Patient-reported outcome questionnaires for people with pain in any spine region. A systematic review

This systematic review investigates the measurement properties of patient-reported outcome (PRO) questionnaires which evaluate disability associated with pain in any area of the spine.

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Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial

Mobilization with movement (MWM) has been shown to reduce pain, increase range of motion (ROM) and physical function in a range of different musculoskeletal disorders. Despite this evidence, there is a lack of studies evaluating the effects of MWM for hip osteoarthritis (OA).

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Effect of stretching with and without muscle strengthening exercises for the foot and hip in patients with plantar fasciitis: A randomized controlled single-blind clinical trial

to compare the effect of stretching with and without muscle strengthening of the foot alone or foot and hip on pain and function in patients with plantar fasciitis.

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Psychological placebo and nocebo effects on pain rely on both expectation and prior experience

Expectation and prior experience are both well-established key mediators of placebo and nocebo effects. However, the investigation of their respective contribution to placebo and nocebo responses is rather difficult since most placebo and nocebo manipulations are contaminated by preexisting treatment expectancies resulting from a learning history of prior medical interventions. To circumvent any resemblance to classical treatments, a purely psychological placebo-nocebo manipulation was established, namely the “visual stripe pattern induced modulation of pain”.

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Transdermal cannabidiol reduces inflammation and pain-related behaviours in a rat model of arthritis

Abstract

Background

Current arthritis treatments often have side-effects attributable to active compounds as well as route of administration. Cannabidiol (CBD) attenuates inflammation and pain without side-effects, but CBD is hydrophobic and has poor oral bioavailability. Topical drug application avoids gastrointestinal administration, first pass metabolism, providing more constant plasma levels.

Methods

This study examined efficacy of transdermal CBD for reduction in inflammation and pain, assessing any adverse effects in a rat complete Freund's adjuvant-induced monoarthritic knee joint model. CBD gels (0.6, 3.1, 6.2 or 62.3 mg/day) were applied for 4 consecutive days after arthritis induction. Joint circumference and immune cell invasion in histological sections were measured to indicate level of inflammation. Paw withdrawal latency (PWL) in response to noxious heat stimulation determined nociceptive sensitization, and exploratory behaviour ascertained animal's activity level.

Results

Measurement of plasma CBD concentration provided by transdermal absorption revealed linearity with 0.6–6.2 mg/day doses. Transdermal CBD gel significantly reduced joint swelling, limb posture scores as a rating of spontaneous pain, immune cell infiltration and thickening of the synovial membrane in a dose-dependent manner. PWL recovered to near baseline level. Immunohistochemical analysis of spinal cord (CGRP, OX42) and dorsal root ganglia (TNFα) revealed dose-dependent reductions of pro-inflammatory biomarkers. Results showed 6.2 and 62 mg/day were effective doses. Exploratory behaviour was not altered by CBD indicating limited effect on higher brain function.

Conclusions

These data indicate that topical CBD application has therapeutic potential for relief of arthritis pain-related behaviours and inflammation without evident side-effects.

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The effect of gabapentin and ketorolac on allodynia and conditioned place preference in antibody-induced inflammation

Abstract

Background

Glucose-6-phosphate isomerase and collagen type II antibody-induced arthritis models (K/BxN and CAIA, respectively) have an inflammatory and a post-inflammatory phase. Both phases display robust tactile allodynia. In previous work, inflammatory phase allodynia was reversed by gabapentin and ketorolac, whereas in late phase only gabapentin was effective. Here, we sought to determine if the effects of these two drugs during the early and late phases of the two arthritis models were observed in the conditioned place preference (CPP) paradigm, indicating a differential drug effect on the aversive state.

Methods

Male C57BL/6 mice received K/BxN serum intraperitoneally, while male BALB/c mice received collagen type II antibody cocktail intravenously. After onset of inflammation and allodynia, we assessed effects of i.p. gabapentin (100 mg/kg) or ketorolac (15 mg/kg) using a CPP paradigm: 2 days adaptation, 2 days conditioning (vehicle in morning and drug in afternoon), preference testing on day 5.

Results

Consistent with the effects upon allodynia, both gabapentin and ketorolac produced a preference for the drug-paired compartment in the early phase of the K/BxN model, while gabapentin, but not ketorolac, resulted in a place preference during late phase. In the CAIA model, consistent with differential effects upon allodynia, gabapentin produced a preference in the early phase and a trend in the late phase, whereas ketorolac was ineffective at either time.

Conclusions

CPP validated the aversive state in the inflammatory and post-inflammatory phases of the K/BxN and CAIA arthritis models and correspondence between the anti-hyperpathic pharmacology as defined by thresholds and CPP.

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Acute pain Factors predictive of post-operative pain and opioid requirement in multimodal analgesia following knee replacement

Abstract

Background

Despite the development of multimodal analgesia for postoperative pain management, opioids are still required for effective pain relief after knee arthroplasty. We aimed to identify the determinants of post-operative pain intensity and post-operative opioid requirement in this context.

