Barbara A. Rakel

Women with knee osteoarthritis have more pain and poorer function than men, but similar physical activity prior to total knee replacement

S. M. Tonelli et al. — Thu, 17 May 2012 08:25:46 PDT

ABSTRACT: BACKGROUND: Osteoarthritis of the knee is a major clinical problem affecting a greater proportion of women than men. Women generally report higher pain intensity at rest and greater perceived functional deficits than men. Women also perform worse than men on function measures such as the 6-minute walk and timed up and go tests. Differences in pain sensitivity, pain during function, psychosocial variables, and physical activity levels are unclear. Further the ability of various biopsychosocial variables to explain physical activity, function and pain is unknown. METHODS: This study examined differences in pain, pain sensitivity, function, psychosocial variables, and physical activity between women and men with knee osteoarthritis (N = 208) immediately prior to total knee arthroplasty. We assessed: (1) pain using self-report measures and a numerical rating scale at rest and during functional tasks, (2) pain sensitivity using quantitative sensory measures, (3) function with self-report measures and specific function tasks (timed walk, maximal active flexion and extension), (4) psychosocial measures (depression, anxiety, catastrophizing, and social support), and (5) physical activity using accelerometry. The ability of these mixed variables to explain physical activity, function and pain was assessed using regression analysis. RESULTS: Our findings showed significant differences on pain intensity, pain sensitivity, and function tasks, but not on psychosocial measures or physical activity. Women had significantly worse pain and more impaired function than men. Their levels of depression, anxiety, pain catastrophizing, social support, and physical activity, however, did not differ significantly. Factors explaining differences in (1) pain during movement (during gait speed test) were pain at rest, knee extension, state anxiety, and pressure pain threshold; (2) function (gait speed test) were sex, age, knee extension, knee flexion opioid medications, pain duration, pain catastrophizing, body mass index (BMI), and heat pain threshold; and (3) physical activity (average metabolic equivalent tasks (METS)/day) were BMI, age, Short-Form 36 (SF-36) Physical Function, Kellgren-Lawrence osteoarthritis grade, depression, and Knee Injury and Osteoarthritis Outcome Score (KOOS) pain subscale. CONCLUSIONS: Women continue to be as physically active as men prior to total knee replacement even though they have significantly more pain, greater pain sensitivity, poorer perceived function, and more impairment on specific functional tasks.

Prolonged ulcerative laryngitis

Barbara A. Rakel et al. — Thu, 17 May 2012 08:17:48 PDT

Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement

Barbara A. Rakel et al. — Thu, 17 May 2012 08:17:46 PDT

This study tested the effectiveness of episodic transcutaneous electrical nerve stimulation (TENS) as a supplement to pharmacologic analgesia on pain with movement and at rest after abdominal surgery and evaluated whether its use during walking and vital capacity maneuvers enhances performance of these activities. TENS, with a modulated frequency, intensity as high as the subject could tolerate, and electrodes placed on either side and parallel to the incision, was compared to placebo TENS and pharmacologic analgesia alone (control) by using a crossover design. Self-report of pain intensity, walking function, and vital capacity were assessed on 33 subjects. TENS resulted in significantly less pain than the control during both walking (P <.5) and vital capacity activities (P <.1) and significantly less pain than placebo TENS during vital capacity (P <.01). TENS also produced significantly better gait speeds than the control (P <.05) and greater gait distances (P <.01) than the control and placebo TENS. Vital capacity and pain intensity at rest were not significantly different among the 3 treatments. These results suggest TENS reduces pain intensity during walking and deep breathing and increases walking function postoperatively when used as a supplement to pharmacologic analgesia. The lack of effect on pain at rest supports the hypothesis that TENS works through reducing hyperalgesia.

