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Cilt - Volume 31

ISSN 1300-0012

Sayı - Number 4 Ekim - October 2019

A RI PAIN TÜRK ALGOLOJİ (AĞRI) DERNEĞİ’NİN YAYIN ORGANIDIR THE JOURNAL OF THE TURKISH SOCIETY OF ALGOLOGY

KARE

Index Medicus-Medline, Web of Science - ESCI, EMBASE/Excerpta Medica, Index Copernicus, Gale, EBSCO, CINAHL ve TÜBİTAK-ULAKBİM tarafından dizinlenmektedir. (Included and Indexed in Index Medicus-Medline, Web of Science - ESCI, EMBASE / Excerpta Medica, Index Copernicus, Gale, EBSCO, CINAHL and the Turkish Medical Index).

www.agridergisi.com


A RI PAIN Editör (Editor-in-Chief ) Gül KÖKNEL TALU Yardımcı Editör (Associate Editor) Ruhiye REİSLİ Bilimsel Danışma Kurulu (Editorial Board) Akgün K Turkey Antonaci F Italy Babacan A Turkey Cahana A Switzerland Çamcı E Turkey Erdine S Turkey İnan L Turkey İnan N Turkey Ketenci A Turkey Kress H Austria Morlion B Belgium Oral E Turkey Özge A Turkey

Özyalçın S Turkey Peker S Turkey Şentürk M Turkey Talu U Turkey Tan E Turkey Unal Çevik I Turkey Uyar M Turkey Vadalouca A Greece van Kleef M Netherlands Varrassi G Greece Vissers K Netherlands Yücel B Turkey


Cilt (Volume) 31, Sayı (Number) 4, Ekim (October) 2019 p-ISSN 1300 - 0012 e-ISSN 2458-9446 Türk Algoloji (Ağrı) Derneği’nin Yayın Organıdır (The Journal of the Turkish Society of Algology)

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Üç Ayda Bir Yayınlanır (Published Quarterly) Sahibi ve Yazı İşleri Müdürü (Ownership and Accountability for Contents) Gül KÖKNEL TALU Türk Algoloji (Ağrı) Derneği The Turkish Society of Algology Başkan (President)

N. Süleyman ÖZYALÇIN

Üyeler (Members)

N. Süleyman ÖZYALÇIN Sema TUNCER UZUN Kenan AKGÜN Levent Ertuğrul İNAN Güngör Enver ÖZGENCİL Hayri Tevfik ÖZBEK Meltem UYAR

İletişim (Correspondence) Editör ve Yazı İşleri Müdürü (Editor-in Chief)

Gül KÖKNEL TALU

Yardımcı Editör (Associate Editor)

Ruhiye REİSLİ

Yürütücü Sekreter (Executive Secretary)

Gül KÖKNEL TALU

Adres (Mailing Address) Tel (Phone) Faks (Fax) e-posta (e-mail) web

İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Algoloji Bilim Dalı, Çapa 34390 İstanbul, Turkey +90 - 212 - 531 31 47 +90 - 212 - 631 05 41 gktalu@yahoo.com www.algoloji.org.tr

Index Medicus-Medline, Web of Science, ESCI, EMBASE/Excerpta Medica, Index Copernicus, Gale, EBSCO, CINAHL ve TÜBİTAK-ULAKBİM tarafından dizinlenmektedir. (Included and Indexed in Index Medicus-Medline, Web of Science, ESCI, EMBASE / Excerpta Medica, Index Copernicus, Gale, EBSCO, CINAHL and the Turkish Medical Index).

Yayıncı (Publisher) KARE YAYINCILIK | karepublishing

KARE Concord İstanbul, Dumlupınar Mah., Cihan Sok., No: 15, B Blok 162, Kadıköy, İstanbul, Turkey Tel: +90 216 550 61 11 Faks (Fax): +90 216 550 61 12 e-posta (e-mail): kareyayincilik@gmail.com / kare@kareyayincilik.com www.kareyayincilik.com Yayın Türü (Type of Publication): Süreli Yayın (Periodical) Basım Tarihi (Press Date): Ekim 2019 (October 2019) Sayfa Tasarımı (Design): Ali CANGÜL Baskı (Press): Filmevi Online Dergi (Web): LookUs

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Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur (This publication is printed on paper that meets the international standart ISO 9706: 1994)


İ Ç İ N D E K İ L E R C O N T E N T S 2019-4

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Yazarlara Bilgi Information for the Authors

KLİNİK VE DENEYSEL ÇALIŞMALAR ORIGINAL AND EXPERIMENTAL ARTICLES 163–171 Validity and reliability of Turkish version of STarT Back Screening Tool STarT- TR Bel Sağlığı Tarama Ölçeği Türkçe versiyonunun geçerliği ve güvenirliği Yılmaz Yelvar GD, Dalkılınç M, Çırak Y, Parlak Demir Y, Karadüz BN, Kolsuz MM 172–177 Kronik migrene dönüşüm üzerine etkili risk faktörlerinin araştırılması Investigation of the risk factors for the transition of episodic migraines to chronic migraines Çimen Atalar A, Yalın OÖ 178–182 Effect of piriformis injection on neuropathic pain Effect of piriformis injection on neuropathic pain Terlemez R, Erçalık T 183–194 The relationship between somatic sense perception levels and comorbid psychiatric diseases in chronic pain patients Kronik ağrı hastalarında bedensel duyumları algılama düzeyi ve psikiyatrik komorbidite arasındaki ilişki Çakmak S, Özbek HT, Geylan Işık AG, Taşdemir A, Pektaş S, Ünlügenç H, Tamam L, Demirkol ME 195–201 Validity and reliability of Turkish version of the Brief Pain Inventory-Short Form for patients with chronic nonmalignant pain Kronik nonmaling ağrısı olan hastalarda Brief Ağrı Envanteri Kısa Formu'nun Türkçe formunun geçerliği ve güvenirliği Yıldırım Y, Parlar Kılıç S, Eyigör S, Eyigör C, Yıldırım Y, Karaman E, Oyur Çelik G, Uyar M

OLGU SUNUMLARI CASE REPORTS 202–205 Anesthetic management of two siblings with congenital insensitivity to pain with anhidrosis syndrome Konjenital ağrı duyarsızlık ve anhidrosis sendromu olan iki kardeşin anestezik yönetimi Destegül D, Kocaöz F, Sarı AS 206–208 Temporal arteritis and trigeminal neuralgia overlap syndrome: A case report Temporal arterit ve trigeminal nevralji overlap sendromu: Bir olgu sunumu İnalkaç Gemici Y, Taşcı İ 209–213 Efficacy of ultrasound-guided bilateral erector spinae plane block in pediatric laparoscopic cholecystectomy: Case series Pediatrik laparoskopik kolesistektomi için ulltrason rehberliğinde yapılan bilateral erector spina plan bloğun etkinliği: Vaka serileri Öksüz G, Gürkan Y, Urfalıoğlu A, Arslan M

EDİTÖRE MEKTUPLAR LETTER TO THE EDITORS 214–215 Erector spinae plane block as rescue analgesia in gestational week 16 16. gestasyonel haftada uygulanan kurtarıcı analjezi amaçlı erektör spina plan bloğu Tukac İC, Çiftçi B, Ekinci M, Atalay YO 216–217 Cardiac arrest after trigger point injection Tetik nokta enjeksiyonu sonrası kardiyak arrest Gökçek E, Akelma H, Kaydu A 218–219 Ultrasound-guided erector spinae plane block for pain management in pancreatic cancer: A case report Pankreas kanserinde ağrı tedavisi için ultrason eşliğinde erektor spina plan bloğu: Olgu sunumu Aydın T, Balaban O, Demir L

TEMMUZ - JULY 2019


YAZARLARA BİLGİ

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İLGİ ALANI VE AMACI Bu dergi Türk Algoloji (Ağrı) Derneği’nin süreli yayın organıdır. Üç ayda bir yayımlanır. Ağrının yapısı, mekanizmaları ve tedavisi ile ilgili özgün araştırmalar yayınlanır. Multidisipliner bir yaklaşım ile ağrı ile ilgili temel ve klinik bilimlerde yapılan araştırmaların geniş kitlelere yayılması için bir forum oluşturulmaya çalışılır. Dergide yayımlanan makaleler Türk Algoloji Derneği’nin resmi görüşünü temsil etmez. Yayımlanan makale ve şekiller derginin malı olur. GENEL AÇIKLAMALAR 1. Dergi Türkçe ve İngilizce olarak yayınlanır. 2. Editoryal Kurul tarafından uygun görülen metinler yayımlanır. Editoryal Kurul, yayın kurallarına uymayan metinleri yayımlamamaya ve düzeltilmek üzere yazarına geri göndermeye yetkilidir. “Derleme” kategorisindeki yazılar, Editoryal Kurul tarafından belirlenen yazarlardan yapılan istek üzerine kabul edilmektedir. Editoryal Kurul tarafından istenmedikçe bu kategoriler için yazı gönderilmemelidir. Ancak bu konuda editöre öneride bulunulabilir. Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. 3. Dergi, uluslararası tıbbi dergi editörleri kurulunca hazırlanan “Biyomedikal dergilere teslim edilecek metinlerde aranan ortak özelliklerin” 3. baskısındaki (1983) kurallara uygun olarak hazırlanmamış yayın metinlerini kabul etmez. Metinler teslim edilmeden once bu kuralların yayınlandığı British Medical Journal 1988;296:401-5 veya Annuals of Internal Medicine 1988;108:258-65’e bakılmalıdır. 4. Dergiye yazı gönderilmesi sadece internet üzerinden yapılmaktadır. Bunun için resmi web sitesi olan www.agridergisi.com adresindeki ilgili basamaklar takip edilmelidir. 5. Yayınlanması istenen metnin dayandığı çalışma, daha önce başka yerde yayınlanmış veya yayınlanmak üzere teslim edilmiş veya kabul edilmiş olmamalıdır. Özet biçiminde yayınlanmış bir ön bildirinin bitmiş haline yer verilebilir. 6. Dergide yayınlanan yazılar için telif hakkı ödenmez. Bu nedenle başvuru mektubunda telif hakkının dergiye bırakılacağı açıklanmalı ve metnin tüm yazarlarca okunduğunu ve onaylandığını belirten bir ifade bulunmalıdır. 7. Yayımlanmış şekil vb. gereçlerin yerinde basılabilmesi, tanınabilecek kişilerin resimlerinin kullanılabilmesi ve katkılarından dolayı kişilerin adlarının belirtilebilmesi için alınmış izinler posta ile ulaştırılmalıdır. 8. Yazarlar teslim ettikleri her şeyin birer kopyasını saklamalıdır. 9. Teslim edilmiş bir metnin tümünün veya bir bölümünün başka bir yerde yayımlanması söz konusu olursa Editoryal Kurul’a bilgi verilmesi zorunludur. 10. Araştırmalar için, ilgili kurumun bağlı bulunduğu etik komitenin onayının alınmış olması şarttır. Bu durum “gereç ve yöntem” bölümünde belirtilmelidir. 11. Yayımlanan yazıların sorumluluğu yazarlarınındır. 12. Yazarlara tıpkıbasım gönderilmeyecektir. İSTENEN DOSYA TÜRLERİ VE MİNİMUM YAZI TESLİM GEREKLİLİKLERİ Elektronik gönderim sistemiyle yazıların tesliminden önce aşağıdaki formatlama özelliklerine göre ayrı ayrı MS Word (.doc) ve Adobe (.pdf ) dosyaları hazırlanmalıdır. Başvuru mektubu ve başlık sayfası olmayan hiçbir yazı kabul edilmeyecektir. 1. Başvuru mektubu: Her türden yazının gönderimi mutlaka bir başvuru mektubunu içermelidir. Başvuru mektubunda yazar(lar) başlık, yazının türü ve yazının gönderim kategorisi ve gönderilen çalışmanın daha önce bir bilimsel bir toplantıda sunulup sunulmadığını belirtmelidir. Bu başvuru mektubu yazı AGRI Dergisi tarafından incelenme sürecindeyken başka bir yerde yayınlanmayacağı veya yayınlanmak üzere değerlendirilmeyeceğine ilişkin bir açıklama içermelidir. Ayrıca başvuru mektubunun alt kısmında yazışmadan sorumlu yazarın tam adı, adresi, telefon numarası ve e-posta adresi dahil iletişim bilgileri verilmelidir. Başvuru mektubu yazışmadan sorumlu yazar tarafından imzalanmalı, tarayıcıdan geçirilmeli, yazının diğer dosyalarıyla birlikte jpg veya .pdf formatında sunulmalıdır. Başvuru mektubu aşağıdaki gibi düzenlenmelidir: a. Başlık, yazının türü. b. İncelenme sürecindeyken başka bir yerde yayınlanmayacağı veya yayınlanmak üzere değerlendirilmeyeceğine ilişkin bir açıklama. c. Yazışmadan sorumlu yazar(lar)ın tam adı, adresi, telefon numarası ve e-posta adresi dahil iletişim bilgileri. d. Yazışmadan sorumlu yazarın imzası. 2. Başlık sayfası: Gönderilen tüm yazı türleri başlık sayfası dosyasına dahil edilmelidir. Lütfen başlık sayfanızı aşağıdaki unsurları da içeren ayrı bir elektronik dosya şeklinde hazırlayın. a. Yazının başlığı. b. Yazar (Yazarların listesi) lütfen yazarların tam adlarını ve her bir yazar için en fazla iki akademik dereceyi belirtin. Bir kurumda üyelik gibi onursal bağlantıları bu listeye dahil etmeyin. c. Her bir yazarın çalıştığı anabilim dalı veya bölüm, kurum, şehir ve ülke gibi bağlantıları. d. Yazışmalardan sorumlu yazarın (yazarların) tam adı, adresi, telefon numarası ve e-posta adresi gibi iletişim bilgilerini kaydedin. e. Fon tedariki veya başka mali destek hakkında bilgi verilmelidir. f. Çıkar çatışması beyanı: Başlık sayfasının en alt kısmında çıkar çatışması beyanı bulunmalıdır. Lütfen, her bir yazar için ICMJE önerilerine (ICMJE Recommendations) uygun biçimde tüm potansiyel çıkar çatışmaları listesi kaydedilmelidir. Çıkar çatışması yoksa lütfen “Çıkar çatışmaları: Beyan edilmemiştir” ibaresini koyun. 3. Özetler: Özetler sayfasına yazar(lar) sırasıyla özet ve anahtar sözcükler (en az 3 sözcük) yazılmalıdır. Anahtar sözcüklerin Medical Subject Headings (MeSH) (http://www.nlm.nih.gov/mesh/MBrowser.html) standartlarına uygun ve Türkiye Bilim Terimleri’nden (http://www.bilimterimleri.com) seçilmiş olması gerekmektedir. 4. Ana Metin: Gönderilen her yazı türü için bir ana metin dosyası bulunmalıdır. Bu dosya başlık, özetler sayfası, yazınızın ana metni ve tek bir elektronik dosya haline getirilmiş kaynaklar bölümünü içermelidir. Kaynaklar bölümünden sonra tablolar da ayrı sayfalar halinde bu dosyaya konulabilir veya tercihinize göre ayrıca elektronik ortama yüklenebilir. Ana metnin yapısı yazının türüne göre farklılık gösterir. Tablolarla birlikte veya yalnız başına özetler, anahtar sözcükler, ana metin, kaynakları içeren bu birleşik dosya orijinal yazının kimliklerin gizlenmiş olduğu versiyonudur. Yazarların adları, akademik ünvanları, kurumları ve adresleri yazılmaz. Yazının değerlendirme süreci istisna olmak üzere, yazara (yazarlara) ilişkin herhangi bir bilgi içeren yazılar farkına varılır varılmaz rededilecektir. 5. Tablolar: Verileri özetleyen tablolar herhangi bir şablon kullanmaksızın net biçimde formatlandırılmalıdır. Tablolardaki veriler tümüyle metin içinde belirtilmemelidir. a. Tablolar ardışık sırayla numaralandırılmalıdır. b. Metinde her bir tabloya referans verilmiş olunmalıdır. c. Her bir tablonun numarası ve başlığı tablodan önce her sayfanın başına yazılmalıdır. d. Tablolar kaynaklar bölümünden sonra ayrı sayfalar halinde bu dosyaya konulabilir veya tercihinize göre ayrıca elektronik ortama yüklenebilir. Tablolar MS Word (.doc) formatında yüklenmeli ve elektronik dosya buna göre adlandırılmalıdır (Tablolar_xxx_vx.doc). Tablolar pdf, jpeg veya başka bir formatta yüklenmemelidir.

EKİM - OCTOBER 2019

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6. Şekiller: Yazıda şekiller varsa, her yazı türü için her bir Şekil ayrı bir dosya halinde yüklenmelidir. Şekil/görüntülerdeki bilgiler tümüyle tekrar edilmemeli, metinde şekil/görüntüye gönderme yapılmalıdır. a. Teknik gereklilikler i. Şekil alt yazıları kaynaklar bölümünden sonra ayrı bir sayfada belirtilmelidir. ii. Yazı gönderimi sırasında şekillerin hepsi metin dosyasından ayrı bir dosyaya yüklenmeli ve buna göre adlandırılmalıdır (Şekil 1_xxx; Şekil 2_xxx). iii. Şekillerin içine herhangi bir alt yazı veya başlık dahil edilmemelidir. iv. Resimler JPEG, EPS veya TIFF formatında saklanmalıdır. v. Lütfen fotograflar ve şekilleri en azından 300 nokta/inç çözünürlükte gönderin. TIFF veya EPS formatında gönderilen şekilleri son derece kolay işlemekteyiz. b. Etik gereklilikler i. Fotoğrafın sahibi ve/veya fotografı çekilen hasta onam formunu imzamalıdır. İzin alınmadan başka kaynaklardan şekiller kopyalanmamalıdır. 7. Açıklamalar, izinler ve imzalar a. Çıkar Çatışması Formu: Esas ilgilenilen konuya (hastaların iyilik hali veya araştırmanın geçerliliği) ait mesleki bir karar ikincil bir ilgi kaynağından (örn maddi kazanç) etkilenebildiğinde çıkar çatışması söz konusudur. Finansal ilişkiler kolayca saptanabilir. Ancak kişisel ilişkiler veya rekabetler, akademik yarışmalar veya entelektüel inanışlar nedeniyle de çatışmalar oluşabilmektedir. Çatışma gerçek veya potansiyel olabilir. En güvenli süreç Editöre tam olarak beyan etmekten geçer. Çatışmaları açıklamamak bir Erratum (yazım hatası) hatta yazının geri çekilmesine yol açabilmektedir. AGRI Dergisine gönderilen yazıların hepsinde potansiyel veya halen mevcut çıkar çatışmaları olduğu düşünülen tüm ilişkilerin beyan edilmiş olması gerekir. Yazarların hepsinden çıkar çatışmalarını beyan etmeleri istenir. b. Hasta Onam Formu: Hayatta olan tanımlanabilir bir hastaya ait kişisel bilgilerin yayınlanması hasta veya hamisinin açıkça onam vermesini gerektirir. Yazarlardan Kaynaklar menüsündeki Formlar, Şablonlar ve Örnekler sayfasında bulunan standart bir hasta onam formunu kullanmalarını bekleriz. c. Telif Hakkının Nakli Formu: Yazarların tümünden telif hakkının nakli formunu doldurmaları istenir. YAZININ FORMATLANMASI Yazının formatı 2013 Ağustosunda güncellenmiş ICMJE Tıp dergilerinde Bilimsel Çalışmaların Yürütülmesi, Raporlanması, Yayına hazırlanması ve Yayınlanması (ICMJE-Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals) kriterlerine uyumlu olmalıdır. Derginin formatına uymayan yazılar daha fazla gözden geçirilmeden düzelti için yazara iade edilecektir. O halde zaman ve emek kaybından kaçınmak için dergi gönderim kuralları dikkatlice gözden geçirilmelidir. Yazının çatısı WAME kılavuzlarıyla (guidelines of WAME) uyumlu olmalıdır. Genel Format 1. Genel Yazı Stili: Yazı Microsoft WordTM formatında tek sütun halinde yazılmalıdır. Tıbbi jargonlardan kaçınmak için her çaba gösterilmelidir. 2. Tanıtıcı Bilgilerin Gizlendiği İlk Gözden Geçirme: Yazarların adları ve akademik ünvanlar, kurumlar ve adresler gibi tanımlayıcı bilgiler gizlenir. Yazara (yazarlara) ait herhangi bir bilgi içeren yazılar rededilecektir. 3. İlaçlar: İlaçların jenerik adları kullanılmalıdır. Dozlar ve uygulama yolları belirtilmelidir. Ana metinde bir ilaç, ürün, bilgisayar donanım veya yazılımından söz edildiğinde, ürünün adı, üreticisi, firmanın bulunduğu il ve ülke gibi ürün bilgileri aşağıdaki formata göre parentez içinde belirtilmelidir [“Discovery St PET/CT scanner (General Electric, Milwaukee, WI, ABD)]” 4. Kısaltmalar: En gerekli olanlar dışında kısaltma kullanılmasını teşvik etmemekteyiz. Yazar için kolaylık olabilmesine rağmen kısaltmalar genellikle okuyucunun yazıyı kolayca anlamasını engeller. Kısaltmaların tümü ilk kez kullanıldığı anda tanımlanmalı (hem özette, hem de ana metinde) ve kısaltmalar tanımlamadan sonra parentezler içinde gösterilmelidir. Yazarlar başlık ve özette kısaltmalar kullanmaktan kaçınmalı, ana metinde de kullanımları sınırlandırılmalıdır. 5. Ondalık noktalar veya virgüller: Ondalık sayılar tam sayılardan noktalarla ayrılmalıdır. Yazı boyunca ondalık sayılar için virgül kullanmayınız. 6. Kaynaklar: Kaynaklar metin içinde ilk kez yazıldığı sırayla art arda numaralandırılmalıdır (6 yazardan sonra ve ark. kullanın). Özetleri kaynak göstermekten veya kamu kaynaklarında mevcut olmayan esaslı bilgiler sağlamadıkça “kişisel konuşmadan” alıntı yapmayın. Kaynak göstermeye ilişkin örnekler aşağıda gösterilmiştir: o Makale: Süleyman Ozyalçin N, Talu GK, Camlica H, Erdine S. Efficacy of coeliac plexus and splanchnic nerve blockades in body and tail located pancreatic cancer pain. Eur J Pain 2004;8(6):539-45. o Kitap: Newton ML. Current practice of pain. 1st ed. St. Luis, MO: Mosby; 1990. o Kitaptan bölüm: Turner JA. Coping and chronic pain. In: Bond MR, Charlton JE, Woolf CJ, editors. Pain research and clinical management. Proceedings of the VIth world congress on pain. Amsterdam: Elsevier; 1991. p. 219-27. o Kurslar ve konferanslar (yayınlanmamış): Erdine S. Pain. Course lecture presented at: International Pain Congress, June 7, 2008, İstanbul. YAZI TÜRLERİ VE SPESİFİK FORMATLAMA KILAVUZLARI Makalenin türü, formatlama ve yazının sözcük sayısı dahil kullanılması gereken kılavuzları belirlediğinden yazı gönderiminde ilk adım makalenin türünün tanımlanmasıdır. Araştırma Makalesi: Ağrıda temel bilimler ve klinik araştırmalara ait özgün çalışmalar: Bu makaleler randomize kontrollü çalışmalar, gözleme dayalı çalışmaları (kohort, olgu-kontrollü veya kesitsel), tanısal doğruluk çalışmaları, sistematik derlemeleri ve metaanalizleri, randomize olmayan davranışsal ve halk sağlığı girişimsel çalışmaları, deneysel hayvan çalışmaları veya başka klinik ve deneysel çalışmaları içerebilir. Araştırma makaleleleri aşağıda belirtilen sayfaları, bölümleri ve yukarıda gerekli dosya türleri bölümünde tanımlanmış dosyaları içermelidir: 1. Özetler Sayfası: Hem İngilizce hem de Türkçe özetlerin olması gerekir. Özetler 250 sözcüğü geçmemeli ve aşağıdaki alt başlıklar halinde yapılandırılmalıdır: Amaçlar, Gereç ve Yöntemler (çalışma tasarımıyla birlikte), Bulgular ve Sonuç (olgu kontrollü çalışma, kesitsel çalışma, kohort çalışması, randomize kontrollü çalışma, tanısal doğruluk çalışmaları, metaanalizler, ve sistematik derleme, hayvan deneyleri, randomize olmayan davranışsal ve halk sağlığı girişimsel çalışmaları vs). İstatistiksel analize göre bulgularınızın önemini vurgulayın ideal olarak etki büyüklüğü ve başlıca sonuçlar için güven aralıklarını da bulgulara dahil edin. 2. Ana Metin: Ana metin şu alt başlıklar halinde yapılandırılmalıdır: Giriş, Gereç ve Yöntemler, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekil Alt Yazıları. a. Giriş: Üç paragraflı yapı kullanılmalıdır. Çalışma konusuna ilişkin arka plan bilgileri (1. paragraf ), çalışmanın bağlamı ve çıkarımları (2. paragraf ), çalışmanın varsayımları ve hedefleri (3. paragraf ). Arka plan: Ortamı oluşturan ve sizi konuyu araştırmaya sevk eden koşullar veya tarihsel bağlamı

