Qualitative Evaluation of Pediatric Pain-Behavior, -Quality and -Intensity Item Candidates and the PROMIS Pain Domain Framework in Children with Chronic Pain

As initial steps in a broader effort to develop and test pediatric Pain Behavior and Pain Quality item banks for the Patient Reported Outcomes Measurement Information System (PROMIS®), we employed qualitative interview and item review methods to 1) evaluate the overall conceptual scope and content validity of the PROMIS pain domain framework among children with chronic /recurrent pain conditions, and 2) develop item candidates for further psychometric testing. To elicit the experiential and conceptual scope of pain outcomes across a variety of pediatric recurrent/chronic pain conditions, we conducted semi-structured individual (32) and focus-group interviews (2) with children and adolescents (8-17 years), and parents of children with pain (individual (32) and focus group (2)).

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Effect of Milnacipran Treatment on Ventricular Lactate in Fibromyalgia : A Randomized, Double-blind, Placebo-controlled Trial

Milnacipran, a serotonin/norepinephrine reuptake inhibitor (SNRI), is FDA-approved for the treatment of fibromyalgia (FM). This report presents the results of a randomized, double-blind, placebo-controlled trial of milnacipran conducted to test the hypotheses that (a) similar to patients with chronic fatigue syndrome, FM patients have elevated ventricular lactate at baseline; (b) 8 weeks of treatment with milnacipran will lower ventricular lactate levels compared to both baseline and to placebo; and (c) treatment with milnacipran will improve attention and executive function in the Attention Network Test compared to placebo.

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Pain Medicine: An Interdisciplinary Case-Based Approach Eds. Hayek SM, Shah BJ, Desai MJ & Chelimsky TC New York, Oxford University Press; 2015; pp. 429; ISBN 978-0-19-993148-4

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Expectancy Biases in Fear and Anxiety and Their Link to Biases in Attention

Evaluation of Sleep Disorders in Patients With Severe Traumatic Brain Injury During Rehabilitation

A perspective taking manipulation leads to greater empathy and less pain during the cold pressor task

The objectives of this study were to demonstrate that empathy and validation could be increased in an observing partner who received a brief perspective taking manipulation, resulting in less pain severity and greater pain tolerance in their partner, who experienced experimental pain. Additionally, we examined the correlations between perceived empathy/validation and behavioral ratings of validation and invalidation. In 126 pain-free romantic couples, one partner was randomly assigned to complete the cold pressor task while the other observed.

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The Communal Coping Model of Pain Catastrophizing in Daily Life: A Within-Couples Daily Diary Study

The Communal Coping Model (CCM) characterizes pain catastrophizing as a coping tactic whereby pain expression elicits assistance and empathic responses from others. Married couples (N = 105 couples; one spouse with chronic low back pain) completed electronic daily diary assessments 5 times/day for 14 days. On these diaries, patients reported pain catastrophizing, pain, function, and perceived spouse support, criticism and hostility. Non-patient spouses reported on their support, criticism, and hostility directed toward patients, as well as their observations of patient pain and pain behaviors.

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Out-of-Pocket Expenditures on Complementary Health Approaches Associated with Painful Health Conditions in a Nationally Representative Adult Sample

National surveys suggest that millions of adults in the United States use complementary health approaches such as acupuncture, chiropractic manipulation, and herbal medicines to manage painful conditions such as arthritis, back pain and fibromyalgia. Yet, national and per person out-of-pocket (OOP) costs attributable to this condition-specific use are unknown. In the 2007 National Health Interview Survey, use of complementary health approaches, reasons for this use, and associated OOP costs were captured in a nationally representative sample of 5,467 adults.

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[Comment] Pain in the USA: states of suffering

Worldwide, chronic pain afflicts more than 1·5 billion individuals.1 In 2013, pain was in the top ten list of causes of years lived with disability (YLD) in 188 countries: low-back pain accounted for more than a mean of 72 million YLD, neck pain more than 34 million YLD, and migraine more than 28 million YLD.2

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Improving postoperative pain management in children by providing regular training and an updated pain therapy concept

Abstract

Background

In recent years, children's hospitals have increasingly implemented postoperative pain management protocols to reduce postoperative pain and improve patient satisfaction. The effectiveness and long-term sustainability of such protocols have rarely been studied. Therefore, we conducted a prospective intervention study to assess the impact of regular training and improvement of clinical processes on the quality of postoperative pain management.

Methods

We conducted an initial assessment of the status quo of postoperative pain management (Audit 1) followed by repeated training and improvement of clinical processes (analgesic pocket card, parents’ brochure, modification of the patient chart, bimonthly advanced trainings sessions) and a follow-up review after 3 years (Audit 2). We used a data entry form, a patient survey, and an anonymous questionnaire for the nursing staff as measurement tools.

Results

Our analysis included a total of 93 and 85 patients in the initial and final audits. The return rates of the nursing staff questionnaire were 83% (Audit 1) and 77% (Audit 2). The training and process improvements resulted in significant improvement in the administration of analgesics for pain requiring treatment, the control of pain measurement after the administration of analgesics and the use of non-pharmacological pain therapies. The patients reported faster administration of analgesics for acute pain and improved pain relief following the intervention.

Conclusions

Repeated training and improvement of clinical processes can significantly improve the long-term quality of postoperative pain management in children with a tolerable amount of effort on the part of health care professionals and institutions.

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Are there different predictors of analgesic response between antidepressants and anticonvulsants in painful diabetic neuropathy?

Abstract

Background

To investigate baseline demographics and disease characteristics as predictors of the analgesic effect of duloxetine and pregabalin on diabetic peripheral neuropathic pain (DPNP).

Methods

Based on data from the COMBO-DN study, a multinational clinical trial in DPNP, the potential impact of baseline characteristics on pain relief after 8-week monotherapy with 60 mg/day duloxetine or 300 mg/day pregabalin was assessed using analyses of covariance. Subgroups of interest were characterized regarding their baseline characteristics and efficacy outcomes.

Results

A total of 804 patients were evaluated at baseline. A significant interaction with treatment was observed in the mood symptom subgroups with a larger pain reduction in duloxetine-treated patients having no mood symptoms [Hospital Anxiety and Depression Scale (HADS) depression or anxiety subscale score <11; −2.33 (duloxetine); −1.52 (pregabalin); p = 0.024]. There were no significant interactions between treatment for subgroups by age (<65 or ≥65 years), gender, baseline pain severity [Brief Pain Inventory Modified Short Form (BPI-MSF) average pain <6 or ≥6], diabetic neuropathy duration (≤2 or >2 years), baseline haemoglobin A1c (HbA1c) (<8% or ≥8%), presence of comorbidities and concomitant medication use.

Conclusions

Our analyses suggest that the efficacy of duloxetine and pregabalin for initial 8-week treatment in DPNP was consistent across examined subgroups based on demographics and disease characteristics at baseline except for the presence of mood symptoms. Duloxetine treatment appeared to be particularly beneficial in DPNP patients having no mood symptoms.

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Temporomandibular pain and jaw dysfunction at different ages covering the lifespan – A population based study

Abstract

Background

Temporomandibular pain and jaw dysfunction can have a negative effect on daily life, but these conditions are not well recognized in the health care systems. The general aim was to examine the cross-sectional prevalence of frequent temporomandibular pain and jaw dysfunction in men and women across the lifespan.