Methods

In this observational prospective study, we recorded patient characteristics, pre-operative pain intensity, anxiety and depression levels, sensitivity and pain thresholds in response to an electrical stimulus, and mu-opioid receptor (OPRM1) and catechol-O-methyltransferase (COMT) single-nucleotide polymorphisms. Multivariate linear regression models were used to identify predictors of post-operative pain at rest and opioid requirement.

Results

We included 109 patients. Pre-operative pain at rest (p = 0.047), anxiety level (p = 0.001) and neuropathic pain symptoms (p = 0.030) were independently and positively associated with mean post-operative pain intensity adjusted for mean post-operative morphine equivalent dose (MED). Mean post-operative pain intensity at rest was lower (p = 0.006) in patients receiving celecoxib and pregabalin in the post-operative period, with all other variables constant. Mean post-operative MED over 5 days was low, but highly variable (78.2 ± 32.1 mg, from 9.9 to 170 mg). Following adjustment for mean post-operative pain intensity, it was independently negatively correlated with age (p = 0.004), and positively correlated with associated paracetamol treatment (p = 0.031). No genetic effect was detected in our sample.

Conclusions

Our findings suggest that clinicians could use the pre-operative pain profile, in terms of anxiety levels, neuropathic pain symptoms, and chronic pre-operative pain intensity, to improve the efficacy of pain management after knee surgery.

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A follow-up on Acute Pain Services in Germany compared to international survey data

Abstract

Background

After the introduction of instruments for benchmarking, certification and a national guideline for acute pain management, the aim of this study was to describe the current structure, processes and quality of German acute pain services (APS).

Methods

All directors of German departments of anaesthesiology were invited to complete a postal questionnaire on structures und processes of acute pain management. The survey asked for staff, techniques and quality criteria, which enabled a comparison to previous data from 1999 and surveys from other countries.

Results

Four hundred and eight (46%) questionnaires were returned. APS have increased considerably and are now available in 81% of the hospitals, mainly anaesthesia based. However, only 45% fulfilled the minimum quality criteria, such as the assignment of personnel, the organization of patient care during nights and weekends, written protocols for postoperative pain management, regular assessments and documenting pain scores. Staff resources varied considerably, but increased compared to 1999. Two daily rounds were performed in 71%, either by physicians and nurses (42%), by physicians only (25%) or by supervised nurses (31%). Most personnel assigned to the APS shared this work along with other duties. Only 53% of the hospitals had an integrated rotation for training their specialty trainees.

Conclusions

The availability of APS in Germany and other countries has increased over the last decade; however, the quality of nearly half of the APS is questionable. Against the disillusioning background of recently reported unfavourable pain-related patient outcomes, the structures, organization and quality of APS should be revisited.

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Establishing clinically meaningful severity levels for the Tampa Scale for Kinesiophobia (TSK-13)

Abstract

Background

Kinesiophobia is an excessive, irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury. The Tampa Scale for kinesiophobia (TSK) is a patient-reported outcome (PRO) measure designed to help identify kinesiophobia. The original version of the TSK had 17 items. A 13-item version was later found to have better psychometric properties and was used in the present study. Although the TSK-13 has been widely studied, one shortcoming is the lack of clinically meaningful score categories. The objective of the present study was to develop severity levels to help aid clinical interpretation of TSK-13 scores.

Methods

After creating four proposed TSK-13 severity ranges, a sample of chronic musculoskeletal pain disorder (CMPD) patients (N = 912) was grouped by TSK-13 scores into: Subclinical (score = 13–22, n = 100; 11%), mild (23–32, n = 271; 30%), moderate (33–42, n = 385; 42%) and severe (43–52, n = 156; 17%) levels of kinesiophobia. These severity groups were then validated by their associations with objective lifting performance (presumed to be highly related to one's level of kinesiophobia) and other PRO questionnaires, assessing depressive symptoms, pain intensity, pain-related anxiety and perceived disability, which all have been shown in previous research to be associated with TSK scores.

Results

The TSK-13 severity level groups were significantly associated with all lifting performance and PRO variables (p < 0.001). As TSK-13 severity levels increased, lifting performance decreased, while pain intensity, depressive symptoms, pain-related anxiety and perceived disability increased.

Conclusions

TSK-13 severity levels were strongly associated with objective lifting performance variables and psychosocial PRO measures, providing support for these severity levels as a guideline for healthcare providers and researchers in interpreting TSK-13 scores.

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GABA receptors in the central nucleus of amygdala are involved in pain- and itch-related responses

Itch and pain are unpleasant sensations that distress patients from many diseases. However, most previous studies have focused on the neural mechanisms of pain, and much less effort has been devoted to itch. It has been reported that itch and pain might share a common pathway, and GABAA receptors in the central nucleus of the amygdala (CeA) are involved in pain modulation. However, the contribution of GABAA receptors in the CeA to the modulation of itch remains poorly understood. Here, we reported that bilateral intra-CeA microinjection of a selective GABAA receptor agonist muscimol (50 ng/side), but not a selective GABAA receptor antagonist bicuculline (20 ng/side) or vehicle, displayed significantly analgesic effects, as reflected by an increase in tail-flick latency and a decrease in allyl isothiocyanate (AITC; mustard oil)-evoked ipsilateral forelimb wipes.