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tanımlayın. Bağlam: Araştırmanızın niçin önemli olduğunu, potansiyel çıkarımlarının neler olduğunu, ilk paragrafta ortaya atılan konularla ilişkisini, bu spesifik araştırmanın niçin bir sonraki mantıksal adım olduğunu, çalışmanın hedeflerini anlatın ve araştırmanın spesifik amacını veya varsayımını ve birincil sonuç ölçümünüzü açıkça belirtin. b. Gereç ve Yöntemler: Yöntem bölümü özgün araştırma makalelerinin en önemli bölümlerinden biri olup yeterince detaylandırılmalıdır. Araştırma yöntemi, çalışma örneği, uygulanmış analizler, kullanılan ticari istatistik programları, ölçüm ve değerlendirmelerin ayrıntıları (örn: biyokimyasal test cihazları ve kitlerin markası ve modeli) tümüyle açık ve net biçimde belirtilmelidir. Prospektif çalışmalar için yerel etik komite ve diğer onay veren yetkili kurumların adları da Yöntemler bölümünde verilmelidir. Yöntemler bölümü mantıksal ve ardışık alt başlıklar şeklinde düzenlenmelidir. c. Bulgular: Çalışma popülasyonunun demografik özellikleri ve hipotez testinin ana ve ikincil bulguları da kaydedilmelidir. Bu bölümde bulguları yorumlamaktan ve literatür bulgularını tartışmaktan kaçınılmalıdır. Analizlerde edinilmiş olabildiğince çok veriyi bir bütün olarak mümkünse grafikler halinde sunun. Testlerde kullanılan istatistikler temelinde bulguların önemini vurgulayın. Bunun için ideal olarak her bir sonuç için etkinin büyüklüğü ve ilişkili %95 güven aralıklarından yararlanın. d. Tartışma: Çalışmanın birincil ve ikincil sonuçları kısaca sunulmalı, literatürdeki benzer bulgularla karşılaştırılmalıdır. Bu bölümde yoğun arka plan bilgileri vermektem kaçınılmalıdır. Yalnızca sonuçlarınızın yorumlanmasıyla doğrudan ilişkili yayınlanmış makaleleri göz önünde bulundurun ve bunları çalışma bağlamına dahil edin. İstatistiksel anlamı klinik önemden fazla vurgulamayın. Bulgularınızı araştırmanızda açıkça incelemediğiniz toplumlar ve koşullara uyarlamayın. Yöntemler ve Bulgular bölümlerinde formel bir maliyet-etkililik analizi sunmadıysanız maliyet ve ekonomik yarar konularında iddialarda bulunmayın. Bir sonraki aşamanın ne olduğunu spesifik olarak belirtmeden. “Daha fazla araştırma gereklidir” önerisinde bulunmayın. İsterseniz “Geriye baktığımızda …” ile başlayan bir paragraf ilave edip içtenlikle çalışmayı tekrarlama fırsatı verilseydi neleri farklı yapmak isterdiniz konusunu tartışarak başkalarının da deneyimlerinizden bir şeyler öğrenebilmesini sağlayabilirsiniz. e. Limitasyonlar: Çalışmanın limitasyonları tartışma sonunda ayrı bir paragraf içinde “Limitasyonlar” altbaşlığı altında belirtilmelidir. Sonuçlarınızın içsel ve dışsal geçerliliğini tehdit eden etmenler de dahil olmak üzere çalışmanızın limitasyonlarını açıkça tartışın. Mümkünse her bir yanlılığın boyut ve yönünü ve sonuçların yorumlanmasını nasıl etkileyebildiğini inceleyin. f. Sonuç: Çalışmanın bulguları ışığında net bir sonuca varılmalıdır. Çalışma sonuçlarının güncel klinik uygulamalar üzerine potansiyel etkileri tek bir cümleyle belirtilmelidir. Çalışmanın sonuçlarıyla desteklenmeyen çıkarımlarda bulunmaktan kaçınılmalıdır. g. Teşekkür: h. Kaynaklar: Kaynaklar ayrı bir sayfada belirtilmelidir. i. Şekil Alt yazıları: Şekil alt yazıları ayrı bir sayfada ana metin içinde belirtilmeli ve bu sayfa ana metin dosyasının sonuna konmalıdır. j. Tablolar: Ana metin dosyasının sonuna ayrı sayfalar veya ayrı bir dosya şeklinde konmalıdır. k. Şekiller: Ana metin dosyasının içine konmamalı ve yukarıda gerekli dosya türleri bölümünde tanımlandığı gibi ayrı dosyalar halinde yüklenmelidir. l. Etik ve İnceleme Kurulunun Onayı: Yazınız orijinal araştırma ise bir kurumsal inceleme veya etik kurul tarafından onaylandığı veya muaf tutulduğunu doğrulamanız istenecektir. AĞRI Dergisi onaylanmamış veya muaf tutulmamış yazılara daha fazla dikkate almayacaktır. (Yalnızca daha önce IRB (bağımsız etik kurul) onay veya muafiyeti bulunan üçüncü tarafların anonim veri tabanlarının analizleri bu kapsamın dışındadır.) Olgu Raporları: Ağrı pratiğinde nadiren rastlanılan ve eğitsel değeri olan klinik olgular veya komplikasyonların kısa anlatımlarıdır. Mevcut literatürde daha önce belgelenmemiş klinik durumları, klinik belirtileri veya komplikasyonları, bilinen tedavi rejimlerinin raporlanmamış yan veya advers etkileri konusunda ileri araştırmayı tetikleyebilen bilimsel bulgular göz önünde bulundurulacaktır. Olgu raporlarının özetleri 150 sözcüğü geçmemeli, ayrı bir sayfaya yazılmalı ve yapılandırılmamalıdır. Olgu serilerinin ana metni aşağıdaki alt başlıklar altında yapılandırılmalıdır: Giriş, Olgu Sunumları, Tartışma ve Kaynaklar. Kısa Rapor: İlk elde edilen veriler, bulgular veya ileri araştırmaların gerekliliğini gösteren küçük çaplı çalışmaların orijinal raporları. Özetler 250 sözcüğü geçmemeli ve araştırma makalesi şeklinde yapılandırılmalıdır. Limitasyonları, en fazla 6 yazar, 4000 sözcük (kaynaklar, tablolar ve şekil alt yazıları dahil) 15 kaynak, 4 tablo ve/veya şekli içerir. Bu kısıtlamalardan başka, araştırma makalelerin tüm formatları, onay, etik ve yazım kılavuzları kısa raporlar için de geçerlidir. Derleme Makalesi: Güncel ağrı uygulamasına ilişkin ulusal ve uluslararası literatürü gözden geçiren kapsamlı makalelerdir. Genellikle AĞRI Dergisi yalnızca davetli yazarların derleme makalelerini yayınlamaktadır. Diğer yazarlar derleme makalelerini göndermeden önce editörle iletişime geçmelidir. Derleme makalesi en fazla 2 yazarlı olmalı, kaynaklar, tablolar ve şekil altyazıları dahil 4000 sözcüğü geçmemelidir. Kaynakların sayısı sınırlandırılmamıştır. Editöre Mektup: AĞRI Dergisi veya başka dergilerde yayınlanmış makalelere ilişkin düşünceler, yorumlar ve önerileri içerir. Mektuplar en fazla 1.000 sözcük içermelidir. Bu tek yazarlı yazılar için en fazla 5 kaynağın referans gösterilmesine izin verilir. Özet yazılması gerekmemektedir. YAZAR KATKI VE İNSAN VE HAYVAN HAKLARI BİLDİRİMİ Bilimsel katkı ve sorumluluklar, ilgili herhangi bir finansal ya da çıkar çatışması varsa belirtilmelidir. Sorumlu yazar, çalışmanın ve yayının hazırlanmasına katkıda bulunan yazarların adlarını içeren formu imzaladıktan sonra yayıncıya göndermelidir. İnsan deneyleri rapor edilirken, yazarlar prosedürlerin 1975 Helsinki Deklerasyonu-2000, 2008 yılında revize edilen- uyarınca insan deneylerinden (kurumsal ve ulusal) sorumlu etik standartlara uygun olarak olup olmadığı belirtmelidir. Hayvanlar üzerindeki deneyler rapor edilirken, yazarlar laboratuvar hayvanlarının bakımı ve kullanımı için kurumsal ve ulusal rehberi uygulayıp uygulamadığını belirtmelidir. Lütfen makale ile ilgili detayları doldurduğunuz formun (Yazar Katkı ile İnsan ve Hayvan Hakları Bildirimi Formu) çıktısını alın ve formu imzaladıktan sonra faks veya elektronik olarak yayıncıya gönderin. BİLGİLENDİRİLMİŞ ONAM BİLDİRİMİ Bilimsel amaç için gerekli olmadığı sürece, yazılı açıklamalarda, fotoğraflarda ve soy ağacında hastaların isimleri, baş harfleri veya hastane numaralarını içeren tanıtıcı bilgiler yayınlanmamalıdır ve hasta (ailesi ya da vasisi) yayınlanması için yazılı bilgilendirilmiş onam vermelidir. Bu amaç için bilgilendirilmiş onam, tanımlanabilir bir hastaya yayınlanacak makalenin gösterilmesini gerektirir. Yazarlar, yazıma destek sağlayan kişileri belirtmeli ve bu destek için fon kaynağını açıklamalıdır. Tanıtıcı detaylar eğer gerekli değil ise göz ardı edilmelidir. Lütfen makale ile ilgili detayları doldurduğunuz ve hasta veya yakınına formu imzalamalarını rica ettiğiniz formun (Bilgilendirilmiş Onam Bildirimi Formu) çıktısını alın, faks ile veya elektronik olarak yayıncıya gönderin. TELİF HAKLARI VE ÇIKAR ÇATIŞMASI BİLDİRİMİ Yazarlar makalede bahsedilen materyal ile ilgili herhangi bir finansal kuruluş ile herhangi bir çıkar çatışması olmadığını belirtmelidir. Kabul edilen makaleler için, tüm yazarlar tarafından imzalanmış telif hakkı formu gönderilmelidir. Lütfen makale ile ilgili detayları doldurduğunuz formun (Telif Hakkı Devir Formu ve Çıkar Çatışması) çıktısını alın ve formu imzaladıktan sonra faks veya elektronik olarak yayıncıya gönderin. YAYIN ÜCRETİ AĞRI erişme açık bir dergidir. Online olarak derginin web sayfasından yazılara ücretsiz olarak ulaşılmaktadır. Yayınlanan sunumlar için yazarlardan herhangi bir ücret talep edilmez.

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SCOPE AND PURPOSE This journal, which is published quarterly, is the official publicalion of Turkish Society of Algology, Reviews, details of interentional techniques, original researehes and case reports on the nature, mechanisms and treatment of pain are published. The journal provides a forum for the dissemination of research in the basic and clinical sciences of multidisciplinary interest. Opinions presented in published articles by no means represent the official endorsement of the Turkish Society of Algology. Articles and illustrations become the property of the Journal after publication. INSTRUCTIONS FOR AUTHORS 1. The journal is published in Turkish and in English. 2. Manuscripts which are accepted by Editorial Board can be published. The Editorial Board have the right ro reject or to send the manuscript for review and revise. All manuscripts are subject to editing and, if necessary, will be returned to the authors for responses to outstanding questions or for addition of any missing information. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval. 3. Articles not written according ro the 3rd editian (1983) of “common properties which are wanted in the articles that will be submitted to the Biomedical Journals” which was deternıined by the International Medical Journal Editorial Board, will not be accepted. Before submission it is adviced to look for these guidelines whieh are published in British Medical Journal 1988;296:401-5 or in Annals of Internal Medicine 1988;108:258-65. 4. All paper types are accepted via internet based manuscript processing system (www.journalagent.com/agri). 5. A paper which has not previously been published or being considered for publication elsewhere are accepted for publication. Papers which were published elsewhere previously as an abstract form may be published. 6. No payment for copyright of the article will be done. Therefore the letter accompanying the manuseript should include a statement that copyright of the article is transferred to the Turkish Society of Algology. The final manuscript should have been read and approved by the responsible authors. 7. If illustrations or other small parts of articles or books aIready published elsewhere are used in papers submitted to journal, the written permission of author and publisher corcerned must be included with the manuscript. 8. Authors should keep a copy of their manuscripts. 9. If a part or whole of a submitted manuscript will be published elsewhere, editor of the journal should be informed. 10. For researches, approvement of the institutional local ethics committee or its equivalent should be submitted. 11. All the responsibilities belong to authors. 12. No reprints will be sent to the author. REQUIRED FILETYPES AND MINIMUM SUBMISSION REQUIREMENTS Before submission via electronic submission system, a number of separate MS Word (.doc) and Adobe (.pdf ) files should be prepared with the following formatting properties. No submissions will be accepted without a Cover Letter and a Title Page. 1. Cover Letter: A cover letter file should be included in all types of manuscript submissions. On the cover letter, the author(s) should present the title, manuscript type and manuscript category of the submission, and whether the submitted work had previously been presented in a scientific meeting. The cover letter should contain a statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration by AGRI Journal. In addition, the full name of the corresponding author and his/her contact information including the address, phone number and e-mail address should be provided at the bottom of the cover letter. The cover letter should be signed by corresponding author, scanned and submitted in .jpg or .pdf format with other manuscript files. The order of a cover letter should be as follows: a. Title, manuscript type. b. Statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration. c. Corresponding author(s) full name, contact information including address, phone, and e-mail address. d. Signature of the corresponding author. 2. Title Page: A title page file should be included in all types of manuscript submissions. Please prepare your title page as a separate electronic file, including the following elements: a. Title of the manuscript b. Author(s) list, please list their full names and up to 2 academic degrees per author; do not include honorary affiliations, such as fellow status in an organization. c. Affiliation(s) of each author, including department or division, institution, city, country. d. Corresponding author(s) full name, contact information including address, phone, and e-mail address. e. Funding or other financial support should be acknowledged. f. Conflict of interest statement: A conflict of interest statement should be provided in bottom of the title page. Please list of all potential conflicts of interest for each author, in accordance with ICMJE recommendations. In case of no conflicts of interests, please provide a statement such as: “Conflicts of Interest: None declared”. 3. Abstracts: On the abstracts page, the author(s) should present abstract and keywords (at least three) in this order. Turkish and English keywords should be chosen from Medical Subject Headings (MeSH) (http://www.nlm.nih.gov/mesh/MBrowser.html) and Türkiye Bilimler Terimleri (http://www. bilimterimleri.com). 4. Main Text: A main text file should be included in all types of manuscript submissions. This file should include title, abstracts page, main text of your manuscript, and the references section combined into a single electronic file. Tables can be included in this file as separate pages after References section, or may be uploaded separately as you prefer. Structure of the main text differs between manuscripts types. a. This combined file with the sections of abstracts, keywords, main text, references with/without tables should be a blinded version of the original manuscript. The names of the authors’, and any identifying information including the academic titles, institutions and addresses must be omitted. Apart from the stage of the manuscript evaluation process, manuscripts submitted with any information pertaining to the author(s) will be rejected as soon as it is noticed. 5. Tables: Tables summarizing the data should be clearly formatted without using any templates. Data presented in the tables should not be included in its entirety in the text. a. Tables must be numbered consecutively. b. Each table must be referred to in the text. c. Number and title of each table should be written at the top of each page before the table. d. Tables can be included in main text file as separate pages after references section, or may be uploaded separately as you prefer. If you prefer a separate file, tables should be uploaded in MS Word (.doc) format and the electronic file should be named accordingly (Tables_xxx_vx.doc). Tables should not be uploaded as pdf, jpeg or else. 6. Figures: If the manuscript includes figures then each figure should be uploaded as a separate file in all types of manuscript submissions. The information contained in the figure/image should not be repeated in its entirety, however reference to the figure/image must be referred in the text.

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a. i. ii. iii. iv. v.

Technical requirements Figure legends should appear on a separate page after the references section. During submission, all figures must be uploaded in a separate file from the text file and should be named accordingly (Figure1_xxx; Figure2_xxx). No legends or titles should be included in the figures. Pictures should be saved in JPEG, EPS or TIFF format. Please submit photographs and figures with a resolution of at least 300 dots per inch. Figures are easiest for us to process if submitted in TIFF or EPS format. b. Ethical requirements i. The owner and/or subject of the photograph must sign the patient consent form. ii. Figures should not be reproduced from other sources without permission 7. Statements, permissions, and signatures: a. Conflict of Interest Form: A conflict of interest exists when professional judgment concerning a primary interest (such as patients’ welfare or validity of research) may be influenced by a secondary interest (such as financial gain). Financial relationships are easily identifiable, but conflicts can also occur because of personal relationships or rivalries, academic competition, or intellectual beliefs. A conflict can be actual or potential, and full disclosure to The Editor is the safest course. Failure to disclose conflicts might lead to publication of an Erratum or even to retraction. All submissions to AGRI must include disclosure of all relationships that could be viewed as presenting a potential or actual conflict of interest. All authors are required to provide a conflict of interest statement and should complete a standard form. b. Patient Consent Form: Publication of any personal information about an identifiable living patient requires the explicit consent of the patient or guardian. We expect authors to use a standard patient consent form. c. Copyright Transfer Form: All authors are required to provide a copyright transfer from with complete a standard form. MANUSCRIPT FORMATTING Manuscript format must be in accordance with the ICMJE-Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals(updated in August 2013). Papers that do not comply with the format of the Journal will be returned to the author for correction without further review. Therefore, to avoid loss of time and work, authors must carefully review the submission rules. Manuscript structure should be complient with the guidelines of WAME. General Format 1. General Style: o The manuscript should be typed in a Microsoft Word™ file, single-column format, Every effort should be made to avoid medical jargon. 2. For the Blind Initial Review: The names of the authors’, and any identifying information including the academic titles, institutions and addresses must be omitted. Manuscripts submitted with any information pertaining to the author(s) will be rejected. 3. Drugs: Generic names for drugs should be used. Doses and routes for the drugs should be stated. When a drug, product, hardware, or software mentioned within the main text product information, including the name of the product, producer of the product, city of the company and the country of the company should be provided in parenthesis in the following format: “Discovery St PET/CT scanner (General Electric, Milwaukee, WI, USA)” 4. Abbreviations: We discourage the use of any but the most necessary of abbreviations. They may be a convenience for an author but are generally an impediment to easy comprehension for the reader. All abbreviations in the text must be defined the first time they are used (both in the abstract and the main text), and the abbreviations should be displayed in parentheses after the definition. Authors should avoid abbreviations in the title and abstract and limit their use in the main text. 5. Decimal points or commas: Decimal numbers should be separated from the integers with points. Commas should not be used in decimals throughout the manuscript. 6. References: References should be numbered consecutively in the order in which they are first mentioned in the text (6 authors then “et al”). Avoid referencing abstracts, or citing a “personal communication” unless it provides essential information not available from a public source. Examples of Referencing are as follows: o Article: Süleyman Ozyalçin N, Talu GK, Camlica H, Erdine S. Efficacy of coeliac plexus and splanchnic nerve blockades in body and tail located pancreatic cancer pain. Eur J Pain 2004;8:539-45. o Book: Newton ML. Current practice of pain. 1st ed. St. Luis, MO: Mosby; 1990. o Book Chapter: Turner JA. Coping and chronic pain. In: Bond MR, Charlton JE, Woolf CJ, editors. Pain research and clinical management. Proceedings of the VIth world congress on pain. Amsterdam: Elsevier; 1991. p. 219-27. o Courses and Lectures (unpublished): Erdine S. Pain. Course lecture presented at: International Pain Congress, June 7, 2008, İstanbul. MANUSCRIPT TYPES AND SPECIFIC FORMATTING GUIDELINES Identification of article type is the first step of manuscript submission because article type dictates the guidelines that should be used, including formatting and word limits of the manuscript. The main categories are outlined below: Research Article: Original studies of basic or clinical investigations in algology. These articles can include randomized controlled trials, observational (cohort, case-control or cross-sectional) studies, destructive studies, diagnostic accuracy studies, systematic reviews and meta-analyses, nonrandomized behavioral and public health intervention trials, experimental animal trials, or any other clinical or experimental studies. Submission of research articles should include below mentioned pages, sections and files as defined above in required filetypes section: 1. Abstracts Page: Both English and Turkish (if relevant) abstracts are required. Abstracts should not exceed 250 words and should be structured with the following subheadings: Objectives, Material and Methods (with design), Results, and Conclusion (case control study, cross sectional study, cohort study, randomized controlled trial, diagnostic accuracy study, meta-analysis and systemic review, animal experimentation, non-randomized study in behavioral sciences and public health, etc.). In your results emphasize the magnitude of findings over test statistics, ideally including the size of effect and its confidence intervals for the principal outcomes. 2. Main Text: The main text should be structured with the following subheadings: Introduction, Material and Methods, Results, Discussion, Acknowledgments, References, Tables, and Figure Legends. a. Introduction: A three-paragraph structure should be used. Background information on study subject (1st paragraph), context and the implications of the study (2nd paragraph) and the hypotheses and the goals of the study (3rd paragraph). Background: Describe the circumstances or historical context that set the stage and led you to investigate the issue. Context: Describe why your investigation is consequential. What are its potential implications? How does it relate to issues raised in the first paragraph? Why is this specific investigation the next logical step? Goals of the study: Clearly state the specific research objective or hypothesis and your primary outcome measure. b. Material and Methods: The method section, is one of the most important sections in original research articles, and should contain sufficient detail. The

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investigation method, study sample, analyses performed, commercial statistical programs used, details of measurement and evaluation (e.g.: make and model of biochemical test devices and kits) should all be clearly stated. The names of local ethics committee or other approving bodies should be provided in Methods section for prospective studies. The Methods section should be organized with logical and sequential subheadings. c. Results: The demographic properties of the study population, the main and secondary results of the hypothesis testing must be provided. Commenting on the results and discussing the literature findings should be avoided in this section. Present as much data as possible at the level of the unit of analysis, graphically if possible. Emphasize the magnitude of findings over test statistics, ideally using size of effect and associated confidence intervals for each outcome. d. Discussion: The main and secondary results of the study should briefly presented and compared with similar findings in the literature. Providing intensive background information should be avoided in this section. Consider only those published articles directly relevant to interpreting your results and placing them in context. Do not stress statistical significance over clinical importance. Avoid extrapolation to populations or conditions that you have not explicitly studied in your investigation. Avoid claims about cost or economic benefit unless a formal cost-effectiveness analysis was presented in the Methods and Results sections. Do not suggest “more research is needed” without stating what the specific next step is. Optionally, you may include a paragraph “In retrospect, . . .” to candidly discuss what you would do differently if given the opportunity to repeat the study, so others can learn from your experience. e. 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EKİM - OCTOBER 2019


Agri 2019;31(4):163–171

doi: 10.14744/agri.2019.99266

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ORIGINAL ARTICLE

Validity and reliability of Turkish version of STarT Back Screening Tool STarT- TR Bel Sağlığı Tarama Ölçeği Türkçe versiyonunun geçerliği ve güvenirliği Gül Deniz YILMAZ YELVAR,1 Murat DALKILINÇ,2 Beyza Nur KARADÜZ,5 Mümine Merve KOLSUZ6

Yasemin ÇIRAK,3

Yasemin PARLAK DEMIR,4

Summary Objectives: The psychosocial factors that may affect the prognosis of patients with low back pain are generally disregarded. The StarT Back Screening Tool can help clinicians to analyze prognostic indicators and the risk associated with outcome by examining physical and psychosocial factors. The aim of this study was to investigate the psychometric properties of the Turkish version of the StarT Back Screening Tool, including cross-cultural adaptation, internal consistency, test-retest reliability, and construct validity. Methods: In this study, 120 patients with non-specific low back pain were included. The Roland Morris Disability Questionnaire, Oswestry Disability Index, Beck Depression Inventory, Tampa Scale for Kinesiophobia, and the StarT Back Screening Tool were administered. One week after the initial testing, the same examiner repeated the tests. Results: The mean age of the patients who participated in the study was 35.54±12.45 years. Cronbach’s alpha coefficients in the analysis of scale reliability were 0.747 for the overall scale and 0.738 for the psychosocial subscale. The test-retest reliability of StarT Back Screening Tool (intraclass correlation coefficient: 0.90-0.93) was found to be excellent. Pearson correlation coefficients for the correlations between the overall StarT Back Screening Tool and the other measures were very good (r=0.678; p<0.001) for the Roland Morris Disability Questionnaire, good (r=0.473; p<0.001) for the Tampa Scale for Kinesiophobia, good (r=0.541; p<0.001) for the Oswestry Disability Index, and moderate (r=0.336; p<0.001) for the Beck Depression Inventory. Conclusion: The Turkish version of the StarT Screening Tool for non-specific back pain was determined to be valid and reliable. A good assessment of both physical and psychosocial factors in symptomatic patients can help clinicians make a thorough prognosis. Keywords: Back screening tool; non-specific low back pain; reliability; Turkish version; validity.

Özet Amaç: Fizyoterapi değerlendirmelerinde genellikle bel ağrılı hastaların prognozunu etkileyebilen psikososyal faktörler gözardı edilmektedir. STarT Bel Sağlığı Tarama Ölçeği (SBST) fiziksel ve psikososyal faktörlerin incelenerek risk seviyeleri konusunda klinisyenlere yardımcı olabilmektedir. Çalışmanın amacı STarT Bel Sağlığı Tarama Ölçeği’nin kültürel adaptasyon, iç tutarlılık, test-tekrar test güvenirliği ve yapı geçerliğini kapsayan psikometrik özelliklerinin incelenmesidir. Gereç ve Yöntem: Çalışmaya non-spesifik bel ağrısı olan 120 birey dahil edildi. Bireylere Roland Morris Engellilik Anketi, Oswestry Özürlülük İndeksi, Beck Depresyon Envanteri, Tampa Kinezyofobi Ölçeği ve STarT Bel Sağlığı Tarama Ölçeği uygulandı. İlk değerlendirmeden 1 hafta sonra aynı ölçümcü tarafından değerlendirmeler tekrar edildi. Bulgular: Çalışmaya katılan bireylerin ortalama yaşının 35,54±12,45 yıl olduğu görüldü. Tüm ölçeğin güvenirliğinin Cronbach alfa katsayısı tüm ölçek için 0,747, psikososyal alt ölçeğinin ise 0,738’di. STarT Bel Sağlığı Tarama Ölçeği’nin test-tekrar test güvenirliği (ICC: 0,90–0,93) mükemmeldi. STarT Bel Sağlığı Tarama Ölçeği ve diğer ölçümlerin Pearson korelasyon katsayıları: Roland Morris Engellilik Anketi için çok iyi (r=0,678, p<0,001), Tampa Kinezyofobi Ölçeği’nin iyi (r=0,473, p<0,001), Oswestry Özürlülük İndeksi için iyi (r=0,541, p<0,001) ve Beck Depresyon Envanteri için orta (r=0,336, p<0,001) olarak bulundu. Sonuç: Start Bel Sağlığı Tarama Ölçeği’nin (STarT-TR) Türkçe versiyonu non-spesifik bel ağrılı bireyler için uygundur ve güvenirliği mükemmeldir. Start Bel Sağlığı Tarama Ölçeği, fiziksel ve psikososyal faktörlerden etkilenen hastaların prognozlarını değerlendirmelerinde klinisyenlere, yardımcı olabilir. Anahtar sözcükler: Bel sağlığı tarama ölçeği; non-spesifik bel ağrısı; güvenirlik; Türkçe versiyon; geçerlik.

Department of Physiotherapy and Rehabilitation, Cyprus Science University School of Health Science, Northern Cyprus Turkish Republic, Northern Cyprus Department of Exercise and Physiotherapy, Presidential Guard, Abu Dhabi, UAE 3 Department of Physiotherapy and Rehabilitation, İstinte University Faculty of Health Science, Istanbul, Turkey 4 Independent Researcher in Physiotherapy and Rehabilitation 5 Department of Physiotherapy and Rehabilitation, Hacettepe University Institute of Health Science, Ankara, Turkey 6 Department of Language and Speech Therapy, Cumhuriyet University Faculty of Health Science, Sivas, Turkey 1 2

Submitted (Başvuru tarihi) 09.12.2018 Accepted after revision (Düzeltme sonrası kabul tarihi) 19.04.2019 Available online date (Online yayımlanma tarihi) 13.06.2019

Correspondence: Dr. Gül Deniz Yılmaz Yelvar. Kıbrıs İlim Üniversitesi Sağlık Bilimleri Yüksekokulu, Fizyoterapi ve Rehabilitasyon Bölümü, Girne, K.K.T.C. Phone: +90 - 533 631 81 99 e-mail: guldenizy@yahoo.com © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Introduction Low back pain (LBP) is an important musculoskeletal problem that is common in the industrialized world, with a lifetime risk of 84% and is seen most frequently in the age range of 45–54 years.[1, 2] The prevalence of LBP and levels of pain-associated depression vary between countries and with socio-economic status and disease-coping strategies of patients. It has been reported as 37%–51% and is increasing in those aged over 40 years in Turkey.[3–5] LBP is defined as acute if recovery is within a month, subacute if it lasts 1–3 months and chronic if it continues longer than 3 months. Most patients recover within 6 weeks but in 2%–7% of patients symptoms increase.[6] The most important factors in the development of chronic LBP are negative attitudes towards the pain and fear of movement. These conditions significantly affect the psychological status of patients and as a result, the patients feel the pain much more severely and associate the pain with other diseases. At the same time it can lead to difficulty in coping with the disease, lack of confidence and depressive symptoms that affect the prognosis of LBP and increase the cost of medical care. The cognitive-behavioural perspective should therefore be taken into consideration when formulating the appropriate approach to the LBP.[7, 8] The identification of possible psychosocial factors that influence the course of the prognosis helps with improved understanding of the patient’s results, signs and symptoms and with establishing a more efficient, disease-specific treatment programme.[6] In response to this challenge, the STarT Back Screening Tool (SBST) was developed by Hill et al.[9] to identify subgroups of patients with LBP and to guide initial decision-making. This tool is based on the presence of potentially modifiable physical and psychological indicators for persistent, disabling symptoms, identified through nine questions. It is a simple, selfadministered, valid and reliable questionnaire for screening patients with LBP. It results in a straightforward risk score, which provides an indication of the approach to take. In the large randomized controlled study, Hill et al suggested that physiotherapy and psychotherapy should be recommended for high-risk individuals; physiotherapy should be recommended for moderate-risk individuals and the low-risk individuals should be offered advice and 164

Assessed for eligibility (n=137) All participants referred to the physiotherapy clinic were diagnosed by physician n=4 surgical history n=5 rheumatological disease n=1 locomotor disease n=7 refused to participate Analyzed n=120

Figure 1. Flowchart for enrollment and testing procedure.

education. This study showed that SBST was a clinical and cost-effectiveness tool.[10] To the best of our knowledge, there is no Turkish screening tool for identifying the possible psychosocial factors that influence the prognosis in patients with LBP. A suitable translation and adaptation of SBST that includes psychosocial factors could therefore enable risk classification for Turkish patients with LBP and help physiotherapists and clinicians in their decision-making. The aim of this study was to investigate the psychometric properties of SBST used to assess the risk status of patients with LBP with regard to cross-cultural adaptation, internal consistency, test–retest reliability and construct validity.

Material and Method The study was performed at the University Hospital Department of Physiotherapy and Rehabilitation and included 120 Turkish-speaking participants who were diagnosed by the clinician as non-specific LBP and referred to physiotherapy unit. The patients had locomotor system or rheumatological disease, or a history of fracture or of spinal or pelvic surgery and radiculopathy were excluded. The study was approved by the University’s Human Investigation Committee (2018-08), and all participants read and signed the informed consent form prior to enrolment in the study. Enrolment and a flow chart of the study are shown in Figure 1. Translation Procedure: We used the guidelines for the cross-cultural adaptation for the translation process.[11] The linguistic and cross-cultural translation procedure is shown in Table 1. Contact was established via mail with the research group at OCTOBER 2019


Validity and reliablity of Turkish version of STarT Back Screening Tool

Table 1. Linguistic and cultural translation prosedure Liaison with STarT developers Contact with the developers Formation of steering committee Translation Translation Back translation Back translation from Turkish to English Synthesis Comparison of translations Translation committee Review of translated versions Reaching consensus and development of pilot version Pilot testing Testing in clinical setting Revision of pilot version Final version Testing of final version

Keele University that developed STarT and allowed to determine whether there were any attempts in progress to develop a Turkish version of their questionnaire. We established a translation team which consisted of two bilingual physiotherapists, two Turkish-speaking physiotherapists and one bilingual native English-speaking teacher of the English language. The original SBST was independently and separately translated from English to Turkish by the four physiotherapists, after which the four Turkish translations were compared for inconsistencies. A reverse translation into English of the draft Turkish version was then conducted by the fifth member of the team. The team reviewed and compared the original and reversed-translated English versions to detect any errors of interpretation or nuances that may have been missed. The original English, Turkish and reverse-translated English versions and the synthesis of translation differences were discussed by the translation team, who reached a consensus regarding linguistic imprecision and cultural differences. The last stage of the translation process was to test the pre-final version. Ten patients with LBP were administered the translated SBST and asked about item ambiguity and difficulty. All responded that the scale was easy to understand. The final version of SBST was then produced by consensus and this became our final Turkish version of STarT, which we refer to as STarT-TR (Appendix).