The relationship between pain and physical function in older adults with knee osteoarthritis

N. Blodgett et al. — Thu, 17 May 2012 08:17:45 PDT

Hypoalgesia in response to transcutaneous electrical nerve stimulation (TENS) depends on stimulation intensity

F. Moran et al. — Thu, 17 May 2012 08:17:43 PDT

Transcutaneous Electrical Nerve Stimulation (TENS) is an electrophysical modality used for pain management. This study investigated the dose response of different TENS intensities on experimentally induced pressure pain. One hundred and thirty TENS naive healthy individuals (18-64 years old; 65 males, 65 females) were randomly allocated to 5 groups (n = 26 per group): Strong Non Painful TENS; Sensory Threshold TENS; Below Sensory Threshold TENS; No Current Placebo TENS; and Transient Placebo TENS. Active TENS (80 Hz) was applied to the forearm for 30 minutes. Transient Placebo TENS was applied for 42 seconds after which the current amplitude automatically reset to 0 mA. Pressure pain thresholds (PPT) were recorded from 2 points on the hand and forearm before and after TENS to measure hypoalgesia. There were significant differences between groups at both the hand and forearm (ANOVA; P = .005 and .002). At 30 minutes, there was a significant hypoalgesic effect in the Strong Non Painful TENS group compared to: Below Sensory Threshold TENS, No Current Placebo TENS and Transient Placebo TENS groups (P < .0001) at the forearm; Transient Placebo TENS and No Current Placebo TENS groups at the hand (P = .001). There was no significant difference between Strong Non Painful TENS and Sensory Threshold TENS groups. The area under the curve for the changes in PPT significantly correlated with the current amplitude (r(2) = .33, P = .003). These data therefore show that there is a dose-response effect of TENS with the largest effect occurring with the highest current amplitudes. PERSPECTIVE: This study shows a dose response for the intensity of TENS for pain relief with the strongest intensities showing the greatest effect; thus, we suggest that TENS intensity should be titrated to achieve the strongest possible intensity to achieve maximum pain relief.

Committee meetings: An electronic alternative

Barbara A. Rakel — Thu, 17 May 2012 08:17:41 PDT

All too often, meetings are called without much thought as to whether or not they are necessary, wasting the staff's time and the organization's money. Sharing information and gathering input through electronic mail eliminates unproductive meetings and increases member productivity.

Redesigning the RN and NA roles

R. Gould et al. — Thu, 17 May 2012 08:17:40 PDT

An investigation of the development of analgesic tolerance to TENS in humans

R. E. Liebano et al. — Thu, 17 May 2012 08:17:38 PDT

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive modality used to control pain. Animal models show that repeated TENS application produces analgesic tolerance and cross-tolerance at spinal opioid receptors. The aim of the present investigation was to examine whether repeated application of TENS produces analgesic tolerance in humans. One hundred healthy subjects were randomly assigned to 1 of 4 groups: control, placebo, low-frequency (4Hz) or high-frequency (100Hz) TENS. TENS was applied daily for 5days to the nondominant upper limb; pressure-pain threshold (PPT) measurements were recorded before and after TENS. Temporal summation to mechanical stimulation was recorded on days 1 and 5, before and after TENS. Diffuse noxious inhibitory control (DNIC) was tested on day 5 using the cold pressor test and PPT measurements. There was an initial increase in PPTs in both low- and high-frequency TENS groups when compared with placebo or control groups. However, by day 5 this TENS-induced increase in PPT did not occur, and there was no difference between active TENS and placebo or control groups. High-frequency TENS decreased temporal summation on day 1 when compared with day 5. DNIC increased the PPT similarly in all groups. These data suggest that repeated daily application of TENS results in a decrease in its hypoalgesic effect by the fifth day and that the tolerance-like effect to repeated TENS results from tolerance at centrally located opioid receptors. The lack of change in DNIC response suggests that TENS and DNIC utilize separate pathways to produce analgesia. Repeated high-frequency and low-frequency transcutaneous electrical nerve stimulation produce analgesic tolerance in humans by the fourth and fifth day of treatment, respectively.

Nonpharmacologic treatment of pain

M. G. Titler et al. — Thu, 17 May 2012 08:17:37 PDT

Nonpharmacologic interventions for pain treatment are important complementary therapies but are not substitutes for pharmacologic management of pain. Use of nonpharmacologic pain treatments in critical care settings is helpful to decrease pain, but the challenge remains for nurses to have the knowledge, time, and skill to use these interventions in a busy daily practice with severely ill patients. Although numerous studies testing the effectiveness of nonpharmacologic interventions for pain management are available, the varying methods and interventions used in these studies make it difficult to draw conclusions. Further research on the use of these interventions for pain reduction is necessary to determine the most effective treatments and the conditions under which they should be used.

