Chronic Postsurgical Pain

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Chronic postsurgical pain: still a neglected topic?

Chronic postsurgical pain: still a neglected topic?

To select journal articles with titles clearly indicating that they are devoted to chronic postsurgical pain (topic-in-title articles), the indication “[Title]” was added to all terms placed into PubMed search boxes. The topic-in-title type of articles were searched as representing chronic pain after surgery in general (when terms “surgery” [Title] OR “post- operative” [Title] were added to pain terms “chronic pain” [Title] OR “neuropathy” [Title]) or as representing chronic pain after specific surgeries (see Table 1). The specific surgeries were selected on the basis of preliminary PubMed searches conducted with inclusion of various specific terms of surgical interventions and specific pain-related terms (indicated in Table 1). In the preliminary searches, the indica- tion “[Title]” in the PubMed search box was not used. The preliminary searches resulted in a total of 1043 references. The topic-in-title articles for a specific group of surgeries were counted only when a preliminary search for this group gave ten or more general (non-topic-in-title) references. Eight groups of surgeries were selected: herniorrhaphy, limb amputation, thoracic surgery, arthroplasty, breast surgery, cardiac surgery, gallbladder surgery, and prostatectomy. For inclusion as the topic-in-title publication, articles found in various searches were reviewed to make sure that they fit the definition of chronic pain after surgery. Articles with titles without certain indication of pain duration, such as
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The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain

The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain

Abstract: Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5–10% of patients one-year after major surgery. Sub- stantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients’ pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.
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Parental risk factors for the development of pediatric acute and chronic postsurgical pain: a longitudinal study

Parental risk factors for the development of pediatric acute and chronic postsurgical pain: a longitudinal study

In conclusion, this study is the first to prospectively exam- ine the relationship between parent and child pain-related psychological risk factors from acute pediatric pain to the development and maintenance of CPSP. Results indicate that while parent and child pain anxiety in the days after surgery interact to predict acute pain levels 2 weeks later, parent pain catastrophizing (48–72 hours after surgery) predicts the presence of CPSP 12 months after surgery. The results suggest the following hypothesis: as time from surgery pro- gresses, parents exert an increasingly greater influence over the pain responding of their children so that by the 12 month mark, parent pain catastrophizing (measured in the days after surgery) is the main risk factor for the development of pediatric CPSP. A next step in this line of research would be to examine how different social and environmental factors,
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Identification of pain-related psychological risk factors for the development and maintenance of pediatric chronic postsurgical pain

Identification of pain-related psychological risk factors for the development and maintenance of pediatric chronic postsurgical pain

scale that assesses the extent to which children experience difficulties in completing specific tasks (eg, walking to the bathroom, eating regular meals, and being at school all day). Typically, the FDI is used as a 5-point Likert scale and yields total scores ranging from 0 to 60. Inadvertently, the FDI in the present study was measured using a 4-point Likert scale and omitted the original 2 (some trouble). Children in this study rated each item on a scale from 0 to 3: (0, no trouble; 1, a little trouble; 2, a lot of trouble; and 3, impossible), yield- ing total scores ranging from 0 to 45. The FDI has excellent internal consistency ( α = 0.86–0.91) and good test–retest reliability at 2 weeks (r = 0.74) and 3 months (r = 0.48). The FDI has been used with many pediatric populations, including children with chronic pain 47–49 and postsurgical
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<p>Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery</p>