Roland–Morris Disability Questionnaire (RMDQ) was developed to assess physical disability due to LBP. It results in a score in the range 0–24, with a score of 14 points or greater indicating risk.[13] We used the items of the Turkish version developed by Küçükdeveci et al.[14]

SBST includes nine items that referred to leg pain, comorbid pain, difficulties in walking, difficulties in dressing, fear of physical activity, anxiety, pain catastrophizing, depressive mood and the overall impact of pain. Items 1–8 are statements that are answered ‘agree’ or ‘disagree’, with positive answers

Oswestry Disability Index (ODI) was developed in a specialist referral clinic for patients with chronic LBP. It includes 10 items (pain intensity, personal hygiene, lifting, walking, sitting, standing, sleeping, sexual activity, social activity and travelling) and is scored on a six-point Likert Scale. The scores are summed and re-

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Total score Q1–9 3 or less

4 or more Psychosocial score Q5–9

Low risk

3 or less

4 or more

Medium risk

High risk

Q: Question

Figure 2. Scoring method of the SBST.

scored as one point and negative as zero points. Item 9 asks how bothersome the pain was over the last 2 weeks and provides a Likert scale from ‘Not at all’ to ‘Extremely’, with ‘Very much’ and ‘Extremely’ scored as one point and the others as zero. The overall score is simply the sum of all nine item scores. The scores for items 5–9 are also added together to form the psychosocial subscale. The scoring method is shown in Figure 2.[10, 12]

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A RI PAIN Table 2. Demographic and clinical characteristics of the patients (n=120) Characteristic Value Gender, n (%) Male Female Age, years, mean (SD) BMI, kg/m², mean (SD) Duration of the back pain, n (%) <1 month 1–3 month 4–6 month Subgroups as classified on the SBST, n (%) High risk Median risk Low risk Marital status, n (%) Single Married Divorced/widowed Current smoker, n (%) Educational status, n (%) Primary-secondary school High school University SBST score Overall (Q1–Q9), mean (SD) Psychosocial subscale (Q5–Q9), mean (SD) RMDQ score, mean (SD) TSK score, mean (SD) ODI score, mean (SD) BDS score, mean (SD)

46 (38.3) 74 (61.7) 35.54 (12.45) 24.78 (3.43) 48 (40) 38 (31.7) 34 (28.3) 20 (16.7) 40 (33.3) 60 (50) 31 (25.83) 77 (64.17) 12 (10) 51 (42.5) 57 (47.5) 35 (29.16) 28 (23.34) 3.90 (2.54) 7.36 (2.62) 9.89 (7.11) 40.39 (7.11) 11.17 (6.84) 9.18 (7.37)

BMI: Body mass index; SD: Standard deviation; Q: Question; SBST: STarT Back Screening Tool; RMDQ: Roland Morris Disability Questionnaire; TSK: Tampa Scale of Kinesophobia; ODI: Oswestry Disability Index (ODI); BDS: Beck Depression Scale.

calculated as percentages from 0 to 100, where 100% refers to the worst possible disability.[15] We used the items of the Turkish version developed by Yakut et al., which has been shown to have good comprehensibility, internal consistency and validity for the assessment of disability in patients with LBP.[16] Beck Depression Inventory (BDI) has 21 items each scored from 0 to 3 according to the intensity of depressive symptoms.[17] We used the items of the Turkish version developed by Hisli.[18] 166

Tampa Scale for Kinesiophobia (TSK) was originally developed by Miller for the assessment of excessive, irrational and debilitating fear of physical movement/(re)injury in patients with back pain but was not published at the time. It was published in 1995 by Vlaeyen et al.[19] We used the items of the Turkish version for which the test–retest reliability has been found to be excellent.[20] Statistical analysis Statistical analysis of the data was performed using Statistical Package for the Social Sciences (SPSS) for Windows 16 software. The Kolmogorov–Smirnov test was used to investigate the normality of distribution of the continuous variables. The descriptive statistics were given as the mean±standard deviation for the continuous variables and as number of patients and percentage for the categorical variables. We excluded items for homogenity, if skewness exceeded ±1. Total sample size required to determine a moderete correlation (r=0.3) between SBST scale scores and RMDQ scores for 90% power was 112. 120 participants include to study for possible drop outs.[21] Reliability was evaluated by measuring both the internal consistency and test–retest reliability. The appropriate length of the interval depends on the stability of the variables. In this study, 7 days was used as a time interval. Internal consistency was assessed using item-total correlation and Cronbach’s alpha. A Cronbach’s alpha coefficient >0.7 was regarded as satisfactory. Test–retest reliability was determined using the intraclass correlation coefficient (ICC) and Pearson correlation analysis. Concurrent validity was examined by using Pearson correlations in relation between SBST and RMDQ, TSK, ODI and BDI. Pearson’s correlation coefficient values ≥0.40 were considered satisfactory (r ≥0.81– 1.0, excellent; 0.61–0.80, very good; 0.41–0.60, good; 0.21–0.40, fair and 0.0–0.20, poor).[22, 23]

Results The mean age of the 120 patients who participated in the study was 35.54±12.45 years, ranging from 18 to 50 years, with 74 (61.7%) female and 46 (38.3%) male. Table 2 shows the demographic and clinical characteristics of the participants. The mean overOCTOBER 2019


Validity and reliablity of Turkish version of STarT Back Screening Tool

Table 3. Reliability of the SBST

Value

Internal consistency: Cronbach’s α (n=120) SBST Overall (Q1–Q9) SBST Psychosocial subscale (Q5–Q9) Test–retest reliability: ICC SBST Overall (Q1–Q9) SBST Psychosocial subscale (Q5–Q9) Test–retest reliability: correlation, r SBST Overall (Q1–Q9) SBST Psychosocial subscale (Q5–Q9)

0.747 0.738 0.904 (95% CI0.762–0.960) 0.934 (95% CI 0.838–0.973) 0.824 (95% CI 0.757–0.874)** 0.877 (95% CI 0.828–0.912)**

SBST: STarT Back Screening Tool; Q: Question; ICC: Intraclass correlation coefficient; **p<0.001.

Table 4. Validity of the SBST Correlation, r RMDQ TSK OID BDS

SBST overall score

SBST psychosocial subscale

0.678 (95% CI 0.568–0.764)** 0.473 (95% CI 0.321–0.601)** 0.541 (95% CI 0.401–0.656)** 0.336 (95% CI 0.167–0.485)**

0.585 (95% CI 0.454–0.691)** 0.480 (95% CI 0.330–0.607)** 0.405 (95% CI 0.244–0.544)** 0.410 (95% CI 0.250–0.548)**

SBST: STarT Back Screening Tool; RMDQ: Roland Morris Disability Questionnaire; TSK: Tampa Scale of Kinesophobia; ODI: Oswestry Disability Index (ODI), BDS: Beck Depression Scale; **p<0.001.

all SBST score (Items 1–9) was 3.90±2.54 and the mean psychosocial subscale score (Items 5–9) was 1.68±1.79.

psychosocial subscale. The Pearson correlation coefficients were 0.824 (p<0.05) for the overall scale and 0.823 (p<0.05) for the psychosocial subscale.

Linguistic and cultural translation During the second and third steps of the translation process, for Item 9 the phrase ‘Overall, how bothersome...’ was translated as ‘Overall, how much bothersome...’. The translation very close to the original wording was used and difficulties in understanding the meaning of the questions were not found by patients.

Validity Pearson correlation coefficients for the correlations between the overall SBST scale and the other measures were as follows: RMDQ very good (r=0.678, p<0.001); TSK good (r=0.473, p<0.001); OID good (r=0.541, p<0.001) and BDI moderate (r=0.336, p<0.001). For the psychosocial subscale these values were as follows: RMDQ good (r=0.585, p<0.001); TSK good (r=0.480, p<0.001); OID good (r=0.405, p<0.001) and BDI good (r=0.410, p<0.001). These results indicate the concurrent validity of the Turkish version of SBST (Table 4).

Reliability Cronbach’s alpha coefficients in the analysis of scale reliability were 0.747 for the overall scale (Items 1–9) and 0.738 for the psychosocial subscale (Items 5–9) (Table 3). When the ‘alpha if item deleted’ values were investigated, all were found to be smaller than the overall alpha values. The ICC score for test–retest reliability was 0.904 (95% confidence interval (CI), 0.762–0.960) for the overall scale and 0.934 (95% CI, 0.838–0.973) for the OCTOBER 2019

Discussion This study demonstrated that the Turkish version of SBST (STarT-TR) is a valid and reliable instrument for Turkish-speaking patients with non-specific LBP. SBST that was translated from English to Turkish by 167


A RI PAIN following international guideline recommendations is provided to literature as a tool with good psychometric properties, easy to use and potentially useful for future epidemiological studies. The quality of our translation process was good acoording to the Guidelines for the Process of CrossCultural Properties of Self-Report Measures.[11] Because our translation process met all the 6 criteria for valid translation. The following 6 steps were: (1) initial (forward) translation, (2) synthesis of the translation, (3) back translation, (4) use of an expert committee, (5) testing the prefinal version, and (6) appraisal of the adaptation process. This 6-item tool evaluates the quality of the translation process into a new language or culture through the following 6 steps: (1) initial (forward) translation, (2) synthesis of the translation, (3) back translation, (4) use of an expert committee, (5) testing the prefinal version, and (6) appraisal of the adaptation process. In literature, only 2 versions (Belgian-French and Mandarin) met all the 6 criteria for valid translation according to the guideline.[24] Most functional questionnaires are developed in the English language. For clinical research the source language is of primary importance. Translation difficulties can be encountered in such cultural adaptation studies. In French and Finnish versions, a few minor discrepancies were changed during the translation process.[25, 26] At the end of the translation process in our study, there was only one item that needed to be changed in the Turkish version: in Item 9 the phrase ‘Overall, how bothersome...’ was translated as ‘Overall, how much bothersome’. We therefore concluded that this questionnaire was easily understandable by the Turkish population. SBST is an internationally recognized, valid and reliable tool for screening patients with LBP and has been translated for different cultures, such as Iranian, Spanish, Danish, Brazilian and French. In general, only the translation procedures with cultural adaptation have been reported for these. However, the discriminative validity was tested in the Danish (STarT-dk) and Iranian versions. Although it contains three psychosocial items that were different and have not been validated, STarT-dk was shown to have sufficient patient acceptability in Denmark. 168

Discriminative validity for the Turkish version should be tested in future studies for development of the psychometric properties. In literature, construct validity was tested in 10 versions by comparing the SBST scores with several constructs of self-reported outcome measures, including pain intensity; functional status; catastrophizing; fear of movement; anxiety and depression; and some quality of life domains.[24] Concurrent validity is considered a subcategory of construct validity and it is another statistical method to test validity, with our study showing the Turkish SBST to be valid for patients speaking the Turkish language. We examined concurrent validity by comparing SBST with RMDQ, TSK, ODI and BDI, which measured similar concepts. Studies translated from the original SBST to different cultures had very different results when examining concurrent validity. The relation between SBST and RMDQ was found to be very good (r=0.68, p<0.001) in this present study. For the French translation, Bruyere[25] observed a high Spearman correlation coefficient of 0.74 between SBST and RMDQ, while the German[28] translation resulted in a moderate Spearman correlation (r=0.55, p<0.001). The Iranian version of SBST was found to be a valid and reliable tool for LBP with lumbar spinal stenosis.[29] They used only the ODI for convergent validity, which showed a strong correlation with the Iranian SBST (r=0.81, p<0.001). In our study, we found a good correlation with ODI (r=0.541, p<0.001). Because of the differences in disease group and risk classification, our study cannot exactly support the Iranian version of SBST. For the German translation, Aebischer et al. observed Spearman coefficient values for the correlation with TSK of 0.40 for the total score and 0.46 for psychosocial subscale.[28] The correlation of the Finnish version of SBST with the BDI gave moderate Spearman coefficient values of 0.38 for the total score and 0.36 for the psychosocial subscale. [26] We found similar results in the present study (total score 0.34 and psychosocial subscale 0.41). Also, the majority of versions were validated in physical therapy settings like our study. [27]

Other version studies assessed internal consistency with Cronbach’s α like our study. Seven studies assessed internal consistency, Cronbach’s α was good (>0.70) except in the Finnish and German versions. [26, 28] In literature, in some versions such as BelgianOCTOBER 2019


Validity and reliablity of Turkish version of STarT Back Screening Tool

French version the methodologic quality was often found to be poor because Cronbach’s α was less than 0.70.[24] But in our study, Cronbach’s α was more than 0.70 for SBST Overall and SBST Psychosocial subscale. Also, our sample size recruiting over 100 subjects for testing internal consistency were adequate. So the Turkish version of SBST have a good internal consistency. In literature, similar to our work, generally the testretest reliability was conducted by using interclass correlation coefficient (ICC). ICC values for SBST ranged from 0.67 (Finnish version) to 0.93 (Mandarin version).[24–30] Smilarly, in our study, the ICC scores for test–retest reliability were excellent for both the overall scale and psychosocial subscale (0.90 and 0.93, respectively). This study had several strengths. It included patients in the adult population with LBP but no symptoms of osteoarthritis and included a good representation of both sexes. The participants fully responded to all the questions and did not experience difficulty in understanding them. Our study showed that test– retest reliability was excellent. However, there were also limitations. We used only concurrent validity for testing validity; discriminative validity should be tested in future studies. Participants between the ages of 18 and 50 years were included in the study, and further assessment of SBST should be performed in an elderly population.

Conclusion STarT-TR is available for non-specific LBP and its reliability in this study was perfect. SBST can help clinicians to evaluate the prognosis of patients that are affected by physical and psychosocial factors and it is a straightforward tool for suggesting the most appropriate form of treatment for each patient. Informed Consent: All participants read and signed the informed consent form prior to enrolment. Ethical Approval: The study was approved by the University’s Human Investigation Committee (2018-08). Conflict-of-interest issues regarding the authorship or article: None declared. Sorces of Support: This study was not funded by any organization. Peer-rewiew: Externally peer-reviewed.

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References 1. Dreyer SJ and Dreyfuss PH. Low back pain and the zygapophysial (facet) joints. Arch Phys Med Rehabil 1996;77(3):290–300. 2. Waddell G. Low back pain: a twentieth century health care enigma. Spine (Phila Pa 1976) 1996;21(24):2820–5. 3. Altinel L, Kose KC, Ergan V, Isik C, Aksoy Y, Ozdemir A, et al. The prevalence of low back pain and risk factors among adult population in Afyon region, Turkey. Acta Orthop Traumatol Turc 2008;42(5):328–33. 4. Gilgil E, Kacar C, Butun B, Tuncer T, Urhan S, Yildirim C, et al. Prevalence of low back pain in a developing urban setting. Spine (Phila Pa 1976) 2005;30(9):1093–8. 5. Tucer B, Yalcin BM, Ozturk A, Mazicioglu MM, Yilmaz Y, Kaya M. Risk factors for low back pain and its relation with pain related disability and depression in a Turkish sample. Turk Neurosurg 2009;19(4):327–32. 6. van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006;15(Suppl 2):169–91. 7. Picavet HS, Vlaeyen JW, and Schouten JS. Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. Am J Epidemiol 2002;156(11):1028–34. 8. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976) 2002;27(5):E109–20. 9. Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008;59(5):632–41. 10. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care manage- ment for low back pain with current best practice (STarT Back): a randomized controlled trial. Lancet 2011;378(9802):1560–71. 11. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976) 2000;25(24):3186–91. 12. Fritz JM, Beneciuk JM, and George SZ. Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain. Phys Ther 2011;91(5):722–32. 13. Roland M, Morris R. A study of the natural history of back pain: 1. Development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8(2):141–4. 14. Kucukdeveci AA, Tennant A, Elhan AH, Niyazoglu H. Validation of the Turkish version of the Roland-Morris Disability Questionnaire for use in low back pain. Spine (Phila Pa 1976) 2001;26(24):2738–43. 15. Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980;66(8):271–3. 16. Yakut E, Duger T, Oksuz C, Yorukan S, Ureten K, Turan D, et al. Validation of the Turkish version of the Oswestry Disabil-

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A RI PAIN ity Index for patients with low back pain. Spine (Phila Pa 1976) 2004;29(5):581–5. 17. Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clin Psych Rev 1988;8(1):77–100. 18. Hisli N. Beck Depresyon Envanterinin geçerliği üzerine bir çalışma. Psikoloji Dergisi 1998;22:118–27. 19. Vlaeyen JW, Kole-Snijders AM, Boeren RG, and van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62(3):363–72. 20. Tunca Yimaz O, Yakut Y, Uygur F, Uluğ N. Tampa Kinezyofobi Ölçeği’nin Türkçe versiyonu ve test-tekrar test güvenirliği. Fizyoter Rehabil 2011;22(1):44–9. 21. Hulley SB, Cummings SR, Browner WS, Grady D, Newman TB. Designing clinical research: an epidemiologic approach. 4th ed. Philadelphia, PA: Lippincott Williams&Wilkins; 2013. 22. Feise RJ, Michael Menke J. Functional rating index: a new valid and reliable instrument to measure the magnitude of clinical change in spinal conditions. Spine (Phila Pa 1976) 2001;26(1):78–86. 23. Kirkwood BR, JAC S. Essential medical statistics. Massachusetts, USA: Oxford Blackwell Publishing Ltd; 2004. 24. Al Zoubi FM, Eilayyan O, Mayo NE, Bussières AE. Evaluation of Cross-Cultural Adaptation and Measurement Properties

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of STarT Back Screening Tool: A Systematic Review. J Manipulative Physiol Ther 2017;40(8):558–72. 25. Bruyere O, Demoulin M, Brereton C, Humblet F, Flynn D, Hill JC. Translation validation of a new back pain screening questionnaire (the STarT Back Screening Tool) in French. Arch Public Health 2012;70(1):12. 26. Piironen S, Paananen M, Haapea M, Hupli M, Zitting P, Ryynanen K, et al. Transcultural adaption and psychometric properties of the STarT Back Screening Tool among Finnish low back pain patients. Eur Spine J 2016;25(1):287– 95. 27. Morso L, Albert H, Kent P, Manniche C, Hill J. Translation and discriminative validation of the STarT Back Screening Tool into Danish. Eur Spine J 2011;20(12):2166–73. 28. Aebischer B, Hill JC, Hilfiker R, Karstens S. German Translation and Cross-Cultural Adaptation of the STarT Back Screening Tool. PLoS One 2015;10:e0132068. 29. Azimi P, Shahzadi S, Azhari S, and Montazeri A. A validation study of the Iranian version of STarT Back Screening Tool (SBST) in lumbar central canal stenosis patients. J Orthop Sci 2014;19(2):213–7. 30. Pilz B, Vasconcelos RA, Marcondes FB, Lodovichi SS, Mello W, Grossi DB. The Brazilian version of STarT Back Screening Tool - translation, cross-cultural adaptation and reliability. Braz J Phys Ther 2014;18(5):453–61.

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Appendix

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Agri 2019;31(4):172–177

doi: 10.14744/agri.2019.65037

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KLİNİK ÇALIŞMA / ORIGINAL ARTICLE

Kronik migrene dönüşüm üzerine etkili risk faktörlerinin araştırılması Investigation of the risk factors for the transition of episodic migraines to chronic migraines Arife ÇIMEN ATALAR,

Osman Özgür YALIN

Özet Amaç: Kronik migren (KM), toplumda sık rastlanan, ciddi sosyoekonomik ve kişisel engelliliğe yol açabilen fakat halen tanısal zorlukların yaşandığı bir migren komplikasyonudur. Bu çalışmada amacımız, üçüncü basamak bir başağrısı polikliniğine başvurmuş ve KM tanısı ile takip edilmekte olan hastalarda, kronik migrene dönüşümde etkili olabilecek faktörlerin belirlenmesi ve bu faktörlerin hastalık prognozuna olan etkilerini araştırmaktır. Gereç ve Yöntem: Baş Ağrısı Polikliniğimize, Şubat 2015–Aralık 2017 tarihleri arasında baş ağrısı yakınması ile başvuran hastalar arasından 115 KM ve 377 epizodik migren (EM) hastası çalışmaya dahil edilmiştir. Hastalık başlangıç yaşı, baş ağrısının süresi ve sıklığı, aura varlığı ve tipi, baş ağrısının klinik özellikleri ve lokalizasyonu, ağrının şiddeti, tetikleyici faktörler, aile öyküsü varlığı, VAS ve ASC skorları, allodini varlığı, MIDAS skorları kaydedilmiş ve iki grup istatistiksel olarak karşılaştırılmıştır. KM e dönüşümde bağımsız risk faktörlerinin belirlenebilmesi amacıyla lojistik regresyon yöntemi kullanılmıştır. Bulgular: 492 hastanın (408 kadın, 84 erkek) yaş ortalaması 36,03±12,67 yıl, hastalık süresi 10,78±10,36 yıl, atak sıklığı 10,35±9,06 atak/ay, atak süresi 30,10±23,54 saat idi. KM tanısı olan 115 hasta (104 kadın, 11 erkek) bulunmaktaydı. Kadın cinsiyet (p=0,015), atak sıklığı (p<0,001), ASC (p=0,002), VAS (p=0,001) ve MIDAS skorları (p<0,001) KM grubunda daha yüksekti. Lojistik regresyon analizinde, KM’e dönüşümde ilaç aşırı kullanımı (RR:0,9) ve allodini varlığı (RR:0,3) bağımsız risk faktörleri olarak bulundu (p<0,05). Sonuç: Üçüncü basamak bir merkezin verilerine dayanan çalışmamızın sonuçları, KM in gerek bireysel gerek toplumsal olarak ciddi engellilik oluşturabilen bir nörolojik hastalık olduğu, özellikle aşırı ilaç kullanımı ve kutanöz allodini tarifleyen hastalarda KM e dönüşüm açısından daha dikkatli olunması gerektiğini göstermektedir. Anahtar sözcükler: Başağrısı; kronik migren; migren yükü.

Summary Objectives: Chronic migraine (CM) is a frequent complication of migraines that has a serious impact on personal and social life and is still underdiagnosed. The aim of this study was to determine risk factors for the progression to CM and to investigate the relationship of these factors to the disease prognosis. Methods: In all, 115 CM and 377 episodic migraine patients from between February 2015 and December 2017 were enrolled. The age of disease onset, headache duration and frequency, presence of aura and type of aura, clinical properties and location of headache, pain severity, trigger factors, presence of family history, visual analogue scale (VAS) and Allodynia Symptom Checklist (ASC) scores, presence of allodynia, and Migraine Disability Assessment (MIDAS) scores were recorded and the 2 groups were compared statistically. Logistic regression was used to determine the independent risk factors for a conversion to CM. Results: The mean age of the 492 patients (408 female, 84 male) was 36.03±12.67 years, the disease duration was 10.78±10.36 years, the attack frequency was 10.35±9.06 attacks/month, and the attack duration was 30.10±23.54 hours. There were 115 patients (104 female, 11 male) with CM. Female gender (p=0.015), attack frequency (p<0.001), ASC score (p=0.002), VAS score (p=0.001), and MIDAS score (p<0.001) had greater representation in the CM group. Medication overuse (relative risk [RR]: 0.9) and allodynia (RR: 0.3) were independent risk factors for a transition to CM in the logistic regression analysis (p<0.05). Conclusion: Based on the present data of a tertiary headache center, it was concluded that CM is a disabling neurological disease with a serious personal and public burden. Special care should be taken among patients with medication overuse and cutaneous allodynia with regard to the possibility of transition to CM. Keywords: Chronic migraine; headache; migraine burden.

Sağlık Bilimleri Üniversitesi, İstanbul Eğitim ve Araştırma Hastanesi, Nöroloji Kliniği, Başağrısı Bölümü, İstanbul Division of Headache, Department of Neurology, Health Sciences University, Istanbul Training and Research Hospital, Istanbul, Turkey Başvuru tarihi (Submitted) 03.02.2019 Düzeltme sonrası kabul tarihi (Accepted after revision) 24.06.2019 Online yayımlanma tarihi (Available online date) 25.06.2019

İletişim (Correspondence): Dr. Arife Çimen Atalar. Sağlık Bilimleri Üniversitesi, İstanbul Eğitim ve Araştırma Hastanesi, Nöroloji Kliniği, Başağrısı Bölümü, İstanbul, Turkey. Tel (Phone): +90 - 533 - 814 18 17 e-posta (e-mail): cimenatalar@yahoo.com.tr © 2019 Türk Algoloji Derneği This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Kronik migrene dönüşüm üzerine etkili risk faktörlerinin araştırılması

Giriş Kronik migren (KM) toplumda sık rastlanan, ciddi sosyoekonomik ve kişisel engelliliğe yol açabilen fakat halen tanısal zorlukların yaşandığı bir migren komplikasyonudur.[1–3] Toplumsal insidansı yaklaşık %2,5 civarında olup tıpkı diğer primer başağrısı sendromlarında olduğu gibi tanısı temel olarak klinik öyküye dayanır.[4] En az 3 ay boyunca, ayda 15 gün ya da fazla ve 4 saatten uzun süren başağrısı atakları ile karakterize olup, bu atakların en az sekizinin migren tanı kriterlerini karşılaması KM tanısı için gerekmektedir.[5] Etyolojisinde epizodik migrenden (EM) dönüşüm çoğunlukla suçlanmakla birlikte, kişinin genetik yatkınlığı ve bazı modifiye edilebilir olan ve olmayan risk faktörlerinin bu dönüşümde rolü olduğu düşünülmektedir.[6] Migren kronifikasyonunda yukarıda belirtildiği gibi çok sayıda faktör suçlanmakla birlikte halen altta yatan patofizyolojik mekanizmalar ve kronikleşmeye neden olan etmenler tam olarak açıklığa kavuşturulamamıştır.[7, 8] Bu çalışmada amacımız, üçüncü basamak bir başağrısı polikliniğine başvurmuş ve kronik migren tanısı ile takip edilmekte olan hastalarda, KM’e dönüşümde etkili olabilecek faktörlerin belirlenmesi ve bu faktörlerin hastalık prognozuna olan etkilerini araştırmaktır.

Gereç ve Yöntem Üçüncü basamak bir merkeze bağlı Baş Ağrısı Polikliniği’ne, Şubat 2015–Aralık 2017 tarihleri arasında baş ağrısı yakınması ile başvuran hastalar arasından, bir nöroloji uzmanı tarafından, Uluslararası Baş ağrısı Derneği (International Headache Society, IHS) kriterlerine (ICHD-3) uygun olarak tanı almış olan ardışık 115 kronik migren (1.3) ve 377 epizodik migren (1.1 ve 1.2) hastası çalışmaya dahil edilmiştir. [5] KM tanı kriterlerini karşılayan hastalar çalışma grubunu oluştururken, hasta grubunun geri kalanı (EM hastaları) kontrol grubu olarak çalışmaya alınmıştır. Türkçe okuma ve yazma bilmeyen hastalar çalışmaya dahil edilmemiştir. Hastalık başlangıç yaşı, baş ağrısının süresi ve sıklığı, aura varlığı ve tipi, baş ağrısının klinik özellikleri ve lokalizasyonu, ağrının şiddeti, tetikleyici faktörler, aile öyküsü varlığı, VAS ve ASC skorları, allodini varlığı, MIDAS skorları gibi klinik ve demografik bilgiler her hasta için baş ağrısı uzmanı tarafından yapılan yüz yüze görüşmelerde standart bir anket formu uygulanarak kaydedilmiştir. EKİM - OCTOBER 2019

Görüşmelerde kullanılan formlardan Vizüel Analog Skala (VAS); horizontal ya da vertikal planda 10 cm lik düz bir çizgi üzerinde hastanın hissettiği ağrı şiddetini; 0= hiç ağrı yok ve 10= en şiddetli ağrı şeklinde belirtmesi ve bu yolla hastanın ağrı yoğunluğunun sübjektif olarak belirlenmesinde kullanılan bir ölçektir. [9,10] Allodini Semptom Anketi (ASC) ise 12 maddeden oluşan, kutanöz allodi varlığını, alt tiplerini ve şiddetini belirlemede kullanılan, Türkçe geçerlik ve güvenilirlik çalışması mevcut olan bir anket formudur.[11–13] MIDAS (Migraine disability assessment); Stewart ve ark. tarafından geliştirilmiş, geçerliliği ve güvenirliği kanıtlanmış, Türkçe validasyonu yapılmış olan bir testtir. Baş ağrısının son 3 ay içindeki etkisini beş sorudan oluşan bir form aracılığıyla, iş ve okul çalışması, ev işleri, aileyle geçirilen zaman ve sosyal durum tespiti yaparak inceler.[14, 15] Her hastanın detaylı sistemik ve nörolojik muayeneleri bir nöroloji uzmanı tarafından yapılarak hastaların kan basıncı, ağırlık ve boy ölçümleri standart cihazlar yardımıyla ölçülerek kaydedilmiştir (Riester/Seri Numarası: 4012835). Çalışmaya dahil edilen hastaların tamamından bilgilendirilmiş onam formu alınmış ve çalışma lokal etik kurul tarafından onaylanmıştır (İstanbul Eğitim ve Araştırma hastanesi. Protokol no: 612/27.02.2015). İstatistiksel analiz İstatistiksel analizler için SPSS (SPSS 22.0, IBM Corp., Armonk, NY, USA) programı kullanıldı. Çalışma verileri değerlendirilirken tanımlayıcı istatistiksel metotların (ortalama, standart sapma, medyan, frekans, oran, minimum, maksimum) yanı sıra, nicel verilerin karşılaştırılmasında normal dağılım gösteren değişkenlerin iki grup karşılaştırmalarında Student’s t test, normal dağılım göstermeyen değişkenlerin iki grup karşılaştırmalarında Mann Whitney U test kullanıldı. Nitel verilerin karşılaştırılmasında ki-kare test kullanıldı. Anlamlılık p<0,05 düzeylerinde değerlendirildi. KM gelişimi üzerine etkili olabilen bağımsız faktörlerin belirlenmesi, istatistiksel olarak anlamlılık gösteren faktörler kullanılarak lojistik regresyon analizi yöntemi aracılığıyla değerlendirilmiştir. Oluşturulan modelde model uyumu için Hosmer-Lemeshow testi kullanılmıştır. Tip 1 hata düzeyi %5’in altında olan durumlar istatistiksel olarak anlamlı kabul edilmiştir (Güven aralığı %95). 173


A RI PAIN Tablo 1. Kronik migren grubu ile kontrol grubunun demografik ve klinik özelliklerinin karşılaştırılması Demografik/klinik özellik Yaş (yıl) Cinsiyet (e/k) (n/%) Hastalık süresi (yıl) Atak sıklığı (n/ay) Atak süresi (saat) Sigara kullanımı (paket/yıl) ASC skoru VAS skoru Sistolik kan basıncı (mmHg) Diastolik kan basıncı (mmHg) MIDAS skoru Vücut kitle indeksi değeri (BMI)

KM grubu (n=115) Ort.±SS

Kontrol grubu (EM) (n=377) Ort.±SS

p**

37.00±12.71 11/104 11.85±11.36 22.68±6.96 31.79±23.74 3.32± 6.79 6.42±5.14 8.79±1.12 120.57±17.93 76.17±11.17 71.47±46.82 27.23±5.57

35.73±12.66 73/304 10.45±10.03 6.59±5.65 29.58±23.49 3.26±7.16 4.58±4.71 8.30±3.62 121.42±18.72 77.64±12.63 22.66±21.40 26.60±6.22

0.213 0.015* 0.443 <0.001* 0.288 0.906 0.002* 0.001* 0.724 0.495 <0.001* 0.465

KM: Kronik migren; EM: Epizodik migren; n: sayı; Ort. Ortalama; SS: Standart sapma; e: Erkek; k: Kadın BMI: Body mass index; ASC: Allodini Semptom Anketi; VAS: Vizüel Analog Skala; MIDAS: Migraine disability assessment; *p<0.05; **Pearson ki-kare.