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Massive diaphragmatic hernia causing shortness of breath and abdominal pain

bmj;351/oct28_3/h5429/FIG1F1fig1A 42 year old woman presented with chronic shortness of breath and left upper quadrant pain. On chest auscultation bowel sounds were audible up to the axillae. Chest...

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Medical Use of Cannabinoids

To the Editor Dr Whiting and colleagues presented a systematic review of medical cannabinoids. The University of California Center for Medicinal Cannabis Research has conducted 5 placebo-controlled clinical trials with smoked or inhaled cannabis for neuropathic pain, representing, to my knowledge, the only studies approved by the US Department of Health and Human Services to be conducted in the United States during the past 2 decades.

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Medical Use of Cannabinoids

To the Editor Dr Whiting and colleagues presented the results of a systematic review and meta-analysis of medical cannabinoids, claiming moderate-quality evidence supporting their use for chronic pain and spasticity. The studies on which they relied included investigations of numerous preparations with varying routes of administration. The products considered each have their own unique pharmacodynamics.

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Efficacy of a Telephone-Delivered Self-Management Intervention for Persons With Multiple Sclerosis: A Randomized Controlled Trial With a One-Year Follow-Up

Longitudinal Study of Headache Trajectories in the Year After Mild Traumatic Brain Injury: Relation to Posttraumatic Stress Disorder Symptoms

Prolotherapy for Refractory Rotator Cuff Disease: Retrospective Case-Control Study of 1-Year Follow-Up

Greater Resting Lumbar Extensor Myofascial Stiffness in Younger Ankylosing Spondylitis Patients Than Age-Comparable Healthy Volunteers Quantified by Myotonometry

Functional and Mental Health Status of United Kingdom Military Amputees Postrehabilitation

Effects of neck-specific exercises compared to waiting list for individuals with chronic whiplash associated disorders: a prospective randomized controlled study

Total Western Diet (TWD) alters mechanical and thermal sensitivity and prolongs hypersensitivity following Complete Freund’s Adjuvant in mice

Obesity and chronic pain are often comorbid and their rates are rising. It is currently unknown whether increased pain is due to greater weight or poor diet quality, or both. Therefore, we utilized a Total Western Diet (TWD) to investigate the functional and physiological consequences of nutritionally-poor diet in mice. During thirteen weeks on the commercially-available TWD, based on the National Health and Nutrition Examination Survey (NHANES), thresholds of TWD-fed mice significantly increased in both thermal and mechanical tests.

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Deterioration in physical activity and function differs according to treatment type in non-small cell lung cancer–future directions for physiotherapy management

Depression trajectories during the first year after spinal cord injury

Putting physical activity whilst experiencing low back pain in context: balancing the risks and benefits

Systematic review of the Face, Legs, Activity, Cry and Consolability scale for assessing pain in infants and children: is it reliable, valid, and feasible for use?

Abstract: The Face, Legs, Activity, Cry and Consolability (FLACC) scale is one of the most widely used behavioural observation pain scales. However, the psychometrics of the scale have not been adequately summarised and evaluated to provide clear recommendations regarding its use. The aim of this study was to rigorously evaluate the reliability, validity, feasibility, and utility of the scale for clinical and research purposes and provide recommendations regarding appropriate use of the scale. Databases searched were MEDLINE, CINAHL, Embase, PsycINFO (using the Ovid, PubMed, and Ebscohost platforms), The Cochrane Database of Systematic reviews and Cochrane Controlled Trials, and Google Scholar. Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the FLACC scale applied to children (birth to 18 years) and randomised controlled trials (RCT) using the FLACC scale to measure a study outcome in infants and children. Data extraction included study design, population demographics, and psychometric data. Analysis involved in this study are quality assessment of the psychometric evaluation studies and the RCTs using the COSMIN checklist and the Jadad scale, respectively, and narrative synthesis of all results. Twenty-five psychometric evaluations studies and 52 RCTs were included. The study population, circumstances, and quality of the studies varied greatly. Sufficient data addressing postoperative pain assessment in infants and children exist. Some positive data support the psychometrics of the scale used to assess postoperative pain in children with cognitive impairment. Limited and conflicting data addressing procedural pain assessment exist. Content validity and scale feasibility have had limited psychometric evaluation. There are insufficient data to support the FLACC scale for use in all circumstances and populations to which is currently applied.

