Pain relief is enhanced when individual pain-relieving strategies are combined. Therefore, health care providers are encouraged to use a mix of strategies to mitigate pain. Parents can be enlisted to help combine and coordinate many of these strategies. For instance, parents can prepare their children, apply topical anesthetics, bring a distraction aid to the appointment, coach the child during deep breathing and hold the child.

Gabapentin (Neurontin 1 ) and pregabalin (Lyrica 2 ) are first- and second-generation 2 ligands, respectively, and are both approved for use as adjunctive therapy in pain control. Although they do not bind to gamma-aminobutyric acid (GABA) receptors they have been successfully used to treat neuropathic pain conditions. Their mechanism of action is not yet fully understood, but research has demonstrated promising results. Despite their similarities, they have been used in combination in both clinical and research situations, and have been noted to have a synergistic effect in pain control without concern for clinically significant pharmacokinetic interactions. This combined approach can be made use of to reduce the dose of an individual agent, its side effects, and to enhance therapeutic response compared to a single agent. Pharmacokinetics, drug interactions, and adverse reaction to combinations have to be taken into consideration before combination therapy with gabapentin and pregabalin is proposed as first-line treatment in refractory pain situations and in patients with low levels of tolerance for an individual agent.

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Another advantage of digital audio signals is the ease with which they can be manipulated. Digital Signal Processing (DSP) technology has advanced to such an extent that almost any audio product, from a mobile phone to a professional mixing console, contains a DSP chip. Once again the reasons for the success of DSP are simple: stability, reliability, enhanced performance and programmability. Signal processing functions can be implemented for a fraction of the cost, and in a fraction of the space required by analog circuitry, as well as providing functionality that simply couldn't be done in analog. In fact, so ubiquitous has it now become that, for many people, the word "digital" has become synonymous with "high quality".

"Recent advancements within the past decade in human hearing indicate the sensitivity of the human ear is such that the dynamic range between the quietest sound detectable and the maximum sound which can be experienced without pain is approximately 120dB. Further studies suggest there is critically important audio information at frequencies up to 40 kHz and possibly 80 kHz"

Computation overflow/underflow is a hardware limitation that occurs when the numerical result of the fixed-point computation exceeds the largest or smallest number that can be represented by the DSP. Many DSPs include additional bits in the MAC unit to prevent overflow in intermediate calculations. Extended sums-of-products, which are common in DSP algorithms, are achieved in the MAC unit with single cycle multiply accumulates placed in an efficient loop structure. The extra bits of precision in the accumulator result register provide extended dynamic range for the protection against overflow in successive multiplies and additions. Thus, no loss of data or range occurs. Table 4 shows a comparison of the extended dynamic ranges of 16-bit, 24-bit, and 32-bit DSPs. Note that the ADSP-21161 SHARC 32-bit DSP has a much higher extended dynamic range than 16- and 24-bit DSPs when executing fixed-point multiplication instructions. The MAC unit on the SHARC contains dual accumulators that can produce an 80-bit fixed-point result when multiplying two 32-bit fixed point values. There are 16 bits of additional precision for the 64-bit MAC result. The SHARC's 80-bit result can yield a fixed-point dynamic range as high as 480 dB for intermediate calculations.

To visually see the benefits of a larger DSP word size, let's take a look at the processing of audio signals from a 16-bit A/D converter that has a dynamic range close to it's theoretical maximum, in this case with a 92 dB signal-to-noise ratio (see Figure 9 below). Figure 10 below shows a conceptual view of a 16-bit data word that is transferred from an A/D converter to the DSP's internal memory. Typically, the data transfer would occur through a serial port interface from the serial A/D converter, and the DSP may be configured to automatically perform a direct memory transfer (DMA) of the sample at the serial port circuitry to internal memory for processing. Notice that for the 24-bit and 32-bit processors, there are adequate 'footroom-bits' below the noise floor (to the right) to protect against quantization errors.

New research conducted within the last decade indicates that the sensitivity of the human ear is such that the dynamic range between the quietest sound detectable and the maximum sound which can be experienced without pain is approximately 120dB. Therefore, 16-bit CD-quality audio is no longer thought to be the highest-quality audio that can be stored and played back. Also, many audiophiles claimed that CD-quality audio lacked a certain warmth that a vinyl groove offered. This may have been due to a combination of the dynamic range limitation of 16-bits as well as the chosen sample rate of 44.1 kHz. The 16-bit words used for CD allow a maximum dynamic range of 96 dB although with the use of dither this is reduced to about 93 dB. Digital conversion technology has now advanced to the stage where recordings with a dynamic range of 120dB or greater may be made, but compact disc is unable to accurately carry them[14].

With many converter manufacturers introducing 24-bit A/D and D/A converters to meet emerging consumer and professional audio standards, the audio systems using these higher resolution converters will require at least 32-bit processing in order to offer sufficient precision to ensure that a filter algorithm's quantization noise artifacts will not exceed the 24-bit input signal. If optimal filter routines are used for complex processing, any quantization noise introduced in the 32-bit computations will never be seen by the 24-bit output D-A converter. In many cases, the audio designer can choose from a number of second-order structures because the result will still be greater than 120 dB. 32-bit processing will guarantee that the noise artifacts remain below the 120-dB noise floor, and hence provide a dynamic range of the audio signal up the human ear's threshold of pain. Therefore, the goal of developing robust audio algorithms is accomplished, and the only limiting factor when examining the signal quality (SNR) of the digital audio system is the precision of the 24-bit A/D and D/A converters.

At least 24 bits are required in processing if the quality of 16 bits is to be preserved. However, even with 24-bit processing, it has been demonstrated that care would need to be taken to ensure the noise floor of the digital filter algorithm is not greater than the established noise floor of the 16 bit signal, especially for recursive IIR audio filters. Recursive IIR filters can introduce quantization noise above the noise floor of a 16-bit converter when using a 24-bit DSP [2, 5] and therefore 24-bit processing requires software overhead to lower the digital filter's noise floor. Again, double precision math is an option, but this can add overhead by as much as a factor of five.

To fully realize the potential of the latest digital audio formats now and into the future requires faster, more flexible DSPs with more accurate and more powerful arithmetic. One such processor is the Analog Devices ADSP-21161, capable of both fixed- and floating-point arithmetic. The ADSP-21161 processor contains the ADSP-2116x SHARC SIMD core (a SIMD processor uses two identical set of ALU, MAC and Shifter) and its dual computational unit supports the following data types:

Throughout my ordeal, I used mindfulness to help me cope with the intense pain and stress, which was accompanied by more than a little anxiety. And it worked to an astonishing degree. My pain gradually subsided and I was able to reduce my intake of painkillers by two-thirds. I also developed a more contented outlook, seeing my injuries as temporary problems that would gradually subside, rather than as limb-threatening ones that might confine me to a wheelchair. Equally, it gave me the mental stamina and clarity of purpose to persevere with the more conventional treatments such as physiotherapy.

In previous weeks I taught you how to reduce pain using the Body Scan and Mindful Movement meditations. These were taken from our book Mindfulness for Health: A Practical Guide to Relieving Pain, Reducing Stress and Restoring Wellbeing. This week you will learn to reduce stress with the Tension Release Meditation. Follow the instructions opposite or download the audio track from www.franticworld.com/huffington be457b7860

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