Tablo 2. Kronik migren ve epizodik migren grubu arasında migren özelliklerinin karşılaştırılması

KM grubu (n=115)

Kontrol grubu (EM) (n=377)

p**

n % n %

Aura varlığı 39 33.9 111 29.4 0.362 İlaç aşırı kullanımı 70 60.9 6 1.6 <0.001* Aile öyküsü 83 72.2 241 63.9 0.103 Allodini varlığı 91 79.1 227 60.2 <0.001* Fizik aktivite ile tetiklenme 110 95.7 345 91.5 0.26 Fotofobi varlığı 95 82.6 318 84.4 0.756 Fonofobi varlığı 97 84.3 321 85.1 0.834 ¥ Menstruasyon ile tetiklenme 67 58.3 164 43.5 0.008* KM: Kronik migren; EM: Epizodik migren; n: sayı; ¥Yalnız kadın hasta grubu için değerlendirme yapılmıştır; *p<0.05; **Pearson ki-kare.

Bulgular Çalışmaya katılan 492 hastanın (408 kadın, 84 erkek) yaş ortalaması 36,03±12,67 yıl, hastalık süresi 10,78±10,36 yıl, atak sıklığı 10,35±9,06 atak/ay, atak süresi 30,10±23,54 saat idi. KM tanısı olan 115 hasta (104 kadın, 11 erkek) bulunmaktaydı. KM grubunda olan ve kontrol grubunu oluşturan hastaların klinik ve demografik verilerinin karşılaştırması Tablo 1’de verilmiştir. Tablo 2’de migren karakteristikleri bakımından iki grup karşılaştırılmıştır. KM grubunda, kadın cinsiyet (p=0,015), yüksek atak sıklığı (p<0,001), ASC (p=0,002), VAS (p=0,001) ve MI174

DAS skorları (p<0,001) EM grubuna göre istatistiksel olarak anlamlı düzeyde yüksek bulundu. Yapılan lojistik regresyon analizi sonucunda, KM’e dönüşümde ilaç aşırı kullanımı (RR:0,9) ve allodini varlığı (RR:0,3) bağımsız risk faktörleri olarak bulunmuştur (p<0,05).

Tartışma Çalışmamız; KM in kadınlarda daha sık görüldüğü ve atak sıklığı, VAS, ASC ve MIDAS skorlarının bu hasta grubunda belirgin olarak yüksek bulunduğunu göstermektedir. Ayrıca ilaç aşırı kullanımı ve allodininin EKİM - OCTOBER 2019


Kronik migrene dönüşüm üzerine etkili risk faktörlerinin araştırılması

bu hasta grubunda daha yüksek oranlarda bulunduğu ve kadın hastalarda menstruasyonun tetikleyici rolü olduğu izlenmiştir. KM’e dönüşümde ilaç aşırı kullanımı (RR:0,9) ve allodini varlığı (RR:0,3) bağımsız risk faktörleri olarak bulunmuştur. Blumenfeld ve ark’nın 2011 de yayınladığı, 9 ülkede 8726 hasta üzerinde yapılmış olan International Burden of Migraine Study (IBMS) sonuçlarına göre KM hastalarında migrenle ilişkili dizabiliteyi yansıtan MIDAS skorları ve ağrı şiddeti ile ilişkili VAS skorları EM grubuna kıyasla belirgin olarak yüksek bulunmuştur (ortalama MIDAS skorları KM için 72,6; EM için 14,5) (p<0,001). Cinsiyet ve yaş ortalaması bakımından iki grup arasında fark gözlenmemiştir.[3] Benzer bir başka çalışmada 520 KM hastası ile 9424 EM’li hasta karşılaştırılmış, KM grubunda hastalık ile ilişkili dizabiliteyi yansıtan MIDAS skorlarının EM’e oranla anlamlı düzeyde yüksek olduğu görülmüştür.[16] VAS ve MIDAS skorlarının KM grubunda belirgin yüksek bulunması, KM’in diğer migren alt tiplerine göre çok daha belirgin engellilik ve yaşam kalitesi bozukluğu nedeni olduğunu göstermektedir. Bizim çalışmamızda da benzer biçimde MIDAS ve VAS skorları kronik migrenli grupta belirgin olarak yüksek bulunmasının yanı sıra, kadın cinsiyette kronikleşme oranları erkek cinsiyete oranla çok daha yüksekti. Migrenin tüm alt gruplarında kadın cinsiyetin baskın olduğu daha önce yapılmış çok sayıda çalışmada gösterilmiştir.[3, 17–21] Hormonal faktörler özellikle de yüksek östrojen düzeyleri ve menstruasyon esnasındaki östrojen çekilmesi, kadın cinsiyetteki artmış migren sıklığından sorumlu tutulmakla birlikte[22] kadın ve erkekte nöronal ve ağrıya dair iletim yolaklarının ve beyin yapılarının farklı olması da üzerinde durulan etkenler arasında yer almaktadır.[23] Menstruasyon ile ilişkili migren, tek başına ciddi dizabilite nedeni olabilen bir migren alt tipi olmasının yanısıra, KM hastalarında daha sık rastlanabildiğine dair yapılmış sınırlı sayıda çalışma mevcuttur.[24] Menstruasyon esnasında meydana gelen hormonal dalgalanmaların, migrenin evolüsyonunu hızlandırabileceği ve hormonal içerikli oral kontraseptiflerin EM den KM’e dönüşüme neden olabileceği öne sürülmüştür.[25, 26] Çalışmamızda kronik migrenli kadın hastalarda menstruasyon ile tetiklenmenin belirgin olması, olası hormonal mekanizmaların kronik migren oluşumu üzerinde etkili olabileceğini destekler EKİM - OCTOBER 2019

niteliktedir.[27] Bu bulgu, menstruasyonun tetiklediği migren atakları olan hastalarda erken tanının ve koruyucu tedavi uygulamalarının önemini vurgulaması bakımından dikkat çekicidir. Lipton RB ve ark.’ı 2015’te yapmış oldukları çalışmada, kronik migren gelişiminde, atak sıklığındaki artışın belirleyici faktörlerden biri olduğu ve migren ataklarının erken dönemde etkin olarak tedavi edilmesinin kronik migrene dönüşümün önüne geçebileceği üzerinde durmuşlardır.[28, 29] Özellikle ayda ≥4 atak geçirmekte olan bireylerde epizodik migrenden kronik migrene olan dönüşümde katlanarak bir artış meydana geldiğini gösteren çalışmalar mevcuttur. [30] Çalışmamızın sonuçları yukarda belirtilen çalışmalar ile benzer olup, atak sıklığında meydana gelen artışın, migrende kronikleşme eğilimini belirgin düzeyde arttırdığını dolayısıyla kronik migrene dönüşümde belirleyici olabileceğini destekler niteliktedir (p<0,001). Nosiseptif ağrı eşiğindeki azalma ve ağrı yolaklarındaki değişikliklerin (santral sensitizasyon), migrende allodininin varlığında rol oynadığı uzun zamandır bilinmektedir.[31] Kutanöz allodini varlığının, aynı zamanda hastalık progresyonunun bir ifadesi olduğu ve KM hastalarında epizodik gruba kıyasla daha yüksek oranlarda saptandığına dair çalışmalar mevcut olup, allodinin migrenli hastalarda migrenle ilişkili dizabiliteyi arttıran bir faktör olduğu düşünülmektedir.[19, 32, 33] Altta yatan patofizyolojik mekanizmalar halen net olmamakla birlikte öne sürülen hipotezler arasında beyin sapı trigeminal çekirdek kompleksi nöronlarının kronik sensitizasyonu ve ağrılı olmayan uyarana karşı artmış sensivite göstermesi dolayısıyla santral sensitizasyon dikkat çekicidir.[32, 34, 35] Santral sensitizasyon geliştiğinde nöronal uyarım eşiği düşmekte, nöronal ateşleme frekansı artmakta ve normalde ağrı uyandırmaması beklenen bir uyarana karşı ağrı hissedilmesi şeklinde bir yanıt meydana gelmektedir.[36] Çalışmamızda kronik migrenli hasta grubunda %79,1 oranında allodini var olduğunu tespit ettik ve bu oran literatürde bildirilen oranlar (%79) ile benzer bulundu.[35] Kronik migren hastalarında artmış kutanöz allodini ve santral sensitizasyon varlığının hastalık progresyonunu göstermede klinik bir belirteç olarak kullanılabileceğini düşünmekteyiz. İlaç aşırı kullanımı çok sayıda çalışmada migren kro175


A RI PAIN nifikasyonunda etkili olduğu düşünülen bir faktör olmakla birlikte, olası ilaç aşırı kullanımının eşlik ettiği KM’li hastalarda arındırma tedavisi sonrası %45 kadar hastada epizodik forma geri dönüş olmadığı bilinmektedir.[37] Bu durum bazı EM li hastalarda kronik forma dönüşmeye karşı bir yatkınlık olabileceği ihtimalini akla getirmektedir.[38] İlaç aşırı kullanımının ağrı yolaklarında modifikasyonlara neden olarak bazı hastalarda geri dönüşümsüz patofizyolojik değişikliklere yol açabilmesi ve sonuç olarak ağrıya olan santral sensitizasyonun arttırması mümkündür. Çalışmamızda ilaç aşırı kullanımının kronik migrenli grupta istatistiksel olarak belirgin şekilde artmış olduğunu ve yapılan regresyon analizi ile oluşturulan modelde ilaç aşırı kullanımının kronik migrene dönüşümde etkili bir faktör olduğunu gördük. Bu sonuç EM li hastalarda erken evrede doğru bir tedavi planı düzenlenerek kronik migren gelişiminin önüne geçilebileceğini düşündürmesi bakımından dikkat çekicidir. İlaç aşırı kullanımı ve allodini varlığı yukarıda vurgulandığı üzere, kronik migren oluşumu bakımından risk faktörü oluşturmasının yanısıra, kronik migren oluşumunun bir sonucu olarak da ortaya çıkabilirler. Kronik migren hastalarında gelişen persistan kortikal hipereksitabilite bu hasta grubunda kutanöz allodini gelişimine yol açabilmektedir.[32, 39] Yine kronik migrenli hastalarda optimum dozda ve efektif tedavilerin uygulanmaması durumda, hastalar aşırı ilaç kullanımına yönelmekte ve bu durum kronik migrenle ilişkili dizabiliteye ilaç aşırı kullanım başağrısının eklenmesine yol açarak mevcut dizabilitede artışa yol açabilmektedir.[31, 38] Çalışmamızın bazı kısıtlılıkları bulunmaktadır. Öncelikle çalışmamız 3. basamak bir başağrısı merkezinde ve genel popülasyona kıyasla dirençli sayılabilecek hastalarla yapılmış bir çalışma olması nedeniyle toplum genelini yansıtmada yetersiz kalabilir. İkincil olarak çalışmada bir hayat kalitesi ölçeği kullanılmamış olması EM ve KM grupları arasında hayat kalitesindeki etkilenmenin karşılaştırılabilmesini MIDAS skorları ile sınırlamaktadır. Son olarak bu hastaların komorbid durumlar (anksiyete, depresyon vb) açısından objektif ölçekler ile değerlendirilememiş olması, komorbid hastalıkların KM oluşumu üzerinde olası olumsuz etkilerinin değerlendirilebilmesini güçleştirmektedir. 176

Sonuç Üçüncü basamak bir başağrısı merkezinin verilerine dayanan çalışmamızın sonuçları, KM in gerek bireysel gerek toplumsal olarak ciddi engellilik oluşturabilen bir nörolojik hastalık olduğu, özellikle aşırı ilaç kullanımı ve kutanöz allodini tarifleyen hastalarda KM e dönüşüm açısından daha dikkatli olunması gerektiğini göstermiştir. KM ve EM arasındaki farklılıkların ve altta yatan nedenlerin aydınlatılmasına yönelik çalışmaların, erken tanı ve etkili koruyucu tedavilerin ortaya çıkmasına zemin oluşturabileceği kanaatindeyiz. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması (conflict of interest) yoktur. Hakem değerlendirmesi: Dış bağımsız.

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doi: 10.14744/agri.2019.34735

A RI PAIN

ORIGINAL ARTICLE

Effect of piriformis injection on neuropathic pain Effect of piriformis injection on neuropathic pain Rana TERLEMEZ,1

Tülay ERÇALIK2

Summary Objectives: The aim of this study was to investigate the effect of a piriformis injection on neuropathic pain in patients with piriformis syndrome. Methods: Thirty patients with unilateral hip and/or leg pain, a positive FAIR test (increased H-reflex latency with Flexion, Adduction and Internal Rotation), and a trigger point at the piriformis muscle were enrolled in this prospective study. All of the patients exhibited neuropathic pain scored according to the Douleur Neuropathique 4 (DN4) of ≥4 for at least 6 months. All of the patients received 4 mL of lidocaine 2%+1 mL of betamethazone to the piriformis muscle under the guidance of ultrasound. The Numeric Rating Scale (NRS), DN4, and the painDETECT (PD) questionnaire were used for outcome assessment. Results: A statistically significant improvement was seen in all scores (p<0.001) when both first week and first month results were compared with the baseline values. Comparison of the first week results with those of the first month revealed a statistically significant improvement in only the NRS and PD scores (p<0.001). The greatest improvement in all scores was seen in the first week after the injection. A mild increase was seen in all scores at the first month compared to the first week. Conclusion: A piriformis injection was found to be effective for both somatic and neuropathic pain in piriformis syndrome patients. Long-term follow-up is needed in order to consider this option alongside other treatment alternatives, like botulinum toxin and myofascial release. Keywords: Neuropathic pain; piriformis muscle syndrome; ultrasound.

Özet Amaç: Piriformis sendromlu hastalarda uygulanan piriformis enjeksiyonunun hastalardaki nöropatik ağrı üzerine etkisini değerlendirmek. Gereç ve Yöntem: Tek taraflı kalça ve/veya bacak ağrısı olan, FAIR testi pozitif ve piriformis kasında palpasyonla tetik nokta saptanan 30 hasta çalışmaya dahil edildi. Bu prospektif çalışmada, tüm hastaların Douleur Neuropathique 4 (DN4) skoru en az 6 aydır 4 veya üzerinde idi. Tüm hastalara ultrason eşliğinde piriformis kasına 4 ml lidokain 2% + 1 ml betametazon enjekte edildi. Post-enjeksiyon 1. hafta ve 1. ayda hastalar değerlendirildi. Çalışmamızda, Numerik ağrı skalası (NAS), DN4, PainDETECT anketi (PDA) yöntemlerini kullandık. Bulgular: Başlangıç değerlerine göre 1. hafta ve 1. ay sonuçları karşılaştırıldığında tüm skorlarda istatistiksel olarak anlamlı düzelme olduğu görüldü (p<0,001). Birinci hafta ve 1. ay sonuçları karşılaştırıldığında istatistiksel anlamlı düzelme sadece NAS ve PDA skorlarında görüldü (p<0,001). Tüm skorlarda en anlamlı azalma 1. Haftanın sonunda görüşmekle beraber; 1. ay sonunda da hafif bir azalma devam etmekteydi. Sonuç: Bu çalışmada piriformis enjeksiyonu hem somatik hem de nöropatik ağrı komponenti üzerine etkili bulundu. Uzun dönem takip içeren çalışmalara, özellikle botulinum toksin ve miyofasyal gevşetme gibi diğer tedavi yöntemlerine karar verme açısından, ihtiyaç vardır. Anahtar sözcükler: Enjeksiyon; nöropatik ağrı; piriformis sendromu; ultrason.

Introduction Piriformis syndrome (PS) is an underestimated cause of sciatic neuralgia. It was thought that sciatica mostly occurs due to degenerative changes of the lumbar region. PS was first described by Yeoman in 1928.[1]

The piriformis is a ‘pear shaped’ muscle which externally rotates the hip in knee extension.[2] The sciatic nerve goes under the piriformis muscle in the gluteal region. Beaton et al. identified some anatomic variations of the close relationship between the piriformis muscle and sciatic nerve.[3]

Department of Physical Medicine and Rehabilitation, Health Sciences University, Şişli Hamidiye Etfal Hospital, Health Research and Application Center, İstanbul, Turkey 2 Department of Algology, Health Sciences University, Şişli Hamidiye Etfal Hospital, Health Research and Application Center, İstanbul, Turkey 1

Submitted (Başvuru tarihi) 05.02.2019 Accepted after revision (Düzeltme sonrası kabul tarihi) 15.05.2019 Available online date (Online yayımlanma tarihi) 28.06.2019

Correspondence: Dr. Rana Terlemez. Sağlık Bilimleri Üniversitesi, Şişli Hamidiye Etfal Hastanesi, Sağlık Araştırma ve Uygulama Merkezi, Fiziksel Tıp ve Rehabilitasyon Kliniği, İstanbul Turkey. Phone: +90 - 535 - 554 46 38 e-mail: ranakaynar@hotmail.com © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Effect of piriformis injection on neuropathic pain

The awareness of PS has increased with prior studies. Correct diagnosis is important because PS is a successfully treatable cause of sciatic neuralgia. PS has both somatic and neuropathic pain components. Somatic pain is commonly related to myofascial origin of PS.[4] On the other hand, hypertrophic and inflamed piriformis leads to the trapping of the sciatic nerve. Mixed pain mechanisms are valid in this syndrome. Maybe chronic PS lead to increase central sensitization and activate the neuropathic pain pathways. In this study we aimed to investigate the effect of piriformis injection on neuropathic pain in patients with PS. Medical agents such as nonsteroidal anti-inflammatory drugs, muscle relaxants and neuropathic pain agents are first choices in the treatment of PS. Stretching exercises and physical therapy modalities should be added. If conservative treatment methods fail, injections to the piriformis muscle should be done by various methods.[5] Injections can be adminstered by using ultrasound (US), electromyography, computed tomography or magnetic resonance imaging. US-guided injection techniques have been well defined in prior studies.[6â&#x20AC;&#x201C;9] Some studies have assessed the effectiveness of US-guided techniques; however, none followed up on patients for neuropathic component.

Material Methods Study design This prospective study was conducted in patients with PS in physical medicine and rehabilitation department of a research and training hosiptal. Informed consent was obtained for all patients in this study. All procedures were in accordance with the ethical standards and with the 1964 Helsinki Declaration and its later amendments. Study population Thirty patients (n=30) diagnosed as PS with neuropathic pain were enrolled in this study between 02/01/2017-30/11/2017. Diagnosis was based on patient history and physical examination; including trigger point at the piriformis muscle and positive FAIR (flexion, adduction, internal rotation) test. We included the cases between the ages of 18 to 60. Patients exhibiting neuropathic pain according to Douleur Neuropathique 4 (DN4)â&#x2030;Ľ4) for at least 6 months were included. DN4 questionnare was developed by OCTOBER 2019

Figure 1. The piriformis muscle as a hyperecoic band under the gluteus maximus muscle.

the French Neuropathic Pain Group in 2005.[10] The Turkish validity and reliability of the DN4 questionnare was made in 2010 with a sensitivity of 95% and a specifity of 96.6%.[11] The exclusion criteria were having a history of the surgery at the lumbar region, restricted range of the hip or lumbar spine, existing neurological deficiency, active infectious disease or active psychiatric disease. Patients with a history of allergic reaction to the local anesthetics or current anticoagulant use were also excluded. The mean Numeric Rating Scale (NRS), Douleur Neuropathique 4 (DN4), Pain Detect Questionnare (PDQ) were evaluated at baseline, 1.week and 1. month after the injection. PDQ was developed by Freynhagen et al. in 2006.[12] PDQ is a simple, self-administered questionnaire which was adapted to Turkish language in 2013 by Alkan et al.[13] Injection technique All injections were done in prone position. After placing a linear US probe at transverse scan, first sacral hiatus was found. Then the US probe was moved towards the greater trochanter. The piriformis muscle was located as a hyperecoic band under the gluteus maximus muscle (Fig. 1). All patients received 4 ml of lidocaine 2% + 1 ml of betametazone to the piriformis muscle in in-plane technique. All injections were performed by the same physiatrist. 179


A RI PAIN Table 1. Time-dependent changes in the scores

Mean

SD

p*

NRS-1 7.1 1.1 NRS-2 2.3 1.9 <0.001a,b,c NRS-3 3.5 1.8 PDQ-1 22.3 4.0 PDQ-2 12.8 5.3 <0.001d,e,f PDQ-3 15.0 5.2 DN4-1 5.1 0.9 DN4-2 2.5 1.4 <0.001g,h,i DN4-3 2.7 1.5 SD: Standard deviation; NRS: Numeric rating scale; PDQ: Pain detect questionnare; DN-4: Douleur neuropathique 4; *Variance analyzes in recurrent measurements; a, d, g: Comparison of the first and second measurements NRS, PDQ, DN-4 (for all) p<0.001; b, e, h: Comparison of the first and third measurements NRS, PDQ, DN-4 (for all) p<0.001; c, f, i : Comparison of the second and third measurements NRS, PDQ, DN-4 (respectively) p=0.001; p=0.009; p=0.326.

Statistical analysis The SPSS 20.0 software bundle was used to analyze the data. variance analysis was used in the analysis of recurrent measurements. Pearson correlation analysis was used for correlations. Statistical significance was set at p<0.05.

Results Fourty-seven patients with PS were admitted to our clinic between 02/01/2017-30/11/2017. Thirty of them meeting the inclusion criteria were included in the study. The mean age of the patients was 52.7±11.6. The mean duration of the symptoms was 10.9±7.8. The study group was consisted of 20 female and 10 male patients. When compared to the baseline scores significant decreases were seen in all measurements. The mean NRS scores at baseline, 1st week and 1st month were 7.1, 2.3 and 3.5 respectively. The mean DN4 scores at baseline, 1st week and 1st month were 5.1, 2.5 and 2.7 respectively. The mean PDQ scores at baseline, 1st week and 1st month were 22.3, 12.8 and 15 respectively. The highest decrease in all scores after injection was seen in the 1st week. A mild increase was seen in all scores at the 1st month compared to the 1st week. However all scores were still lower than baseline scores (Table 1). In post hoc analyzes, when compared to the baseline results with both 1st week and 1st month results, statistically significant im180

Table 2. Correlation of NRS, PDQ and DN-4 scores for time-dependent changes Baseline- 1st week PDQ DN-4 Baseline- 1st month PDQ DN-4 1st week- 1st month PDQ DN-4

NRS* r

PDQ*

pǂ r pǂ

0.657 <0.001 0.636 <0.001 0.578 0.001 0.617 <0.001 0.706 <0.001 0.442 0.014 0.698 <0.001 0.697 <0.001 0.636 <0.001

*The scores given represent the data of their own group; ǂPearson correlation analyzes.

provement were seen in all scores (p<0.001). When compared to the 1st week results with 1st month results, statistically significant improvement were seen in only NRS and PD scores (p<0.001). When the correlation of the changes in NRS, PD and DN-4 scores were examined, a strong positive correlation was found between NRS and PD; also NRS and DN-4. There was a moderate corralation between PD and DN-4 (Table 2).

Discussion Pain in PS is usually characterized by two components; somatic and neuropathic. The somatic component is mostly related to myofascial origin while the neuropathic component is related to nerve compression or irritation.[14, 15] In this study we aimed to investigate the effect of piriformis injection on neuropathic pain in PS. Patients exhibiting neuropathic pain according to DN-4 for at least 6 months were included. When compared to the baseline scores significant decreases were seen in both 1st week and 1st month results for NRS, DN-4 and PD. We saw that the piriformis injection is effective not only on the somatic pain but also on neuropathic pain in PS. The piriformis muscle originates from anterior part of the sacrum then passes through the greater sciatic notch and inserts to the medial aspect of the greater trochanter. The sciatic nerve usually passes through the greater sciatic notch below the piriforOCTOBER 2019


Effect of piriformis injection on neuropathic pain

mis muscle.[3, 16] While there are still some uncertanities in etiologic factors of PM. This close relationship between the piriformis muscle and the sciatic nerve is the most accepted cause of sciatica in PS. Irritation of the fibular branch of the sciatic nerve commonly leads to pain or paresthesia in the posterior thigh or leg. We evaluated the symptom severity by using NRS, DN-4 and PD. Neuropathic pain has a greater effect on quality of life of the patients and higher health care costs than the other types of pain.[17] It requires different kind of assessment tools and treatment methods.[18, 19] PD and DN-4 are widely used and accepted questionnares for assessment of neuropathic pain. PD and DN-4 demonstrated a sensitivity of 85% and 83% and a specificity of 80% and 90% respectively, in some studies.[10, 12] Scores of all NRS, PD and DN-4 are positively correlated with each other supporting previous studies. In this studya strong positive correlation was found between NRS and PD; also NRS and DN-4. There was a moderate corralation between PD and DN-4. In a recent study Gudala et al. found good discriminant validity between PD and DN-4.[20] There is still no definite diagnostic criteria for PS. Piriformis injection is an accepted method for both diagnosis and treatment.[8, 9, 21] Steroid is a widely used medical agent for injection in PS and possitive effect of injection on somatic pain was shown in majority of the studies.[8, 21–24] Our study also showed the reduction in neuropathic pain scores. Because of the quick response to injection, it can be used as a diagnostic tool. But the effect of the duration is still remain unclear. In present study, the highest improvement in all scores after injection was seen in the 1st week. A mild increase was seen in all scores at the 1st month compared to the 1st week. However all scores were still lower than baseline scores. It is our limitation that having a short follow-up period. Botulinum toxin therapy is also be considered that could be effective for a longer period. Fishman et al. reported that 24 of the 27 patients had a good response to the botulinum toxin injection.[25] Fishman et al. also showed that botulinum toxin provide more pain relief than other agents like steroids.[26] But botulinum toxin therapy should not be considered as the first option in terms of cost effectiveness. OCTOBER 2019

Conclusion Injection for the piriformis syndrome with steroid, under the guidance of ultrasound was found to be effective for both somatic and neuropathic pain in this study. Long-term follow-up is needed for considering other treatment options like botulinum toxin or myofascial release. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

References 1. Yeoman WB. The relation of arthritis of the sacroiliac joint to sciatica: with an analysis of 100 cases. Lancet 1928;2:1119– 22. 2. G. Windisch, Braun EM, Anderhuber F. Piriformis muscle: clinical anatomy and consideration of the piriformis syndrome. Surg Radiol Anat 2007;29(1):37–45. 3. Beaton LE, Anson BJ. The relation of the sciatic nerve and of its subdivisions to the piriformis muscle. Anat Rec 1937;70(1):1–5. 4. Reus M, de Dios Berna J, Vazquez V, Redondo MV, Alonso J. Piriformis syndrome: a simple technique for US-guided infiltration of the perisciatic nerve. Preliminary results. Eur Radiol 2008;18(3):616–20. 
 5. Kirschner JS, Foye PM, Cole JL. Piriformis syndrome, diagnosis and treatment. Muscie Nerve 2009;40(1):10–8. 6. Huerto AP, Yeo SN, Ho KY. Piriformis muscle injection using ultrasonography and motor stimulation--report of a technique. Pain Physician 2007;10:687–90. 7. Chen CP, Shen CY, Lew HL. Ultrasound-guided injection of the piriformis muscle. Am J Phys Med Rehabil 2011;90(10):871–2. 8. Jeong HS, Lee GY, Lee EG, Joe EG, Lee JW, Kang HS. Longterm assessment of clinical outcomes of ultrasound-guided steroid injections in patients with piriformis syndrome. Ultrasonography 2015;34(3):206–10. 9. Misirlioglu TO, Akgun K, Palamar D, Erden MG, Erbilir T. Piriformis syndrome: comparison of the effectiveness of local anesthetic and corticosteroid injections: a doubleblinded, randomized controlled study. Pain Physician 2015;18(2):163–71. 10. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005;114(1–2):29–36. 11. Unal-Cevik I, Sarioglu-Ay S, Evcik D. A comparison of the DN4 and LANSS questionnaires in the assessment of neuropathic pain: validity and reliability of the Turkish version of DN4. J Pain 2010;11(11):1129–35. 12. Freynhagen R, Baron R, Gockel U, Tölle TR. Pain DETECT: a new screening questionnaire to identify neuropathic com-

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A RI PAIN ponents in patients with back pain. Curr Med Res Opin 2006;22(10):1911–20. 13. Alkan H, Ardic F, Erdoğan C, Sahin F, Sarsan A, Fındıkoğlu G. Turkish version of the painDETECT questionnaire in the assessment of neuropathic pain: a validity and reliability study. Pain Medicine 2013;14(12):1933–43. 14. Chen WS: Sciatica due to piriformis pyomyositis. Report of a case. J Bone Joint Surg 1992;74(10):1546–8. 15. Sayson SC, Ducey JP, Maybrey JB, Wesley RL, Vermilion D. Sciatic entrapment neuropathy associated with an anomalous piriformis muscle. Pain 1994;59(1):149–52. 16. Pecina M. Contribution to the etiological explanation of the piriformis syndrome. Acta Anat 1979;105(2):181–7. 17. Kleinman N, Patel AA, Benson C, Macario A, Kim M, Biondi DM. Economic Burden of Back and Neck Pain: Effect of a Neuropathic Component. Popul Health Manag 2014;17(4):224–32. 18. Haanpää M, Attal N, Backonja M, Baron R, Bennett M, Bouhassira D,et al. NeuPSIG guidelines on neuropathic pain assessment. Pain 2011;152(1):14–27. 19. Smith BH, Torrance N. Epidemiology of Neuropathic Pain and Its Impact on Quality of Life. Curr Pain Headache Rep 2012;16(3):191–8. 20. Gudala K, Ghai B, Bansal D. Usefulness of four commonly

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used neuropathic pain screening questionnaires in patients with chronic low back pain: a cross-sectional study. Korean J Pain 2017;30(1):51–8. 21. Jankovic D, Peng P, van Zundert A. Brief review: piriformis syndrome: etiology, diagnosis, and management. Can J Anaesth 2013;60(10):1003–12. 22. Ozisik, Pinar Akdemir, et al. “CT-guided piriformis muscle injection for the treatment of piriformis syndrome.” Turkish neurosurg 2014;24(4):471–7. 23. Cassidy L, Walters A, Bubb K, Shoja MM, Tubbs RS, Loukas M. Piriformis syndrome: implications of anatomical variations, diagnostic techniques, and treatment options. Surg Radiol Anat 2012;34(6):479–86. 24. Reus M, de Dios Berna J, Vazquez V, Redondo MV, Alonso J. Piriformis syndrome: a simple technique for US-guided infiltration of the perisciatic nerve. Preliminary results. Eur Radiol 2008;18(3):616–20. 25. Fishman LM, Konnoth C, Rozner B. Botulinum neurotoxin type B and physical therapy in the treatment of piriformis syndrome: A dose-finding study. Am J Phys Med Rehabil 2004;83(1):42–50. 26. Fishman LM, Anderson C, Rosner B. Botox and physical therapy in the treatment of piriformis syndrome. Am J Phys Med Rehabil 2002; 81(12):936–42.

