mean arterial blood pressure were recorded. Pain at surgical site requiring supplemental analgesics was recorded. Cephalad spread of sensory blocks was higher with bupivacaine (median level, cold T(4) and pinprick T(7)) than with ropivacaine (cold T(6) and pinprick T(9)) (P<0.001). Eight patients in Group Ropivacaine received IV alfentanil (P<0.01). Onset time (mean +/- SD) to T(10) anesthesia and offset time at L2 were not different (bupivacaine = 13 +/-8 min, 127+/-41 min; ropivacaine = 11+/-7 min, 105+/-29 min). Complete motor blockade occurred in 43 patients with bupivacaine and in 41 patients with ropivacaine (not significant). Total duration of motor blockade was not different. No difference in hemodynamic effects was detected between groups. No patient reported back pain. We conclude that 15 mg of intrathecal ropivacaine provided similar motor and hemodynamic effects but less potent anesthesia than 10 mg of bupivacaine for endoscopic urological surgery.

Aged↗

PubMed1999

Intrathecal bupivacaine in humans: influence of volume and baricity of solutions.

BACKGROUND: The effects of volume and baricity of spinal bupivacaine on block onset, height, duration, and hemodynamics were studied. METHODS: Ninety patients undergoing endoscopic urologic procedures were randomized to receive 10 mg of intrathecal bupivacaine at L2-L3 level in sitting position. In the operating room, commercial products were diluted as needed with NaCl 0.9% to obtain isobaric solutions (density, 1.005-1.008) or with NaC 10.9% and glucose 30% to obtain hyperbaric solutions (density, 1.031-1.037) of 2, 5, or 10 ml (six groups of 15 patients each). Three minutes after spinal injection the patients were placed in lithotomy position. Sensory blockade was assessed using pinprick and cold sensation tests, and motor blockade was assessed using a four-point scale. RESULTS: Onset times to maximal cephalad spread of spinal blockade were similar with isobaric and hyperbaric solutions. A greater maximal cephalad spread of anesthesia was obtained with diluted isobaric bupivacaine but was not associated with more hypotension. Volume had no effect on cephalad extent of anesthesia with hyperbaric bupivacaine. Times for regression of anesthesia to L2 and offset of motor block were longer with isobaric than with hyperbaric solutions of bupivacaine. The intensity of motor blockade was decreased with diluted hyperbaric bupivacaine. No patient reported back pain. CONCLUSION: In this study, volume had no significant influence on either cephalad spread or duration of sensory blockade for either isobaric or hyperbaric bupivacaine. Time for offset of anesthesia was shorter with hyperbaric bupivacaine compared with isobaric solutions.

Aged↗

PubMed2000

Clinical neuropsychology in the criminal forensic setting.

This article reviews the application of clinical neuropsychology to criminal court proceedings, a complex, underserved, yet growing area of neuropsychological practice. The authors write from the perspective that the audience is primarily neurorehabilitation clinicians with limited experience in criminal matters. Discussions on the theoretical differences between clinical and forensic work, the forensic evaluation process with conceptual model, historical and current perspectives on criminal competencies and responsibility, prediction of dangerousness, and professional and ethical issues often encountered in criminal neuropsychology are provided.

Ethics, Medical↗

PubMed1989

Assessing sincerity of effort in maximal grip strength tests.

The measurement of maximum hand grip strength in ergonomic or clinical settings has been a useful means of assessing physical characteristics, progress in rehabilitation and degree of disability in upper extremity injuries. The validity of the peak forces observed in such measurements is compromised by the requirement of subject cooperation in giving a maximum effort. Thus, an easily administered analysis of subject sincerity would improve this basic strength-testing tool. Several variables were developed for the discrimination of faking (submaximal) from sincere (maximal) grip contractions. A microcomputer-based grip force data collection system was assembled in which analog output from a Jamar hand dynamometer was sampled at 200 Hz and digitally analyzed. A total of 43 normal subjects (20 male, 23 female) were tested under sincere and faking conditions (three trials of each condition for each hand). The force-time curves of each trial were analyzed for peak and average forces and force variability. From these basic parameters five discriminator variables were developed. The frequency distribution of the sincere values for each of these variables was used to determine a criterion value for discrimination of sincere from faking trials. The five discriminators correctly detected 95.0, 92.5, 100, 100 and 97.5% of the male faking trials. Female faking was less successfully detected: 59.7, 52.2, 78.3, 71.7 and 87.0% correct detection resulted for the variables (with a 95% confidence level of correctly identifying sincerity). Multiple variable predictions improved the female faking detection up to 93.5% with little apparent decrement in sensitivity to sincerity identification.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMedDate not supplied

Coefficient of variation in maximal and feigned static and dynamic grip efforts.