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Pain hypersensitivity and spinal nociceptive hypersensitivity in chronic pain: prevalence and associated factors

Abstract: Hypersensitivity of pain pathways is considered a relevant determinant of symptoms in chronic pain patients, but data on its prevalence are very limited. To our knowledge, no data on the prevalence of spinal nociceptive hypersensitivity are available. We studied the prevalence of pain hypersensitivity and spinal nociceptive hypersensitivity in 961 consecutive patients with various chronic pain conditions. Pain threshold and nociceptive withdrawal reflex threshold to electrical stimulation were used to assess pain hypersensitivity and spinal nociceptive hypersensitivity, respectively. Using 10th percentile cutoff of previously determined reference values, the prevalence of pain hypersensitivity and spinal nociceptive hypersensitivity (95% confidence interval) was 71.2 (68.3-74.0) and 80.0 (77.0-82.6), respectively. As a secondary aim, we analyzed demographic, psychosocial, and clinical characteristics as factors potentially associated with pain hypersensitivity and spinal nociceptive hypersensitivity using logistic regression models. Both hypersensitivity parameters were unaffected by most factors analyzed. Depression, catastrophizing, pain-related sleep interference, and average pain intensity were significantly associated with hypersensitivity. However, none of them was significant for both unadjusted and adjusted analyses. Furthermore, the odds ratios were very low, indicating modest quantitative impact. To our knowledge, this is the largest prevalence study on central hypersensitivity and the first one on the prevalence of spinal nociceptive hypersensitivity in chronic pain patients. The results revealed an impressively high prevalence, supporting a high clinical relevance of this phenomenon. Electrical pain thresholds and nociceptive withdrawal reflex explore aspects of pain processing that are mostly independent of sociodemographic, psychological, and clinical pain-related characteristics.

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The migraine brain in transition: girls vs boys

Abstract: The prevalence of migraine has an exponential trajectory that is most obvious in young females between puberty and early adulthood. Adult females are affected twice as much as males. During development, hormonal changes may act on predetermined brain circuits, increasing the probability of migraine. However, little is known about the pediatric migraine brain and migraine evolution. Using magnetic resonance imaging, we evaluated 28 children with migraine (14 females and 14 males) and 28 sex-matched healthy controls to determine differences in brain structure and function between (1) females and males with migraine and (2) females and males with migraine during earlier (10-11 years) vs later (14-16 years) developmental stages compared with matched healthy controls. Compared with males, females had more gray matter in the primary somatosensory cortex (S1), supplementary motor area, precuneus, basal ganglia, and amygdala, as well as greater precuneus resting state functional connectivity to the thalamus, amygdala, and basal ganglia and greater amygdala resting state functional connectivity to the thalamus, anterior midcingulate cortex, and supplementary motor area. Moreover, older females with migraine had more gray matter in the S1, amygdala, and caudate compared to older males with migraine and matched healthy controls. This is the first study showing sex and developmental differences in pediatric migraineurs in brain regions associated with sensory, motor, and affective functions, providing insight into the neural mechanisms underlying distinct migraine sex phenotypes and their evolution that could result in important clinical implications increasing treatment effectiveness.

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Neuropathic pain phenotyping by international consensus (NeuroPPIC) for genetic studies: a NeuPSIG systematic review, Delphi survey, and expert panel recommendations

Abstract: For genetic research to contribute more fully to furthering our knowledge of neuropathic pain, we require an agreed, valid, and feasible approach to phenotyping, to allow collaboration and replication in samples of sufficient size. Results from genetic studies on neuropathic pain have been inconsistent and have met with replication difficulties, in part because of differences in phenotypes used for case ascertainment. Because there is no consensus on the nature of these phenotypes, nor on the methods of collecting them, this study aimed to provide guidelines on collecting and reporting phenotypes in cases and controls for genetic studies. Consensus was achieved through a staged approach: (1) systematic literature review to identify all neuropathic pain phenotypes used in previous genetic studies; (2) Delphi survey to identify the most useful neuropathic pain phenotypes and their validity and feasibility; and (3) meeting of experts to reach consensus on the optimal phenotype(s) to be collected from patients with neuropathic pain for genetic studies. A basic “entry level” set of phenotypes was identified for any genetic study of neuropathic pain. This set identifies cases of “possible” neuropathic pain, and controls, and includes: (1) a validated symptom-based questionnaire to determine whether any pain is likely to be neuropathic; (2) body chart or checklist to identify whether the area of pain distribution is neuroanatomically logical; and (3) details of pain history (intensity, duration, any formal diagnosis). This NeuroPPIC “entry level” set of phenotypes can be expanded by more extensive and specific measures, as determined by scientific requirements and resource availability.

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Laser-evoked potentials mediated by mechano-insensitive nociceptors in human skin

Abstract

Objectives

Laser-evoked potentials (LEP) were assessed after peripheral nerve block of the lateral femoral cutaneous nerve (LFCN) in healthy volunteers from partially anesthetized skin areas to differentially stimulate mechano-insensitive nociceptors.