A new transient sham TENS device allows for investigator blinding while delivering a true placebo treatment

Barbara A. Rakel et al. — Thu, 17 May 2012 08:17:35 PDT

This study compared a new transient sham transcutaneous electrical nerve stimulation (TENS) that delivers current for 45 seconds to an inactive sham and active TENS to determine the degree of blinding and influence on pain reduction. Pressure-pain thresholds (PPT), heat-pain thresholds (HPT), and pain intensities to tonic heat and pressure were measured in 69 healthy adults before and after randomization. Allocation investigators and subjects were asked to identify the treatment administered. The transient sham blinded investigators 100% of the time and 40% of subjects compared to the inactive sham that blinded investigators 0% of the time and 21% of subjects. Investigators and subjects were blinded only 7% and 13% of the time, respectively, with active TENS. Neither placebo treatment resulted in significant changes in PPT, HPT, or pain intensities. Subjects using higher active TENS amplitudes (> or =17 mAs) had significantly higher PPTs and lower pain intensities to tonic pressure than subjects using lower amplitudes (<17 >mAs). HPTs and pain intensities to tonic heat were not significantly changed. The transient TENS completely blinds investigators to treatment and does not reduce pain, thereby providing a true placebo treatment. PERSPECTIVE: This article presents the benefits of a new transient sham TENS device for use in prospective, randomized, clinical trials. This device facilitates blinding of subjects and investigators to eliminate expectation bias and determine the true efficacy of TENS for use in clinical populations.

Interventions related to patient teaching

Barbara A. Rakel — Thu, 17 May 2012 08:17:34 PDT

This study validated 13 nursing interventions related to patient teaching. Four of the labels address the process of patient teaching, whereas the other nine concern content specific to teaching efforts. With the help of 46 master's-prepared nurses from across the country, critical (major) and supporting (minor) activities for each label were identified. This study is one of many steps toward the construction of a taxonomy of nursing interventions focused on direct care treatments that nurses perform on behalf of patients. The ultimate goal is to provide nurses with a standardized language that can be used to document their unique role in providing quality patient care and provide an appropriate avenue for reimbursement of nursing services.

Effects of transcutaneous electrical nerve stimulation on pain, pain sensitivity, and function in patients with knee osteoarthritis: A randomized controlled trial

C. G. Vance et al. — Thu, 17 May 2012 08:17:32 PDT

Background and Objective:Transcutaneous Electrical Nerve Stimulation (TENS) is commonly used for treatment of pain; however the effects on a variety of pain and function measures is unclear. The purpose of the current study was to determine the effect of high (HF) and low (LF) frequency TENS, on a variety of outcome measures: resting pain, movement-evoked pain, and pain sensitivity in subjects with osteoarthritis of the knee. SUBJECTS:75 subjects with knee osteoarthritis (31-94 years, M=29, F=46) were assessed. METHODS:Subjects were randomly assigned to receive HF-TENS (100 Hz) (n=25), LF-TENS (4 Hz) (n=25) or Placebo (P) TENS (n=25) [pulse duration=100msec; intensity=10% below motor threshold]. The following measures were assessed before and after a single TENS treatment: cutaneous mechanical pain threshold (CMPT), pressure pain threshold (PPT), heat pain threshold (HPT), heat temporal summation (HTS), Timed Up and Go (TUG) test, and pain intensity at rest and during the TUG test. A linear mixed model ANOVA compared differences before and after TENS, and between groups (HF, LF, and P). RESULTS: When compared to P-TENS, HF-TENS and LF-TENS increased PPT at the knee; HF-TENS also increased PPT over the anterior tibialis muscle. There was no effect on CMPT, HPT, or HTS. HF-, LF- and P-TENS significantly reduced the pain at rest and during the TUG test. CONCLUSION:When compared to P-TENS, HF- and LF-TENS reduced pressure pain sensitivity le in knee OA subjects -P-TENS had no significant effect on PPT. Cutaneous pain measures were unaffected by TENS. Subjective pain ratings at rest and during movement were similarly reduced by active and placebo TENS suggesting a strong placebo component to the effect of TENS.