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Agri 2019;31(4):183–194

doi: 10.14744/agri.2019.68725

A RI PAIN

ORIGINAL ARTICLE

The relationship between somatic sense perception levels and comorbid psychiatric diseases in chronic pain patients Kronik ağrı hastalarında bedensel duyumları algılama düzeyi ve psikiyatrik komorbidite arasındaki ilişki Soner ÇAKMAK,1 Hayri Tevfik ÖZBEK,2 Abdülkadir Geylan IŞIK,2 Hakkı ÜNLÜGENÇ,5 Lut TAMAM,1 Mehmet Emin DEMIRKOL1

Ali TAŞDEMIR,3

Sinan PEKTAŞ,4

Summary Objectives: The purpose of the study was to evaluate any comorbid psychiatric disorders in patients with chronic pain and to examine the effects of sociodemographic details and the level of somatic sense perception on the severity of these diseases. Methods: In this study, 51 chronic pain patients were evaluated in a consultation with a psychiatrist. Sociodemographic characteristics of the patients, such as age, gender, education level, and marital status were recorded, and Structured Clinical Interview for DSM-IV results were assessed. The patients’ chronic pains were classified as idiopathic or secondary to organic etiology. In addition, the Symptom Checklist-90, Somatosensory Amplification Scale (SSAS), Hamilton Depression Rating Scale, and the Hamilton Anxiety Scale (HAM-A) were used. Results: The incidence of psychiatric disorders in chronic pain patients was found to be 74.5%. Somatoform disorders were the most frequently diagnosed, at 37.3%. The rate of depressive and anxiety disorders was, respectively, 29.4% and 23.5%. Comorbid anxiety scores (p=0.019) and SSAS scores (p=0.046) were significantly higher in chronic pain patients with a somatoform disorder. HAM-A scores were found to be significantly higher in patients with depression (p=0.004). A positive and linear relationship was determined between the SSAS score and depression, anxiety, and the severity of mental symptoms. Conclusion: Structured or semi-structured interviews can be performed in pain polyclinics or psychiatric outpatient clinics to determine the level of perception of somatic sensations. This could be beneficial in the treatment of chronic pain and comorbid psychiatric disorders. Keywords: Chronic pain; comorbidity; psychiatry; somatic sense perception.

Özet Amaç: Biz bu çalışmada kronik ağrı hastalarında komorbid psikiyatrik hastalıkları araştırdık ve bu hastalıkların şiddeti üzerinde hastaların bedensel duyumları algılama düzeylerinin ve sosyodemografik özelliklerinin etkilerini inceledik. Gereç ve Yöntem: Bu çalışmada 51 kronik ağrı hastası konsültasyon yoluyla psikiyatri hekimi tarafından değerlendirilmiştir. Katılımcılara DSM-IV için yapılandırılmış klinik görüşme (SCID I) uygulanmış, yaş, cinsiyet, medeni durum, eğitim düzeyi gibi sosyodemografik verileri alınarak, ağrı etiyolojileri belirlenmiş ve ağrı hastaları idiopatik ve organik etiyolojiye sekonder kronik ağrı hastaları olarak sınıflandırılmıştır. Katılımcılara Ruhsal Belirti Tarama Listesi (SCL-90R), Bedensel Duyumları Algılama Ölçeği (SSAS), Hamilton Depresyon Derecelendirme Ölçeği (HAM-D), Hamilton Anksiyete Dercelendirme Ölçeği (HAM-A) uygulanmıştır. Bulgular: Kronik ağrı hastalarında psikiyatrik bozuklukların yaygınlığı %74.5 olarak bulunmuştur. Somatoform bozukluklar %37.3 ile en sık teşhis edilen bozukluk olup, depresif bozukluklar %29.4, anksiyete bozuklukları %23.5 oranında bulunmuştur. Somatoform bozukluk saptanan kronik ağrı hastalarında komorbid anksiyete puanları (p=0.019) ve SSAS puanları (p=0.046) anlamlı olarak yüksek bulunmuştur. Depresyon tanısı alan katılımcılarda HAM-A puanları anlamlı olarak yüksek bulunmuştur (p=0.004). SSAS puanları ile hastalardaki depresyon, anksiyete ve ruhsal belirti şiddeti arasında pozitif bir ilişki olduğu saptanmıştır. Sonuç: Bedensel duyumları algılama düzeylerini belirleme ile ilgili olarak ağrı polikliniklerinde veya psikiyatri polikliniklerinde yapılandırılmış veya yarı yapılandırılmış görüşmelerin uygulanması bu hastalarda kronik ağrının ve komorbid psikiyatrik rahatsızlıkların tedavisi ve prognozunda yarar sağlayacaktır. Anahtar sözcükler: Kronik ağrı; komorbidite; bedensel duyumlar; psikiyatri.

Department of Psychiatry, Çukurova University Faculty of Medicine, Adana, Turkey Department of Algologia, Çukurova University Faculty of Medicine, Adana, Turkey 3 Department of Psychiatry, Niğde State Hospital, Niğde, Turkey 4 Department of Anesthesia, Van Research Hospital, Van, Turkey 5 Department of Anesthesia, Çukurova University Faculty of Medicine, Adana, Turkey 1 2

Submitted (Başvuru tarihi) 03.09.2018 Accepted after revision (Düzeltme sonrası kabul tarihi) 15.05.2019 Available online date (Online yayımlanma tarihi) 29.05.2019

Correspondence: Dr. Soner Çakmak. Çukurova Üniversitesi Tıp Fakültesi, Ruh Sağlığı ve Hastalıkları Anabilim Dalı, Adana, Turkey. Phone: +90 - 322 - 338 60 60 / 3204 e-mail: drsoncak@hotmail.com © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Introduction It has been known that psychiatric problems significantly affect somatic disorders, make treatment difficult, and affect the prognosis negatively. Patients who were diagnosed with appropriate methods could help to understand the complex relationship between psychiatric disorders and chronic pain. Psychiatric structured and semi-structured tests are rarely used in patients with chronic pain.[1] Despite clinical importance, psychiatric disorders are often ignored in pain clinics. In recent years, the incidence of psychiatric comorbidity has increased in patients who are referred to tertiary care pain clinics. Therefore, it is thought that chronic pain may also be the effect of common psychiatric diseases.[2] In many studies, the rates of psychiatric disorders in patients with chronic pain were found higher than the general population.[3–5] Chronic pain is correlated with psychiatric disorders. Reactive psychological symptoms such as depression and anxiety can play an important role in the exacerbation of pain perception.[6] There is evidence that depression, anxiety and emotional distress symptoms in chronic pain patients contribute strongly to sustained and long-term outcomes such as physical disability, job disability, health care costs, mortality and suicide (more powerful than pain intensity in many studies).[7–12] Studies investigating the relation between chronic pain and psychiatric morbidity were generally related to depression. Depression is the most frequently reported disorder in patients with chronic pain.[2] In these early studies, it was stated that the depression rates in patients with chronic pain was increasing with advanced ages and lower education levels.[13] It was also pointed that there was a difference between genders and it was suggested that depression was seen more in women.[14] In order to explain these findings, interpretations were made as women had lower pain thresholds, that their pain beliefs differed from men, and that they experienced depression as a reaction to pain.[15] However, recent studies do not support all these relations. Wijeratne et al. have compared the depression rates between young (<65 years) and elder (65 years and older) patients who came to the chronic pain clinic.[16] They have not found a link between age and depression. Furthermore, there was no relationship between major depressive disorder and gender and duration of pain in the same study. 184

Similarly, Geerlings et al. have found that age is not an effect on depression in pain patients.[17]

[16]

Anxiety can also be expected to be seen as a common psychiatric symptom in patients with chronic pain. In some studies it has been suggested that there is a relationship between pain intensity and fear; pain catastrophy and anxiety, in chronic pain patients.[18] In a study, anxiety disorders were found 35% in patients with chronic pain and 17% in healthy individuals. Generalized anxiety disorder is the most common psychiatric disorder in primary care. Patients often complain about pain and somatic symptoms more than anxiety; therefore, diagnosis is difficult and patients cannot be treated completely.[19] In chronic pain patients, the number of studies on anxiety disorders is less than those associated with depression. However, there is growing evidence that the pharmacological treatment of anxiety can significantly decrease the pain.[20] Somatoform pain disorder among somatoform disorders is a common psychiatric disorder in patients with chronic pain. In a study with 89 patients in China, the incidence of somatoform disorders in patients with chronic pain was found as 33.7%.[21] Polatin et al. and Dersh et al. have found that depressive and somatoform disorders are the most common psychiatric disorders in chronic pain patients, similar to those in China.[21–23] The association of chronic pain with depression and anxiety may become permanent over time.[24, 25] The purpose of this study was to find the frequency of psychiatric comorbidities (depression, anxiety and somatoform disorders) in patients who applied to the pain outpatient clinic and had psychiatric consultation; and to determine whether these disorders were associated with pain related factors such as sociodemographic characteristics, pain etiology and exaggeration of somatic sensations.

Material and Method Fifty-one patients who were admitted to Cukurova University School of Medicine, pain outpatient clinic between August 2013–March 2014, who had chronic pain complaints and who were consulted to the psyOCTOBER 2019


The relation between somatic sense perception levels and comorbid psychiatric diseases in chronic pain patients

chiatrist by pain physician for possible psychiatric comorbidities. Fifty-five patients were interviewed and four patients who did not approve participation in the study were excluded from the study and 51 were included in the study. Participants’ psychiatric diagnostic evaluation was performed after medical and psychiatric history and sociodemographic features were noted. The data were recorded in a form. Approval of the local ethics committee and written consent of the patients were taken. Patients who were 18 years of age or older and had chronic pain complaints for at least one year were included in the study. Patients with mental retardation, organic mental problems and dementia (those with a Minimental test score lower than 24) were excluded from the study. Sociodemographic data such as age, gender, marital status, educational level were taken after the evaluation of the pain clinic physicians. Participants’ chronic pains were classified as idiopathic and secondary to organic etiology according to the information given by the pain physician. The study population was small, which restricts the power of statistical analyzes. The study group consisted of patients continuing to the pain outpatient clinic, so there was a bias in patient selection. Our study was conducted with patients with different types of pain. However, the results are still not universal for all chronic pain patients. Sociodemography data form; It is the data form prepared by us that records participants’ age, gender, marital status and educational level. SCL-90-R Symptom Checklist; The SCL-90-R Symptom Screening List is defined as a psychiatric symptom screening tool that identifies the level of stress experienced by the individual. This test was developed by Derogatis, in 1997.[26] In 1991, the scale was adapted to Turkish by İhsan Dağ.[27] Reliability and validity analysisensured that the scale was applicable in Turkey. SCL-90-R has 90 questions and 9 different symptom groups. The average symptom score is obtained by the scores of 9 sub-symptom groups (Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid thought and Psychotism) OCTOBER 2019

and the score of additional scale. There is 5 choices in every question as “None, very few, moderate, high, very high “ and scored with 0-1-2-3-4 respectively. Then, three general points are calculated from the scale. Positive Symptom Index (PSI) is obtained by summing the raw numbers of the other items except those that are ‘none’ selected. The Positive Symptom Distress Index (PSDI) is obtained by dividing the sum of the grading points of the items except the ones marked as ‘none’ to the PSI. The Global Symptom Index (GSI) score is obtained by dividing the total score of the test to the all items except the ones left blank. This score points to the increase in distress experienced due to psychiatric symptoms and it is accepted as the most reliable parameter of the scale. When it is used for survey purposes, cut-off score of GSI is often taken as 1 point. For the subscales, the value obtained by dividing the score obtained from the sum of all the questions constituting that subscale by the number of questions is used. As a surveillance scale, SCL-90-R, is not used for diagnosis, but numerical values above 1 are considered to be higher than the general average. The general reliability of the SCL-90 scale that was applied to the participants was found high (α=0.971).

Hamilton Depression Rating Scale (HAM-D):The scale developed by Hamilton aims to measure the severity of depressive symptoms.[28] The scale used by the physicians contain scores from 0 to 4 for each of the 17 depressive manifestations. Turkish validity and reliability study was conducted by Akdemir et al. in 1996.[29] Hamilton Anxiety Rating Scale (HAM-A):The scale developed by Hamilton in 1959 was prepared to determine the level of anxiety and symptom distribution, and to measure the changes in the intensity of symptoms.[30] The validity and reliability study of the Turkish version was made by Yazıcı et al. in 1998.[31] At this scale of 14 items, the practitioner scores from 0 to 4 for each item. Score range is 0–56. 1, 2, 3, 5 and 6th items are calculated as psychic subscores and 4, 7, 8, 9, 10, 11, 12, 13rd items are calculated as somatic subscores. Somatosensory Amplification Scale (SSAS): The scale was developed by Barsky et al.[32] Turkish validity and 185


A RI PAIN reliability studies were conducted by Guleç et al.[33] It is an assessment scale that measures how patients experience somatic symptoms and their susceptibility to somatization. In addition to those with psychiatric disorders, it can also be used in patients with any medical condition or in healthy population. 10 items in the questionnaire are scored on a five-point Likert scale. Its a self report scale. Participants using the scale are asked to score each question between 1 (not at all) and 5 (extremely). The total score is between 10–50. The cut-off score of the scale is not calculated. This scale is used in comparative studies. In the internal consistency study of the scale, Coronbach alpha values were ranged from 0.62–0.76. The total score of the scale showed adequate test-retest consistency (r=0.73). Statistical Analysis All statistical evaluations of our study were conducted with IBM The Statistical Package for Social Sciences (SPSS) Statistics v20 (IBM Corporation, New York, United States). Categorical variables were compared with Chi-square test, frequencies and ratios, and Fisher’s exact Chi-square test was applied where necessary. The averages of the continuous variables of the two groups were compared with Student T test. Pearson Correlation test was used for correlation of categorical variables. Descriptive statistics on sociodemographic data are also presented.

Results The socio-demographic properties of the patients were summarized in the table (Table 1). 72.5% of the patients were female and 27.5% were male. 81.2%

of the patients were married and 11.8% were single. 45.1% of the patients had primary education or lower, and 54.9% had secondary education or higher education levels. The mean age was 41.1±11.4 for women and 38.2±10.3 for men. The mean age of all patients was 40.3±11.1 (Table 1). Participants’ pain types and pain etiologies were assessed with patients history and pain outpatient clinic records (Table 2). Chronical headache was present in 13 of the patients (organic etiology was not defined in 7), chronic back and neck pain was present in 9 of the patients (organic etiology was not defined in 2), extremity pain was present in 8 of the patients (organic etiology was not defined in 5), pelvic and abdominal pain was present in 3 of the patients (organic etiology was not defined in 1), common musculoskeletal pain was present in 18 of the patients (organic etiology was not defined in 12, 6 of them were diagnosed with fibromyalgia). Organic etiology was defined in 24 (47%) of the patients and organic etiology was not defined in 27 (53%) patients. Localized pain was defined in 33 (64.7%) of the patients and common musculoskeletal pain was defined in 18 (35.3%) of the patients (Table 2). All patients were assessed with SCID I by an experienced psychiatrist and comorbid psychiatric diseases were investigated. The prevalence of current psychiatric disorders was found as 74.5%. Somatoform disorders are the most frequently diagnosed cases (37.3%).The rates of depressive and anxiety disorders were 29.4% and 23.5%, respectively (Table 3).

Table 1. Sociodemographic characteristics of the patients

Female (n=37) (72.5%)

n % n % n %

Martial status Married Single Education status Primary education and lower Secondary education and higher Age (Mean±SD)

Male (n=14) (27.5%)

Total (n=51) (%)

34 91.9 11 78.6 45 81.2 3 8.1 3 21.4 6 11.8 16 23

43.2 56.8 41.1±11.4

7 7

50 50 38.2±10.3

23 28

45.1 54.9 40.3±11.1

n: Number of patients; SD: Standart deviation.

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The relation between somatic sense perception levels and comorbid psychiatric diseases in chronic pain patients

Table 2. Type, localization and etiological properties of the pain Pain type Organic etiology (+)

Organic etiology (-)

Total

n

Head and face pain Neck and low back pain Extremity pain Pelvicand abdominal pain Common musculoskeletal pain Total

6 25 7 25.9 13 25.5 2 after spinal anesthesia, 1 trigeminal neuralgia, 1 after jaw surgery, 1 tuberculous meningitis, 1 migraine 7 29.2 2 7.4 9 17.7 6 vertebral hernie, 1 ankylosing spondylitis 3 12.5 5 18.5 8 15.7 2 after epidural anesthesia, 1 alcoholic neuropathy 2 8.3 1 3.7 3 5.8 2 after orchitis and testis operation 6 25 12 44.4 18 35.3 6 fibromyalgia 24 47 27 53 51 100

Localized pain

% n % n %

n: Number of patients.

Table 3. Psychiatric diagnoses identified with SCID I assessment Anxiety disorders Somatoform disorders Depressive disorder Psychiatric diagnoses (total)

n=51 12 19 15 38

% 23.5 37.3 29.4 74.5

SCID I: Structured Clinical Interview for DSM-IV; n: Number of patients.

Participants chronic pains were classified as idiopathic and secondary to organic etiology according presence or absence of organic etiology of the pain. For both groups, Symptom Check List-90 (SCL-90R), Somatosensory Amplification Scale (SSAS), Hamilton Depression Rating Scale (HAM-D) and Hamilton Anxiety Scale (HAM-A) tests were used and scores of the groups were compared. (Table 4). There was no significant difference between SCL 90, SSAS, HAM-D and HAM-A scores in terms of presence or absence of organic etiology of the pain (Table 4). Sociodemographic variables, SCLR 90, SSAS, HAMOCTOBER 2019

A, HAM-D, were compared between the patients with and without psychiatric diagnosis (Table 5). There was no significant difference between these two groups in terms of gender, marital status, education status and age. However, it was found that the scores of HAM-D, HAM-A, SSAS and SCL-90 were significantly higher in the chronic pain patients who had psychiatric diagnosis. This significant difference has increased the reliability of the semi-structured DSM IV-directed SCID I diagnostic evaluation in our study (Table 5). Chronic pain patients were divided into two groups in terms of presence or absence of comorbid somatoform disorders. HAM-A, HAM-D, SSAS scale were assessed to determine whether there was any significant difference between these two groups. Comorbid anxiety scores and SSAS scores were significantly higher in chronic pain patients who had somatoform pain disorder. There was no significant difference between these two groups in terms of demographical properties except martial status. Somatoform pain disorder was found significantly higher in married patients than in single patients. 187


A RI PAIN Table 4. Comparison of SCLR 90, SSAS, HAM-A, HAM-D scores according to the presence or absence of organic etiology of the pain n (%) SCL-GSIscore SCL-PSIscore SCL-PSDI score SSAS HAM-A HAM-D

Organic etiology (+) n=24 (Mean±SD)

Organic etiology (-) n=27 (Mean±SD)

1.1±0.7 46.7±21.9 1.9±0.6 26.1±10.3 15.9±8.0 17.1±9.8

f

1.2±0.7 49.1±22.9 2.1±0.5 27.8±8.8 18.4±8.5 18.8±10.2

t

p

0.014 0.497 0.621 0.516 0.393 0.696 0.298 1.292 0.202 2.739 0.644 0.523 0.110 1.083 0.544 0.343 0.611 0.781

n: Number of patients; SD: Standart deviation; SCL: Symptom Screening List; GSI: Global Symptom Index; PSI: Positive Symptom Index; PSDI: Positive Symptom Distress Index; SSAS: Somatosensory Amplification Scale; HAM-D: Hamilton Depression Rating Scale; HAM-A:Hamilton Anxiety Rating Scale.

Table 5. Comparison of sociodemographic properties and scale scores of the patients with and without psychiatric diagnosis n (%) Gender Female Male Martial status Married Single Educational status Primary education and lower Secondary education and higher Age (Mean±SD) HAM-A (Mean±SD) HAM-D (Mean±SD) SSAS (Mean±SD) SCL-GSI puan (Mean±SD) SCL-PSI puan (Mean±SD) SCL-PSDI puan (Mean±SD)

Psychiatric diagnosis (+) Psychiatric diagnosis (-) (n=38) (n=13)

f

t

p

30 (81.1) 8 (57.1)

7 (18.9) 6 (42.9)

– – 0.08

33 (73.3) 5 (83.3)

12 (26.7) 1 (16.7)

– – 0.598

16 (69.6) 22 (78.6) 40.8±11.2 19.5±6.5 20.3±9.3 29.0±9.6 1.4±0.7 54.5±20.3 2.2±0.6

7 (30.4) 6 (21.4) 38.6±10.9 10.7±9.7 11.7±9.5 21.1±5.9 0.5±0.4 28.9±16.2 1.7±0.5

– – 0.463 0.065 3.272 0.019 2.576 8.591 3.664 0.867

0.613 0.543 -3.715 0.001 -2.859 0.006 -2.752 0.008 -3.977 <0.001 -4.108 <0.001 -2.652 0.011

n: Number of patients; Sd: Standart deviation; HAM-A: Hamilton Anxiety Rating Scale; HAM-D: Hamilton Depression Rating Scale; SSAS: Somatosensory Amplification Scale; SCL: Symptom Screening List; GSI: Global Symptom Index; PSI: Positive Symptom Index; PSDI: Positive Symptom Distress Index.

There was no significant difference between the levels of depression in chronic pain patients with and without somatoform pain disorder (Table 6). Chronic pain patients were divided into two groups in terms of presence or absence of anxiety disorders. There was no significant difference between these two groups in terms of demographical properties. Also there was no significant difference between HAM-D and SSAS scores in these patients. Although there was no significant difference in demographic 188

characteristics among participants who were diagnosed with depression, HAM-A scores were significantly higher in these patients. These finding suggested that depression could be a factor that facilitate anxiety in chronic pain patients (Table 7, 8). An important relation that we investigated was to reveal the relationship between exaggeration of physical sensations and the level of psychological symptoms. Pearson’s correlation analysis indicated that there was a positive and linear correlation beOCTOBER 2019


The relation between somatic sense perception levels and comorbid psychiatric diseases in chronic pain patients

Table 6. Comparison of sociodemographic properties and scale scores of the patients with and without somatoform disorder n (%) Gender Female Male Martial status Married Single Educational status Primary education and lower Secondary education and higher Age (Mean±SD) HAM-A (Mean±SD) HAM-D (Mean±SD) SSAS (Mean±SD)

Somatoform disorder (+) Somatoform disorder (-) (n=19) (n=32)

f

t

p

16 (43.2) 3 (21.4)

21 (56.8) – – 0.150 11 (78.6)

19 (42.2) 0 (0)

26 (57.8) – – 0.044 6 (100)

9 (39.1) 10 (35.7) 43.3±10.3 20.7±6.9 21.0±8.7 30.4±10.6

14 (60.9) – – 0.802 18 (64.3) 38.5±11.3 0.069 -1.522 0.134 15.2±8.4 0.627 -2.422 0.019 16.3±10.3 1.889 1.638 0.108 25.0±8.2 0.706 -2.052 0.046

n: Number of patients; SD: Standart deviation; HAM-A: Hamilton Anxiety Rating Scale; HAM-D: Hamilton Depression Rating Scale; SSAS: Somatosensory Amplification Scale.

Table 7. Comparison of sociodemographic properties and scale scores of the patients with and without anxiety disorder n (%) Gender Female Male Martial status Married Single Educational status Primary education and lower Secondary education and higher Age (Mean±SD) HAM-D (Mean±SD) SSAS (Mean±SD)

Anxiety disorder (+) (n=12)

Anxiety disorder (-) (n=39)

f

t

p

10 (27) 2 (14.3)

27 (73) 12 (85.7)

– – 0.338

9 (20) 3 (50)

36 (80) 3 (50)

– – 0.104

3 (13) 9( 32.1) 36.3±12.8 15.4±7.8 27.6±8.6

20 (87) 19 (67.9) 41.5±10.3 18.8±10.4 26.8±9.8

– – 0.110 0.700 1.441 1.294 1.058 0.422 -0.299

0.156 0.295 0.797

n: Number of patients; SD: Standart deviation; HAM-D: Hamilton Depression Rating Scale; SSAS: Somatosensory Amplification Scale.

tween the high level of SSAS scores and the severity of depression and psychological symptoms in the patient (Table 9).

Discussion The determined prevalence of psychiatric disorders in our study (74.5%), was found similar to studies of Ho et al. (63%), Polatin et al. (59%) and Dersh et al.’s (65%).[21–23] Depression, anxiety and emotional OCTOBER 2019

distress are the most frequently assessed negative psychological factors in patients with chronic pain. Recent systematic studies report that chronic pain patients exhibit elevated levels of the factors described as self-reported adverse effects in all indices compared to painless controls.[3,34] Similar to these studies, depressive and somatoform disorders were the most common psychiatric disorders in our study.

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A RI PAIN Table 8. Comparison of sociodemographic properties and scale scores of the patients with and without depressive disorder n (%)

Depressive disorder (+) (n=15)

Gender Female Male Martial status Married Single Educational status Primary education and lower Secondary education and higher Age (Mean±SD) HAM-A (Mean±SD) SSAS (Mean±SD)

Depressive disorder (-) (n=36)

f

t

p

11 (29.7) 4 (28.6)

26 (70.3) – – 0.935 10 (71.4)

13(28.6) 2 (33.3)

32 (71.1) – – 0.822 4 (66.7)

6 (26.1) 9 (32.1) 41.2±9.7 22.3±5.4 30.2±11.5

17 (73.9) – – 0.637 19 (67.9) 39.9±11.7 0.670 -0.384 0.703 15,1±8.4 1.544 -1.555 0.004 25.7±8.3 2.864 -3.009 0.126

n: Number of patients; SD: Standart deviation; HAM-A: Hamilton Anxiety Rating Scale; SSAS: Somatosensory Amplification Scale.

Table 9. Pearson’s correlation analysis between SSAS scores and depression, anxiety, and mental symptom severity

HAM-A

HAM-D

SSAS

SCL-GSI

SCL-PSI

SCL-PSDI

HAM-A r 1 0.657 0.440 0.487 0.484 0.416 p – <0.001 0.001 <0.001 <0.001 0.002 HAM-D r 0.657 1 0.308 0.463 0.393 0.443 p <0.001 – 0.028 0.001 0.004 0.001 SASS r 0.440 0.308 1 0.672 0.591 0.539 p 0.001 0.028 – <0.001 <0.001 <0.001 SCL-GSI r 0.487 0.463 0.672 1 0.921 0.755 p <0.001 0.001 <0.001 – <0.001 <0.001 SCL-PSI r 0.484 0.393 0.591 0.921 1 0.501 p <0.001 0.004 <0.001 <0.001 – <0.001 SCL-PSDI r 0.416 0.443 0.539 0.755 0.501 1 p 0.002 0.001 <0.001 <0.001 <0.001 – HAM-A: Hamilton Anxiety Rating Scale; HAM-D: Hamilton Depression Rating Scale; SSAS: Somatosensory Amplification Scale; SCL: Symptom Screening List; GSI: Global Symptom Index; PSI: Positive Symptom Index; PSDI: Positive Symptom Distress Index.