Methods

An ultrasound-guided nerve block of the LFCN was performed in 12 healthy male subjects with Ropivacain 1%. After 30 min, the nerve block induced significantly larger anesthetic areas to mechanical stimuli than to electrical stimuli revealing an area of differential sensitivity. LEPs, reaction times and pain ratings were recorded in response to the laser stimuli of (1) completely anesthetic skin, (2) mechano-insensitive, but electrically excitable skin (‘differential sensitivity’), (3) normal skin.

Results

LEP latencies in the area of differential sensitivity were increased compared to unaffected skin (228 ± 8.5 ms, vs. 181 ± 3.6 ms, p < 0.01) and LEP amplitudes were reduced (14.8 ± 1.2 μV vs. 24.6 ± 1.7 μV, p < 0.01). Correspondingly, psychophysically assessed response latencies in the differentially anesthetic skin were increased (649 ms vs. 427 ms, p < 0.01) and pain ratings reduced (1.5/10 vs. 5/10 NRS, p < 0.01).

Conclusion

The increase in LEP latency suggests that mechano-insensitive heat-sensitive Aδ nociceptors (MIA, type II) have a slower conduction velocity or higher utilization time than mechano-sensitive type II Aδ nociceptors. Moreover, widely branched, slowly conducting and mechano-insensitive branches of Aδ nociceptors can explain our finding. LEPs in the differentially anesthetized skin provide specific information about a mechanically insensitive but heat-sensitive subpopulation of Aδ nociceptors. These findings support the concept that A-fibre nociceptors exhibit a similar degree of modality specificity as C-fibre nociceptors.

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The association of total and central body fat with pain, fatigue and the impact of fibromyalgia in women; role of physical fitness

Abstract

Background

The relationship between estimates of total and central body fat with fibromyalgia pain, fatigue and overall impact has not been fully described. We aimed to assess the individual and combined association of body fat (total and central) with pain, fatigue and the overall impact in fibromyalgia women; and to study the possible mediation role of physical fitness in these associations.

Methods

A total of 486 fibromyalgia women with a mean (standard deviation) age of 52.2 (8.0) years participated. Pain was measured with self-reported measures and algometry, whereas fatigue with the Multidimensional Fatigue Inventory. The impact of fibromyalgia was measured with the Revised Fibromyalgia Impact Questionnaire (FIQR) total score. Total and central body fat were assessed by means of bioelectrical impedance and waist circumference, respectively. The Functional Senior Fitness Test battery and the handgrip strength test were used to assess physical fitness.

Results

Total and central body fat were positively associated with pain- and fatigue-related measures and the FIQR total score (β from 0.10 to 0.25; all, p < 0.05). A combined effect of total and central body fat was observed on pain (FIQR and 36-item Short-Form Health Survey), general and physical-related fatigue and FIQR total score (all, overall p < 0.05), so that the group with no total and central obesity had more favourable results than those with total and central obesity. Cardiorespiratory fitness partially mediated (between 22–40% of the total effect) the associations between total and central body fat with pain, general fatigue, physical fatigue and reduced activity, and largely mediated (80%) the association of central body fat with the FIQR total score.

Conclusions

Physical fitness might potentially explain the association between obesity and fibromyalgia symptoms.

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Are individual levels of pain anxiety related to negative interpretation bias? An examination using an ambiguous word priming task

Abstract

Background

Cognitive processes like attentional and interpretation biases have been suggested to play a vital role in the onset and exacerbation of chronic pain. Research consistently supports the occurrence of interpretation bias (IB) in pain patients and healthy individuals high in pain anxiety. Nevertheless, studies on the indirect assessment of IB or the relation between IB and responses to pain are limited. The present studies examined the association between indirect assessed IB and pain anxiety, while Study 2 additionally examined IB as a mediator in the relation between pain anxiety and pain responses.

Method

In Study 1 (N = 125) and Study 2 (N = 73), anxiety sensitivity, injury/illness sensitivity (IS) and pain catastrophizing were assessed with questionnaires. IB was indirectly derived from performance on an ambiguous word priming task. In Study 2, an experimental heat pain induction was used to assess pain responses (i.e. tolerance and subjective pain experience).

Results

Results showed a positive correlation between pain anxiety and IB, albeit that the strength of the observed associations differed between both studies. Furthermore, IB was inversely related to pain tolerance, and found to mediate the relation between IS and pain tolerance in Study 2.

Conclusions

Current findings underscore the importance of interpretational processes in the context of physical health threat. Furthermore, the ambiguous word priming task is proposed as a suitable paradigm for further research on the indirect assessment of IB. Nevertheless, further research is warranted to deepen our understanding of IB and its contribution to the experience of (chronic) pain.

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Attenuation of pain behaviour by local administration of alpha-2 adrenoceptor antagonists to dorsal root ganglia in a rat radiculopathy model

Abstract

Background

There were several reports suggesting α-adrenoceptor antagonists are effective to treat neuropathic pain. The aims of this study were as follows: (1) to introduce drug delivery system for dorsal root ganglion (DRG) neurons; (2) to elucidate the effects of α-adrenoceptor antagonists in acute, subacute or chronic phase and (3) to determine which subtype of adrenoceptor was mainly involved.

