Light Exercise May Lead To Faster Recovery After Concussion When athletes suffer concussions, the common practice has been to prescribe lots of rest, both physically and cognitively. But a new take on treatment, where small amounts of light exercise are encouraged, may actually lead to faster recover-ies from concussions, according to two studies recently pub-lished by researchers at Canisius College and the University of Buffalo, both located in Buffalo, New York.

The first study experimented with a new style of treatment that actually encourages exercise for the purpose of improv-ing patients’ health who are suffering from post-concussion syndrome (PCS).1-2 “We started out wanting to determine if athletes who suffer from PCS could exercise at a level that wouldn’t bring out symptoms but would allow them to stay conditioned while recuperating,” said Karl Kozlowski, PhD, assistant professor of kinesiology at Canisius College.

To do this, Dr. Kozlowski and his co-researchers tested 34 patients with PCS to determine their threshold for exer-cise.2 From that, they developed a low-level workout program (only 10 or 15 minutes) for each patient. Patients were asked to keep track of their symptoms and within 3 weeks, they reported feeling better. New regimens were tailored and after several months of this routine, concussion symptoms were significantly reduced or went away entirely for all the patients.

“The brain likes blood pressure to be very stable,” Dr. Kozlowski told Practical Pain Management. After a concus-sion, however, healthy blood flow to the brain is compromised. Rest is the commonly prescribed cure for concussion patients, but Dr. Kozlowski and his team, who referenced rehabilita-tion exercise for curing other sports injuries, felt that exercise could be used to help cure concussions as well.

“We found that gradual exercise, rather than rest alone, actually helps to restore the balance of the brain’s auto-regula-tion mechanism, which controls the blood pressure and sup-ply to the brain,” Dr. Kozlowski said. While he stressed that the treatment has yet to be established as an effective form

of therapy for PCS, he believes that this is a step in the right direction. “The fact that we’re ready to move towards a real treatment option is encouraging,” he added.

“With brain injuries we were asking why athletes were being told not to do anything,” Dr. Kozlowski said. “This seemed to go against what we learned about with rehabili-tation therapy.” Dr. Kozlowski noted that scientists are still learning about why concussions affect the brain the way they do, but their new research points to better solutions than strict rest. “We’re still in the infancy of what we know about con-cussions,” Dr. Kozlowski said. “It is an interesting paradigm that we’re exploring but so far the results seem very positive.”

Significantly Improved RecoveryResearchers at the University at Buffalo School of Medicine and Biomedical Sciences have conducted similar tests where they also have found positive results from a “graded exercise program.”3 In their tests, researchers measured concussion patients’ threshold for cardiovascular stress. After finding the threshold of aerobic exercise that the athletes could do without exasperating their symptoms, they prescribed them a regular routine of this graded exercise.

When they compared the results with concussion patients that simply did stretching exercises, they found much faster recoveries in the patients that were exercising.

“People recover two times faster,” said Barry Willer, PhD, director of research at University of Buffalo’s Concussion Management Clinic. “Our approach is proactive and it works.” Dr. Willer and his colleagues even worked with the Department of Defense in bringing these new treatments to soldiers who suffer concussions on the battlefield. The new research allowed the Department of Defense to draft a new system of treating soldiers with concussions.

Prior to these findings, soldiers who suffered concussions were told to rest in their tents, away from light, physical activity or cognitive stimulation for a long period of time. “Psychologically, it’s a bad idea,” Dr. Willer said, “[rest] isn’t going to give [them] the speediest recovery.”

With new evidence to support a change in how concussions are being treated, researchers are excited about the future of treating PCS. “We’re changing the nature by which concus-sions are being managed,” Dr. Willer said.

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Falling Risk After Knee Replacement Decline With Regional Anesthesia Research suggests spinal and epidural anesthesia, peripheral nerve blocks safe to use

Regional anesthesia may be a safe pain management option for patients undergoing knee replacement. A recent study of almost 200,000 patients found that spinal and epidural anesthesia, as well as peripheral nerve blocks, did not increase the risk of falls in the first days after surgery.4 This finding contradicts earlier studies that raised the question about fall-risks following regional anesthesia.