Methods

The analysis was based on data from 137,718 individuals (mean age 35 years, SD 22.7) who answered three questions (3Q/TMD) included in the digital health declaration in the Public Dental Health care in the county of Västerbotten, Sweden; Q1: ‘Do you have pain in your temple, face, jaw or jaw joint once a week or more?’; Q2: ‘Does it hurt once a week or more when you open your mouth or chew?’; and Q3: ‘Does your jaw lock or become stuck once a week or more?’

Results

The prevalence of frequent temporomandibular pain (Q1) was 5.2% among women and 1.8% among men (p < 0.0001). The prevalence of frequent pain on jaw movement (Q2) was 2.5% among women and 0.9% among men (p < 0.0001). The prevalence of frequent locking of the jaw (Q3) was 2.7% among women and 1.2% among men (p < 0.0001).

Conclusions

The study shows that the cross-sectional prevalence of temporomandibular pain and jaw dysfunction varies during the lifespan. For men and women, respectively, symptoms increase during adolescence, peak in middle age and then gradually diminish. The prevalence of these symptoms is significantly higher among women except from the first and last decades of a 100-year lifespan.

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Cervical & Thoracic Manipulations: Acute Effects upon Pain Pressure Threshold and Self-Reported Pain in Experimentally Induced Shoulder Pain

Emerging evidence suggests that cervical and thoracic joint manipulations may be advocated in treating patients with shoulder pain.

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Validity and Reliability of the Low Flexion Measurement for Posterior Glenohumeral Joint Capsule Tightness

Posterior shoulder tightness is a problem in many patients with shoulder pain. Tightness manifests as decreased ROM caused by loss of posterior capsule or posterior shoulder muscle flexibility. The posterior capsule often loses flexibility in throwing athletes and may also be present in patients with impingement symptoms. A valid and reliable measurement of posterior capsule tightness is critical to making informed decisions about interventions to improve capsule flexibility. Low Flexion (LF) is a new test shown to be valid for assessing change in posterior capsule flexibility.

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Pretreatment anxiety and pain acceptance are associated with response to trigger point injection therapy for chronic myofascial pain

Abstract

Background and Aim

This study examined the psychosocial profile of patients who responded or did not respond to trigger point injection therapy for chronic myofascial pain.

Methods

Seventy one patients with a diagnosis of chronic myofascial pain of the paraspinous muscles completed a pretreatment questionnaire measuring demographic and social factors, and validated scales to assess pain intensity, pain interference (physical and emotional), and defined psychological characteristics (pain catastrophizing, pain acceptance, pain self-efficacy, mood and anxiety). Trigger point injection therapy of the affected areas of myofascial pain was performed and follow-up was conducted by telephone at one week (n = 65) and one month (n = 63) post intervention to assess treatment outcome (pain intensity and pain-related physical interference).

Results

At one week follow-up and one-month follow-up, using pain-related physical interference as the outcome measure, we found that those who responded well to treatment were characterized by a lower level of pretreatment anxiety and a higher level of pain acceptance, with anxiety being the strongest predictor.

Conclusion

These results suggest that responses to interventional pain management in chronic myofascial paraspinous pain may be influenced by psychological characteristics, especially pretreatment anxiety.

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Is levorphanol a better option than methadone?

Abstract

Background

Methadone has been a stalwart pharmacologic option for the management of opioid drug dependence for many years. It substitutes for opioid agonists and possesses certain pharmacokinetic properties that confer characteristics preferable to those of other opioids for this application. Methadone is likewise used as an option for the treatment of pain, particularly chronic pain. It has a spectrum of pharmacodynamic activity, including contributions from non-opioid components, that translates to its specific clinical attributes as an analgesic. Unfortunately, basic science studies and accumulated clinical experience with methadone have revealed some undesirable, and even worrisome, features, including issues of safety. The benefit/risk ratio of methadone might be acceptable if there was no better alternative, but neither its pharmacokinetic nor pharmacodynamic properties are unique to methadone.

Objective

We review the basic and clinical pharmacology of methadone and suggest that levorphanol should receive attention as a possible alternative.

Conclusion

Unlike methadone, levorphanol is a more potent NMDA antagonist, possesses a higher affinity for DOR and KOR, has a shorter plasma half-life yet longer duration of action, has no CYP450 interactions or QTc prolongation risk, can be a viable option in the elderly, palliative care, and SCI patients, requires little to no need for co-administration of adjuvant analgesics, and has potentially a lower risk of drug-related Emergency Department visits compared to other opioids.

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Attitudes of Primary Care Practitioners in Managing Chronic Pain Patients Prescribed Opioids for Pain: A Prospective Longitudinal Controlled Trial

Abstract

Objective

There is increasing concern among primary care practitioners (PCPs) regarding medication misuse and noncompliance among chronic pain patients prescribed opioids for pain. This study investigated the benefits of interventions designed to track potential opioid misuse and to improve practitioner confidence in managing patients with chronic pain through the use of risk assessment, monthly monitoring of compliance, and specialty support.

Methods

Fifty-six PCPs and 253 chronic pain patients were recruited into the study. All patients were assessed for risk and called once a month for 6 months to monitor pain and opioid compliance. Practitioner knowledge about opioids, concerns about analgesic prescriptions, practice behavior, and attitudes of managing chronic pain patients were assessed and questionnaires were repeated after 1 year. Practitioners in the experimental group received monthly patient summary reports that consisted of pain, mood, activity levels, healthcare utilization, and results of the Opioid Compliance Checklist, while practitioners in the control group did not receive the monthly reports.

Results

After 1 year all the PCPs reported improvement in identifying patients at risk for misuse (P < 0.05), perceived confidence in prescribing opioids for pain (P < 0.05) and increased satisfaction with communication with pain specialists (P < 0.05). The patients reported greater compliance with their opioid medication and felt that the monthly monitoring was beneficial. Despite modest improvements, many PCPs still lacked confidence in managing pain patients and reported reluctance to prescribe opioids for chronic noncancer pain, especially among younger practitioners. This study demonstrates the benefits of careful monitoring of chronic pain patients and need for pain management support within primary care.

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SCOPE of Pain: An Evaluation of an Opioid Risk Evaluation and Mitigation Strategy Continuing Education Program

Abstract

Objective

Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioid analgesics to fund continuing education based on a FDA Blueprint. This article describes the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program, an ER/LA opioid analgesic REMS program, and its impact on clinician knowledge, confidence, attitudes, and self-reported clinical practice.

Method

Participants of the 3-h SCOPE of Pain training completed pre-, immediate post- and 2-month post-assessments.

Subjects

The primary target group (n = 2,850), and a subset (n = 476) who completed a 2-month post-assessment, consisted of clinicians licensed to prescribe ER/LA opioid analgesics, who care for patients with chronic pain and who completed the 3-h training between February 28, 2013 and June 13, 2014.

Results

Immediately post-program, there was a significant increase in correct responses to knowledge questions (60% to 84%, P ≤ 0.02) and 87% of participants planned to make practice changes. At 2-months post-program, there continued to be a significant increase in correct responses to knowledge questions (60% to 69%, P ≤ 0.03) and 67% reported increased confidence in applying safe opioid prescribing care and 86% reported implementing practice changes. There was also an improvement in alignment of desired attitudes toward safe opioid prescribing.

Conclusions

The SCOPE of Pain program improved knowledge, attitudes, confidence, and self-reported clinical practice in safe opioid prescribing. This national REMS program holds potential to improve the safe use of opioids for the treatment of chronic pain.