The prevalence of chronic pain is higher in individuals diagnosed with depression, and in contrast, the prevalence of depression in chronic painful individuals is also increasing.[35] In our study, comorbid depressive disorder was diagnosed in 29.4% of patients 190

with chronic pain, which was very low compared to Huang et al.’s study (73%).[36] In studies using only the DSM criteria, the prevalence of depressive disorder was reported to range from 30% to 55%.[37] This rate was close to our study. Depression exacerbates the OCTOBER 2019


The relation between somatic sense perception levels and comorbid psychiatric diseases in chronic pain patients

pain experience and is an important determinant of pain-related disability.[38] The opposite is true. In the process of diagnosing the severity of depression, symptoms of pain may lead to “criterion contamination”.[39] In order to make this distinction, it may be appropriate to assess the compatibility of nonphysical criteria with physical criteria.[40] In our study, there was no significant difference in exaggeration levels of physical sensations in depressed patients when compared to those who were diagnosed with DSM IV. However, a positive correlation was found between the increased depression scores that measured with HAM-D scale and SSAS scores, in chronic pain patients. These results are interpreted as the fact that the level of exaggeration of somatic sensations may increase the severity of depression but not the development of depression. It should be noted that many social factors could cause reactive depressive disorders in pain patients. Semi-structured interviews, such as SCID, provide more benefits for psychiatric diagnostic evaluation in pain patients to eliminate criterion contamination. According to Cassem, the risk of not being aware of depression and not being treated is more important risk factor than the risk of unnecessary treatment.[41] The incidence of depression in clinic-based studies ranges from 1.5% to 100%.[2] Pain-related factors, such as pain severity, were found as risk factors for depression in various pain disorders and diffuse pain.[14, 42, 43] In our study, it was also found that the anxiety symptom severity scores were higher in chronic pain patients who had a comorbid depression when compared to those without depression. This was interpreted as anxiety symptoms may be high in patients with chronic pain secondary to depression. The exaggeration level of somatic sensations has not been evaluated as a risk factor in the development of comorbid depression. However, a significant and positive correlation was found between increased SSAS scores and the severity of depressive symptoms and anxiety symptoms in the Spearman correlation analysis. In the study by Knaster et al., most of the patients completed the criterion of having at least one psychiatric disorder for 12 months.[2] Mood disorder was found in 45% of patients and anxiety disorder was found in 25% of patients. Pain levels were correlated with psychiatric disorders. Analyzes in this study showed that anxiety disorders usually begin before the painbut ofOCTOBER 2019

ten depressive disorders follow it. Recent studies have reported high comorbidity between chronic pain and anxiety.[44] However, our study results showed that the chronic pain patients with depression could be a risk factor for anxiety disorders. In our study, same as previously reported in Wijeratne et al.[16] and Geerlings et al.,[17] there was no difference between patients with or without depression in terms of age,[13] gender,[14, 15] or educational level.[13] In one study, it was shown that the chance of achieving acceptable pain control was inversely related with depression. Perception of pain’ is the beliefs of patients about the causes of pain, severity, predictability, controllability.[37, 45] Negative distorted pain cognitions, which are similar to the well-known cognitive triad of depression, are used to show the distinction between depressive chronic pain patients and non-depressive patients.[46] In patients with chronic pain, there is also low acceptable pain control perception, which leads to hopelessness and depression for the future. This is the ‘pain perception’ most associated with depression by the regression analysis.[21] In this study, we found that the degree of exaggeration of physical sensations was related to the severity of depressive symptoms. Pain physicians should be cautious about the exaggerated pain perception which may indicate depression. The high SSAS scores in this study can be considered as a factor associated with exaggerated pain perception and may be considered as a risk factor for the development of depression in pain patients. In pain clinics, with structured or semi-structured scales, assesment of exaggerated somatic sensation levels and susceptibilities to somatoform disorders and early pharmacological and psychotherapeutic treatments to these could be beneficial. The relationship between pain and depression/ anxiety is complicated. Evaluation of the relation between pain and psychiatric disorders has been revealed by some theories. According to consequence theory, depression is expressed as a result of pain and pain comes before depression. But antecedent theory claims the opposite.[2] Fishbain et al. reviewed the literature in terms of this issue and reported that most of the studies has supported the consequence theory.[47] The knowledge of how anxiety, depression and chronic pain are correlated is very important 191


A RI PAIN because it affects the treatment. Treatment of previously experienced anxiety and depression-related stressful environment and genetic predispositions to chronic pain is harder than treating pain related anxiety or depression.[2] Pain association with specific anxiety and depression disorders has been shown in a recent study.[48] But this relationship is not clear. Anxiety disorder is more severe and more chronic in patients with chronic pain.[49] In a sample with no prior history of depression or anxiety disorder, chronic pain was identified as a significant predictor of the onset of anxiety disorders.[50] Pain and depression probably share neural pathways.[51, 52] Genetic factors such as catechol-O-met[53] and seratonin transporter polymorphisims[54] may provide a possible link between pain sensitivity and psychological symptoms. Recent brain imaging studies show depressed patients with impaired pain regulation and altered brain responses.[55] Moreover, the efficacy of some antidepressant drugs for depression, anxiety and pain suggests that the common neural mechanisms are shared.[2, 56, 57] Correlation between the severity of pain and severity of depression/anxiety symptoms in chronic pain patients was not investigated in our study, but we found a positive correlation between the severity of depression and anxiety symptoms with exaggeration levels of somatosensory symptoms. Exaggeration of a physical sensations such as pain exacerbates the symptoms of anxiety and depression and they positively correlate with each other. This result supports the prediction that pain shares some common neural pathways with depression and anxiety. Limitation The study population was small, which restricts the power of statistical analyzes. The study group consisted of patients who are continuing to the pain outpatient clinic, so there was a bias in patient selection. Our study was conducted with patients with different types of pain. Therefore, the results are still not universal for all chronic pain patients.

Conclusion In this study, 74.5% of the patients, who were consulted to psychiatrist for possible psychiatric disorder, were actually diagnosed. This may be due to the fact that pain physicians’ rate of diagnosis were high 192

and their sensitivity was high to the subject. Therefore, we recommend that psychiatric evaluations should be considered in pain clinics. We also think that pain physicians need to be more cautious about the patients, especially those with more than 1 year chronic pain. In this study, the percentage of psychiatric morbidity in chronic pain patients is higher than in the general population and can be compared with the studies in the west. Somatoform disorders and depressive disorders are the most commonly diagnosed cases. Psychiatric disorders may be associated with highly related with special pain parameters, pain perceptions, and social factors. A better understanding of the anticipatory factors of psychiatric disorders in pain patients will help chronic pain management in the long term. Chronic pain has been correlated with high psychiatric disorder rates. The main focus of clinical trials is depression. In future studies, anxiety may also be of interest. Pain-related psychiatric disorders frequently complicate the treatment protocols, so it is important that they are fully assessed. The use of psychiatric evaluation methods such as SCID provides an understanding of the problem of comorbidity. Although the mechanisms of the relationship between chronic pain and psychiatric disorders are not fully understood, effective management of both pain intensity and comorbid psychiatric conditions is necessary for the quality of life of patients. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

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Agri 2019;31(4):195–201

doi: 10.14744/agri.2019.25901

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ORIGINAL ARTICLE

Validity and reliability of Turkish version of the Brief Pain Inventory-Short Form for patients with chronic nonmalignant pain Kronik nonmaling ağrısı olan hastalarda Brief Ağrı Envanteri Kısa Formu'nun Türkçe formunun geçerliği ve güvenirliği Yasemin YILDIRIM,1 Emine KARAMAN,1

Serap PARLAR KILIÇ,2 Sibel EYIGÖR,3 Gülay OYUR ÇELIK,6 Meltem UYAR4

Can EYİGOR,4

Yusuf YILDIRIM,5

Summary Objectives: The aim of this study was to evaluate the validity and reliability of the Turkish version of the Brief Pain InventoryShort Form for patients with chronic nonmalignant pain. Methods: An analytical design was used. A total of 192 patients were included in the study. A demographic questionnaire and the Brief Pain Inventory-Short Form were used to collect data. Content validity was assessed by experts and construct validity was tested using exploratory factor analysis. Reliability analyses estimated the internal consistency and test-retest reliability. Cronbach’s alpha and the item-total correlations were calculated for the subscales to examine internal consistency. Results: Exploratory factor analysis yielded 2 factors: pain severity and pain interference, which accounted for 68.81% of the total variance. The coefficient alpha of both subscales demonstrated good internal consistency. The item-total correlations of the scale ranged between 0.56 and 0.87. The test-retest reliability was r=0.774 for pain severity and r=0.808 for pain interference (p=0.001). Conclusion: The Turkish version of the Brief Pain Inventory-Short Form is a valid and reliable instrument to assess chronic nonmalignant pain. Keywords: Brief pain inventory short form; chronic nonmalignant pain; pain assessment; validity; reliability.

Özet Amaç: Bu çalışmanın amacı, kronik nonmaling ağrısı olan hastalarda Brief Ağrı Envanteri Kısa Formu’nun Türkçe versiyonunun geçerliğini ve güvenirliğini değerlendirmektir. Gereç ve Yöntem: Analitik çalışma deseni kullanıldı. Çalışmaya 192 hasta dahil edildi. Veri toplamada sosyodemografik soru formu ve Brief Ağrı Envanteri Kısa Formu kullanıldı. Envanterin geçerliğini değerlendirmek için içerik ve yapı geçerliği kullanılmıştır. Içerik geçerliği uzman görüşü ile değerlendirildi. Yapı geçerliği için açımlayıcı faktör analizi kullanılmıştır. Güvenirlik analizi için iç tutarlılık ve test tekrar test güvenirlik analizleri yapılmıştır. İç tutarlılık için alt boyutların Cronbach alfa ve maddetoplam korelasyonları hesaplandı. Bulgular: Açımlayıcı faktör analizi 2 faktör göstermiştir, ağrı şiddeti ve ağrı girişimi. İki faktör toplam varyansin %68.81’ini açıklamıştır. Her iki alt boyutun alfa katsaysı iyi iç tutarlılık göstermiştir. Ölçeğin madde toplam korelasyonları 0.56 ile 0.87 arasındadır. Test–retest güvenirliği ağrı şiddeti için r=0.774 ve ağrı girişimi için r=0.808’dir (p=0.001). Sonuç: Brief Ağrı Envanteri Kısa Formu’nun Türkçe versiyonu, kronik nonmaling ağrıyı değerlendirmek için güvenilir ve geçerli bir araçtır. Anahtar sözcükler: Brief ağrı envanteri kısa formu; nonmaling ağrı; ağrı değerlendirmesi; geçerlik; güvenirlik.

Department of Internal Medicine Nursing, Ege University Faculty of Nursing, İzmir, Turkey Department of Internal Medicine Nursing, İnönü University Faculty of Health Sciences, Malatya, Turkey 3 Department of Physical Therapy and Rehabilitation, Ege University Faculty of Medicine, İzmir, Turkey 4 Department of Anestesiology, Pain Clinic, Ege University Faculty of Medicine, İzmir, Turkey 5 Department of Gynecological Oncology, İzmir, Turkey 6 Department of Surgical Nursing, Izmir Katip Çelebi University Faculty of Health Sciences, İzmir, Turkey 1 2

Submitted (Başvuru tarihi) 24.02.2018 Accepted after revision (Düzeltme sonrası kabul tarihi) 18.04.2019 Available online date (Online yayımlanma tarihi) 13.06.2019

Correspondence: Dr. Yasemin Yıldırım. Ege Üniversitesi Hemşireşik Fakültesi, Bornova 35100, İzmir, Turkey. Phone: +90 - 232 - 311 55 38 e-mail: yasemin.kyildirim@ege.edu.tr © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Introduction Chronic pain and its treatment are an important economic burden on healthcare systems. All over the world, it is the most common symptom that requires professional support.[1] Affecting millions of people every year, chronic pain has a negative effect on the quality of life and causes physical, functional, and psychological problems.[2, 3] Patient assessment is the most important step in the management of chronic pain, which has both material and spiritual importance.[4] Pain assessment is a major step in the diagnosis and treatment of the patients suffering from pain.[5] Not only the severity of the pain, but also its duration, localisation, somatosensorial characteristics, and accompanying emotional symptoms should be taken into consideration. Nevertheless, pain control may be a problematic process due to the inadequacy of objective evaluation methods.[6, 7] Reliable and valid instruments can provide guidance for healthcare professionals in clinical practice in terms of pain assessment. The Brief Pain Inventory (BPI) was developed in 1994 by Cleeland and Ryan for two reasons; the subjective severity of pain and the interference caused by pain. The BPI is a valid, reliable, and commonly used scale which evaluates the localisation and severity of pain during the past 24 hours as well as its effect on activity in individuals with pain.[8] It is a quick and useful scale with validity and reliability performed in different populations and different languages.[9â&#x20AC;&#x201C;16] Although the BPI has been primarily used to assess cancer-related pain, it is validated for non-malignant pain, as well.[16, 17] Since chronic pain affects functional activity and psychology, these aspects of pain should also be assessed with regard to multidisciplinary treatment. The BPI allows to assess these aspects, as well. The BPI is comprised of two parts. The first part includes eight items which question pain location, pain severity, analgesic use, and pain relief. The second part evaluates the effect of pain on daily life activities.[8, 18] In Turkey, there have been no multi-dimensional scales except for the McGill Pain Questionnaire used to assess all aspects of pain. Although the BPI has been validated in several languages and tested in surgical patients in Turkey, a validated Turkish version of the inventory for patients with chronic nonmalignant pain has not been 196

available until now. For this reason, the purpose of this study is to determine validity and reliability of the BPI-SF in patients with chronic nonmalignant pain, and to provide with a multi-dimensional scale to be used in chronic pain assessment in Turkey.

Material and Method Study Design This was a descriptive and psychometric study. Participant and Data Collection This study was conducted on both inpatients and outpatients in the clinic of physical therapy and rehabilitation, rheumatology, and algology at two university hospitals in Izmir and Gaziantep, Turkey. Inclusion criteria of patients were as follows; 1) being diagnosed with chronic pain by a specialist, 2) having a pain duration of at least three months, 3) being over the age of 18, 4) being able to communicate verbally, and 5) giving informed consent. Patients who had a history of previous surgery in the last two weeks were excluded from the study due to the different nature of nonmalignant pain and surgical pain. Also, patients who were newly diagnosed with cancer were not included in the study. The sample group of the study consisted of 192 patients. The number of items in the BPI-SF (n=9) was taken into consideration in determining the appropriate sample size for the study. At least 3 or more patients are recommended for each scale item in the scale study. [19] The number of patients included in this study was twenty times of the number of BPI-SF items. In the study of the test-retest reliability of the scale, 30 patients were administered the same scale again after two weeks. Data Collection The pilot study was conducted among 10 patients with chronic pain in order to assess the comprehensibility and ease of use for the Turkish Brief Pain Inventory (BPI-SF-Tr). For application to larger study populations, the final version of the scale was formed. Patients who participated in the pilot study were not included in this study. All study data were collected by using face-to-face interview methods. The questions were read to the participants and then their answers were marked on the questionnaires. Translation procedure for the Brief Pain Inventory OCTOBER 2019


Reliability, Validity of the Brief Pain Inventory (SF)

(SF): Language validity of the scale was performed in the first step of the study. The original form of the BPI-SF was translated from English to Turkish by the research team (three nursing lecturers and four doctor lecturers) and also two native Turkish speakers who spoke English fluently (one was a nursing lecturer and the other one was an English lecturer who is also native English speaker). Then, two bilingual translators translated the Turkish items back into English. None of experts had seen the original English text of the scale.[11] After we compared with the back-translated version and the original version, we found them to be nearly the same. No changes were made in them. Finally, the Turkish version of the BPISF was produced for final use upon consensus of the translation committee. Validity of the Brief Pain Inventory (SF): Content validity and construct validity were performed to assess the validity of the BPI-SF. Content validity is conducted according to expert opinion and is related to whether questions on the assessment tool are in accordance with the measurement objective and represent the area intended to be measured or not. Content validity of the BPI-SF-Tr was assessed by four experts. These professionals comprised of two algologists and two algology nurses. These experts were asked to evaluate the each item of the BPI-SF over a 100% agreement level.[20] And then, its final form was composed. Construct validity of the BPI-SFTr was tested using exploratory factor analysis. Firstly, permission for use of the BPI-SF was obtained from the author who developed the tool. Institutional approval was received from the Ethics Committee of Faculty of Nursing. Furthermore, written consent from the institutions and informed consent from each participant were taken. Measures: Two instruments were used to collecting the data of the study. The demographic questionnaire was developed upon a literature review. The questionnaire included socio-demographic characteristics (gender, age, marital status, educational status, social security, employment, and economic condition) and medical characteristics (diagnosis of the disease, duration of disease, treatment, duration of pain, and intensity of the pain) of the patients. The BPI-SF is a patient-rated and easy-to-understand inOCTOBER 2019

strument. Developed by Cleeland and Ryan (1994), the inventory allows patients to rate the severity of their pain and the degree to which their pain interferes with common dimensions of feeling and function. The BPI-SF measures their current, worst, least, and average pain during the past 24 hours. These four items are assessed by using a numeric scale, with 0= no pain and 10= pain as bad as you can imagine. The other seven items evaluates how much pain interfered with various daily activities, including general activity, walking, work, mood, enjoyment of life, relations with others, and sleep. Again, a 0 to 10 scale, with 0= no interference and 10= interferes completely, is used.[8, 21] The BPI-SF also retains the body diagram from the initial questionnaire and questions about effectiveness of pain treatment.[21] The Cronbach’s alpha reliability of the original version of the BPI ranges from 0.77 to 0.91.[8] Statistical Analysis The Statistical Package for The Social Sciences 13.0 for Windows was used to conduct statistical analysis. P values of less than 0.05 were accepted as statistically significant. Firstly, descriptive statistics were performed to assess characteristics of participants. Also, means and standard deviations were calculated for each item of the subscales. Secondly, reliability and validity analysis of the BPI-SF-Tr was carried out. Content validity and construct validity were calculated for assessing the validity of the BPI-SF-Tr. In order to examine construct validity, exploratory factor analysis was used. Principal component analysis for extraction method and varimax with Kaiser Normalization for rotation method were assessed. Cronbach’s alpha coefficient and item total correlation were calculated to establish internal consistency reliability of the subscales.[20, 22] For the purpose of assessing the test–retest reliability for the scale, the Pearson correlation coefficient was performed.

Results A total of seven patients were excluded from the sample group due to their refusal to participate in the study. Finally, 192 patients were included in this study. Table 1 illustrates socio-demographic and medical characteristics of the patients. As shown in Table, 64.6% were female, 78.6% were married, and 45.9% were primary school graduates. The mean age was 49.35±15.49 (range 17 to 84) years. 197


A RI PAIN Table 1. Characteristics of the sample

Table 2. Descriptive results of the BPI-Tr

BPI item

Gender Female Male Marital status Married Single Level of education Literate Primary school (age 7 to 12) Secondary school (age 13 to 17) University Occupation Employee Selfemployed Retired Housewife Total Age (years) Duration of disease (years) Duration of pain (years)

Frequency Percentage 124 68

64.6 35.4

151 41

78.6 21.4

24

12.5

88

45.9

43 37

22.4 19.3

58 30.2 11 5.7 41 21.4 82 42.7 192 100.0 Mean SD 49.35 15.49 4.34 4.74 3.52 3.94

SD: Standard deviation.

All patients had health insurance and 64.1% were not currently working (retired or a housewife). The mean time from the diagnosis was 4.34±4.74 (range one to 25) years. The mean duration of pain was 3.52±3.94 years. Descriptive results of the Turkish Brief Pain Inventory (SF) Table 2 illustrates descriptive statistics for each item of the subscales. The mean worst pain score was 6.99±2.11 and the mean least pain was 3.22±2.17. Patients reported that the highest score was obtained in pain’s interference with general activity, which was followed by normal work, mood, enjoyment of life, sleep, walking ability, and relationship with other. Validity of the Turkish Brief Pain Inventory (SF) The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy value was 0.88 with a statistically signifi198

Pain Severity (0–10) Pain worst Pain least Pain on average Pain now Pain interference (0–10) General activity Mood Walking ability Normal work Relationships with others Sleep Enjoyment of life

Mean

SD

6.99 3.23 5.19 5.11

2.11 2.18 1.95 2.52

6.02 5.29 4.54 5.98 3.84 4.81 5.19

2.42 2.81 3.05 2.54 2.92 3.11 3.09

BPI: Brief Pain Inventory; SD: Standard deviation.

Table 3. The 2 factors and factor loadings of the BPI-Tr items BPI item Pain severity Pain worst Pain least Pain on average Pain now Pain interference General activity Mood Walking ability Normal work Relationships with others Sleep Enjoyment of life

Factor I (PI)

Factor II (PS)

0.53 0.08 0.34 0.22

0.65 0.93 0.86 0.84

0.63 0.57 0.81 0.20 0.71 0.10 0.66 0.42 0.79 0.18 0.60 0.36 0.82 0.23

BPI: Brief Pain Inventory; SD: Standard deviation; PI: Pain interference; PS: Pain severity. The bold figures represent factor 1 and factor 2.

cant Barlett sphericity (BS) (p=0.001). After exploratory factor analysis; it was loaded on two factors as pain intensity and pain interference in this study by using principal component extraction method with varimax rotation. Table 3 illustrates the two factors and factor loadings of the BPI items. The first factor consisted of all seven interference items and accounted for 55.5% of the variance. The second factor consisted of the four pain intensity scales and OCTOBER 2019


Reliability, Validity of the Brief Pain Inventory (SF)

Table 4. Item analysis andinternal consistency of the BPI-Tr BPI item

Item-total correlation

If Item deleted alpha

Pain severity (0–10) Pain worst 0.70 0.89 Pain least 0.79 0.86 Pain on average 0.87 0.83 Pain now 0.75 0.88 Pain interference (0–10) General activity 0.72 0.87 Mood 0.73 0.86 Walking ability 0.56 0.89 Normal work 0.71 0.87 Relationships with others 0.70 0.87 Sleep 0.60 0.88 Enjoyment of life 0.77 0.86 Total BPI-Tr

Cronbach alpha

0.89

0.89

0.91

BPI: Brief Pain Inventory.

accounted for another 13.3% of the variance. Both factors accounted for 68.8% of the total variance. Factor loads of these two factors ranged from 0.60 to 0.93. The eigenvalues of the two factors were 6.10 and 1.46. Reliability of the Turkish Brief Pain Inventory (SF) Internal consistency and test- retest reliability were performed in order to assess the reliability of the BPI. For the internal consistency, Cronbach’s alphas and the item-total correlations were calculated for the pain interference and pain severity scales. The alpha coefficient was 0.89 for the pain severity scale, and 0.89 for the pain interferences scale. The total Cronbach’s alpha coefficient was high as 0.91 for all items (BPI-SF-Tr) of the scale. All alpha values indicated good internal consistency.[23–25] The item-total correlations of the scale ranged between 0.56 and 0.87 (Table 4). The item-total correlations for all items of the scale were adequate criteria.[20, 26] Table 4 illustrates the alpha values when items are deleted. The test–retest reliability measurement was performed to assess the stability of the BPI-SF-Tr over time. After patients completed the BPI-SF-Tr, 30 patients were administered the same scale again two weeks later. Pearson correlations for test-retest reliability were r=0.77, p=0.001 for the pain severity, and r=0.81, p=0.001 for the pain interference. OCTOBER 2019

Discussion The this study has revealed that the BPI-SF-Tr is a valid and reliable instrument to assess pain severity and interference in patients with chronic nonmalignant pain. Validity refers whether an assessment instrument accurately measures what is supposed to measure or not. When an instrument is valid, it truly reflects the concept it is supposed to measure.[20] Three types of validity are content validity, criterion-related validity, and construct validity.[24] The content validity and construct validity were performed for validity of this study. Construct validity was confirmed by using the factor analysis. The KMO and BS are used to assess the adequacy for factor analysis of data. For factorability, KMO should be greater than 0.4.[27] KMO and BS values obtained in this study showed that the sample size and correlation matrix of the scale items were suitable for factor analyses.[22, 27] After factor analysis, a total of 11 items were loaded on two factors as pain severity and pain interference. This result is consistent with numerous other factor analysis results in many different countries.[8–12, 14, 15] Only two studies reported three factors: pain severity, pain activity, and mood interference.[13, 28] Reliability is consistency among independent measurements of the same variable.[24, 28] The reliability of an assessment tool refers to the tool producing consistent, adequate, homogeneous, repeatable results. 199


A RI PAIN Table 5. Reliability coefficient of the pain severity and pain interference bubscales of the various versions of the BPI Country Brazil China France Germany Greece Italy Japan Lebanon North India Norway Russia Taiwan Turkey

PS α

PI α

0.91 0.87 0.86 0.91 0.86 0.90 0.88 0.92 0.89 0.85 0.78 0.78 0.81 0.81 0.82 0.92 0.89 0.91 0.87 0.92 0.93 0.95 0.81 0.89 0.89 0.89

BPI: Brief Pain Inventory; PI: Pain interference; PS: Pain severity. Bolded numbers are results of the present study in Turkey.

The reliability of an assessment instrument is the extent to which it yields consistent, reproducible estimates of what is assumed to be an underlying true score.[30] There is an inverse relationship between reliability and random error. Despite its necessity, reliability alone is not sufficient for validity.[24, 28] In order to assess the reliability of the BPI, internal consistency and test-retest reliability were performed.

[29]

Internal consistency is usually measured with Cronbach’s alpha. Cronbach’s alpha reliability coefficient is the indicator of the homogeneity of the items included in the scale.[23, 24] Internal consistency ranges between 0 and one[23, 25, 28] and literature suggests that a reliability of 0.70 is considered as acceptable. [33–36] An alpha within the range of 0.80 and 0.90 was accepted as good internal consistency.[23–25] In this study, both coefficient alphas of the subscales and the total scale were above 0.80. The Cronbach’s alpha coefficient values indicated that items correlated with each other and the BPI-SF-Tr were reliable.[23] When Cronbach’s alpha coefficient values obtained in this study were compared to other BPI validation studies, it was found in some cases higher than those reported in other studies (Table 5).[9, 10] The acceptable item-total correlation for each item should be 0.30 and items with a correlation coefficient lower 200

than 0.30 generally are recommended to be omitted from the scale.[20, 26] Because the item total correlations for each item were above 0.30, any item from these two subscales was not eliminated.[28] Test-retest reliability measures the stability over time. For test-retest analyses, the group should consist of at least 30 people, and the duration between two tests should be short enough to remember the answers given in the first application, and long enough to allow a considerable change in responders in terms of the features measured by the scale. [28] A typical interval is several weeks.[24] The results of test-retest study showed an acceptable correlation coefficient for the BPI-SF-Tr.

Conclusion The study confirmed that the BPI-SF in patients with chronic nonmalignant pain was determined to be a valid and reliable instrument for Turkish populations. It can be used as a tool for comprehensive pain assessment in patients suffering from chronic nonmalignant pain. It is recommended that this scale should be further evaluated both in different regions of Turkey with larger samples and in diverse populations. Acknowledgements: The authors thank all patients who participated in the study. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

References 1. Davis DB. Caring for people in pain. Florence, KY: Routledge; 2000. p. 159–78. 2. Elliott TE, Renier CM, Palcher JA. Chronic pain, depression, and quality of life: correlations and predictive value of the SF-36. Pain Med 2003;4:331–9. 3. Lapane KL, Quilliam BJ, Benson C, Chow W, Kim MS. Impact of Noncancer Pain on Health-Related Quality of Life. Pain Pract 2015;15(4):333–42. 4. Polomano RC, Dunwoody CJ, Krenzischek DA, Rathmell JP. Perspective on pain management in the 21st century. J Perianesth Nurs 2008;23(1 Suppl):4–14. 5. Comley AL, De Meyer E. Assessing patient satisfaction with pain management through a continuous quality improvement effort. J Pain Symptom Manage 2001;21(1):27–40. 6. McCaffery M, Ferrell BR, Pasero C. Nurses’ personal opinions about patients’ pain and their effect on recorded assessments and titration of opioid doses. Pain Manag Nurs 2000;1(3):79–87.

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Reliability, Validity of the Brief Pain Inventory (SF) 7. Gordon DB, Pellino TA, Miaskowski C, Mc Neill JA, Paice JA, Laferriere D, et al. A 10-year review of quality improvement monitoring in pain management: Recommendations for standardized outcome measures. Pain Manag Nurs 2002;3:116–30. 8. Cleeland CS, Ryan KM. Pain assessment: Global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994;23(2):129–38. 9. Saxena A, Mendoza T, Cleeland CS. The Assessment of cancer pain in North India: The validation of the Hindi Brief Pain Inventory-BPI-H. J Pain Symptom Manage 1999;17:27–41. 10. Mystakidou K, Mendoza T, Tsilika E, Befon S, Parpa E, Bellos G, et al. Greek Brief Pain Inventory: Validation and utility in cancer pain. Oncology 2001;60(1):35–42. 11. Yun YH, Mendoza TR, Heo DS, Yoo T, Heo BY, Park HA, et al. Development of a cancer pain assessment tool in Korea: a validation study of a Korean version of the brief pain inventory. Oncology 2004;66(6):439–44. 12. Aisyaturridha A, Naing L, Nizar AJ. Validation of the Malay Brief Pain Inventory questionnaire to measure cancer pain. J Pain Symptom Manage 2006;31(1):13–21. 13. Dicle A, Karayurt Ö, Dirimese E. Validation of the Turkish Version of the Brief Pain Inventory in surgery patients. Pain Manag Nurs 2009;10(2):107–13. 14. Ferreira KA, Teixeira MJ, Mendonza TR, Cleeland CS. Validation of brief pain inventory to Brazilian patients with pain. Support Care Cancer 2011;19(4):505–11. 15. Ballout S, Noureddine S, Huijer HA, Kanazi G. Psychometric evaluation of the Arabic Brief Pain Inventory in a sample of Lebanese cancer patients. J Pain Symptom Manage 2011;42(1):147–54. 16. De Andres J, Cruces Prado LM, Canos Verdecho MA, Penide Villanueva L, Hoyos DVM, Herdman M, et al. Validation of the Short Form of the Brief Pain Inventory (BPI-SF) in Spanish Patients with Non-Cancer-Related Pain. Pain Pract 2015;15(7):643–53. 17. Upadhyay C, Cameron K, Murphy L, Battistella M. Measuring pain in patients undergoing hemodialysis: a review of

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pain assessment tools. Clin Kidney J 2014;7(4):367–72. 18. Niklasson B, Georgsson Ohman S, Segerdahl M, Blanck A. Risk factors for persistent pain and its influence on maternal wellbeing after cesarean section. Acta Obstet Gynecol Scand 2015;94(6):622–8. 19. Erdoğan S. Ölçümlerde Geçerlilik ve Güvenilirlik. Ankara, 2014;56-189. 20. Lobiondo-Wood G, Haber J. Reliability and validity. In: G. Lobiondo-Wood, Haber J, editors. Nursing research methods, critical appraisal, and utilization. 5th ed. St. Louis: Mosby; 2002. p. 311–46. 21. Cleeland CS. The Brief Pain Inventory User Guide 2009. Available at: https://www.mdanderson.org/documents/ Departments-and-Divisions/Symptom-Research/BPI_ UserGuide.pdf. Accessed December 13, 2011. 22. Akgül A. Tıbbi araştırmalarda istatistiksel analiz teknikleri SPSS uygulamaları. 3rd ed. Ankara: Emek Ofset; 2005. p. 440–6. 23. Tezbaşaran AA. Likert tipi ölçek geliştirme kılavuzu. Ankara: Türk Psikologlar Derneği; 1997. 24. Erefe I. Veri Toplama Araçlarının Niteliği. In: Erefe I, editor. Hemsirelikte Arastirma. Istanbul: Odak Ofset; 2002. p.169– 88. 25. George D, Mallery P. SPSS for windows step by step: A simple guide and reference. 11.0 update. 4th ed. Boston: Allyn & Bacon; 2003. 26. Farketich S. Focus on psychometrics: aspects of item analysis. Res Nurs Health 1991;14(2):165–8. 27. Büyüköztürk Ş. Sosyal Bilimler İçin Veri Analizi El Kitabı. Ankara: Pegem Akademi; 2009. 28. Karasar N. Bilimsel Arastırma Yontemi. 7th ed. Ankara: 3A Araştırma Eğitim Danışmanlık Ltd; 1995;147–53. 29. Çakmur H. Araştırmalarda Ölçme Güvenilirlik-Geçerlilik. TAF Preventive Medicine Bulletin 2012;11:339–44. 30. American Thoracic Society, Quality of Life Resource. Available at: http://qol.thoracic.org/sections/measurementproperties/reliability.html. Accessed March 27, 2015.