A number of studies have shown that spinal or epidural (neuraxial) anesthesia and peripheral nerve blocks (PNB) provide better pain control and lead to faster rehabilitation and fewer complications than general anesthesia. But some surgeons avoid using them due to concerns regional anes-thesia may cause motor weakness, making patients more likely to fall when they are walking in the first days after knee replacement surgery.

“We found that not only do these types of anesthesia not increase the risk of falls, but also spinal or epidural anesthe-sia may even decrease the risk compared to general anesthe-sia,” said Stavros G. Memtsoudis, MD, PhD, professor of anesthesiology and public health and director of critical care services, Hospital for Special Surgery, New York City, and lead author of the article. “This work suggests that fear of in-hospital falls is not a reason to avoid regional anesthesia for orthopedic surgery,” according to a press release from the American Society of Anesthesiologists.

Study DesignThe researchers analyzed the types of anesthesia used in 191,570 knee replacement surgeries in the Premier Perspective database: 76.2% of patients had general anesthesia, 10.9% had spinal or epidural anesthesia, and 12.9% had a combina-tion of neuraxial and general anesthesia. In addition, 12.1% of all patients had PNB. Researchers then analyzed the type of anesthesia used for those who suffered from an inpatient fall.

Of patients who had general anesthesia, 1.62% fell, com-pared to 1.3% of those who had neuraxial anesthesia and 1.5% who had general and neuraxial anesthesia. Patients who also received a PNB had a fall rate of 1.58%.

When patients fall during recovery, they are more likely to have worse outcomes, including increased cardiac and respi-ratory problems and higher rates of death within 30 days of surgery. Spinal or epidural anesthesia and PNB are used far less often than general anesthesia because of concern that regional forms of anesthesia – particularly PNB – may increase muscle weakness and make patients more prone to falls.

Summary“In this study using data from a wide range of hospital set-tings we found this concern seems unfounded, especially because hospitals and physicians performing these proce-dures use fall prevention programs and are able to reduce the impact of other factors shown to increase fall risk, such as higher narcotic use,” said Dr. Memtsoudis.

Sedation Before Nerve Block Increases Risks, Not Pain Relief

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Sedating patients before performing a nerve block to diagnose or treat chronic pain increases costs, risks, and unnecessary surgeries, while providing no increased patient satisfaction or long-term pain control, according to an article reported online in Pain Medicine.5

 “Sedation doesn’t help, but it does add expense and risk,” said the lead author of the study, Steven P. Cohen, MD, a professor of anesthesiology and critical care medicine at the Johns Hopkins School of Medicine in Baltimore, Maryland. “In some places, every patient is being sedated. Our research shows sedation should be used very sparingly.”

 Nerve blocks are commonly performed ahead of surgery and other invasive procedures, such as the ablation of nerves to treat arthritis in the back, to more accurately pin down the source of pain. If the nerve block fails to numb pain, surgery or the nerve ablation may not help. Increasingly, physicians have used light or even deep sedation in a bid to ease anxi-ety and pain while the injection is given.

 The multicenter study recruited 73 patients with back or limb pain who were scheduled to receive multiple nerve blocks. Roughly half of the group received the first injection with sedation and the second without. The remaining patients received their injections in the opposite order. Patients were given 6-hour pain diaries, and were asked to rate their sat-isfaction with the treatment. A month after the procedure, the patients were seen for follow-up evaluation and asked to rate their pain and function after the treatment.

Results of the new study found that sedation before a nerve block significantly increased false-positive results, poten-tially causes unnecessary follow-up procedures. Although the sedated patients reported less pain immediately after the nerve block injection, on every other measure—from 30-day pain assessments to overall patient satisfaction—the results were the same whether or not they were sedated. “A lot of cost for very little benefit,” noted Dr. Cohen.

False-Positive ResultsMany factors may account for the increase in false-positive results, Dr. Cohen said. The medication used for the seda-tion itself can have pain-relieving properties and relax mus-cles. But if patients believe that the nerve block eased their underlying pain (when it did not), “the physician will often conclude he or she has found the source and will move ahead with the appropriate treatment, which may include spinal fusion or radiofrequency ablation of nerves for arthritis,” he noted. In the end, he says, many patients end up back at square one—still in pain, but having suffered through a potentially unnecessary operation.