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A Case for the Chronic Disease Management and the Integrated Care Model for Pain Medicine: An Affordable Care Act Imperative and Global Trend

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Correlation of Subjective Effects with Systemic Opioid Exposure from Fixed-Dose Combinations of Oxycodone/Acetaminophen in Recreational Users of Prescription Drugs

Abstract

Objective

To correlate abuse-related pharmacodynamic measures and pharmacokinetic measures after administering immediate-release/extended-release and immediate-release oxycodone/acetaminophen fixed-dose combination analgesics

Design

Randomized, double-blind, active- and placebo-controlled, 7-way crossover study

Setting

Contract research organization

Subjects

Nondependent recreational users of prescription opioids.

Methods

Participants received single doses of intact immediate-release/extended-release and immediate-release oxycodone/acetaminophen 15/650 mg, intact immediate-release/extended-release and immediate-release oxycodone/acetaminophen 30/1,300 mg, crushed immediate-release/extended-release and immediate-release oxycodone/acetaminophen 30/1,300 mg, and placebo. Measures of pharmacodynamics (pupillometry, drug liking, drug high, good drug effects) and pharmacokinetics were assessed predose and up to 24 hours postdose, and correlations between pharmacokinetic parameters and pharmacodynamic data were explored.

Results

Of 61 participants, 55 completed all 7 treatments. Intact immediate-release/extended-release oxycodone/acetaminophen produced 50% lower oxycodone peak plasma concentration (C_max) than immediate-release oxycodone/acetaminophen. Median oxycodone time to C_max (t_max) was significantly longer (P<0.001) for intact immediate-release/extended-release oxycodone/acetaminophen than immediate-release oxycodone/acetaminophen. The pharmacokinetics of crushed immediate-release/extended-release and immediate-release oxycodone/acetaminophen (30/1,300 mg) followed a similar pattern. Crushing did not shorten the median oxycodone t_max for immediate-release/extended-release oxycodone/acetaminophen (30/1,300 mg). Strong correlations were observed between oxycodone C_max and area under the curve from time 0 to time x peak effects and area under the subjective effect curve from time 0 to time x for all subjective effects (R²=0.711–0.997).

Conclusion

Immediate-release/extended-release oxycodone/acetaminophen produced lower oxycodone C_max and longer t_max than immediate-release oxycodone/acetaminophen. Lower oxycodone concentrations, particularly at earlier time points, were strongly correlated with lesser positive subjective drug effects.

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Acceptance and Commitment Therapy and Selective Optimization with Compensation for Institutionalized Older People with Chronic Pain

Abstract

Objective

Recent studies support the efficacy of Acceptance and Commitment Therapy (ACT) with people with chronic pain. In addition, Selective Optimization with Compensation strategies (SOC) can help the elderly with chronic pain to accept their chronic condition and increase functional autonomy. Our aim was to analyze the efficacy of an ACT treatment program combined with training in SOC strategies for elderly people with chronic pain living in nursing homes.

Methods

101 participants (mean age = 82.26; SD = 10.00; 78.6% female) were randomized to the intervention condition (ACT-SOC) or to a minimal support group (MS). Complete data are available for 53 participants (ACT-SOC: n = 27; MS: n = 26). Assessments of functional performance, pain intensity, pain acceptance, SOC strategies, emotional well being and catastrophizing beliefs were done preintervention and postintervention.

Results

Significant time by intervention changes (P = 0.05) were found in acceptance, pain related anxiety, compensation strategies, and pain interference in walking ability. Simple effects changes were found in acceptance (P = 0.01), selection strategies (P = 0.05), catastrophizing beliefs (P = 0.03), depressive symptoms (P = 0.05), pain anxiety (P = 0.01) and pain interference in mood and walking ability (P = 0.03) in the ACT-SOC group. No significant changes were found in the MS group.

Conclusions

These results suggest that an ACT intervention combined with training in SOC strategies could help older people with pain to improve their emotional well being and their functional capability.

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Targeting cells of the myeloid lineage attenuates pain and disease progression in a prostate model of bone cancer

Abstract: Tumor cells frequently metastasize to bone where they can generate cancer-induced bone pain (CIBP) that can be difficult to fully control using available therapies. Here, we explored whether PLX3397, a high-affinity small molecular antagonist that binds to and inhibits phosphorylation of colony-stimulating factor-1 receptor, the tyrosine-protein kinase c-Kit, and the FMS-like tyrosine kinase 3, can reduce CIBP. These 3 targets all regulate the proliferation and function of a subset of the myeloid cells including macrophages, osteoclasts, and mast cells. Preliminary experiments show that PLX3397 attenuated inflammatory pain after formalin injection into the hind paw of the rat. As there is an inflammatory component in CIBP, involving macrophages and osteoclasts, the effect of PLX3397 was explored in a prostate model of CIBP where skeletal pain, cancer cell proliferation, tumor metastasis, and bone remodeling could be monitored in the same animal. Administration of PLX3397 was initiated on day 14 after prostate cancer cell injection when the tumor was well established, and tumor-induced bone remodeling was first evident. Over the next 6 weeks, sustained administration of PLX3397 attenuated CIBP behaviors by approximately 50% and was equally efficacious in reducing tumor cell growth, formation of new tumor colonies in bone, and pathological tumor-induced bone remodeling. Developing a better understanding of potential effects that analgesic therapies have on the tumor itself may allow the development of therapies that not only better control the pain but also positively impact disease progression and overall survival in patients with bone cancer.

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Early increasing-intensity treadmill exercise reduces neuropathic pain by preventing nociceptor collateral sprouting and disruption of chloride cotransporters homeostasis after peripheral nerve injury

Abstract: Activity treatments, such as treadmill exercise, are used to improve functional recovery after nerve injury, parallel to an increase in neurotrophin levels. However, despite their role in neuronal survival and regeneration, neurotrophins may cause neuronal hyperexcitability that triggers neuropathic pain. In this work, we demonstrate that an early increasing-intensity treadmill exercise (iTR), performed during the first week (iTR1) or during the first 2 weeks (iTR2) after section and suture repair of the rat sciatic nerve, significantly reduced the hyperalgesia developing rapidly in the saphenous nerve territory and later in the sciatic nerve territory after regeneration. Nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) expression in sensory neurons and spinal cord was reduced in parallel. iTR prevented the extension of collateral sprouts of saphenous nociceptive calcitonin gene–related peptide fibers within the adjacent denervated skin and reduced NGF expression in the same skin and in the L3 dorsal root ganglia (DRG). Injury also induced Na+–K+–2Cl− cotransporter 1 (NKCC1) upregulation in DRG, and K+–Cl− cotransporter 2 (KCC2) downregulation in lumbar spinal cord dorsal horn. iTR normalized NKCC1 and boosted KCC2 expression, together with a significant reduction of microgliosis in L3-L5 dorsal horn, and a reduction of BDNF expression in microglia at 1 to 2 weeks postinjury. These data demonstrate that specific activity protocols, such as iTR, can modulate neurotrophins expression after peripheral nerve injury and prevent neuropathic pain by blocking early mechanisms of sensitization such as collateral sprouting and NKCC1/KCC2 disregulation.

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An unusual case of a painful big toe

A 70 year old woman presented because of pain in her right big toe for 10 years. Clinically, there was bony prominence over the condyle of the proximal phalanx (fig 1). Radiography showed cortical...

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The Relationship Between Sociodemographic Characteristics and Clinical Features in Burning Mouth Syndrome

Abstract

Objective

To compare sociodemographic and clinical characteristics in patients with burning mouth syndrome (BMS) and their relationship with pain.