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Agri 2019;31(4):202–205

doi: 10.14744/agri.2019.91297

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CASE REPORT

Anesthetic management of two siblings with congenital insensitivity to pain with anhidrosis syndrome Konjenital ağrı duyarsızlık ve anhidrosis sendromu olan iki kardeşin anestezik yönetimi Dilek DESTEGÜL,1

Fazilet KOCAÖZ,1

Ahmet Sinan SARI2

Summary Congenital insensitivity to pain with anhidrosis (CIPA) is a rare syndrome characterized by a lack of sensitivity to pain due to congenital sensory and autonomic neuropathies, anhidrosis, an inability to regulate body temperature, growth retardation, mental retardation at different levels of severity, and inadvertent self-harm. It is an autosomal recessive disorder that is result of a mutation in the neurotrophic receptor tyrosine kinase 1 gene, which encodes neurotrophic tyrosine kinase. CIPA patients are frequently admitted to hospitals with unrecognized traumatic fractures and unhealed wounds due to the lack of a pain response. Presently described is the method of anesthetic management used for 2 siblings, aged 17 and 14 years, with a generalized lack of pain, anhidrosis, mental retardation, and septic arthritis. Sedation with midazolam alone provided satisfactory surgical comfort without causing hemodynamic instability in these 2 patients with CIPA syndrome. Keywords: Congenital insensitivity to pain syndrome with anhidrosis; pain insensitivity.

Özet Konjenital ağrıya duyarsızlık sendromu, konjenital duysal ve otonomik nöropatiye bağlı gelişen ağrıya duyarsızlık, anhidrozis, epizodik ateş, gelişme geriliği, farklı düzeylerde mental retardasyon ve kendine zarar verme ile karakterize nadir görülen bir sendromdur. Nörotrofik tirozin kinazın kodlandığı nörtrofik tirozin kinaz-1 genindeki mutasyon sonucu meydana gelen otozomal resesif bir sendromdur. Çoğu hasta hastaneye ağrısız iyileşmeyen yaralar ve farkedilmeyen travmatik kırıklar ile başvurmaktadır. Bu yazımızda on yedi ve on dört yaşında ağrıyı hissetmeme, anhidrosis, mental retardasyon ve septik artriti olan iki kardeşi sunmaktayız. Konjenital ağrıya duyarsızlık sendromu olan hastalarda, tek başına midazolom ile sedasyon, tatminkar bir cerrahi konforu, herhangi bir hemodinamik bir instabilite yaratmadan sağlamaktadır. Anahtar sözcükler: Ağrıya duyarsızlık; CIPA; konjenital ağrıya duyarsızlık sendromu.

Introduction Pain is an important protection mechanism for the body.[1] Loss of pain sensation can lead to serious problems. Congenital pain insensitivity syndrome with anhidrosis (CIPA) was first described by Dearborn in 1932.[2] Although there is no data about the prevelance of the syndrome, it is a very rare entity. The Syndrome consist of the pain insensitivity due to congenital sensory and autonomic neuropathies, anhydrosis, increase of episodic body temperature , growth retardation, mental retardation at different levels and self-harm. Dick et al.[3] (1993) classified CIPA as 5 subgroups. CIPA syndrome type IV hereditary sen-

sorial and autonomic neuropathy (HSAN-IV), is one of the most common type of these subgroups.[4] It is thought that the mutation of neurotrophic tyrosine kinase receptor 1 (NTRK1) gene, which is autosomal recessive inheritance and responsible for the effects of the nerve growth factor in the embryonic period causes the syndrome.[5–6] In these patients pain sensation is lost, and heat insensitivity and autonomic function are impaired while touch and pressure sensations are intact. An increase in body temperature, seen in episodes of early ages, can be the first symptom of the disease.[7] Additionally fingers and lip bites, painless fractures, joint deformities causing chronic osteomyelitis, and neurogenic arthropathy (charcot joint) can

Department of Anesthesiology and Reanimation, Ömer Halisdemir University Faculty of Medicine, Niğde, Turkey Department of Orthopedic and Traumatology, Ömer Halisdemir University Faculty of Medicine, Niğde, Turkey

1 2

Submitted: 16.07.2018 Accepted after revision: 25.04.2019 Available online date: 25.06.2019

Correspondence: Dr. Dilek Destegül. Niğde Ömer Halisdemir Üniversitesi Tıp Fakültesi Anesteziyoloji ve reanimasyon Anabilim Dalı, 51000 Niğde, Turkey. Phone: +90 - 505 - 357 74 99 e-mail: dilekyas@hotmail.com © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Anesthetic management of two siblings with congenital insensitivity to pain with anhidrosis syndrome

be seen in the patients.[8] Despite patients are insensitive to pain, general anesthesia or sedation may be necessary because of disturbing conditions such as tactile hyperesthesia during the surgical procedure.[9] Experience on anesthesia management of these patients is limited due to few number of cases. We aimed to present our experience about the anesthesia management of two siblings with CIPA syndrome.

Case Report Here we report sixteen and thirteen years old two siblings who were diagnosed with CIPA syndrome. Patients were consulted to anesthesiology clinic for preoperative evaluation due to chronic and acute septic arthritis in ankles (Fig. 1). The older sister diagnosis was made in infancy period while being investigated for fever etiology. Her medical history revealed episodic increase in body temperature, self-harming behaviours, recurrent surgical procedure from knees, hands, fingers and heels in ortopedia clinics due to traumatic and none traumatic reasons. Moderate mental retardation diagnosis had been made by pediatric psychiatry. Physical examination revealed, retardation in mental function, dry skin, thickening of the palms of both hands,

Figure 1. Chronic septic arthritic image of sixteen years old patient.

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and old scars with new wounds on their fingers. Also we learned from medical history a failed surgical attempt to close chronic fistula which was located on left foot ankle about one year ago. Because of the fact that she had CIPA diagnosis, after the birth of her brother, genetic analysis was done and he was also diagnosed with CIPA syndrome. And his medical history and physical examination have shown similar findings with his sister. Other systemic examinations of both patients were normal. The mallampati scores were II in their airway assessments. Laboratory values and chest X-rays were normal except leukocytosis, and elevation of values of C-Reaktive Proteins and erythrocyte sedimentation rates. Routine monitoring with electrocardiography, noninvasive arterial blood pressure, pulse oximetry and temperature were performed in the patients. Vital signs were normal. The response of the patients to touch and painful stimuli were evaluated. It was decided to start with sedation since patients did not feel any pain and were cooperative. During the perioperative period, preparations were made for general anesthesia if needed. Before the surgical procedure, the patients did not feel any pain during the vascular access. Midazolam was administered intravenously as a bolus dose of 0.06 mg/kg. Oxygen was given at 3 L/min with face mask and end-tidal CO2 (ETCO2) levels were followed. The operation room temperature was kept at around 240C. In surgical procedures, ankles were inserted with a 4 cm incision. The skin and subcutaneous tissues were passed through bluntly by paying attention to the tendons, veins and nerve packs. There were no sensation of pain in patients in the meantime. After reaching the ankle joint, all infected looking tissues were debrided (Fig. 2). The ankles were washed with plenty of saline and closed in each patient. Short leg splint were performed. There were no sensation of pain in patients in the meantime. Operation times were approximately 45 and 70 minutes. In both cases there were no increase in heart rate and blood pressure, no decrease in oxygen saturation, no alterations in ETCO2 and body temperature throughout the operation. No additional anesthetic inter203


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Figure 2. Debridement image of sixteen years old patient.

vention was required. At the end of the operation, the patients were observed in the postoperative unit for 20 minutes and then, were sent to the orthopedic clinic for further follow-up and treatment. There were no analgesic requirement in the postoperative period. Before the preoperative period, the parents of the patients were informed about our anesthesia methods that could be applied and their written informed consent was obtained.

Discussion Congenital pain insensitivity syndrome is a rare syndrome characterized by pain insensitivity, mental and growth retardation, impaired sweat secretion, and temperature regulation. In a study, Bar-On et al.[10] investigated 13 patients with congenital pain insensitivity syndrome and reported that type-IV, was the most common CIPA syndrome. Our cases were congenital pain insensitivity syndrome type IV and had mental retardation, pain insensitivity and absence of sweat. Pain is a very important sensation that allows people to protect themselves, and various problems arise in its absence. Today the pathophysiology of these diseases is not fully understood and there is no treatment. However, the diagnosis of disease with genetic testing can be done at the beginning of pregnancy by 98%.[11] In our cases, the family had a genetic test for the infant born after the sick child, and the CIPA was diagnosed. These patients are susceptible to numerous anesthetic complications such as hemodynamic instabil204

ity and risk of hyperthermia because of autonomic dysfunction. For this reason, determining the method of anesthesia, choosing the anesthetic drugs and adjusting the dose of the drugs is important for the anesthetist. The experience of anesthesia management is also limited due to the rare occurrence of the syndrome. Although general anesthesia was preferred in most of the studies,[12] there were case presentations which only sedation was performed. [13] Even though general anesthesia provides surgical comfort for surgeon, it increases the susceptibility to anesthesia complications due to hemodynamic instability and hyperthermia because of autonomic dysfunction. Therefore, we decided to performed sedation first. Zlotnik et al.[14] examined 358 operations performed under general anesthesia in 35 CIPA patients. The ratio of the anesthetic agents used in these operations was; thiopental 4%, ketamine 27%, propofol 71%, opioid 8%, muscle relaxants 27%. Ă&#x2013;zmete and colleagues administered propofol for depth sedation after premedication with midazolam, atropine, and ketamine for endoscopic intervention in CIPA syndrome patient.[13] Only midazolam administration was enough in our cases. In some studies, bispectral index (BIS) monitoring was used to evaluate the depth of anesthesia.[13â&#x20AC;&#x201C;14] We could not monitor the BIS because the conditions in our clinic were not appropriate. Although the cardiovascular reflexes are protected in CIPA syndrome, the levels of epinephrine and norepinephrine levels are reduced. Tomioka et al. reported hypotension and bradycardia in the perioperative period due to decreased catecholamine levels.[15] In our cases, hypotension and bradycardia were not observed during the operation.

Conclusion To our knowledge this is the first case presentation in the literature which were only used midazolam for sedation. According to the mental level of the patient and the type and size of the surgical procedure, we think sedation with midazolam alone is provides satisfying surgical comfort without causing any hemodynamic instability in patients, under the mandatory monitorization. OCTOBER 2019


Anesthetic management of two siblings with congenital insensitivity to pain with anhidrosis syndrome

Informed Consent: Written informed consent was obtained from the patient for the publication of the case report and the accompanying images. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

References 1. Kılınç G, Çetin M. Congenital insensivity-to-pain with anhidrosis (CIPA):A case report Atatürk Üniv. Diş Hek. Fak. Derg. J Dent Fac Atatürk Uni 2015;11:8–12. 2. Dearborn G.A case of congenital pure analgesia.J Nerv Ment Dis 1932;75:612–5. 3. Dick PJ, Thomas PK. Neuronal atrophy and degeneration predominantly affecting peripheral sensory and autonomic neurons. In: Griffin JW, Low PA, editors. Peripheral Neuropathy. Philadelphia: WB Saunders; 1993. p.1065–93. 4. Kucukdurmaz F, Imren Y, Uruc V, Sen C. Congenital insensitivity to pain with anhidrosis (CIPA) manifested with chronic osteomyelitis; A case report. J Clin Anal Med 2015;6:230– 2. 5. Van den Bosch GE, Baartmans MG, Vos P, Dokter J, WhiteT, Tibboel D. Pain insensitivity syndrome misinterpreted as inflicted burns. Pediatrics 2014;133(5):e1381–7. 6. Perez-Lopez LM, Cabrera-Gonzales M, Gutierrez-de laIglesia D, Ricart S, Knörr-Gimenez G. Update review and clinical presentation in congenital insensitivity to pain and anhydrosis. Case Rep Pediatr 2015;2015:589852. 7. Swanson AG. Congenital insensivity to pain with anhydro-

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sis. A unique syndrome in two mail siblings. Arch Neurol 1963;8:299–306. 8. Okuda K, Arai T, Miwa T, Hiroki K. Anesthetic management of children with congenital insensivity to pain with anhydrosis. Pediatr Anaesth 2000;10(5):545–8. 9. Oliveira CR, Paris VC, Pereira RA, Lara FA. Anaesthesia in a patient congenital insensivity to pain with anhydrosis. Rev Bras Anestesiol 2009;59(5):602–9. 10. Bar-On E, Weigl D, Parvari R, Katz K, Weitz R, Steinberg T. Congenital insensitivity to pain. Orthopaedic manifestation. J Bone Joint Surg 2002;84(2):252–7. 11. Shatzky S, Moses S, Levy J, Pinsk V, Hershkovitz E, Herzog L, et al. Congenital insensitivity to pain with anhidrosis(CIPA) in Israeli Bedovins: genetic heterogenecity, novel novel mutations in the TRKA/NGF receptor gene, clinical findings, and results of nevre conduction studies. Am J Med Genet 2000;92(5):353–60. 12. Urfalioglu A, Arslan M, Duman Y, Gisi G, Öksüz G, Yıldız H, et al. Anesthesia Procedure for Congenital Insensitivity to Pain in a Child with Anhidrosis Syndrome: A Rare Case. J Nippon Med Sch 2017;84(5):237–40. 13. Özmete Ö, Şener M, Bali Ç, Çalışkan E, Arıboğan A. Congenital insensitivity to pain: How should anesthesia be managed? Turk J Pediat 2017;59:87–9. 14. Zlotnik A, Natanel D, Kutz R, Boyko M, Brotfain E, Gruenbaum BF, et al. Anesthetic Management of Patients with Congenital Insensitivity to Pain with Anhidrosis: A Retrospective Analysis of 358 Procedures Performed Under General Anesthesia. Anesth Analg 2015;121:1316–20. 15. Tomioka T, Awaya Y, Nihei K, Sekiyama H, Sawamura S, Hanaoka K. Anesthesia for patients with congenital insensitivity to pain and anhidrosis: A questionnaire study in Japan. Anesth Analg 2002;94(2):271–4.

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doi: 10.14744/agri.2019.33600

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CASE REPORT

Temporal arteritis and trigeminal neuralgia overlap syndrome: A case report Temporal arterit ve trigeminal nevralji overlap sendromu: Bir olgu sunumu Yağmur İNALKAÇ GEMICI,

İrem TAŞCI

Summary Temporal arteritis and trigeminal neuralgia are rare causes of a headache, and the combination is rarer still. The present patient was diagnosed with temporal arteritis at the age of 60 years and presented with trigeminal neuralgia after the sedimentation rate had returned to normal under treatment. The underlying cause of neuralgia in cases of temporal arteritis varies. This report is an examination of the rare association of the 2 conditions and the available literature. Keywords: Inflammation; overlap syndrome; temporal arteritis; trigeminal neuralgia.

Özet Temporal arterit ve trigeminal nevralji başağrısının az görülen nedenlerinden olup birliktelikleri çok daha nadirdir. Sunmuş olduğumuz olgu 60 yaşında önce temporal arterit tanısı alıp tedavi altında sedimentasyon normale döndükten sonra trigeminal nevralji ile prezente olmuştur. Temporal arteritte nevralji görülmesinin altında yatan neden ise değişken olabilir. Biz bu vakada literatür eşliğinde nadir görülen bu birlikteliği ele almayı amaçladık. Anahtar sözcükler: Inflamasyon; overlap sendromu; temporal arterit; trigeminal nevralji.

Introduction Temporal arteritis (TA) is an inflammatory vasculitis affecting large and medium arteries. TA is mostly seen in people aged over 50 years and can involve the central and peripheral nervous systems.[1] One of the peripheral involvements is a short-lasting neuralgiform headache characterized by unilateral electric shock-like pain.[2] In this report, we reviewed a patient who presented with TA followed by with trigeminal neuralgia (TN) in light of literature.

Case Report A 60-year-old female patient was admitted to our outpatient clinic with a two-month history of a throbbing pain in her left temple which occurred every day and continued throughout the day and blurry vision in the left eye. The patient also had sensitivity in the temple area along with nausea and fever. The patient was prediagnosed with TA based on the

patient history and an erythrocyte sedimentation rate (ESR) of 132 mm/h. Accordingly, the patient was hospitalized and initiated on pulse steroid therapy (1,000 mg/day methylprednisolone) without biopsy due to the risk of vision loss and since the patient met 4 out of the 5 diagnostic criteria for TA. The laboratory parameters assessed during the differential diagnosis were as follows: C-reactive protein (CRP), 17.8 mg/dl; ESR: 132 mm/h, haemoglobin: 10.3% and platelet count: 547,000 μ/L. Vasculitis panel was negative. The patient showed a dramatic response to the treatment and also had reduced fever, improved anaemia and thrombocytosis, and a reduction trend in ESR. Depending on these findings, the patient was referred to the Rheumatology clinic. The patient was started on immunosuppressant therapy with leflunomide but was later switched to monthly treatment with anti-IL-6 monoclonal antibody therapy with the addition of oral steroids (methylprednisolone). The oral steroid dose was gradually reduced to 8 mg/

Department of Neurology, Malatya Training and Research Hospital, Malatya, Turkey Submitted: 13.12.2018 Accepted after revision: 28.05.2019 Available online date: 26.06.2019

Correspondence: Dr. İrem Taşcı. Malatya Eğitim ve Araştırma Hastanesi, Nöroloji Kliniği, Malatya, Turkey. Phone: +90 - 536 - 955 05 34 e-mail: tasciiirem@gmail.com © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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day. After the initiation of the treatment, the patient had a sensation of pain in the form of a short-lasting electric shock extending from the back of the left ear to the ophthalmic region which occurred 15â&#x20AC;&#x201C;20 times per minute and was not accompanied by autonomic findings. The trigger point was detected on examination and the ESR was 12 mm/h. The patient had an MR-incompatible implant and thus no cranial magnetic resonance imaging (MRI) scan could be performed. A computed tomography (CT) scan showed normal cerebral and carotid-vertebral arteries on angiography and no intracranial aneurysm or arterial compression that could trigger TN. The vertebral and basilar arteries were also normal. Following treatment with carbamazepine 200 mg 2*1/day, neuralgia completely disappeared. The patient was diagnosed as having TN based on the International Headache Society (IHS) diagnostic criteria.

Discussion Temporal arteritis (TA) may manifest with central and peripheral nervous system findings. TA is an inflammatory granulomatous vasculitis characterized by unilateral headache and vision loss, mostly affecting people aged over 50 years.[1] In a study conducted with 214 patients in 1990, Hunder et al. defined 5 criteria for the diagnosis of TA: (I) an age of â&#x2030;Ľ50 years at the time of disease onset, (II) localized headache of new onset, (III) sensitivity or decreased pulse of the temporal artery, (IV) ESR >50 mm/h, and (V) granulomatous segmental inflammation in temporal artery biopsy. The presence of 3 out of these 5 criteria is diagnostic.[3] TN is a paroxysmal, suddenonset, severe, short-term, knife-like or electric shocklike pain which is mostly localized in the divisions of the trigeminal nerve and can involve the central or peripheral nervous system. Diagnosis is often made based on patient history.[4] According to the IHS, the diagnostic criteria of TN are as follows: (I) paroxysmal pain attacks that affect one or more branches of the trigeminal nerve and last from one second to two minutes, including criteria II or III, (II) a pain characteristically including at least one of the following criteria: a) intense, sharp, superficial or knife-like pain, b) stimulation of pain with triggering regions or increase with triggering factors, (III) attacks which are different for each patient and patient-specific, and (IV) absence of clinically significant neurological deficit.[5] In a case report published in 2005, Blaise et OCTOBER 2019

al. reported that peripheral neuropathy might be a symptom of TA. Of note, the authors also reported that the C5 root, sciatic, and the medial and radial nerves were involved and ischemia was considered to be the underlying mechanism due to the sudden onset of a C5 plexopathy in the patient.[1] Our patient was a 60-year-old woman and presented with sensitivity in the temporal region, new onset of gradually increasing headache, and blurry vision. Moreover, laboratory workup indicated an ESR of over 100 mm/h. Following the diagnosis, however, the ESR became normal and the patient was diagnosed as having TN due to the presence of electric shocklike recurrent pain which lasted for 5â&#x20AC;&#x201C;10 seconds in the same area throughout the day. In a previous case report, Jundt et al. evaluated a patient with TA and reported that occipital artery inflammation was present in the aetiology of occipital neuralgia while sedimentation was normal.[6] Similarly, literature reviews indicate that the coexistence of TA and TN may have an etiology of ischemia or inflammation. [1, 6] Kawaguchi et al. reported that the coexistence of TN and TA is extremely rare.[2] In our patient, the treatment was performed without biopsy due to the risk of vision loss and urgent treatment indications and also because TA biopsy is not performed in our centre. A computed tomography (CT) scan and carotid-vertebral arteries on angiography showed normal. Accordingly, Ischemia was ruled out in the etiology of TN secondary to TA. Additionally, due to the presence of ophthalmic branch involvement and the anatomical proximity of the ophthalmic branch of the trigeminal nerve to the temporal artery, we considered that the aetiology was not coincidental. In conclusion, the case presented in this report indicated that inflammation may play a role in the pathogenesis of TN secondary to TA. Moreover, given that inflammation may be present despite normal ESR levels, as seen in our patient, inflammation can be considered in the etiology of this condition once other causes have been ruled out. Informed Consent: Written informed consent was obtained from the patient who participated in this study. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed. 207


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References 1. Blaise S, Liozon E, Nadalon S, Vidal E. Horton’s disease revealed by brachial C5 plexopathy. Rev Med Interne 2005;26(7):578–82. 2. Kawaguchi Y, Ebina M, Sato T, Ishiguro Y, Yagihashi S, Hirota K. A case of trigeminal neuralgia complicated by ipsilateral temporal arteritis. J Anesth 2010;24(1):139–42. 3. Hunder GG, Bloch DA, Michel BA, Stevens MB, Arend WP, Calabrese LH, et al. The American College of Rheumatol-

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ogy 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum 1990;33(8):1122–8. 4. Cruccu G. Trigeminal Neuralgia. Continuum (Minneap Minn) 2017;23(2):396–420. 5. Headache Clasification Subcommittee of the International Headache Society. The International Clasification of Headache Disorders. Cefalgia 2004;24(1):126–7. 6. Jundt JW, Mock D. Temporal arteritis with normal erythrocyte sedimentation rates presenting as occipital neuralgia. Arthritis Rheum 1991;34(2):217–9.

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doi: 10.14744/agri.2019.88896

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CASE REPORT

Efficacy of ultrasound-guided bilateral erector spinae plane block in pediatric laparoscopic cholecystectomy: Case series Pediatrik laparoskopik kolesistektomi için ulltrason rehberliğinde yapılan bilateral erector spina plan bloğun etkinliği: Vaka serileri Ömer KARACA,1

Hüseyin Ulaş PINAR2

Summary Postoperative opioid administration can cause various side effects, such as drowsiness, respiratory distress, postoperative nausea, and vomiting. The use of non-opioid medications as part of a multimodal analgesia method has been increasingly suggested in the management of acute postsurgical pain. Erector spinae plane block (ESPB), which is a regional anesthesia technique, blocks both visceral and somatic nerve fibers. Though it is infrequently used in young patients, presently described is a series of cases in which ESPB was successfully used in the performance of pediatric laparoscopic cholecystectomy. Ultrasound-guided bilateral ESPB was performed on 4 patients who underwent a laparoscopic cholecystectomy. An injection of 0.25% bupivacaine was administered into the interfascial area on each side in the pre-incisional period after the anesthesia induction (total anesthetic: 2.5 mg/kg). Postoperative pain control was planned at 10 mg/kg intravenous paracetamol every 8 hours. Numeric rating scale pain scores were less than 3 points in the post-anesthetic care unit, and at 1, 2, 4, 8, 12, and 24 hours. No rescue analgesic (1 mg/kg tramadol) was needed. None of the typical complications, such as drowsiness or nausea, were observed and no block-related complications were recorded. Bilateral ESPB that is a part of multimodal analgesia regimen can provide effective analgesia for pediatric laparoscopic cholecystectomy patients in the first 24 hours postoperatively. Keywords: Erector spinae block; laparoscopic cholecystectomy; pediatrics; postoperative pain; ultrasound.

Özet Ameliyat sonrası opioid uygulaması uyku hali ve solunum sıkıntısı, bulantı ve kusma gibi çeşitli yan etkilere neden olabilir. Multimodal analjezinin bir parçası olarak opioid olmayan ilaçlar, akut cerrahi sonrası ağrının tedavisinde giderek artan ölçüde öne sürülmektedir. Bölgesel bir anestezi tekniği olan Erector spinae plan bloğu (ESPB) hem visseral hem de somatik sinir liflerini bloke eder. Pediatrik cerrahi olgularda çok az uygulaması olan laparoskopik kolesistekomide postoperatif ağrı için bir ESPB vaka serisi sunduk. Laparoskopik kolesistektomi yapılan dört hastaya ultrason eşliğinde bilateral ESPB yapıldı. Anestezi indüksiyonundan sonra, insizyon öncesi dönemde her iki taraftaki fasyalar arasındaki alanına% 0.25 bupivakain enjekte edildi. (toplam anestezi: 2.5 mg/kg) Ameliyat sonrası ağrı kontolü, her sekiz saatte bir 10 mg / kg’lık parasetamol ile planlandı. NRS (sayısal puanlama ölçeği) ağrı skorları, anestezi sonrası bakım ünitesinde (PACU) 1, 2, 4, 8, 12 ve 24. saatlerde üç puanın altındaydı. Kurtarma analjeziklerine (1 mg/kg tramadol) ihtiyaç olmadı. Bu yüzden, uyuşukluk, bulantı ve kusma gibi komplikasyonlar olmadı. Blokla ilişkili herhangi bir komplikasyonla karşılaşılmadı. Multimodal analjezi rejiminin bir parçası olan ESPB’un iki taraflı uygulanması, pediatrik laparoskopik kolesistektomi için postoperatif ilk 24 saatte etkili analjezi sağlamaktadır. Anahtar sözcükler: Erector spina blok; laparoskopik kolesistektomi; pediatri; postoperatif ağrı; ultrason.

Introduction Laparoscopic cholecystectomy is performed mostly in adults and less frequently in pediatric cases.[1] Postoperative pain after laparoscopic cholecystectomy (LC) can be moderate in intensity. The etiology of the pain has been attributed to tissue injury, residual pneumoperitoneum, and stretching of the

diaphragm with associated phrenic neuropraxia. Multimodal analgesia in laparoscopic cholecystectomy is usually provided with a combination of paracetamol, nonsteroidal anti-inflammatory drugs, opioids and regional anesthesia methods.

[2]

Erector spinae block (ESPB) is a suitable regional anesthesia method which has been observed to have

Deparment of Anaethesia and Reanimation, Private Anit Hospital, Konya, Turkey Department of Anaesthesia and Reanimation, Baskent University, Konya, Turkey

1 2

Submitted: 25.02.2019 Accepted after revision: 28.05.2019 Available online date: 14.06.2019

Correspondence: Dr. Ömer Karaca. Özel Konya Anıt Hastanesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, Konya, Turkey. Phone: +90 - 530 - 156 57 76 e-mail: dromerkaraca@hotmail.com © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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A RI PAIN characteristics of postoperative analgesia in various thoracic and abdominal operations because it blocks both somatic and visceral pain. As a result of local anesthetic injection into the interfascial space between the transverse process of the vertebrae and the erector spinae muscle, ESPB is performed with the spreading of local anesthesia into multiple paravertebral spaces.[3] We wanted to report the ESPB in pediatric patients. We performed pre-incisionally in laparoscopic cholecystectomy operations for cholelithiasis as a case series study. In all of the cases, both the block to be applied and that the cases might be reported have been told to the legally responsible individuals and written consent was obtained.