<p>Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery</p>

While there is extensive literature on the transition from acute to chronic post-surgical pain in adults, 7 far fewer pediatric studies have been published on the topic. As with adults, the transition to CPSP in children is thought to follow a biopsychosocial model 8 that includes child factors, such as genetics, sex, pre-surgical pain, sleep, anxi- ety, and pain catastrophizing, but parent factors as well, such as parent cognitive appraisals of their child ’ s pain 9 and parent pain catastrophizing. 2 The main outcome in many of the biopsychosocial models of chronic pain is functional disability (ie, disability in doing activities of everyday life) or pain-related disability (ie, dif fi culty due to pain engaging in everyday activities, including social, emotional, cognitive, physical, and recreational aspects). 8,10 Pain is an important driver of pain-related disability 11 and general functional disability 12,13 though not all studies of pediatric CPSP have measured this construct. Of the studies that actually measured functional disability 2,14,15 or a proxy variable, such as number of days of school missed 16 or activity limitations; 15 only three 2,14,15 reported on the predictive relationship between pain and functional disability 2 or the proxy variable. 15 This is an important omission since disability is the main outcome variable in biopsychosocial models of chronic pain. Both Pagé et al 2 and Chidambaran et al 14 report similar fi ndings: the pre- sence of moderate/severe CPSP 2 or persistent pain 14 one year after surgery was not accompanied by high levels of functional disability (or scores on the Functional Disability Index of 13 or more 17 ). Moreover, functional disability inventory scores did not differ signi fi cantly between chil- dren with moderate-to-severe pain and those with no-to- low CPSP 2 or between those with and without persistent pain. 14 In contrast, Rabbitts et al 15 found that one year after surgery, the late pain recovery group showed worse health-related quality of life, as measured by the Pediatric Quality of Life Scale, and greater activity limitations than the early pain recovery group after controlling for age and sex, but importantly the authors did not control for base- line quality of life or baseline activity limitations. It is therefore not clear whether pain trajectory group member- ship in fact predicts greater activity limitations one year after surgery when taking into account the variance con- tributed by the pre-operative values of these variables. That is, it may be that children with worse quality of life and greater activity limitations before surgery have the
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<p>No Differences in the Prevalence and Intensity of Chronic Postsurgical Pain Between Laparoscopic Hysterectomy and Abdominal Hysterectomy: A Prospective Study</p>

<p>No Differences in the Prevalence and Intensity of Chronic Postsurgical Pain Between Laparoscopic Hysterectomy and Abdominal Hysterectomy: A Prospective Study</p>

The pathogenic mechanisms underlying the transition from acute pain to chronic pain after surgery are largely unknown. The nervous system is sensitized in response to noxious stimuli, but this response returns to normal after healing. In certain cases, the sensitization persists, and this may result in chronic pain. 3 Yarnitsky et al 33 suggested that a low ef fi ciency of diffuse noxious inhibitory control is related to chronic post-thoracotomy pain, re fl ecting individual differences in the endogenous analgesic system. We found that the prevalence of chronic pain after hysterectomy was about 20%, 10%, and 6% at 3, 6, and 12 months after surgery. The prevalence of chronic pain reduced over time in patients who underwent LH or AH, data that are consistent with the fi ndings of other scholars. 34,35 One could speculate that spontaneous remis- sion of chronic pain is natural because only two cases in each group were administered an analgesic for CPSP 12 months after surgery. On the other hand, pelvic pain is common among fertile women and, thus, post- hysterectomy pain may indicate pain in the general population. 36 The prevalence of chronic pelvic pain
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Risk stratification for the development of chronic postsurgical pain

Risk stratification for the development of chronic postsurgical pain

Chronic pain is currently regarded as a complex heritable trait with heritability in the range of 30% to 70%. 5 It is therefore not surprising that CPSP has genetic risk factors. Limited evidence has been found for mutations of single candidate genes such as those encoding ion channels (potassium and calcium) and purinergic receptors influencing severity or frequency of CPSP, eg, after mastectomy or amputation. 5 Furthermore, mutations of the gene encoding catechol-O-methyltransferase, an enzyme in the monoaminergic pathway influencing pain inhibition, and the OPRM1 gene encoding the m -opioid receptor have been shown to affect CPSP. 11 Limited findings have been reported with a number of other genes, including GCH1, CACNG, CHRNA6, P2X7R, cytokine-associated genes, human leucocyte antigens, DRD2, and ATXN1. 11 Currently, genome-wide approaches are under way to identify further target genes. 5
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Assessment of chronic postsurgical pain after knee replacement : a systematic review

Assessment of chronic postsurgical pain after knee replacement : a systematic review

of a neuropathic nature (25), which may prove useful in informing future assessments of chronic pain after TKR. In addition, more comprehensive OA pain measures have been developed and are starting to be used (e.g., the mea- sure of Intermittent and Constant Osteoarthritis Pain) (26). This review found that the AKSS was overwhelmingly the most commonly used outcome measure to assess chronic pain after TKR. This is true for other interventions, with reviews finding that the AKSS has been one of the tools most commonly reported upon in orthopedic studies (12,27). The AKSS includes only a single question on pain with multiple response options; the scale involves a clinician-conducted assessment and calculation of a com- posite score based on pain, functional ability, and mea- surements such as range of motion and joint stability. Although it is widely used, the AKSS was not formally validated during its development and subsequent studies assessing its psychometric properties have identified lim- itations such as a low correlation between items and poor inter- and intraobserver reliability (28,29). Furthermore, clinician-administered tools have been widely criticized because of the recognized discordance between the views of patients and clinicians (30,31). It is therefore apparent that, despite its extensive use, the AKSS has a limited utility in the assessment of pain-related postoperative out- come. This suggests that continued use of the AKSS rep- resents a conservative approach to outcome assessment in orthopedics, with convention hindering progression. However, our review identified a slight reduction in the use of the AKSS over time accompanied by an increased use of the WOMAC, which may herald a change due to an increased awareness of the importance of assessing out- come from the perspective of the patient. In the UK, this change is reflected in the national patient-reported out- come measures (PROMs) initiative, which collects Oxford Hip and Knee Scores on all patients undergoing elec- tive primary lower extremity replacement in the NHS (32). In the US and other countries, PROMs are increasingly promoted as an appropriate way to collect information about patient outcomes (33,34). Future research will be required to explore if this early trend away from clinician- administered tools and toward PROMs continues in orthopedics. Additionally, future research could explore the trends in data collection methods (e.g., postal or on- line questionnaire versus data collected during clinic ap- Table 3. Aspects of pain assessed by the single-item questions*
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Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials

Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials

Background: Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psycho- logical approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes. Materials and methods: We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias.
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Adolescent Loss-of-Control Eating and Weight Loss Maintenance After Bariatric Surgery

Adolescent Loss-of-Control Eating and Weight Loss Maintenance After Bariatric Surgery

follow-up. Although not statistically significant, these increases appeared to be steeper for eating behavior characterized by LOC-C relative to LOC-OBE. Finally, although reporting LOC eating at presurgery and 6-month follow-up was not associated with later weight change, engaging in LOC eating at 1-, 2-, or 3-year follow-up was prospectively associated with greater subsequent weight regain. Taken together, results reveal that assessing for the presence of LOC eating in the postsurgical period may be warranted because this phenotype is associated with poorer weight outcomes.
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Patterns of health care utilization related to initiation of amitriptyline, duloxetine, gabapentin, or pregabalin in fibromyalgia

Patterns of health care utilization related to initiation of amitriptyline, duloxetine, gabapentin, or pregabalin in fibromyalgia

Our study highlights several important issues in the management of fibromyalgia. First, fibromyalgia drugs ap- pear to have little effect on reducing health care utilization by patients with fibromyalgia, as seen in previous studies of pregabalin, duloxetine, and TCAs [10-13]. Whether the lack of effect on health care utilization is due to inad- equate benefits or concurrent benefit with new side effects of treatment is unclear. It is also difficult to determine whether the use of health care was inappropriately high or clinically necessary. Second, discontinuation rates are high across all study drugs. In previous studies, researchers have found that the effectiveness of these medications is limited [23], and many patients discontinue these medica- tions due to side effects [24]. Third, pharmacologic treat- ment alone may not be effective in fibromyalgia [25]. Prior meta-analyses of various nonpharmacologic treatments such as massage therapy, aquatic physical therapy, balneo- therapy, and hydrotherapy showed mixed results on fibro- myalgia symptoms [25-28], although beneficial effects of aerobic exercise and cognitive behavioral therapy on pain and mood were consistently noted [29,30]. Nonetheless, in future longitudinal study, investigators should explore the utility of multifaceted approaches to the treatment of Table 2 Patients ’ continuation of fibromyalgia treatment a
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Sleep deprivation of rats increases postsurgical expression and activity of L-type calcium channel in the dorsal root ganglion and slows recovery from postsurgical pain

Sleep deprivation of rats increases postsurgical expression and activity of L-type calcium channel in the dorsal root ganglion and slows recovery from postsurgical pain

Perioperative sleep disturbance is a risk factor for persistent pain after surgery. Clinical studies have shown that patients with insufficient sleep before and after surgery experience more intense and long-lasting postoperative pain. We hypothesize that sleep deprivation alters L-type calcium channels in the dorsal root ganglia (DRG), thus delaying the recovery from post-surgical pain. To verify this hypothesis, and to identify new predictors and therapeutic targets for persistent postoperative pain, we first established a model of postsurgical pain with perioperative sleep deprivation (SD) by administering hind paw plantar incision to sleep deprivation rats. Then we conducted behavioral tests, including tests with von Frey filaments and a laser heat test, to verify sensory pain, measured the expression of L-type calcium channels using western blotting and immunofluorescence of dorsal root ganglia (an important neural target for peripheral nociception), and examined the activity of L-type calcium channels and neuron excitability using electrophysiological measurements. We validated the findings by performing intraperitoneal injections of calcium channel blockers and microinjections of dorsal root ganglion cells with adeno- associated virus. We found that short-term sleep deprivation before and after surgery increased expression and activity of L-type calcium channels in the lumbar dorsal root ganglia, and delayed recovery from postsurgical pain. Blocking these channels reduced impact of sleep deprivation. We conclude that the increased expression and activity of L-type calcium channels is associated with the sleep deprivation-mediated prolongation of postoperative pain. L-type calcium channels are thus a potential target for management of postoperative pain.
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A systematic review of outcome measures utilised to assess self management in clinical trials in patients with chronic pain