Design

Cross-sectional clinical study.

Setting

University-Hospital.

Subjects

75 BMS patients were enrolled.

Methods

The study was conducted between September 2011 and March 2012 at the “Federico II” University of Naples. Demographic characteristics and clinical information including age, sex, educational level, marital status, job status, age at disease onset, oral symptoms, and triggers were collected via questionnaire interviews. To assess pain intensity the visual analogue scale (VAS) was administered. Descriptive statistics were collected, and Pearson Chi-square tests, Kruskal–Wallis nonparametric tests and the Spearman bivariate correlation were performed.

Results

The mean age was 61.17 (±11.75, female/male ratio = 3:1). The mean age at disease onset was 56.75 (±12.01). A low educational level (8.57 ± 4.95) and 80% of unemployment were found. Job status and age at disease onset correlated with the VAS scale (P = 0.019 and P = 0.015, respectively). Tongue morphology changes, taste disturbances, and intraoral foreign body sensation have a significant dependence on gender (P = 0.049, 0.001, and 0.045, respectively); intraoral foreign body sensation has a significant dependence on marital status (P = 0.033); taste disturbances have a significant dependence on job status. (P = 0.049); xerostomia has a significant dependence on age (P = 0.039); and tongue color changes and a bitter taste have a significant dependence on educational level (P = 0.040 and 0.022, respectively). Marital status and educational level have a significant dependence on the triggers (P = 0.036 and 0.049, respectively).

Conclusions

The prevalence of BMS is higher in women, and in married, unemployed, and less highly educated patients. Burning is the most frequent symptom while stressful life events are the most frequent trigger reported.

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An Analysis of Rescue Medication Utilization from a 3-Month, Randomized, Double-Blind, Placebo-Controlled Study in Patients with Chronic Low Back Pain Treated with Single-Entity, Twice-Daily, Extended-Release Hydrocodone

Abstract

Objective

To evaluate the durability of pain relief provided by a new formulation of single-entity, hydrocodone extended-release (ER) (Zohydro^® ER) throughout the 12-hour dosing interval by examining patterns of rescue medication use.

Design

Phase 3, enriched enrollment, randomized withdrawal study with an open-label, conversion/titration phase (≤6 weeks) followed by a placebo-controlled, double-blind treatment phase (12 weeks).

Setting

Fifty-seven study sites in the United States enrolled patients

Subjects

One hundred and fifty-one opioid-experienced subjects with moderate to severe chronic low back pain who were treated with hydrocodone ER once every 12 hours.

Methods

Post hoc analysis of rescue medication use by frequency and distribution of use following the morning and evening dose of hydrocodone ER.

Results

No rescue medication was used following the morning or evening dose of hydrocodone ER during 36.0% and 76.7% of the dosing days, respectively. Time distribution of rescue medication use showed that 79.3% of all rescue medication doses were administered following the morning dose, with the highest rate of usage (46.2%) occurring 4–8 hours postdose, followed by 18.7% and 14.4% usage 0–4 and 8–12 hours postdose, respectively. Examination of the three 4-hour intervals following the evening dose of hydrocodone ER revealed similar minimal rescue medication use (5.6–8.2%).

Conclusions

End-of-dose failure was not observed based on the use of rescue medication after administration of single-entity, twice daily, hydrocodone ER capsules (Zohydro ER).

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Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy

Effects of low back pain and of Stabilization or Movement-System-Impairment treatments on induced postural responses: a planned secondary analysis of a randomized controlled trial

Motor retraining for non-specific chronic low back pain (LBP) often focuses on voluntary postural tasks. This training, however, may not transfer to other known postural impairments, such as automatic postural responses to external perturbations.

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A letter to the editor - Movement-based subgrouping in low back pain: Synergy and divergence in approaches

The role of psychological factors in persistent pain after caesarean section

This French multicentric prospective cohort study recruited 391 patients to investigate the risk factors for persistent pain after elective caesarean section, focusing on psychosocial aspects as adjusted to other known medical factors. Perioperative data was collected and specialised questionnaires were completed to assess the report of pain at the site of surgery. Three dependent outcomes were considered: pain at the 3rd month after surgery (M3, n = 268; risk = 28%), pain at the 6th month after surgery (M6, n = 239; risk =19%), and the cumulative incidence (up to M6) of neuropathic pain, as assessed using the DN4 (n = 218; risk = 24.5%).

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[Perspectives] Metaphors and medically unexplained symptoms

Her job entailed looking at diseases under a microscope in a hospital laboratory. At some point she started to have vague symptoms. Nausea, fatigue, malaise. She looked that up online. She began to obsess about food. Dizziness, ringing in the ears, back pain. She saw her doctor repeatedly and underwent scans and blood tests—the results were always normal. Jaw tightness, shortness of breath, sleep problems. She had an itch on her arm and was certain that meant pancreatic cancer. A persistent lump in her throat was suspicious for a thyroid malignancy.

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A woman with pelvic pain

A 33 year old woman presented to her general practitioner because of severe cramping pain associated with her periods. The pain was felt mainly in her left groin. Her periods were regular, every 28...

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Latent Class Analysis of the Short and Long-Form of the Chronic Pain Acceptance Questionnaire- Further Examination of Patient Subgroups

A substantial literature indicates that pain acceptance is a useful behavioral process in chronic pain rehabilitation. Pain acceptance consists of willingness to experience pain and to engage in important activities even in the presence of pain and is often measured using the Chronic Pain Acceptance Questionnaire (CPAQ). Previous traditional cluster analyses of the 20-item CPAQ identified three patient clusters which differed across measures of patient functioning in meaningful ways. The aims of this study were to replicate the prior study in a new sample, using the more robust method of Latent Class Analysis (LCA), and to compare the cluster structure of the CPAQ and the shorter CPAQ-8.

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Biotechnology: Opiates made in yeast from scratch

Biotechnology: Opiates made in yeast from scratch

Nature 524, 7565 (2015). doi:10.1038/524268d

Engineered strains of laboratory yeast can make small quantities of opiates that are used in pain medications, such as hydrocodone.Poppy farms are currently the main source of opiates, but production is uncertain because of weather, pests and other factors. Christina Smolke of Stanford University

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Exploring patients’ opinions of activity pacing and a new activity pacing questionnaire for chronic pain and/or fatigue: A qualitative study

Measuring patients’ experience of rehabilitation services across the care continuum. Part II: Key dimensions

Watching your pain site reduces pain intensity in chronic back pain patients

Abstract

Background

Chronic back pain (CBP) is a frequent debilitating and often treatment-resistant disorder. The awareness of one's own body seems to be essential in pain reduction through visual input. Visual feedback of the back reduces experimental pain perception in CBP at this site and watching the back during repeated lumbar spine movements reduces movement-evoked pain. In this study, we tested whether visual feedback alone can reduce habitual pain in CBP.

Methods

In a within-subject design, 19 CBP patients participated in an online visual feedback condition, watching one's own back. This was compared to several control conditions, such as watching a neutral object (book), a video of another person of the same sex, a picture of the own back, and keeping one's eyes closed in randomized order on five separate days. In each experimental session, participants rated habitual pain intensity and unpleasantness before and after the experimental manipulation.

Results

We present evidence that visual feedback by watching the site of chronic pain on a video screen alone is sufficient to reduce habitual chronic pain. No additional manipulation or movement was necessary.