Hyperalgesia increases in older adults after total knee replacement surgery (Abstract)

Barbara A. Rakel et al. — Thu, 17 May 2012 08:17:31 PDT

From book to bedside: Putting evidence to use in the care of the elderly

M. G. Titler et al. — Thu, 17 May 2012 08:17:30 PDT

BACKGROUND: Infusion of research findings into clinical practice is a challenging part of the research process. Because the length of time between discovery and use of knowledge averages 20 years, methods are needed to speed translation of research findings into practice. Few efforts have been made to coordinate the generation of new knowledge with the dissemination of findings from research to improve care of the elderly. RESEARCH-BASED PRACTICE PROTOCOLS: The Research Development and Dissemination Core (RDDC) of the Gerontological Nursing Interventions Research Center (GNIRC) at the University of Iowa emphasizes development of research-based (RB) protocols, which requires collecting relevant literature, critiquing studies, and synthesizing research findings for practice. GNIRC-generated research is disseminated to nurses in practice, and the RDDC links nurses who identify clinical problems in care of the elderly with GNIRC scientists. Currently, 19 RB protocols are offered for dissemination through the RDDC, and 5 protocols are under development. Implementation and evaluation of research-based practices on "Split Thickness Skin Graft Donor Site Care" and "Nasogastric/Nasointestinal Tube Placement" are described. CONCLUSIONS: Lessons learned on the basis of experience in disseminating and implementing research-based practices include the necessity of tailoring them to the local needs of various clinical settings in which they are used, reinfusing them periodically to keep staff motivated, and making them consumer friendly. The challenge remains to integrate these practices into the fiber of organizations and to keep staff educated and motivated to carry out research-based practices to improve the care of the elderly.

Managing constipation using a research-based protocol

G. R. Hall et al. — Thu, 17 May 2012 08:17:28 PDT

Clinical outcome of emergency repeat coronary artery bypass surgery

J. H. Lemmer Jr. et al. — Thu, 17 May 2012 08:17:26 PDT

To determine the clinical outcome of patients requiring emergency repeat coronary artery bypass graft (CABG) procedures, we reviewed 23 such procedures performed for ongoing myocardial ischemia refractory to medical management. The operative mortality was 17%. On follow-up, an average of 24.9 months after emergency reoperation, 14 of the 19 survivors (74%) had recurrent angina. As compared to a randomly selected group of 25 patients who underwent elective repeat CABG procedures during the same time period, the incidence of late cardiac events was significantly higher (79% in the emergency group, 30% in the elective surgery group) and fewer patients had received internal mammary artery (IMA) grafts (9% vs 52%). Emergency repeat CABG operations have considerable operative mortality and poor postoperative functional results with the majority of survivors developing recurrent ischemic syndromes within a short period of time.

Physical modalities in chronic pain management

Barbara A. Rakel et al. — Thu, 17 May 2012 08:17:25 PDT

The following conclusions can be made based on review of the evidence: There is limited but positive evidence that select physical modalities are effective in managing chronic pain associated with specific conditions experienced by adults and older individuals. Overall, studies have provided the most support for the modality of therapeutic exercise. Different physical modalities have similar magnitudes of effects on chronic pain. Therefore, selection of the most appropriate physical modality may depend on the desired functional outcome for the patient, the underlying impairment, and the patient's preference or prior experience with the modality. Certain patient characteristics may decrease the effectiveness of physical modalities, as has been seen with TENS. These characteristics include depression, high trait anxiety, a powerful others locus of control, obesity, narcotic use, and neuroticism. The effect on pain by various modalities is generally strongest in the short-term period immediately after the intervention series, but effects can last as long as 1 year after treatment (e.g., with massage). Most research has tested the effect of physical modalities on chronic low back pain and knee OA. The effectiveness of physical modalities for other chronic pain conditions needs to be evaluated more completely. Older and younger adults often experience similar effects on their perception of pain from treatment with physical modalities. Therefore, use of these modalities for chronic pain in older adults is appropriate, but special precautions need to be taken. Practitioners applying physical modalities need formal training that includes the risks and precautions for these modalities. If practitioners lack formal training in the use of physical modalities, or if modality use is not within their scope of practice, it is important to consult with and refer patients to members of the team who have this specialized training. Use of a multidisciplinary approach to chronic pain management is of value for all adults and older individuals in particular [79-81]. Historically, physical therapists have been trained to evaluate and treat patients with the range of physical modalities discussed in this article. Although members of the nursing staff traditionally have used some of these modalities (e.g. some forms of heat or cold and massage), increasing numbers of nurses now are being trained to apply more specialized procedures (e.g., TENS). Healthcare professionals must be knowledgeable about the strength of evidence underlying the use of physical modalities for the management of chronic pain. Based on the limited research evidence available (especially related to assistive devices, orthotics, and thermal modalities), it often is difficult to accept or exclude select modalities as having a potential role in chronic pain management for adults and older individuals. Improved research methodologies are needed to address physical modality effectiveness better.