Method

We used 130 male Sprague-Dawley rats. After root constriction, rats received three local injections of α-adrenoceptor antagonists around DRG. We administered the non-selective α-adrenoceptor antagonist phentolamine for 3 consecutive days from day 0, 4 or 11 after the surgery, and the α₁-adrenoceptor antagonist prazosin, the α₁-adrenoceptor antagonist silodosin, the more preferred α₁-adrenoceptor than prazosin and the α₂-adrenoceptor antagonist yohimbine for 3 consecutive days from day 0 after the surgery.

Results

Phentolamine and yohimbine continually attenuated pain behaviour. Prazosin at high dose attenuated pain behaviour, however, prazosin at low dose did not attenuate pain behaviour every experimental day. Silodosin had no analgesic effect. Phentolamine injections from day 4 after surgery attenuated pain behaviour that had been established on the 3rd experimental day until the 28th post-operative day, although effect of phentolamine wore off. Phentolamine injections from day 11 after surgery temporarily attenuated pain behaviour that had been established on the 3rd, 7th and 10th experimental days.

Conclusions

This study showed α-adrenoceptor antagonists could suppress pain behaviour via α₂-adrenoceptor in acute phase and temporary attenuate pain behaviour in chronic phase. These findings presented potentials sympathetic nerve blockade contributed to treat neuropathic pain.

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Long-term opioid therapy for chronic non-cancer pain in Germany

Abstract

Background

No data are available on the prevalence and predictors of (high-dose) long-term opioid therapy (LTOT) and on abuse/addiction of prescribed opioids by patients with chronic non-cancer pain (CNCP) outside North America and Scandinavia.

Methods

We analysed randomly selected claims records of 870,000 persons (10% of insureds) in a large German medical health insurance organization during the fiscal year 2012.

Results

The prevalence of LTOT prescriptions (defined by at least one opioid prescription per quarter for at least three consecutive quarters) for CNCP was 1.3% of all insureds. The mean daily dosage of LTOT was 58 (SD 79; minimum 0.3, maximum 2010) mg morphine equivalent/day. The percentage of insureds with high-dose opioid prescriptions (≥100 mg morphine equivalent/day) among LTOT insureds was 15.5%. High-dose LTOT (compared to traditional dose) prescription was associated with younger age, male gender, diagnoses of chronic pain disease, somatoform pain disorder, depression and prescription of anticonvulsants. The pooled 1-year prevalence of abuse/addiction of prescribed opioids (defined by hospital stays because of mental and behavioural disorders due to alcohol, opioids, tranquilizers, multiple substances and intoxications by narcotic agents) was 0.008%. Abuse/addiction of prescribed opioids was associated with younger age, diagnoses of somatoform pain disorder, depression and prescription of tranquilizers.

Conclusions

The study found no signals of an ‘opioid epidemic’ in Germany. However, careful selection of patients with CNCP considered for LTOT and continuous evaluation during LTOT are warranted.

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A small yet comprehensive subset of human experimental pain models emerging from correlation analysis with a clinical quantitative sensory testing protocol in healthy subjects

Abstract

Background

Picturing the complexity of pain in human experimental settings has increased the predictivity for clinical pain but requires increasingly complex test batteries. This raises problems in studies in which time is objectively limited, for example by the course of action of an analgesic drug. We addressed the selection of a small yet comprehensive set of pain tests for the use in such a situation.

Method

Nineteen different pain measures from ‘classical’ pain models (n = 9) and a clinically established QST-pain test battery (n = 10), were obtained from 72 healthy volunteers (34 men). The nonparametric correlation structure among the various pain measures was analysed using Ward clustering.

Results

Four clusters emerged, each consisting of highly correlated pain measures. The pain model groups emerged comprised (I) pain thresholds and tolerances to blunt pressure or electrical pain; (II) pain thresholds to thermal stimuli; (III) pain measures obtained following application of punctate mechanical, intranasal CO₂ chemical or cutaneous laser heat stimuli; and (IV) detection thresholds to thermal stimuli. The first three clusters agreed with an immediate mechanistic interpretation as reflecting C-fibre mediated pain, thermal pain and A_δ-fibre mediated pain, respectively, whereas the last cluster contained non-painful measures and was disregarded.

Conclusions

When basing a selection of a small comprehensive set of pain models on the assumption that highly correlated pain measures account for redundant results and therefore, one member of each group suffices an economic yet comprehensive pain study, results suggest inclusion of established C-fibre, A_δ-fibre mediated and thermal pain measures.

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Modulation of pain via expectation of its location

Abstract

Background

The spatial precision of expectancy effects on pain is unclear. We hypothesized that expecting nociceptive stimuli at particular skin sites would have an analgesic effect on nociceptive stimuli presented between them (middle zone).