A systematic review of outcome measures utilised to assess self management in clinical trials in patients with chronic pain

Psychometric properties of these included measures were summarised (in Table 6) following Terwee and colleague [21]. The content validity was established as positive or intermediate in 10 out of 13 measures and nine measures had high internal consistency (Cronbach’s ) between 0.70 and 0.95 with each of the sub-scales and/or the total scores. Only eight measures for construct validity and four measures for reliability had positive or intermediate ratings. Agreement, responsiveness, and floor and ceiling effects had no or negative ratings for all 13 measures. Intermediate quality of interpretability was reported for only two out of 13 measures. These findings highlight, a lack of research in reproducibility, responsiveness and interpretability data for these outcomes. Further, Arthritis Self-efficacy Scale (ASES), Self- Efficacy Scale (SES), Pain Self Efficacy Questionnaire (PSEQ), Chronic Pain Self-Efficacy Scale (CPSES), Chronic Pain Coping Inventory (CPCI) and Health Education Impact Questionnaire (heiQ) had better psychometric properties than the other included scales (with three or more positive ratings out of eight assessed- in Table 6). Among these six scales CPSES, CPCI and heiQ were developed either for patients with any condition or with chronic pain.
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<p>Chronic Pain Patients&rsquo; Kinesiophobia and Catastrophizing are Associated with Activity Intensity at Different Times of the Day</p>

<p>Chronic Pain Patients&rsquo; Kinesiophobia and Catastrophizing are Associated with Activity Intensity at Different Times of the Day</p>

Table 6 for study comparisons. This result was surprising given the severe health status of our participants, who had higher scores for kinesiophobia, catastrophizing, and depression compared to other studies. 44–47 Our chronic pain population engaged in, on average, 484.4±118.6 mins of light activity over a 4-day period, whereas the large Canadian sample reported light activity as 245 – 258 mins, suggesting that our chronic pain population parti- cipated in more light activity than the Canadian population. 41 Another study suggested that individuals with chronic pain participate in similar levels of seden- tary and light activity compared to the general population. 48 However, individuals with chronic pain are presumed to avoid movement so they do not aggra- vate their pain. Our fi nding that individuals in chronic pain are less sedentary compared to a healthy population is surprising, but this may be more of a statement about physical activity levels in the general population. One explanation may be that a healthy population is typically employed in a sedentary job, 49,50 whereas our study par- ticipants were generally unemployed, and thus may have participated in more frequent light activity (ie, house- work, errands, etc.). There is evidence to supporting little or no relationship between physical function and pain. 51 Therefore, future interventions encouraging physical activity in chronic pain patients may be in fl uenced by the quantity, intensity, and the time of the day this popu- lation participates in physical activity. Perhaps interven- tions aimed at increasing activity in the afternoon are better tolerated by the chronic pain population than ori- ginally thought.
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Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique

Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique

Several of the microdialysis studies identified in the present review have few subjects, which entails the risk of low power and inconclusive results. Results also need to be confirmed by independent groups to be valid. Patient cohorts need to be better characterized with respect to inclusion and exclusion criteria, diagnoses and their criteria, pain severity, psycho- logical stress, work participation, and sick leave. There is also a need to better characterize the physical fitness level of the subject and, if possible, the daily activity pattern of the investigated muscle, eg, with respect to working tasks. A global measure of the severity of the investigated pain condition can be an advantage when comparing studies.
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A classification of chronic pain for ICD-11.

A classification of chronic pain for ICD-11.

Irrespective of its etiology, chronic pain is a major source of suffering and requires special treatment and care. Our proposal may not represent a perfect solution for the classification of all manifestations of chronic pain. However, it does represent the first systematic approach to implementing a classification of chronic pain in the ICD. It is based on international expertise and agreement, and consistent with the requirements of the ICD regarding the structure and format of content models. The 7 major categories of chronic pain were identified after considerable research and discussion. They represent a compromise between comprehensiveness and practical applicability of the classification system. Several clinically important conditions that were neglected in former ICD revisions will now be mentioned, eg, chronic cancer pain or chronic neuropathic pain. Etiological factors, pain intensity, and disability related to pain will be reflected. With the introduction of chronic primary pain as a new diagnostic entity, the classification recognizes conditions that affect a broad group of patients with pain and would be neglected in etiologically defined categories. We hope that this classification strengthens the representation of chronic pain conditions in clinical practice and research and welcome comments to improve it further.
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Effectiveness of anodal transcranial direct current stimulation in patients with chronic low back pain: Design, method and protocol for a randomised controlled trial