The purpose of this study was to investigate the validity of the coefficient of variation as an identifier of feigned grip effort. Seventeen healthy female aged 20 to 25 yr participated in the study. Maximal and feigned efforts were measured isometrically and isokinetically (concentric and eccentric) using the Jamar and KinCom dynamometers, respectively. Findings indicated that, in all situations, the coefficient of variation derived from the maximal effort was significantly (P < 0.0001) lower than that derived from the feigned effort. However, the extent of overlapping between the two was sufficiently large to render the test sensitivities very low. Consequently, regardless of the measurement method, the coefficient of variation is not a valid tool for identifying feigned grip effort in healthy subjects.

Adult↗

PubMedDate not supplied

Detection of a "faked" strength task effort in volunteers using a computerized exercise testing system.

The objective of this study was to develop an experimental method to separate a "faked" strength effort from a "best" effort in volunteers. Thirty-four pain-free volunteers (18 males, 16 females) performed a shoulder press and pull-down on an isokinetic computerized exercise testing system (CETS), giving a best effort followed by a faked effort. Two months later, a randomly selected subgroup (6 males) repeated the experiment to test the predictive validity of the derived variables. In the statistical analysis, best efforts were first compared with fake efforts by paired ttest for 80 CETS variables for males and females separately. Variables showing a strong difference between the best and faked effort were then selected for further analysis. In the second step of the analysis, the method of multiple correlations (r2 method) was used to reduce the number of redundant CETS variables to five in both the male and female groups. In the third step, a stepwise discriminant analysis was used to select predictor variables for the male and female groups. For the variables selected by the discriminant analysis for both males and females, sensitivities and specificities were calculated. Finally, the developed discriminant formula was used in the predictive validity part of the study to determine the sensitivities and specificities of the developed method. The discriminant analysis selected the following CETS variables for male and female groups, respectively: duty cycle down, work weight/down, peak value up (males); and average power up, 40% repetition down, duty cycle up (females). For males, using their three variables, the discriminant function classified 77.14% of the efforts correctly with 88.9% sensitivity and 64.7% specificity. For females, using their three variables, the discriminant function classified 90.63% of the efforts correctly with 100% sensitivity and 81.3% specificity. In the predictive validity group, the discriminant function classified 75% of the efforts correctly with 83.3% sensitivity and 66.7% specificity. This pilot study indicates that the method developed here may be useful in the experimental study for the discrimination between faked and best efforts on this isokinetic CETS machine. Future studies using this method will need to involve a larger number of volunteers.

Adult↗

PubMed1989

Objective documentation of musculoskeletal pain syndrome by pressure algometry during thiopentone sodium (Pentothal) anesthesia.

Work and injury related musculoskeletal pain is often complicated by psychological and medicolegal factors that obscure the validity of the pain presentation. Pressure algometry and stretching during thiopentone sodium (Pentothal) anesthesia was studied in 45 cases of musculoskeletal injury. A total of 40 cases were determined as genuine, organic pain, four cases were negative (i.e., nonorganic pain), and one case was equivocal. In unilateral pain cases, a right to left pressure threshold difference of 2.0 kg/cm2 predicted 94% of true organic pain cases and 100% of cases at a pressure threshold of 1.5 kg/cm2 if combined with stretching. Results of stretching painful areas correlated highly with pressure threshold assessments.

Achilles Tendon↗

PubMed1990

Patterns of conscious failure to provide accurate self-report data in patients with low back pain.

Assessment and treatment responses were compared in 17 subjects with chronic low back pain assessed as showing at least one clear consciously produced inconsistency in statements and/or behaviors during their participation in an interdisciplinary treatment program and 143 subjects assessed as showing no such inconsistency. Numerous statistically significant differences emerged: Inconsistent subjects were more likely to have pending litigation and to be assessed by staff as showing a higher degree of focus on pain and more dramatized complaints, lower levels of medical findings and attention and interest in treatment, and poor compliance with treatment and assessment procedures. In addition, these subjects reported lower levels of physical activity and generally more inconsistent or negative responses to lumbar sympathetic injections with fewer expected changes in physical sensations. Though not definitive, these results suggested a syndrome of characteristics among such subjects which are similar to those proposed as likely characterizing malingerers. The need for a particularly careful validation of self-report data in patients showing many of these characteristics was emphasized.