Methods

Laser stimuli (evoking pin-prick pain) were delivered to three discrete skin zones on the forearm, under two conditions. During ‘Localization’, participants’ expectation of stimuli was spatially divided between two locations (expected stimuli in only the outer two skin zones): pain intensity and stimulus location were judged. During ‘No-localization’ (control condition), participants had no expectation concerning stimulus location; only pain intensity was rated. Additional experiments assessed the importance of the actual location on the forearm by: shifting all skin zones proximally towards the elbow (control for joint proximity, Experiment 2); adding a fourth zone distally (control for interaction between joint proximity and enhanced distal inhibition, Experiment 3).

Results

All experiments demonstrated spatially specific pain modulation, but only Experiment 2 (near elbow) supported our hypothesis: middle zone pain intensity was significantly lower (p = 0.02) during Localization than No-localization. Experiment 1 (near wrist) found reduced pain intensity during Localization only for the distal zone (p = 0.04). Experiment 3 confirmed this effect: reduced pain during Localization occurred only for the most distal zone (p = 0.046).

Conclusion

Expecting a painful stimulus in non-adjacent skin sites has spatially specific effects on pain modulation, but this reflects an interaction between the expected location of stimulation and the actual location. This suggests a more complex connection between somatotopic maps and nociceptive modulation than previously thought; several distinct mechanisms likely contribute.

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The effect of patient–practitioner communication on pain: a systematic review

Abstract

Background and objective

Communication between patients and health care practitioners is expected to benefit health outcomes. The objective of this review was to assess the effects of experimentally varied communication on clinical patients’ pain.

Databases and data treatment

We searched in July 2012, 11 databases supplemented with forward and backward searches for (quasi-) randomized controlled trials in which face-to-face communication was manipulated. We updated in June 2015 using the four most relevant databases (CINAHL, Cochrane Central, Psychinfo, PubMed).

Results

Fifty-one studies covering 5079 patients were included. The interventions were separated into three categories: cognitive care, emotional care, procedural preparation. In all but five studies the outcome concerned acute pain. We found that, in general, communication has a small effect on (acute) pain. The 19 cognitive care studies showed that a positive suggestion may reduce pain, whereas a negative suggestion may increase pain, but effects are small. The 14 emotional care studies showed no evidence of a direct effect on pain, although four studies showed a tendency for emotional care lowering patients’ pain. Some of the 23 procedural preparation interventions showed a weak to moderate effect on lowering pain.

Conclusions

Different types of communication have a significant but small effect on (acute) pain. Positive suggestions and informational preparation seem to lower patients’ pain. Communication interventions show a large variety in quality, complexity and methodological rigour; they often used multiple components and it remains unclear what the effective elements of communication are. Future research is warranted to identify the effective components.

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Relationship between adaptation and cardiovascular response to tonic cold and heat pain Adaptability to tonic pain and cardiovascular responses

Abstract

Background

The mechanisms of adaptation to tonic pain are not elucidated. We hypothesized that the adaptability to tonic pain is related to the cardiovascular system.

Methods

Twenty-six subjects received over two sessions in a random order: tonic cold (7 ± 0.2 °C) and heat pain (47.5 ± 0.5 °C) on the hand for 5 min. Pain intensity, blood pressure (BP), and heart rate (HR) were continuously monitored.

Results

Pain experience during the heat (HIT) and cold (CIT) immersion tests exhibited different average time courses, being approximated with a linear and cubic function, respectively. In each test, two groups of participants could be identified based on the time course of their tonic thermal pain: one-third of participants were pain adaptive and two-thirds non adaptive. The adaptive group exhibited higher initial pain, lower last pain, and shorter latency to peak pain than the non-adaptive one. Interestingly, some participants were adaptive to both pain stimuli, most were not. HIT as well as CIT produced a stable elevation of BP. However, BP was higher during CIT than HIT (p = 0.034). HR was also increased during CIT and HIT, but the two tests differed with respect to the time course of responses. Finally, the intensity and time course of pain rating to both HIT and CIT correlated with neither BP nor HR responses.

Conclusions

These results suggest that individual sensitivity and adaptability to tonic thermal pain is related to the intensity of initial pain rating and the latency to peak pain but not to cardiovascular responses.

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Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury

Abstract

Background

Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment.

Methods

The PROTACT study is a prospective follow-up study aiming to estimate the incidence and prognostic factors responsible for the development of chronic pain after musculoskeletal injury. Data including sociodemographic, pain, clinical, injury- or treatment-related and psychological factors of 435 patients were collected from registries and questionnaires at ED visit, 6-week, 3- and 6-month follow-up.

Results

At 6 months post-injury, 43.9% of the patients had some degree of pain (Numeric Rating Scale (NRS) ≥1) and 10.1% had chronic pain (NRS ≥4). Patients aged over 40 years, in poor physical health, with pre-injury chronic pain, pain catastrophizing, high urgency level and severe pain at discharge were found to be at high risk for chronic pain.

Conclusions

Two prognostic factors, severe pain at discharge and pain catastrophizing, are potentially modifiable. The implementation of a pain protocol in the ED and the use of cognitive–behavioural techniques involving reducing catastrophizing might be useful.