Effectiveness of anodal transcranial direct current stimulation in patients with chronic low back pain: Design, method and protocol for a randomised controlled trial

The proposed study presents the first high quality ran- domised controlled trial on tDCS for the reduction of chronic pain. As identified in a recently published Cochrane review [51] and a systematic review and metaanalysis conducted by our group (Luedtke et al., Clin. J. Pain, accepted), only 8 studies have investigated tDCS for chronic pain reduction [16-23]. None of these was adequately powered to allow valid conclu- sions on it ’ s effectiveness. Additional risk of bias was introduced by methodological issues, such as invalid randomisation procedures and unclear blinding, lead- ing to a grading of the current level of evidence as “ low ” (Luedtke et al., Clin. J. Pain, accepted) according to the GRADE system [52]. Computer generated ran- domisation lists and a tDCS device that produces pre- programmed stimulation paradigms (verum and sham) initialised by 5 digit number codes, will address these issues in the proposed study. The sample size estima- tion ensures adequate power (90%) to allow valid con- clusions regarding the effectiveness of tDCS on the two primary outcome parameters pain intensity (VAS) and disability (ODI).
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Progression of fibromyalgia: results from a 2-year observational fibromyalgia and chronic pain study in the US

Progression of fibromyalgia: results from a 2-year observational fibromyalgia and chronic pain study in the US

In this descriptive observational study of FM − CWP − , FM − CWP + , and FM + CWP + subjects, the majority of subjects remained in the same group classification at both assessment points. For FM − CWP − and FM − CWP + subjects, marked pain and suboptimal physical function and pain inter- ference with sleep may signal a transition to FM + CWP + . For FM + CWP + subjects, recent diagnosis, along with less severe pain and better physical function, may be associated with an improvement in FM. The results suggest that some patients may experience fluctuation in symptoms, such as pain, physi- cal function, and sleep over time, which may reflect the wax- ing and waning nature of FM. These findings suggest a need for further research to better understand the type of patients who transition into or out of the FM + CWP + group.
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Prediction of clinical outcomes in individuals with chronic low back pain: a protocol for a systematic review with meta-analysis

Prediction of clinical outcomes in individuals with chronic low back pain: a protocol for a systematic review with meta-analysis

Low back pain (LBP) is one of the most prevalent types of chronic pain in clinical practice [1]. Researchers esti- mate that low back pain affects 4–33% of the population at any given point, and will affect 60–80% of the popula- tion at some point during life, and this prevalence in- creases with age [2–4]. After an acute low back pain episode, the majority (about 90%) recovers in a few months [5, 6], although recurrences are common (vary- ing between 25 to 50% in a year) [7]. Furthermore, LBP recurrences are the main occurrence responsible for seeking health care, sick leave and other work-related problems and activity limitations, which lead to a major impact on financial and human resources [7]. Definitions of onset or conclusion of an acute or subacute low back pain episode and what is considered recovery are still unclear [8].
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EFFICACY OF LAPAROSCOPY IN CHRONIC ABDOMINAL PAIN

EFFICACY OF LAPAROSCOPY IN CHRONIC ABDOMINAL PAIN

chronic abdominal pain is a unique problem faced by every physician .chronic abdominal pain is defined as pain exceeding more than 3 months duration.,in era of early diagnosis and treatment of chronic abdominal pain has significant impact on physicians ability to diagnose and treatment,chronic abdominal pain .it is the 3 rd most common complaint of individual enrolled in any large healthcare system..chronic abdominal pain cases undergo multiple investigations in multiple medical centre but pain remains undiagnosed ,.a single centric observational prospective study was done in 63 patients at l.t.m.mc and l.t.m.g.hospital ,sion, mumbai .chronic abdominal pain patients whose limit of non invasive testing was reached and not responding to medical treatment were projected to diagnostic and therapeutic laparoscopy.in this study efficacy of laparoscopic surgery had significant role in pin pointing pathology of the chronic abdominal pain , laparascopy also proved to be effective in therapeutic accuracy and avoided unneccesary laparotomy.it was concluded that diagnostic laparoscopy has definitive role in management of chronic abdominal pain,had very high efficacy, should be considered as important investigating tool in armamentarium of all surgeons. Keywords: laparoscopy,chronic abdominal pain,diagnostic scopy.
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