Case Series Four patients, ages of 10, 12, 14, 11 years and weights of 25, 30, 45, 25 kg respectively, planned laparoscopic cholecystectomy due to cholecystitis and recurrent attacks of cholecystitis. There were no features in the preoperative evaluations of patients 1, 3 and 4. Only patient 2 had a history of tonsillectomy at the age of 5. The laboratory findings of all the patients were normal. All patients underwent the same preoperative preparation. After electrocardiography, saturation oxygen and non-invasive blood pressure measurements, a 24-gauge peripheral venous line was opened for fluid replacement and drug administration. Ringer’s lactate/glucose (4:1) 5 ml/kg was given intravenously (IV) for fluid replacement. 2–3 mg/kg propofol, 1 µg/kg fentanyl and 0.6 mg/kg rocuronium were used and intubated after anesthesia induction. Afterwards, anesthesia was maintained by ventilation with 0.05 µ/kg remifentanil (IV) and oxygen mixture with 6% desflurane in 50% air. Depending on the hemodynamic parameters, the dose of remifentanil was increased to 1.5 µg/kg. Normocarbic ventilation was aimed. After intubation, patients were turned to prone position. The thoracic vertebrae region including the lower end of the scapula was sterilized with povidone iodine. With the help of the lower end of the scapula, the T7 vertebrae spinous process was determined. After the 5-13 MHz linear ultrasound probe (Fujifilm SonoSite, WA, USA) was coated with a sterile sheath, it was placed over the T7 vertebrae spinous process at the sagittal plane and then was slid by 1.5-2 cm laterally at 210

Figure 1. Scanning ultrasonogram displaying Trapezius (T), Rhomboid Major (Rh M) and Erector Spinae Muscle (ESM), Pleura (P), T7 transverse process (TP), Needle (N) and spread of local anesthetic (LA). Erector spinae plane block performs at level of T7 transverse process. The needle inserts with in-plane technique and the tip of needle contacts the TP. Then local anesthetic (LA) injects into the fascial plane on the anterior face of ESM.

the midsagittal region. After the trapezius, rhomboid major, erector spinae muscles and the transverse process of vertebrae were visualized, a 22-gauge 10 cm needle (Stimuplex A, B Braun, Melsungen, Germany) was inserted using in-plane cephal-to-caudal approach. The tip of needle was situated into the fascial plane on the anterior (deep) face of erector spinae muscle. The total dose of 0.5% bupivacaine used was designed to be 2.5 mg/kg. The local anaesthetic was prepared as 0.25% bupivacaine for each side. Localization of the needle tip: bupivacaine was injected after separation with hydrodissection was confirmed by giving 0.5-1 ml of fluid to the deep fascia of the erector spinae muscle above the bone shadow of the transverse process of the T7 vertebrae. Spread of the local anesthetic was observed (Fig. 1). The same procedure was repeated on the other side. At the end of the operation, the pneumoperitoneum was evacuated. Patients were extubated after the wounds were sutured and closed and they showed adequate muscle strength, and they were transferred to postanesthesia care unit (PACU). The patients were sent to the wards when the Aldrete Score System was at least 9 in PACU. No nebulized local anesthetic was administered intraperitoneally to the wounds. The patients were discharged after 36 hours of follow-up. OCTOBER 2019


Efficacy of ultrasound-guided bilateral erector spinae plane block for pediatric laparoscopic cholecystectomy: Case series

Table 1. Demographic characteristic of patients

1. 2. 3. 4. child child child child

Age, year Sex Height, cm Weight, kg BMI Operation time, min Anesthesia time, min

10 12 14 11 F M F F 126 141 150 130 24 33 44 26 15.1 16.6 19.6 15.4 85 95 98 85 95 106 110 97

BMI: Body mass index; min: Minute.

Pain management The Numeric Rating Scale (NRS), which best reflects the severity of the pain of the patients at the PACU, 1st, 2nd, 4th, 8th, 12th and 24th hours was used to evaluate the postoperative pain. The 11-point numeric scale ranges from ‘0’ respecting no pain to ‘10’ respecting the worst imaginable pain. NRSs during movement and rest were evaluated and recorded. If NRS was ≥3, 1 mg/kg tramadol (IV) was planned to be administered.

Results Age, sex, weight, height, body mass index and ASA scores, surgical and anesthesia durations was shown in Table 1. ESPB block was successfully performed in 4 pediatric patients without any complications such as pneumothorax, bleeding or subcutaneous emphysema. Looking at the pain assessments at the PACU, 1st, 2nd, 4th, 8th, 12th and 24th hours in the postoperative period, the NRS scores were observed to not be at 3 or above during both rest and movement (coughing/movement). No rescue analgesic was needed. None of the patients had shoulder pain, nausea or vomiting.

Discussion Our case series have shown that ESPB block provide long-term analgesia in pediatric laparoscopic cholecystectomy. If acute postoperative pain after laparoscopic cholecystectomy is inadequate treatment, side effects and serious problems is encountered, which include: increased incidence of persistent postoperative pain; OCTOBER 2019

rehabilitation defect; hospital stay or recurrent hospitalization; intact quality of life; and excessive sedation, nausea, vomiting and itching due to opioid. In such cases, if analgesic treatment is initiated after a painful stimulus, treatment of postoperative pain may be difficult due to the possibility of peripheral hypersensitivity and central nervous system hyperexcitability. Postoperative effective pain control offers benefits such as earlier mobilization, increased patient satisfaction, lower hospital costs and shorter hospital stay.[4] Although laparoscopic cholecystectomy has advantages over open surgery, acute pain caused by the procedure is common. The peak of pain intensity following laparoscopic cholecystectomy is between the first and eighth hours and usually decreases 2 or 3 days after surgery. Pain is usually seen in the back, shoulder and port incision regions. Sympathetic pain occurs in approximately 30–50% of patients and this can be difficult to cope with. Severe acute postoperative pain that may occur weeks or months after surgery may lead to chronic pain.[4] Therefore, the treatment of acute pain in especially pediatric patients is a very important issue. Peripheral blocks form a part of the multimodal analgesic regimen. Regional blocks do not only reduce the use of other analgesics such as opoid, but also prevent their side effects. Studies have been conducted on the efficiency of transversus abdominis plane block (TAP) and ultrasound-guided oblique subcostal transversus abdominis plane block (OSTAP) for laparoscopic cholecystectomy;[3] however, both blocks have the ability to affect the cutaneous fibers and are therefore more effective on somatic pain. Ortiz et al. revealed that TAP block had no significant analgesic activity for this purpose.[5] Altiparmak et al. showed that ESPB block was more effective on postoperative tramadol consumption and pain scores than OSTAP block in adult patients undergoing laparoscopic cholecystectomy. They also thought that the dermatomal extension of the local anesthetic in the ESPB block is greater than the OSTAP block.[6] Because ESPB block is targeted to ventral, dorsal ramie and ramie communicators of spinal nerves. On the other hand, OSTAP block affects somatic and parietal components of postoperative pain and has no effect on visceral component.[6, 7] 211


A RI PAIN Another method is the paravertebral block which is a denser block. Although this block is performed under ultrasound, there are serious complications such as vascular, neuronal and plevral puncture, cardiac depression, epidural or intrathecal dissemination.[8] Visoiu et al. compared bilateral paravertebral block and local anesthesia to the port sites in pediatric LC. They showed that PVB has no significant superiority to local anesthetic infiltration.[2] While Ueshima and Hiroshi block supported paravertebral extension of local anesthesia for ESPB.[9] Forea et al. reported that the spinal nerves spread to both ventral and dorsal ramies.[7] In a recent cadaveric study, Ivanusic et al. showed that local anesthesia did not spread to paravertebral space and ventral ramie.[10] On the other hand, in an magnetic resonance imaging and anatomical study have been reported epidural and intercostal spread.[11] In another study, when the ESPB block was performed at the lower thoracic level, it was revealed that the local anesthetic extended to the anterior and entered the thoracic paravertebral space. So, it is stated that ramie communicants was also blocked.[12] Because author ESPB block applied at lower thorasic level (T7), author thought that the block provided adequate analgesia by acting on visceral, parietal and somatic pain as a result of the spread of the local anesthetic over a large area. Pneumothorax and motor weakness were two complicaitons reported for ESPB block.[13, 14] Since the block is performed under ultrasound, it is difficult to encounter pneumothorax. However, it can occur as a result of carelessness. Motor weakness may occur when the block applied lower thoracic and lumbar level, which local anesthesia is allowed to spread to the lumbar plexus.[15] Author did not encounter any complications related to block in any of the cases. Local Anesthesia Systemic Toxicity (LAST), which is caused by local anesthesia spreading and high volume application is also mentioned.Aksu and Gurkan applied 0.5 ml/kg 0.25% with a maximum bupivacaine dose of 20 ml/per side in ESPB block for pediatric LC ve herhangi bir LAST ile karşılammışlardır.[17] Thomas and Tulgar performed ESPB block by applying 15 ml of bilateral, 30 ml of total 0.25% bupivacaine to a 23 kg pediatric patient exposed to lapa212

roscopic cholecystectomy.[17] Although they did not observe LAST, the maximum dose of bupivacaine was seen to be exceeded in this volume. However, the maximum dose for bupivacain is 3 mg/kg.[18] Tulgar et al. applied 2.5 mg/kg for bupivacaine plus 4 mg/kg for lidocaine during ESPB block permormed and run across LAST related sentral nervous system toxicity such as aphasia/apthia, short-lasting loss of conciousness and tinnitus/vertigo.[15] The author performed a total of 2.5 mg/kg of 0.25% bupivacain to the bilateral ESPB block. The complications related to the cardiovascular system such as hypotension, dysrhythmia and cardiac arrest during the peroperative period, and central nervous system complications such as disorientation, tinnitus and seizures during postoperative period were not encountered. The ESPB block can only act in the paraspinal area, but may also block the lateral side of the thoracoabdominal areas and the mid-abdomen. Therefore, block failure/lack of efficiency was defined the first time by Tulgar et al.[15] Author did not evaluate dermatom areas in the postoperative period. However, author indicated that the block was effective, due to the postoperative NRS scores <3 and the absence of any analgesics requirement. Our cases needed no analgesic in the postoperative period either. Dissimilar to the literature, we found that sufficient analgesia was provided at 24th postoperative hour in pediatric patients exposed to LC as a result of total 2.5 mg/kg bupivacaine bilateral administration. ESPB block is a safe and effective regional anesthesia method for multimodal analgesia. The results obtained from our case series will be useful for randomized studies. Informed Consent: Written informed consent was obtained from the patient for the publication of the case report and the accompanying images. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

References 1. Zeidan MM, Pandian TK, Ibrahim KA, Moir CR, Ishitani MB, Zarroug AE. Laparoscopic cholecystectomy in the pediatric population: a single-center experience. Surg Laparosc Endosc Percutan Tech 2014;24(3):248–50.

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Efficacy of ultrasound-guided bilateral erector spinae plane block for pediatric laparoscopic cholecystectomy: Case series 2. Visoiu M, Cassara A, Yang CI. Bilateral Paravertebral Blockade (T7-10) Versus Incisional Local Anesthetic Administration for Pediatric Laparoscopic Cholecystectomy: A Prospective, Randomized Clinical Study. Anesth Analg 2015;120(5):1106–13. 3. Tulgar S, Kapakli MS, Senturk O, Selvi O, Serifsoy TE, Ozer Z. Evaluation of ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: A prospective, randomized, controlled clinical trial. J Clin Anesth 2018;49:101–6. 4. Karaca O, Pınar HU, Turk E, Dogan R, Ahiskalioglu A, Solak SK. The Effects of Pregabalin Plus Ibuprofen on Acute Pain after Laparoscopic Cholecystectomy. J Invest Surg 2019;32(3):189–95. 5. Ortiz J, Suliburk JW, Wu K, Bailard NS, Mason C, Minard CG, et al. Bilateral transversus abdominis plane block does not decrease postoperative pain after laparoscopic cholecystectomy when compared with local anesthetic infiltration of trocar insertion sites. Reg Anesth Pain Med 2012;37(2):188–92. 6. Altıparmak B, Korkmaz Toker M, Uysal AI, Kuşçu Y, Gümüş Demirbilek S. Ultrasound-guided erector spinae plane block versus oblique subcostal transversus abdominis plane block for postoperative analgesia of adult patients undergoing laparoscopic cholecystectomy: Randomized, controlled trial. J Clin Anesth 2019;57:31–6. 7. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block.Reg Anesth Pain Med 2016;41(5):621– 7. 8. Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia. Br J Anaesth 2016;117(3):382–6.

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9. Ueshima H, Hiroshi O. Spread of local anesthetic solution in the erector spinae plane block. J Clin Anesth 2018;45:23. 10. Ivanusic JJ, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med 2018;43(6):567–71. 11. Adhikary SD, Bernard S, Lopez H, Chin KJ. Erector Spinae Plane Block Versus Retrolaminar Block: A Magnetic Resonance Imaging and Anatomical Study. Reg Anesth Pain Med 2018;43(7):756–62. 12. Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery a report of 3 cases. Reg Anesth Pain Med 2017;42(3):372–6. 13. Ueshima H. Pneumothorax after the erector spinae plane block. J Clin Anesth 2018;48:12. 14. Selvi O, Tulgar S. Ultrasound guided erector spinae plane block as a cause of unintended motor block. Rev Esp Anestesiol Reanim 2018;65:589–92. 15. Tulgar S, Selvi O, Senturk O, Serifsoy TE, Thomas DT. Ultrasound-guided Erector Spinae Plane Block: Indications, Complications, and Effects on Acute and Chronic Pain Based on a Single-center Experience. Cureus 2019;11(1):e3815. 16. Aksu C, Gürkan Y. Ultrasound-guided bilateral erector spiane block could provide effective postoperative analgesia in laparoscopic cholecystectomy in pediatric patients. Anaesth Crit Care Pain Med 2019;38(1):87–8. 17. Thomas DT, Tulgar S. Ultrasound-guided Erector Spinae Plane Block in a Child Undergoing Laparoscopic Cholecystectomy. Cureus 2018;10(2):e2241. 18. Butterworth JF, Mackey DC, Wasnick JD. Morgan and Mikhail’s Clinical Anesthesiology. 5th ed. New York, ABD: McGraw-Hill Education; 2013. p.272.

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Agri 2019;31(4):214–215

doi: 10.14744/agri.2019.06926

A RI PAIN

LETTER TO THE EDITOR

Erector spinae plane block as rescue analgesia in gestational week 16 16. gestasyonel haftada uygulanan kurtarıcı analjezi amaçlı erektör spina plan bloğu İsmail Cem TUKAC,

Bahadır ÇIFTÇI,

Mürsel EKINCI,

To the Editor, Nonobstetric operations are sometimes necessary during pregnancy, with an estimated incidence of about 2% among pregnant women. In recent years, laparoscopic procedures have been preferred for abdominal surgery in pregnancy, as these are well tolerated by both the mother and fetus during all trimesters of pregnancy.[1, 2] Postoperative pain management is important for pregnant patients undergoing a nonobstetric procedure, as pain may increase the risk of premature labor. For pain management during pregnancy, paracetamol is the drug of choice, and nonsteroidal anti-inflammatory drugs should be avoided. Regional blockade techniques are preferred, as they reduce the risk of opioidinduced hypoventilation.[3] Among regional block techniques, ultrasound (US)-guided erector spinae plane block (ESPB) is a novel interfacial plan block, which was first described by Forero et al. in 2016 as a treatment for thoracic neuropathic pain.[4] There are a number of case reports in the literature on the analgesic effect of ESPB after laparoscopic surgeries. [5] To our knowledge, this is the first report of ESPB performed for a pregnant patient as postoperative rescue analgesia. Written informed consent was obtained from the patient for this report. Herein, we describe successful postoperative pain management using ESPB in a 34-year-old, American Society of Anesthesiologists physical status I woman at 16 wk of gestation who had laparoscopic surgery

Yunus Oktay ATALAY

for a gastrointestinal stromal tumor under general anesthesia. After successful and uncomplicated surgery, 1 g/kg of paracetamol (IV) was administered 20 min before the end of the surgery for postoperative pain management. Nonsteroidal anti-inflammatory drugs and opioids were avoided because of the pregnancy. Although paracetamol was administered, the patient’s postoperative visual analog score (VAS) was 8 in the postanesthesia care unit. Thus, we decided to perform single-shot bilateral ESPB as rescue analgesia. The patient was placed in the sitting position (Fig. 1a). After local anesthetic infiltration of the skin under aseptic conditions, a linear US probe (12 MHz) with a sterile sheath was placed in a sagittal paramedian orientation at the level of the T7 transverse process. After visualizing the trapezius, rhomboid major, and erector spinae muscles superficial to the hyperechoic transverse process shadow (Fig. 1b), a 22-gauge, 50-mm block needle (Braun Stimuplex Ultra 360; Germany) was inserted within the interfacial plane between the rhomboid and erector spinae muscles in a caudal-to-cephalad direction. Then, 2 ml of saline were injected to confirm the proper injection site, followed by administration of a 20 ml dose of 0.25% bupivacaine, injected bilaterally (Fig 1c) (40 ml in total). The pain subsided, the VAS score was 2 points, and the patient appeared relaxed 10 min after the block procedure. A dose of 1 g of paracetamol was then administered every 8 h. The maximum VAS score that the patient experienced was 2 over a 36-h period. No other analgesic was required.

Department of Anesthesiology and Reanimation, İstanbul Medipol University Faculty of Medicine, İstanbul, Turkey Submitted: 27.05.2019 Accepted after revision: 24.06.2019 Available online date: 26.06.2019

Correspondence: Dr. Bahadır Çiftçi. İstanbul Medipol Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İstanbul, Turkey. Phone: +90 - 532 - 503 44 28 e-mail: bciftci@medipol.edu.tr © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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An ESPB for a pregnant woman (a)

(b)

(c)

Figure 1. (a) Ultrasound and patient positioning under aseptic conditions for block preparation. (b) Sonographic anatomy of the block. (c) The needle direction in a cranio-caudal way and spread of local anesthetic in the fascia of erector spina muscle.

A previous case report described the use of ESPB during pregnancy in a 13-wk pregnant woman who complained of chronic spinal-related pain.[6] In this case report, the patient received paracetamol and physical therapy. However, she was unable to tolerate the physical therapy and required conservative therapies. Following the failure of these conservative therapies, ESPB was performed. The patient was symptom free 12 wk after the ESPB, and there was no recurrence of symptoms. US-guided ESPB has a number of advantages, including a reduced risk of complications because it is away from pleural and neurological structures. ESPB can provide both thoracic and abdominal analgesia, depending on the level at which it is administered. [7] In some case reports and case series, ESPB provided abdominal analgesia when performed at the level of T7-T9.[7, 8] We performed ESPB in the present case because the patient experienced pain in the low thoracic and abdominal region. In common with the findings of the previous case report on ESPB during pregnancy,[6] ESPB reduced the VAS score in our patient. Further prospective studies evaluating the analgesic effectiveness of ESPB in pregnant women are needed.

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In conclusion, we conclude that ESPB may be used during pregnancy for postoperative analgesia management after laparoscopic procedures.

References 1. Juhasz-Böss I, Solomayer E, Strik M, & Raspé C. Abdominal surgery in pregnancy—an interdisciplinary challenge. Dtsch Arztebl Int 2014;111(27–8):465–72. 2. Skubic JJ, Salim A. Emergency general surgery in pregnancy. Trauma Surg Acute Care Open 2017;2:1–5. 3. Upadya M, Saneesh PJ. Anaesthesia for non-obstetric surgery during pregnancy. Indian J Anaesth 2016;60(4):234– 41. 4. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41(5):621–7. 5. Tulgar S, Selvi O, Kapakli MS. Erector Spinae Plane Block for Different Laparoscopic Abdominal Surgeries: Case Series. Case Rep Anesthesiol 2018;2018:3947281. 6. Restrepo-Garces CE, Urrego J, Mejia-Loaiza C, Giraldo L. The erector spinae plane block for radicular pain during pregnancy. Int J Obstet Anesth 2019;39:143–4. 7. Restrepo-Garces CE, Chin KJ, Suarez P, Diaz A. Bilateral continuous erector spinae plane block contributes to effective postoperative analgesia after major open abdominal surgery: A case report. AA Case Rep 2017;9(11):319–21. 8. Chin KJ, Malhas L, Perlas A. The erector spinae plane block provides visceral abdominal analgesia in bariatric surgery: a report of 3 cases. Reg Anesth Pain Med 2017;42(3):372–6.

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Agri 2019;31(4):216–217

doi: 10.14744/agri.2019.15045

A RI PAIN

LETTER TO THE EDITOR

Cardiac arrest after trigger point injection Tetik nokta enjeksiyonu sonrası kardiyak arrest Erhan GÖKÇEK,1

Hakan AKELMA,2

Ayhan KAYDU1

To the Editor, Neurocardiogenic (vasovagal) syncop is a sudden loss of consciousness, occurring by decline of blood flow to the brain and the arterial blood pressure with neural mechanisms as a result of sudden vasodilation.[1, 2] Cardiac arrest can be observed by following bradycardia and hypotension in this case. When the syncope events observed in the operation room are examined, there are some reasons such as high doses of local anesthetics or opioid agents, intravenous injection of local anesthetics, painful injection, hypoxemia, hypercarbia, sympathetic blockade after intense sedation, autonomic impairment during recovery of neuroaxial blockade, cardiac arrest due to intense sympathetic blockade of psychogenic origin during spinal or epidural anesthesia.[1] Vasovagal syncope has a mortality rate of 6%, especially when the underlying cause is not known.[3] When clinical image of vasovagal syncope is examined; short-term dizziness, nausea and weakness, and subsequent loss of consciousness and myoclonic movements are observed. In general, these syncopal episodes are temporary and do not recur frequently. The reason of half recurrent episodes is unknown. In this case report, it has been aimed to be discussed the vasovagal syncope that develops during the application of TNE procedure and proceeds to the cardiac arrest. 36-year-old female patient complained of widespread pain in especially left sides of bilateral neck

and back region for the last 3 months. A physician and medical treatment was recommended for the patient who was not considered to have surgery operation after MR by orthopedic policlinic. The patient who could not receive treatment response was directed to our pain clinic for trigger point injection therapy. In the physical examination of the patient who had no history of resume and family history; American Society of Anesthesiologists (ASA) I, TA: 139/65 mmHg, Heart Rate: 72 / min. BMI: 27,8 kg / m2 (overweight) was natural to hear heart sounds. Preoperative laboratory findings were also detected within the normal limits and the patient was taken to the operating room. 20 Gauge angiocut was used to open the vein, and 100cc / h of 0.9% NaCl solution was added. Noninvasive blood pressure arterial (NIBP), pulse, peripheral oxygen saturation (SpO2) and electrocardiogram (ECG) monitoring were performed. The area to be treated was covered at a sterilized way by being cleaned with antiseptic solution containing povidone-iodine. Painful point was detected by examination and cardiac arrest occurred following bradycardia and continued during being applied TNE with 27 G, 1.5 inch (Germany) dental needle with 5 ml 2% lidocain + 5 ml 0.9% NaCl by the anesthesiologist. The patient was immediately given 5 mg ephedrine iv. With the mask, 100% oxygen ventilation and cardiac massage started at 1: 5. After 35 s, the heart rate resumed and vital signs and consciousness became normal after an aggression period of 30 s. Patients were discharged after followed up 24 hours in intensive care unit without any pathology found in vital or laboratory findings.

Department of Anesthesia and Reanimation, Diyarbakır Selahaddini Eyyübi State Hospital, Diyarbakır, Turkey Department of Anesthesia and Reanimation, Diyarbakır Gazi Yaşargil Training and Training Hospital, Diyarbakır, Turkey

1 2

Submitted: 14.12.2018 Accepted after revision: 18.04.2019 Available online date: 26.06.2019

Correspondence: Dr. Erhan Gökçek. Diyarbakır Selahaddini Eyyübi Devlet Hastanesi, Anestezi ve Reanimasyon Kliniği, Diyarbakır, Turkey. Phone: +90 - 412 - 228 54 30 e-mail: gokcekerhan_44@hotmail.com © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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As a result, regardless of the size of the operation to be performed, the patients should be effectively evaluated in all the surgical procedures and the necessary material for resuscitation during the procedure should be available.

References Figure 1. Asystole continuing 30 seconds.

Although vagal reflexes-related bradycardia is a common condition, associated syncope and cardiac arrest are rarely seen. Houk et al. have shown that sudden cardiac arrest may occur not only by ischemia, trauma, or local tissue damage, but also by neurogenic mechanisms.[4] The most common cause of sudden cardiac arrest (80%) is coronary artery disease. When the literature isexamined, it has been shown that strabismus surgery, open abdominal operations, needle biopsies, foreign body aspiration, and even exercise and psychological reasons may occur in patients without previous cardiac complaints.[5]

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1. Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole: Relationship to vasovagal syncope and the BezoldJarisch reflex. Br J Anaesth 2001;86(6):859–68. 2. Prakash ES, Madanmohan. When the heart is stopped for good: hypotension-bradycardia paradox revisited. Adv Physiol Educ 2005;29(1):15–20. 3. Sprung J, Abdelmalak B, Schoenwald PK. Vasovagal cardiac arrest during the insertion of an epidural catheter and before the administration of epidural medication. Anesth Analg 1998;86(6):1263–5. 4. Houk PG, Smith V, Wolf SG. Brain mechanisms in fatal cardiac arrhythmia. Integr Physiol Behav Sci 1999;34(1):3–9. 5. Baggot MG. General anesthesia, respiratory and cardiac standstill triggered by the extra-integumentary mechanical stimulation of foreign bodies in the airways. Med Hypotheses 1997;49(1):93–100.

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Agri 2019;31(4):218–219

doi: 10.14744/agri.2019.09815

A RI PAIN

LETTER TO THE EDITOR

Ultrasound-guided erector spinae plane block for pain management in pancreatic cancer: A case report Pankreas kanserinde ağrı tedavisi için ultrason eşliğinde erektor spina plan bloğu: Olgu sunumu Tayfun AYDIN,

Onur BALABAN,

Lokman DEMİR

To the Editor, Management of end-stage cancer pain is challenging that may require interventional methods. Ultrasound-guided erector spinae plane (ESP) blocks has a wide variety of indications including chronic pain management which provides immediate pain relief in patients with chronic pain.[1–4] Reports about ESP blocks used for cancer pain is rare. In a previous case report, ESP block provided sufficient continuous pain relief for a patient with pulmonary malignancy.[5] We present a case of unilateral ESP block that provided sufficient acute pain relief in a patient with end stage pancreas malignancy. Written informed consent has been obtained from the patient for this report. The patient was 68 yearold male who was admitted to our pain department with complaints of severe low thoracic pain. The pain started two days before which was evaluated by the patient as 7-8/10 on a numerical rating scale (NRS). The pain was unilateral (at right side) and was involving the dermatomes starting from T10 up to L1. He was on chemotherapy for six weeks and was not using any analgesic drugs. We planned to perform a unilateral single injection ESP block as a primary method for immediate acute pain relief. At the same time we started oral analgesic drugs. After obtaining written informed consent for the procedure and excluding a coagulation disorder, the patient was positioned in sitting at our pain intervention room. After preparation of the block site and the ultrasound probe in sterile manner, a high frequency

linear probe (Mindray® Medical Electronics Co., Ltd. Shenzhen, China) was placed 2 cm lateral to the neuraxial midline on the T10 vertebra level. The intended vertebra level was determined by counting up the ribs starting from 12th rib. Using the in-plane technique, a 10 cm block needle was advanced cranial to caudal direction towards the T10 vertebra transverse process under ultrasound guidance (Fig. 1). When the tip of the needle reached to the transverse process and a bone contact was felt, 25 ml bupivacaine 0.25% was injected. Craniocaudal distribution was observed between the erector spinae muscle and the transverse process. NRS score reduced to 2/10, 5 minutes after local anesthetic injection and the ESP block provided 20 hours of analgesia. Thereafter, the patient received oral analgesics in the remaining course of pain man-

Figure 1. Ultrasound image of erector spinae plane block. ESM: Erector spinae muscles, LA: Local anesthetic distribution within the erector spinae fascia plane.

Department of Anesthesiology and Pain Medicine, Kutahya Health Sciences University, Kutahya, Turkey Submitted: 14.02.2019 Accepted after revision: 18.04.2019 Available online date: 13.11.2019

Correspondence: Dr. Lokman Demir. Kütahya Sağlık Bilimleri Üniversitesi, Anesteziyoloji ve Ağrı Anabilim Dalı, Kütahya, Turkey. Phone: +90 - 505 - 153 71 13 e-mail: drlkmndmr@gmail.com © 2019 Turkish Society of Algology This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Ultrasound-guided erector spinae plane block for pain management in pancreatic cancer

agement without a need of interventional technique. ESP block provided sufficient acute pain relief in our patient with end-stage pancreas malignancy suffering from severe unilateral low thoracic pain. ESP catheter placement may also provide continuous analgesia for the remaining course of pain management. The alternative interventional method for continuous analgesia may be neurolitic coeliac ganglion blockade in this patient. However, a good professionalism and experience is needed to perform these neuroleptic interventions using a C-arm device. ESP block is a promising method in cancer pain with ease of application under US guidance with a simple sonoanatomy. Further research is warranted to compare ESP block with other interventional techniques.

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References 1. De Cassai A, Bonvicini D, Correale C, Sandei L, Tulgar S, Tonetti T. Erector spinae plane block: a systematic qualitative review. Minerva Anestesiol 2019;85(3):308–19. 2. Ueshima H, Otake H. An erector spinae plane block for chronic pain management after tissue expander insertion. J Clin Anesth 2018;55:4. 3. Ahiskalioglu A, Alici HA, Ciftci B, Celik M, Karaca O. Continuous ultrasound guided erector spinae plane block for the management of chronic pain. Anaesth Crit Care Pain Med 2019;38(4):395–6. 4. Forero M, Rajarathinam M, Adhikary S, Chin KJ Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series. Scand J Pain 2017;17:325–9. 5. Aydın T, Balaban O, Acar A. Ultrasound guided continuous erector spinae plane block for pain management in pulmonary malignancy. J Clin Anesth 2018;46:63–4.

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