Conclusions

These results suggest that online video feedback may be helpful in alleviating chronic pain.

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Understanding patient beliefs regarding the use of imaging in the management of low back pain

Abstract

Background

Imaging for low back pain (LBP) remains common despite guidelines recommending against routine imaging. Patient beliefs about imaging may contribute to the problem. This study aimed to quantitatively investigate patient beliefs regarding the need for imaging in managing LBP and to investigate whether personal characteristics, pain characteristics or back pain beliefs are associated with imaging beliefs.

Methods

A survey was performed of consecutive patients presenting to general medical practitioners in Sydney, Australia. Nine medical clinics were selected across varied socioeconomic regions. Survey questions assessed beliefs about the importance of imaging for LBP, collected demographic information, LBP history and general beliefs about back pain. Descriptive statistics and multivariate logistic regression were used to analyse findings.

Results

Three hundred completed surveys were collected with a 79.6% response rate. The mean age was 44 years and 60.7% of respondents were women. Exactly, 54.3% (95%CI: 48.7–58.9%) believed that imaging was necessary for the best medical care for LBP. Exactly, 48.0% (95%CI: 42.4–53.6%) believed that everyone with LBP should obtain imaging. Increased age, lower education level, non-European or non-Anglo-saxon cultural background, history of previous imaging and Back Beliefs Questionnaire scores were associated with beliefs that imaging was necessary.

Conclusion

Approximately, half of all patients presenting to a medical doctor consider low back imaging to be necessary. This may have important implications for overutilization of low back imaging investigations. Knowledge of the factors associated with the patient's belief that imaging is necessary may be helpful in designing appropriate interventions to reduce unnecessary imaging for LBP.

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Future goals of adolescents and young adults with chronic musculoskeletal pain

Abstract

Background

Chronic non-specific musculoskeletal pain is a common problem among adolescents. This study investigates the importance of future goals and goal frustration for adolescents and young adults with chronic musculoskeletal pain compared to healthy adolescents. It also explores the impact that pain intensity, pain catastrophizing and depressive symptoms have on goal frustration for adolescents with chronic pain.

Methods

Using a cross-sectional design, we compared the importance and frustration of future goals for 42 adolescents and young adults with chronic musculoskeletal pain (41 women, 1 man) to those of 42 adolescents without pain (35 women, 7 men). For the adolescents with chronic pain, we also examined levels of pain intensity, pain catastrophizing and depressive symptoms to assess their ability to explain goal frustration levels. Statistics included t-tests, Mann–Whitney test and multivariate regression analysis.

Results

We found no differences in the importance of future goals, except for goals related to health, which were more important for adolescents with chronic pain (p = 0.03). Furthermore, adolescents with chronic pain perceived higher levels of goal frustration in all domains, except that related to school (p = 0.16). Depression explained goal frustration related to personal values (p = 0.02), social acceptance (p < 0.01), self-acceptance (p < 0.01) and health (p < 0.01).

Conclusions

Dealing with chronic pain in adolescence and early adulthood does not seem to change future goals, but is associated with perceiving barriers to achieving them. The level of depressive symptoms seems to influence this relationship. Some caution is required in generalizing the results due to the relatively low number of male participants.

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Characterization of pain in familial amyloid polyneuropathy

Familial amyloid polyneuropathy (FAP) due to transthyretin (TTR) mutation is small fiber predominant polyneuropathy, exposing patients with TTR-FAP to develop neuropathic pain. However, the question of the painful nature of TTR-FAP has never been specifically addressed. In this study, we compared two groups of 16 patients with either painless or painful TTR-FAP regarding various clinical and neurophysiological variables, including laser evoked potential (LEP) recording and quantitative sensory testing.

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Frequency of hospitalizations for pain and association with altered brain network connectivity in sickle cell disease

Sickle cell disease (SCD) is a hemoglobinopathy affecting more than 100,000 individuals in United States. The disease is characterized by presence of sickle hemoglobin and recurrent episodes of pain. Some individuals with SCD experience frequent hospitalizations and high burden of pain. The role of central mechanisms in SCD pain has not been explored. Twenty-five adolescents and young adults with SCD underwent functional MRI (fMRI). Participants were stratified into high or low pain groups based on the number of hospitalizations for pain in preceding 12 months.

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Efficacy of Epidural Perineural Injection of Autologous Conditioned Serum in Unilateral Cervical Radiculopathy: A Pilot Study

Study Design. Prospective randomized pilot study. Objective. Evaluation of the efficacy of epidural perineural injection of autologous conditioned serum (ACS) versus methylprednisone (MPS) in unilateral cervical radiculopathy patients. Summary of Background Data. Cervical radiculopathy is often treated by nonoperative and operative means. Guided injections of steroids have been used previously. We used ACS, an orthobiologic derived from patients' own blood in patients of unilateral cervical radiculopathy. Methods. Forty patients were equally allocated into ACS and MPS groups and were injected with 2.5 to 3 mL of ACS or MPS, respectively, under image guidance into the perineural area of the affected nerve root. They were followed up for 6 months with visual analogue scale for pain, neck pain disability scale in Hindi language, neck disability index, and Short Form of Health Survey-12 (SF-12). Results. Patients who had received injections of ACS and MPS both had improvements in the scores of the evaluation tools. The improvement in the ACS patients was gradual and sustained during the entire study period whereas that in the MPS group had some deterioration over time. No major complications were noted among the 2 groups. Minor complications were noted in both the groups. Conclusion. ACS can be considered an equally good or better modality of nonoperative management in patients of unilateral cervical radiculopathy as MPS. The safety profile is good and the improvement seen is sustained over time. Thus, it may be offered to affected patients before offering them surgery. Level of Evidence: 2

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Evaluation of 12 Novel Molecular Markers for Degenerated Nucleus Pulposus in a Chinese Population

Study Design. A transcriptional expression assessment of human samples. Objective. To evaluate 12 new candidate nucleus pulposus (NP) markers in degenerative disc disease in a Chinese population. Summary of Background Data. Disc degeneration is a major contributor of low back pain. However, no specific and reliable markers of degeneration of NP are available. Methods. Specimens of NP were collected from 81 patients and grouped into the degenerated disc group (undergoing discectomy and fusion with significant signs of disc degeneration) and the trauma control group (undergoing anterior vertebral body and disc excision and fusion without signs of disc degeneration). Lumbar spine magnetic resonance imaging, hematoxylin-eosin staining, and safranin O staining of sections of NP tissues were conducted to evaluate the severity of the disc degeneration in all samples. Quantitative reverse transcription polymerase chain reaction was performed to investigate the levels of mRNA expression of these genes, as well as those of aggrecan, type II collagen, and SRY-box 9 (SOX-9). Degenerated samples were also divided into groups according to Pfirrmann grading system to elucidate the association of severity of degeneration and gene transcriptional levels. We also tested the relationship between mRNA levels of these genes and clinical characteristics such as hypertension and diabetes mellitus. Results. We demonstrated that 11 of the 12 candidates showed significant differential expression in degenerated discs. Changes in the expression of these 11 genes were determined to be risk factors in degenerative disc diseases. The expression of neurochondrin (NCDN), keratin 8 (KRT8), and matrix Gla protein (MGP) even showed significant changes among subgroups of patients with degenerative disc disease stratified according to the Pfirrmann grading system. The expression of keratin 18 (KRT18), cadherin 2 (CDH2), synaptosomal-associated protein 25 (SNAP25), KRT8, and NCDN was significantly decreased in patients with hypertension. In contrast, the expression of MGP and cartilage oligomeric matrix protein was significantly upregulated in patients with diabetes mellitus. Conclusion. Overall, we demonstrated the clinical utility of 11 novel NP markers for degenerative disc disease. Among them, the expression of NCDN, KRT8, and MGP may indicate the severity of disc degeneration. Level of Evidence: N/A