The research was funded by the Center for Rehabilitation Sciences Research, part of the Uniformed Services University

of the Health Sciences in Bethesda, Md. Haroon Hameed, MD, and Michael E. Erdek, MD, both of Johns Hopkins, contributed to this study, as well as researchers from Walter Reed National Military Medical Center in Bethesda; the Uniformed Services University of the Health Sciences; the Mayo Clinic in Scottsdale, Ariz.; the Cleveland Clinic in Ohio; and the University of Florida in Gainesville.

Music Therapy Effective Supplement To AnalgesicsMusic may be a useful non-pharmacological method to treat postoperative pain, according to researchers at the University of Eastern Finland. Published in the January issue of Pain Management, the researchers reviewed the medical literature and found that music can be used in conjunction with anal-gesics to help further reduce pain in patients.6

Because pain can be a highly subjective experience for patients, the authors hypothesized that other treatment options, especially music, should be explored so as to help alleviate the stress caused by pain. The researchers cited a previous study in which patients recovering from open-heart surgery were allowed to listen to music to help alleviate pain. The study found that pain intensity decreased in the music therapy group before, immediately after, 30 minutes, and 1 hour after surgery (5.8, 3.1, 2.5 and 2.4, respectively). This decrease in pain intensity was significantly more than seen in the control group (4.7, 4.7, 4.8 and 4.9, respectively).7

The current study focused on pain relief in postoperative patients, who commonly experience moderate to severe pain after a surgery. After reviewing the literature, the authors suggest that “music medicine” could be supplied to patients after their surgeries in the form of headphones. They cited

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numerous recent studies that have examined the effects of music on pain management in virtually every age group, including infants, adolescents, adults, and the elderly.8-12 The authors found that few adverse effects came from adminis-tering music to patients.13 In fact, music has commonly been found to reduce stress in people, lowering their respiratory and cardiovascular rates, reducing postoperative delirium, improving their stay at the hospital after surgery, and pro-viding a healing environment for the patients.10,15-17

“The effects [of music therapy] could be studied by using versatile research methods,” Dr. Kankkunen and Dr. Vaajoki told Practical Pain Management. “The focus should be on patients’ experiences.”

Issues with Music TherapyThe article did, however, make mention of the obvious cave-ats associated with music therapy studies. Some patients can be severely disturbed by music that doesn’t fit their individ-ual taste. Some people have no connection to or find any meaning in listening to music.7,18-20 Infections can also spread if hospitals begin administering headphones, and playing music on an open-space speaker can lead to more diffi-cult communication between anesthesiologists and patients during surgery.15 Because of these factors, the authors sug-gested that patients use their own personal headphones or a music pillow to prevent these problems from occurring.

The article mentions the fact that studies concerning music therapy have contradictory conclusions, but they attribute this to the wide variations of methodologies used in the studies. Factors like “small sample sizes, nonobjective out-come measures and non-validated instruments” have forced

much research to remain technically inconclusive, they noted. Furthermore, subjects of research always know that they are in the music-administered or non-music-administered groups of the studies. Because of this, subjects can’t be thoroughly blinded and so conclusions must be based more on specu-lation than the results from experimentation.6,21

The authors suggest that if music is administered to patients after surgery, the patient’s age, cultural background, and musical taste should be taken into account, with clas-sical music being the safest genre to administer in acute situations.13,22 Music lessens the stress of surgery, but does not remove all pain. “Studies have shown that patients still suffer from moderate or severe pain postoperatively,” Dr. Kankkunen and Dr. Vaajoki told Practical Pain Management, and they believe that this is “scientific evidence of the impor-tance of effective preventative pain management.”

Future StudiesThe authors wish to conduct an impact study to yield more conclusive quantifiable and qualitative evidence as to the effects of music therapy on patients after surgery. They posit the question of whether the effects of music therapy can be assessed through raw numbers or if other means of docu-mentation would be more suitable. Regardless, music ther-apy should be researched more as a means to supplement analgesic pain management for patients suffering from post-operative pain.

—Reported by Thomas G. Ciccone

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References

1. Newswise. Exercise may be best medicine to treat post-concussion syndrome (PCS). http://www.newswise.com/articles/exercise-may-be-best-medicine-to-treat-post-concussion-syn-drome-pcs. Accessed February 26, 2014.