Adult↗

PubMed1997

Bias effects in three common self-report pain assessment measures.

OBJECTIVE: Past research has shown response biases to influence the accuracy of results from self-report measures. In pain assessment, where a percentage of patients have financial and other reasons to minimize or exaggerate psychological disturbance, it becomes especially important to identify the influence of response bias in self-report of adjustment. This study investigated the susceptibility of three commonly used self-report pain assessment measures to response bias. DESIGN: This study used a within-subjects (asymptomatic subjects) design with two experimental conditions and nonequivalent control group (chronic pain patients). SUBJECTS: Experimental group: 40 students enrolled in an occupational therapy program at a major southeastern United States university. CONTROL GROUP: 200 subjects referred to a multidisciplinary pain clinic at a major teaching hospital. MEASURES: Coping Strategies Questionnaire, Multidimensional Pain Inventory, and Pain Beliefs and Perceptions Inventory. RESULTS: With few exceptions, asymptomatic subjects scored significantly differently on these measures while portraying themselves as either coping well or coping poorly. In addition, when using the "coping poorly" response set, asymptomatic subjects reproduced scores similar to those of symptomatic chronic pain patients. CONCLUSION: The susceptibility to manipulation appeared constant across the three measures, a finding that highlighted the difficulties clinicians and researchers encounter in accurate interpretation of results from these measures in the absence of validity indicators. This study also emphasizes the ease with which subjects with sufficient motivation can present themselves in an untruthful and manipulative manner and can generate scores that are, on their own, difficult to distinguish from those of a group of typical chronic pain patients.

Adaptation, Psychological↗

PubMedDate not supplied

Critical issues in the use of muscle testing for the determination of sincerity of effort.

Over the past 20 years, there have been numerous attempts to identify methodologies that are capable of the determination of sincerity of effort during muscle testing. The ensuing paper reviewed this literature and drew several conclusions. Injured patients and healthy volunteers do produce less force and more variable force while performing submaximal contractions than maximal contractions. However, submaximal efforts during strength testing can be reproduced and the use of force variability is not adequate to distinguish sincerity of effort. Visual examination of the shape of force output curves is also not adequate for distinguishing sincerity of effort. Furthermore, much of the research using strength ratios, difference scores, and an assortment of different parameters derived during strength testing has not established reliable and clinically useful methods of differentiating effort levels. Methods examining motion variability, radial/ulnar force output ratios, difference scores of eccentric-concentric ratios, and electromyography offer some promise, but numerous critical issues need to addressed. The use of the coefficient of variation, for example, is statistically untenable given the number of trials appropriate for clinical samples. Several studies have inadequate sample size to number of variable ratios. Many studies have questionable or at least unknown generalizability to patient samples and actual functional capacity. It is critical that other explanatory variables such as fear of injury, pain, medications, work satisfaction, and other motivational factors be considered. It is our opinion that there is not sufficient empirical evidence to support the clinical application of muscle testing to determine sincerity of effort.

Electromyography↗

PubMedDate not supplied

Detecting deception in facial expressions of pain: accuracy and training.

Clinicians tend to assign greater weight to nonverbal expression than to patient self-report when judging the location and severity of pain. However, patients can be successful at dissimulating facial expressions of pain, as posed expressions resemble genuine expressions in the frequency and intensity of pain-related facial actions. The present research examined individual differences in the ability to discriminate genuine and deceptive facial pain displays and whether different models of training in cues to deception would improve detection skills. Judges (60 male, 60 female) were randomly assigned to 1 of 4 experimental groups: 1) control; 2) corrective feedback; 3) deception training; and 4) deception training plus feedback. Judges were shown 4 videotaped facial expressions for each chronic pain patient: neutral expressions, genuine pain instigated by physiotherapy range of motion assessment, masked pain, and faked pain. For each condition, the participants rated pain intensity and unpleasantness, decided which category each of the 4 video clips represented, and described cues they used to arrive at decisions. There were significant individual differences in accuracy, with females more accurate than males, but accuracy was unrelated to past pain experience, empathy, or the number or type of facial cues used. Immediate corrective feedback led to significant improvements in participants' detection accuracy, whereas there was no support for the use of an information-based training program.

Adolescent↗

PubMed1993