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A Comparison of Anterior Cervical Corpectomy and Fusion Combined With Artificial Disc Replacement and Cage Fusion in Patients With Multilevel Cervical Spondylotic Myelopathy

Study Design. A retrospective study. Objective. The aim of this study was to compare clinical and radiological outcomes of anterior cervical corpectomy and fusion (ACCF) combined with artificial disc replacement (C-ADR) and ACCF combined with anterior cervical discectomy and fusion (ACDF) in patients with consecutive 3-level cervical spondylotic myelopathy (CSM). Summary of Background Data. The optimal surgical strategy for multilevel CSM (MCSM) remains undefined. C-ADR maintains motion at the level of the surgical procedure and decreases strain on the adjacent segments. The clinical results of multilevel C-ADR have not yet been elucidated. ACCF combined with 1-level C-ADR for the treatment of consecutive 3-level CSM may be a reasonable alternative to 3-level fusion. Methods. We retrospectively reviewed the histories of patients who underwent surgery for consecutive 3-level CSM between C3–4 and C6–7 from June 2007 to August 2011. A total of 42 patients were divided into 2 groups. Group A (n = 19) underwent ACCF combined with 1-level C-ADR; group B (n = 23) underwent ACCF combined with 1-level ACDF. We compared perioperative parameters, clinical parameters, and radiological parameters. Results. There were no significant differences in the average age, sex ratio, the preoperative heights of the disc space or average blood loss between the 2 groups. Group A had longer operation times than group B (P < 0.05). During the follow-up period, group A showed a better Neck Dysfunction Index recovery (P < 0.05) at 24 months postoperatively, and less visual analogue scale scores at 12 and 24 months postoperatively (P < 0.05 and P < 0.001, respectively). Moreover, group A exhibited better C2–C7 range of motion recovery at 6, 12, and 24 months postoperatively (P < 0.05, respectively). Conclusion. Group A was superior to Group B in terms of better Neck Dysfunction Index recovery, less intermediate term pain, and better C2–C7 ROM recovery. ACCF hybrid 1-level C-ADR may be a suitable choice for the management of 3-level CSM in appropriate patients. Level of Evidence: 3

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Postoperative Narcotic Consumption in Workman's Compensation Patients Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion

Study Design. Retrospective cohort analysis of a prospective registry. Objective. To assess the differences in perioperative narcotic consumption between Workman's compensation (WC) and non-Workman's compensation (non-WC) patients after a single-level minimally invasive transforaminal lumbar interbody fusion. Summary of Background Data. There is concern regarding the potential overutilization of opioid pain medication in WC patients. However, the impact of WC status on perioperative narcotic consumption after lumbar spine procedures has not been previously reported. Methods. A cohort of patients who underwent primary 1-level minimally invasive transforaminal lumbar interbody fusion procedures for degenerative spinal pathology between 2007 and 2013 was retrospectively analyzed using a prospectively collected registry. First, preoperative and perioperative characteristics were compared between WC and non-WC patients. Second, mean oral morphine equivalent was compared between WC and non-WC patients with adjustment for any preoperative or perioperative differences between cohorts. Results. A total of 136 single-level, primary minimally invasive-transforaminal lumbar interbody fusion procedures were included in the analysis, of which 46 (33.8%) were WC patients. WC patients were younger (47.8 ± 11.2 vs. 57.9 ± 10.4 yr; P < 0.001) and had a lower comorbidity burden (Charlson Comorbidity Index: 1.85 ± 1.30 vs. 3.42 ± 2.07; P < 0.001) than non-WC patients. The distribution of ethnicity differed between WC and non-WC patients (P = 0.002). WC patients incurred longer procedural times (135.2 ± 52.2 vs. 118.9 ± 33.7 min; P < 0.05). However, the estimated blood loss, length of hospital stay, and day of discharge were no different between WC and non-WC patients. Mean oral morphine equivalent consumption did not differ between WC and non-WC patients after adjustment for differences in age, ethnicity, Charlson Comorbidity Index, and procedural time between cohorts. Conclusion. Despite concerns for greater opioid use in the WC population, this analysis demonstrated similar total narcotic consumption between WC and non-WC patients during the immediate postoperative period. Long-term studies are warranted to assess whether this similarity in regard to perioperative narcotic consumption persists beyond the immediate postoperative period. Level of Evidence: 3

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Minimum 20 Years Long-term Clinical Outcome After Spinal Fusion and Instrumentation for Scoliosis: Comparison of the SRS-22 Patient Questionnaire With That in Nonscoliosis Group

Study Design. A retrospective minimum 20-year follow-up study using 4 standard self-administered questionnaires, one of which, the SRS-22 was also administered to control groups. Objective. To evaluate long-term postoperative pain and other clinical outcomes of scoliosis correction and fusion surgery with Harrington instrumentation using Moe square-ended rods for better preservation of sagittal alignment. Summary of Background Data. Only a few long-term outcome studies have used standardized and validated self-administered tools, and no studies have established SRS-22 control data within their own population. There is no previous minimum 20-year follow-up evaluation after correction surgery preserving thoracic kyphosis and lumbar lordosis. Methods. Of 86 consecutive patients who underwent instrumentation surgery for scoliosis by a single surgeon, 61 patients participated using Japanese Orthopaedic Association, Roland-Morris Disability Questionnaire, Oswestry Disability Index, and Scoliosis Research Society (SRS-22) questionnaires and 51 patients were included in this study. Results were analyzed for pain and other clinical outcomes. A total of 771 hospital employees were sent SRS-22 questionnaires. A total of 763 responded, resulting in 2 control groups composed of nonscoliosis and untreated mild scoliosis controls of the same culture and language as the long-term follow-up group. Results. The prevalence of continuous low back pain was about 15%. Average Japanese Orthopaedic Association, Oswestry Disability Index, and Roland-Morris Disability Questionnaire scores at follow-up were 25 points, 7.3%, and 1.6, respectively. The average SRS-22 scores were 4.2 (function), 4.3 (pain), 3.7 (self-image), and 3.9 (mental health) for the postoperative follow-up group compared with 4.5 (function), 4.3 (pain), 3.5 (self-image), and 3.5 (mental health) for the nonscoliosis controls. Conclusion. Improved preservation of normal sagittal alignment resulted in a prevalence of low back pain comparable with the age-matched general population. Moreover, SRS-22 results for self-image and mental health were positive compared with the controls, possibly reflecting the surgeon's emphases on mental health and management of patient expectations. Level of Evidence: 4

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SRS22R Appearance Domain Correlates Most With Patient Satisfaction After Adult Deformity Surgery to the Sacrum at 5-year Follow-up