Split-thickness skin graft donor site care: A quantitative synthesis of the research

Barbara A. Rakel et al. — Thu, 17 May 2012 08:17:23 PDT

Split-thickness skin grafting (STSG) is a frequently used reconstructive technique but is associated with a large variation in practice. The purposes of this article are to integrate and synthesize the available empirical evidence regarding STSG donor site dressings, identify which dressings are associated with the best outcomes, and provide practice recommendations. This review of 33 studies found transparent film to be the best dressing for the care of STSG donor site wounds. Transparent film was associated with one of the fastest healing rates (9.47 days), a smooth epithelialized surface, a low infection rate (10 out of 394 patients or 3%), the least amount of pain (1.59 on 0 to 10 scale), and minimal cost ($.005 per square inch) when compared with other dressings.

Development of alterations in learning: Situational learning disabilities

Barbara A. Rakel et al. — Thu, 17 May 2012 08:17:22 PDT

Until now the nursing diagnosis knowledge deficit has served as a label for all teaching/learning situations. This is inadequate and does not effectively give direction to correct intervention(s). The purpose of this article is to present the diagnostic concept, situational learning disability (SLD), a component of Alterations in Learning, which has been identified as an area to be developed in the Knowing pattern of the NANDA taxonomy. A thorough review of the literature and empirical support involving 20 cardiology patients on a 27-bed telemetry step-down unit is provided. The data support the development of two nursing diagnoses: (1) situational learning disability: impaired ability to learn; and (2) situational learning disability: lack of motivation to learn. The proper identification of these diagnoses can assist nurses in discriminating between patients who can learn, those who cannot learn, and those who need adjustments made in order to facilitate their learning. With this information nurses will be able to make decisions concerning the timing and type of intervention that is most appropriate.

Adjusting pulse amplitude during transcutaneous electrical nerve stimulation (TENS) application produces greater hypoalgesia

M. A. Pantaleao et al. — Thu, 17 May 2012 08:17:18 PDT

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive technique used for pain modulation. During application of TENS there is a fading of current sensation. Textbooks of electrophysical agents recommend that pulse amplitude should be constantly adjusted. This seems to be accepted clinically despite the fact that there is no direct experimental evidence. The aim of the current study was to investigate the hypoalgesic effect of adjusting TENS pulse amplitude on pressure pain thresholds (PPTs) in healthy humans. Fifty-six healthy TENS naive participants were recruited and randomly assigned to 1 of 4 groups (n = 14 per group): control, placebo TENS, fixed pulse amplitude TENS, and adjusted pulse amplitude TENS. Both active and placebo TENS were applied to the dominant forearm. PPTs were recorded from 2 points on the dominant forearm and hand before, during, and after 40 minutes of TENS. TENS increased the PPTs on the forearm (P = .003) and hand (P = .003) in the group that received the adjusted pulse amplitude when compared to all other groups. The mean final pulse amplitude for the adjusted pulse amplitude TENS group was 35.51 mA when compared to the fixed pulse amplitude TENS group, which averaged 31.37 mA (P = .0318). PERSPECTIVE: These results suggest that it is important to adjust the pulse amplitude during TENS application to get the maximal analgesic effect. We propose that the fading of current sensation allows the use of higher pulse amplitudes, which would activate a greater number of and deeper tissue afferents to produce greater analgesia.