2. Kozlowski KF, Graham J, DeVinney-Boymel LA, et al. Exercise intolerance in post concussion syndrome. J Athl Train. 2013;48(5):627-635.

3. Leddy JJ, Willer B, Cox JL, et al. Exercise Treatment for Postconcussion Syndrome: A Pilot Study of Changes in Functional Magnetic Resonance Imaging Activation, Physiology, and Symptoms. J Head Trauma Rehabil. 2013;28(4):241-249.

4. Memtsoudis SG, Danninger T, Rasul R, et al. In-patient falls after total knee athroplasty; the role of anesthesia type and peripheral nerve blocks. Anesthesiology. 2014;120(3):551-563.

5. Cohen SP, Hameed H, Kurihara C, et al. The ef-fect of sedation on the Accuracy and Treatment outcomes for diagnostic injections: a random-ized, controlled, crossover study. Pain Medicine. 13 Feb 2013.

6. Kankkunen P, Vaajoki A. Songs for silent suffer-ing: could music help with postsurgical pain? Pain Management. 2014;4(1):1-3.

7. Jafari H, Zeydi A, Khani S, et al. The effects of listening to preferred music on pain intensity after open heart surgery. Iran J Nurs Midwifery

Res. 2012;17(1):1-6.

8. Bellieni C, Alagna M, Buonocore G. Analgesia for infants’ circumcision. Ital J Pediatr. 2013;39,38.

9. Kleiber C, Adamek MS. Adolescents’ perceptions of music therapy following spinal fusion surgery. J Clin Nurs. 2012;22:412-422.

10. Vaajoki A, Kankkunen P, Pietilä AM, et al. Music as a nursing intervention: effects of music listening on blood pressure, heart rate, and respiratory rate in abdominal surgery patients. Nurs Health Sci. 2011;13:412-418.

11. Angioli R, De Cicco Nardone C, Plotti F, et al. The use of music to reduce anxiety during office hysteroscopy: a prospective randomized trial. J Minim Invasive Gynecol. 20 Jul 2013.

12. Rantala M, Kankkunen P, Kvist T, et al. Post-op-erative pain management practices in patients with dementia – the current situation in Finland. Open Nurs J. 2012;6:72-82.

13. Matsota P, Christodoulopoulou T, Smurnioti ME, et al. Music’s use for anesthesia and analgesia. J Altern Complent Med. 2013;19(4):298-307.

14. McCaffery R. The effect of music on acute con-fucsion in older adults after hip or knee surgery. Appl Nurs Res. 2009;22:107-112.

15. Moris D, Linos D. Music meets surgery: two sides to the art of ‘healing’. Surg Endosc J. 2013;27:719-723.

16. Gooding L, Swezey S, Zxischenberger JB. Using music interventions in perioperative care. South Med J. 2012;105(9):486-489.

17. Vaajoki A, Kankkunen P, Pietilä AM, et al. The impact of listening to music on analgesic use and length of hospital stay while recovering from laparotomy. Gastroenter Nurs. 2012;35(4):279-284.

18. Gravesen M, Sommet T. Perioperative music may reduce pain and fatigue in patients undergoing laparoscopic cholecystectomy. Acta Anaestehsiol Scand. 2013;57:1010-1016.

19. Bernazky G, Prech M, Anderson M. Emotional foundations of music as a non-pharmocological pain management tool in modern medicine. Neurosci Biobehav Rev. 2011;35:1989-1999.

20. Vaajoki A, Pietilä AM, Kankkunen P. Music intervention study in abdominal surgery patients: challenges of an intervention study in clinical practice. Int J Nurs Pract. 2013;19:206-213.

21. Polit DF, Gillespie BM, Griffin R. Deliberate igno-rance. A systematic review of blinding in nursing clinical trials. Nurs Res. 2011;60:9-16.

22. Allameh T, Jabalalemi M, Lorestani K. The efficacy of Quran sound on anxiety and pain of patients under cesarean section with regional anesthesia: a randomized case-con-trolled clinical trial. J Isfahan Med School. 2013;31(235):601-610.

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