Study Design. Longitudinal cohort. Objective. To evaluate the relationship between Scoliosis Research Society-22R (SRS22-R) domains and satisfaction with management in patients who underwent surgical correction for adult spine deformity. Summary of Background Data. The SRS-22R is used to measure clinical outcomes in adult spine deformity patients. The relationship between patient satisfaction and SRS-22R domain scores, the Oswestry Disability Index (ODI) and radiographical parameters has not been reported at 5-year follow-up. Methods. 135 patients with adult spinal deformity at a single institution who underwent a posterior spinal fusion of 5 levels or more to the sacrum and had complete SRS-22R pre- and minimum 5-year postoperative were identified. Wilcoxon tests were used to compare preoperative and 5-year postoperative scores. Spearman correlations were used to evaluate associations between the 5-year SRS-22R Satisfaction score and changes in SRS-22R domain scores, SubScore (SRS-22R Total—Satisfaction), ODI, and radiographical parameters. Results. There were 125 females and 10 males with a mean BMI of 26.6 kg/m2 and mean age of 53.6 years. There were 74 primary and 61 revision surgeries with a mean 9.9 levels fused and mean follow-up of 67 months. There was a statistically significant improvement between paired pre- and 5-year postop SRS-22R domain scores and most radiographical parameters, commonly P ≤ 0.001. The majority of patients had an SRS-22R Satisfaction score of 3.0 or more (88%) or 4.0 or more (67%), consistent with a moderate ceiling effect. Correlations for SRS-22R domain scores were all statistically significant and either weak [Mental (0.26), Activity (0.27), Pain (0.35), or moderate (Appearance (0.59))]. SRS-22R SubScore (0.54) and ODI (0.43) also had a moderate correlation. Correlations for all radiographical and operative parameters were either very weak or weak. Conclusion. SRS-22R Appearance, SubScore, and ODI correlate most with patient satisfaction in adult deformity patients undergoing 5 or more level fusion to the sacrum at 5-year follow-up. Level of Evidence: 2

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Utility of Flexion-Extension Radiographs in Lumbar Spondylolisthesis: A Prospective Study

Study Design. Prospective cohort study in consecutive patients. Objective. To investigate and compare the use of 2 diagnostic modalities in the evaluation of stability in lumbar spondylolisthesis. Summary of Background Data. Evaluating potential instability in lumbar spondylolisthesis is significant to its management. Lateral lumbar flexion-extension (FE) radiograph is frequently obtained on the basis of a thought that this forward-backward movement can actually describe hypermobility at the listhetic segment. However, simply comparing standard upright lumbar lateral radiograph (U) with a supine sagittal magnetic resonance image (S) (combined, US), something typically conducted for patients with lumbar spondylolisthesis, may also be used. Methods. This prospective study included a cohort of 68 consecutive patients with lumbar spondylolisthesis seen in the outpatient clinic of a single hospital. The mobility observed in US was compared with that observed in FE. The ability to identify “instability” using US was compared with that using FE. In addition, the relationships between mobility determined using FE or US and sex, age, height, weight, body mass index, primary symptom (with or without back pain), nature of spondylolisthesis (degenerative or isthmic), listhetic segment, slippage grade, and focal disc height were examined. Results. Overall, the mobility in US was significantly higher than that in FE (7.68 ± 5.34% vs. 4.90 ± 3.82%, t =−3.545, P = 0.001). The ability to identify “instability” on the basis of US was improved compared with that obtained using FE. Female patients demonstrated higher mobility in FE than male patients to a significant degree. Back pain, isthmic spondylolisthesis, and slippage grade also showed some relevance with mobility but without statistical significance. Conclusion. US may offer an easily available, alternative diagnostic modality in lumbar spondylolisthesis, with the potential of reducing both radiation exposure and costs. Further studies should focus on its influence in clinical decision making. Level of Evidence: 2

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The efficacy of different types of mobilization techniques in patients with primary adhesive capsulitis of the shoulder: a systematic review

What is evidence-based about myofascial chains? A systematic review

Evidence for sustained mechanical pain sensitization in women with chronic temporomandibular disorder versus healthy female participants

Generalized dysfunction of the nociceptive system has been hypothesized as an important pathophysiological process underlying TMD pain. To date, studies have not identified sensitization among TMD participants with chronic pain to painful stimuli administered prospectively across consecutive days. We attempted to isolate an empirically derived laboratory-based marker of sustained mechanical pain sensitization. We examined whether this index accounted for variance in prospective assessments of clinical TMD pain.

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Manual Physical Therapy versus Surgery for Carpal Tunnel Syndrome: a Randomized Parallel-Group Trial

This randomized clinical trial investigated the effectiveness of surgery compared with physiotherapy consisting of manual therapies including desensitization maneuvers in carpal tunnel syndrome (CTS). The setting was a public hospital and 2 physiotherapy practices in Madrid, Spain. One hundred and twenty women with CTS were enrolled between February 2013 and January 2014 with 1-year follow-up completed in January 2015. Interventions consisted of 3 sessions of manual therapies including desensitization manoeuvres of the central nervous system (physiotherapy group, n=60), or decompression/release of the carpal tunnel (surgical group, n=60).

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Effects of a guided Internet-delivered self-help intervention for adolescents with chronic pain

Cognitive behavioral therapy (CBT) is effective in reducing the frequency and intensity of chronic pain in adolescents. However, CBT seems not to be considered acceptable by all adolescents. The main aim of our study was therefore to evaluate the effects of a guided Internet-delivered self-help for adolescents with chronic pain. Adolescents (N=69) were assessed on the outcome measures: pain, coping, disability, catastrophizing, rewarding of pain behavior by parents, and quality of life. Measures were taken seven weeks before treatment, pre-treatment, post-treatment, and at three months follow-up.

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Response rates for CBT for anxiety disorders: Need for standardized criteria

The effects of cognitive behavior therapy for adult depression on dysfunctional thinking: A meta-analysis

Deconstructing Chronic Low Back Pain in the Older Adult—Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment Part III: Fibromyalgia Syndrome

Abstract

Objective

To present the third in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributors to pain and disability in older adults with CLBP. This article focuses on fibromyalgia syndrome (FMS).

Methods

A modified Delphi approach was used to create the evaluation and treatment algorithm, the table discussing the rationale behind each of the algorithm components, and the stepped-care drug recommendations. The team involved in the creation of these materials consisted of a principal investigator, a 5-member content expert panel, and a 9-member primary care panel. The evaluation and treatment recommendations were based on availability of medications and other resources within the Veterans Health Administration (VHA) facilities. However, non-VHA panelists were also involved in the development of these materials, which can be applied to both VA and civilian settings. The illustrative clinical case was taken from the clinical practice of the principal investigator.

Results

Following expert consultations and a review of the literature, we developed an evaluation and treatment algorithm with supporting materials to aid in the care of older adults with CLBP who have concomitant FMS. A case is presented that demonstrates the complexity of pain evaluation and management in older patients with CLBP and concomitant FMS.

Conclusions

Recognition of FMS as a common contributor to CLBP in older adults and initiating treatment targeting both FMS and CLBP will lead to improved outcomes in pain and disability.

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CPM Test–Retest Reliability: “Standard” vs “Single Test-Stimulus” Protocols

Abstract

Objectives

Assessment of pain inhibitory mechanisms using conditioned pain modulation (CPM) is relevant clinically in prediction of pain and analgesic efficacy. Our objective is to provide necessary estimates of intersession CPM reliability, to enable transformation of the CPM paradigm into a clinical tool.

Design

Two cohorts of young healthy subjects (N = 65) participated in two dual-session studies. In Study I, a Bath-Thermode CPM protocol was used, with hot water immersion and contact heat as conditioning- and test-stimuli, respectively, in a classical parallel CPM design introducing test-stimulus first, and then the conditioning- and repeated test-stimuli in parallel. Study II consisted of two CPM protocols: 1) Two-Thermodes, one for each of the stimuli, in the same parallel design as above, and 2) single test-stimulus (STS) protocol with a single administration of a contact heat test-stimulus, partially overlapped in time by a remote shorter contact heat as conditioning stimulus. Test–retest reliability was assessed within 3–7 days.

