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Pain related to orthopedic surgery, dental extractions, or any injury that involves connective tissue is caused in large part by inflammation which occurs because of prostaglandin release into the surrounding tissues.
Non-steroidal Anti-inflammatory Drugs NSAIDs block these prostaglandins and therefore should be a mainstay of pain treatment alone or perhaps combined with other agents such as opioids as long as there are no medical contraindications. Certainly some patients could benefit from the combined use of NSAIDs plus opioids — this should presumably have been true for a case such as the well-publicized basketball injury endured last year by Louisville athlete Keven Ware.
But, there has been much unsubstantiated controversy over whether or not NSAIDs are beneficial or detrimental in cases involving bone healing. Although most of these pills were prescribed for medical purposes, many ended up in the hands of people who misused or abused them.
I for one was mortified last year when asked to lecture to a large healthcare system in the Northeast. While teaching on general concepts of acute and chronic pain management, I learned that patients frequently were admitted through the emergency department for days at a time pretty much to receive intravenous hydromorphone aka Dilaudid for unidentified pain.
And yes, they got the drug even with a clear history of substance abuse. Because the reimbursement model is based on their pain scores — and that may have been more important to the institution than doing the right thing medically. But what the heck, right — it was only a few days of hydromorphone; no harm, no foul, the hospital system looks good, and the reimbursement is elevated.
However this polemic stirs up significant angst and sometimes indifference among the surgeons who spend limited time addressing pain issues post-operatively unless there are pain-related surgical complications such as infection. NSAIDs delay bone healing through their inhibition of prostaglandins.
Prostaglandin H2 is the precursor to active prostaglandins and thromboxane. COX1 is expressed in most cells and is involved in physiological processes such as reducing acid secretion in the gastrointestinal tract and regulating blood flow in the kidneys.
COX2 activation is results in pain, inflammation and fever. Selective blockade of COX2 therefore plays a critical role in reducing or preventing the inflammatory process following orthopedic surgery.
But, many studies have also found that COX1, and especially COX2, also play an essential role in bone formation, bone union, and resorption following a fracture. I was asked to address some seemingly very simple questions. After discontinuation of the NSAID, does time eventually make up for the delayed bone healing, and if so, are there adverse consequences?
Are the diminished bone-fusion effects if valid reversible without adverse consequences once the NSAID is discontinued? After an extensive literature search, I was unable to find compelling evidence to unequivocally answer these dilemmas, but new questions surfaced. Does the avoidance of NSAIDs have potential for elevating intolerable pain that could otherwise be kept at bay?
And, could this uncontrolled pain following a bone fracture or orthopedic surgery lead to complications, such as the development of complex regional pain syndrome CRPSa chronic pain disorder that is extremely difficult to treat? Complex regional pain syndrome is a chronic systemic disorder characterized by pain in combination with sensory, autonomic, trophic, and motor abnormalities.
The exact pathophysiology of this disease state is not understood and therefore treatment of this syndrome is difficult. Patients with CRPS have chronic pain which in many cases can lead to disability.
Many studies have found fractures and post-operative pain as risk factors for the development of CRPS. This study estimated an incidence rate of CRPS as 5.
Furthermore, a study published last year by Moseley, et al found a correlation between the level of pain post-fracture and the development of CRPS.
While the data is lacking on which fractures or surgeries most commonly increase the risk for developing CRPS, the most common ones seen through a literature search included fractures of the distal radius and post total knee arthroplasty, after fasciectomy for Dupuytren contracture, and after carpal tunnel surgery.
There have been no randomized controlled trials on the effects of NSAIDs on post-operative healing in humans. Every randomized controlled trial to date is an animal study which includes rats, mice, rabbits, goats, and even one trial on dogs.
Animal data cannot necessarily be extrapolated to humans.
The majority of trials reviewed studied fracture healing in the short-term. Many trials looked at fracture healing as early as 21 days post-surgery and at latest, 12 weeks post-surgery.
Even though the healing time of a fracture in animals may differ compared to humans, normally it takes months for a fracture to completely heal.
Therefore the short-term effect of NSAIDs on overall fracture healing in the long-term is unclear even in animal studies. While NSAIDs may or may not delay healing of fractures, if the fracture completely heals within a reasonable time period, does it matter how long it takes if there is a significantly lower risk of developing complications i.
CRPS, depression, anxiety, opioid-dependence post-surgery? In my mind this is quite puzzling. This is likely due to the retraction of several studies by Dr. However init was found that Dr. Reuben fabricated the data in at least 21 of his articles.The findings suggest that second language classroom anxiety is a more general type of anxietyabout learning a second language with a strong speaking anxiety element, whereas second language writing anxiety is a language-skill-specific anxiety.
Kuan Chung Chen Kuan Chung Chen (Licensed acupuncturist). Kuan Chung Chen (Median) is a Master of natural energy healing. While practicing under his father in Taiwan, he has helped many people with both their physical and mental problems through the natural energy practices of Tai Chi and Qi Gong.
Holly Dobbie has a U.B.C. BEd. degree and is a former high school English, Journalism, Social Studies, Women’s Studies and Stagecraft teacher.
Her volunteer work includes the Red Cross Child Abuse Prevention Program, The Pacific Association for Autistic Citizens, Big Brothers and Big Sisters as a school mentor, and The Hub for at risk and homeless youth.
Over the next month, 55+ million children and adolescents will be returning to their classrooms in public and private schools around the country. This study revealed that student writers' anxiety might stem from a variety of sources related to (1) instructional practices, (2) personal beliefs about writing and learning to write, (3) self-perceptions, and (4) interpersonal threats.
Based on the findings, some suggestions for L2 composition instruction are provided. Sixty-five EFL learners' reports of L2 writing anxiety were drawn upon to generate an initial pool of scale items. A pilot test was conducted on the initial pool of items to help establish a preliminary version of L2 writing anxiety scale for further refinement and evaluation in the formal study.