Results

The STS-CPM had superior reliability intraclass correlation (ICC_2,1 = 0.59) over Bath-Thermode (ICC_2,1 = 0.34) or Two-Thermodes (ICC_2,1 = 0.21) protocols. The hand immersion conditioning pain had higher reliability than thermode pain (ICC_2,1 = 0.76 vs ICC_2,1 = 0.16). Conditioned test-stimulus pain scores were of good (ICC_2,1 = 0.62) or fair (ICC_2,1 = 0.43) reliability for the Bath-Thermode and the STS, respectively, but not for the Two-Thermodes protocol (ICC_2,1 = 0.20).

Conclusions

The newly developed STS-CPM paradigm was more reliable than other CPM protocols tested here, and should be further investigated for its clinical relevance. It appears that large contact size of the conditioning-stimulus and use of single rather than dual test-stimulus pain contribute to augmentation of CPM reliability.

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Response to Letter by Dr. Lipetz

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Familial Contributions to Self-Reported Sleep and Pain in Female Twins

Abstract

Objective

The relationship between sleep quality and pain has been studied in populations with chronic pain and in nonclinical populations using experimental paradigms. Little is known about the familial contributions to this relationship. This study examines self-reported sleep quality and pain in a nonclinical sample and to explore familial (i.e., shared genetic and common family environment) confounding in those relationships.

Design

Cross-sectional.

Subjects

Ninety nine community-based female twin pairs (N = 198) with a mean age of 29 years; 72% monozygotic.

Methods

The short form McGill Pain Questionnaire (McGill), a visual analog scale (VAS), a body map, and the Pittsburgh Sleep Quality Index (PSQI) measured self-reported pain and sleep quality. Mixed model regression adjusted for age was used to examine relationships between the pain indices and PSQI in overall and within-pair models.

Results

Higher PSQI total scores were significantly associated with higher scores across the McGill sensory (B = 0.37, p < 0.001), affective (B = 0.16, p < 0.001), total scores (B = 0.54, p < 0.001), the VAS (B = 2.41, p < 0.001), and number of sites with any pain on the body map (B = 0.42, p = 0.001). All of these associations were diminished and rendered nonsignificant in within-pair analyses that accounted for genetic and familial factors (all p's ≥ 0.01; Bonferroni α = 0.01).

Conclusions

These findings support an association between poor sleep quality and pain and suggest that this relationship may be confounded by shared genetic and environmental factors, which could elucidate biological mechanisms that underlie the development and maintenance of pain and sleep problems.

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Abdominal Aortic Aneurysm as a Long Time Cause of Low Back Pain and Vertebral Scalloping

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Prescription opioid and benzodiazepine use after road traffic injury

Abstract

Background

Motor vehicle crash victims with physical injury are likely to receive prescription opioids and benzodiazepines. Potential mental trauma and lack of primary treating physician contribute to the risk of adverse opioid outcomes for this group. The purpose of this study is to characterise opioid and benzodiazepine prescribing after road traffic injury.

Method

Individuals who claimed Transport Accident Commission compensation for a noncatastrophic injury that occurred between 2010 and 2012 in Victoria, Australia and who provided consent for pharmaceutical benefits scheme (PBS) linkage were included (n = 734). PBS records dating between 12 months preinjury and 18 months postinjury were provided by the Department of Human Services.

Results

In the year before injury, 10.5% of participants received prescription opioids; after injury, 45.1% of hospitalized and 21.1% of nonhospitalized participants received opioids. Benzodiazepines were used by 4.8% preinjury, and 7.0% and 7.4% postinjury (with and without hospitalization, respectively). Postinjury, 39% of opioid use and 73% of benzodiazepine use was potentially unrelated to the injury.

Conclusions

Prescription opioid and benzodiazepine before road traffic injury was substantial: the significance of postinjury prescription drug use cannot be established without taking preinjury use into account. It may be beneficial for pain medication to be managed by a pain treatment coordinator, in this injured population with high rates of pre-existing opioid and benzodiazepine use.

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Comparative effectiveness of Pilates and yoga group exercise interventions for chronic mechanical neck pain: Quasi-randomised parallel controlled study

Title: Response to letter to the editor re ‘Movement based subgroups in people with low back pain: synergy and divergence in approaches’

Listening to music helps reduce pain and anxiety after surgery, review shows

Listening to music before, during, or after surgery notably decreases patients’ pain and anxiety and reduces their use of analgesic drugs, a review published in the Lancet has shown.1Use of music has...

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Pain Catastrophizing and Fear of Pain predict the Experience of Pain in Body Parts not targeted by a Delayed-Onset Muscle Soreness procedure

The present study examined whether pain catastrophizing and pain-related fear predict the experience of pain in body regions that are not targeted by an experimental muscle injury protocol. A delayed-onset muscle soreness (DOMS)-protocol was used to induce pain unilaterally in the pectoralis, serratus, trapezius, latisimus dorsi, and deltoid muscles. The day following the DOMS-protocol, participants were asked to rate their pain as they lifted weighted canisters with their targeted arm (i.e. injured) and their not-targeted arm.

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Can hip abduction and external rotation discriminate sacroiliac joint pain?

The primary aim of the study is to determine if Hip Abduction and External Rotation (HABER) test is capable of reproducing familiar pain in individuals with low back pain (LBP) of sacroiliac joint (SIJ) origin (SIJ-positive) when compared with LBP of Non-SIJ origin (SIJ-negative). If so, the secondary aim is to determine the diagnostic accuracy of HABER test against the reference standard of pain provocation tests, and to determine which increments of the HABER test has highest sensitivity and specificity for identifying SIJ-positive individuals.

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Editorial Board

Encouraging healthy spine habits to prevent low back pain in children: an observational study of adherence to exercise

Effects of spinal manipulation on sensorimotor function in low back pain patients – a randomized controlled trial

Low back pain (LBP) is a major health problem in industrialized societies. Spinal manipulation (SM) is often used for treating LBP, though the therapeutic mechanisms remain elusive. Research suggests that sensorimotor changes may be involved in LBP. It is hypothesized that SM may generate its beneficial effects by affecting sensorimotor functions.

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Risk Factors for Persistent Delinquent Behavior among Juveniles: A Meta-Analytic Review

Physical activity engagement in early rheumatoid arthritis: A qualitative study to inform intervention development

Distinguishing feigned from sincere performance in psychophysical pain testing

Self-report, the most widely used, gold standard measurement of pain, is crucial for pain research, diagnosis and management. However, there are currently no accurate, reliable methods for detecting dishonesty in self-reports when there is incentive for pain deception. We introduce a novel approach to detecting pain deception by analyzing performance patterns of honest and dishonest psychophysical pain testing. Warmth sensation (WST) and heat pain (HPT) thresholds were measured in healthy subjects (n=37) under two conditions: standard instruction (i.e., provide sincere reports) and instructions to simulate intense pain (i.e., provide feigned reports) with the intention of deceiving.

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Bias in randomised controlled trials: comparison of crossover group and parallel group designs

The efficacy and side effects of the synthetic cannabinoid nabilone were compared with those of the weak opioid dihydrocodeine in the treatment of chronic neuropathic pain. A randomised, double...

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