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Giant exudative masses of major joints

bmj;351/oct21_23/h5178/FIG1F1fig1A 61 year old man with schizophrenia presented with fever, fatigue, leg pain, and difficulty walking. He had rigid masses in his legs and elbows; the largest (14 cm...

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Description of Common Clinical Presentations and Associated Short-Term Physical Therapy Clinical Outcomes in Patients With Neck Pain

Pain Sensitivity and Pain Catastrophizing Are Associated With Persistent Pain and Disability After Lumbar Spine Surgery

Results of an Active Neurodynamic Mobilization Program in Patients With Fibromyalgia Syndrome: A Randomized Controlled Trial

Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis

Pharmacological Treatment of Acute Low Back Pain

This randomized trial compared improvement in functional outcomes among patients with low back pain discharged from the emergency department and receiving naproxen with either placebo, cyclobenzaprine, or oxycodone/acetaminophen.

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Measuring emotion regulation and emotional expression in breast cancer patients: A systematic review

Low back pain misdiagnosis or missed diagnosis: Core principles

Consensus guidelines for the management of low back pain recommend that the clinician use contemporary best practice for assessment and treatment, consider biopsychosocial factors and, if chronic, use a multimodal and multi-disciplinary approach. Where guidelines are not followed and basic assessment is inadequate the diagnosis may be compromised and the sequelae of errors compounded. Factors such as a lack of knowledge or recognition of the common structure specific pain referral patterns, poor clinical reasoning, inappropriate referral and predilection for popular management approaches also contribute to mis-diagnosis and mis-management.

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Remove policies that restrict access to opioids in developing countries, says report

The global community must take concrete action to tackle the major gap in access to controlled drugs in low and middle income countries, particularly opioids for pain relief, a new report has...

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Editorial Board

It's complicated: The relation between cognitive change procedures, cognitive change, and symptom change in cognitive therapy for depression

A lifetime approach to major depressive disorder: The contributions of psychological interventions in preventing relapse and recurrence

Up-scaling clinician assisted internet cognitive behavioural therapy (iCBT) for depression: A model for dissemination into primary care

A resilience framework for promoting stable remission from depression

Neurostimulation as an intervention for treatment resistant depression: From research on mechanisms towards targeted neurocognitive strategies

The Prevalence of Myofascial Trigger Points in Spinal Disorders: a Systematic Review and Meta-Analysis

From pulses to pain relief: an update on the mechanisms of rTMS-induced analgesic effects

Abstract

Background

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive technique that allows cortical stimulation. Recent studies have shown that rTMS of the primary motor cortex or dorsolateral prefrontal cortex decreases pain in various pain conditions. The aim of this review was to summarize the main characteristics of rTMS-induced analgesic effects and to analyse the current data on its mechanisms of action.

Databases

Medline, PubMed and Web of Science were searched for studies on the analgesic effects and mechanisms of rTMS-induced analgesic effects. Studies on epidural motor cortex stimulation (EMCS) were also included when required, as several mechanisms of action are probably shared between both techniques.

Results

Stimulation site and stimulation parameters have a major impact on rTMS-related analgesic effects. Local cortical stimulation is able to elicit changes in the functioning of distant brain areas. These modifications outlast the duration of the rTMS session and probably involve LTP-like mechanisms via its influence on glutamatergic networks. Analgesic effects seem to be correlated to restoration of normal cortical excitability in chronic pain patients and depend on pain modulatory systems, in particular endogenous opioids. Dopamine, serotonin, norepinephrine and GABAergic circuitry may also be involved in its effects, as well as rostrocaudal projections.

Conclusions

rTMS activates brain areas distant from the stimulation site. LTP-like mechanisms, dependence on endogenous opioids and increase in concentration of neurotransmitters (monoamines, GABA) have all been implicated in its analgesic effects, although more studies are needed to fill in the still existing gaps in the understanding of its mechanisms of action.

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Effects of insular stimulation on thermal nociception

Abstract

Background

Electrical stimulation used for brain mapping in the postero-superior insula can evoke pain. The effects of prolonged high frequency insular stimulation on pain thresholds are unknown.

Objective/Hypothesis

Prolonged high frequency insular stimulation, by virtue of its inhibitory properties on networks, could decrease thermal nociception.

Methods

Epileptic subjects had electrodes implanted in the insular cortex for the purpose of epileptic focus resection. Thermal and pressure nociceptive thresholds were tested bilaterally on the forearm on two consecutive days. Randomly assigned double-blind high frequency (150 Hz) insular stimulation took place for 10 min before pain testing either on the first day or on the second day.

Results

Six subjects (three females; mean age of 35 years) were included. Insular stimulation increased heat pain threshold on the ipsilateral (p = 0.003; n = 6) and contralateral sides (p = 0.047; n = 6). Differences in cold pain threshold did not reach statistical significance (ipsilateral: p = 0.341, contralateral: p = 0.143; n = 6), but one subject had a profound decrease in both heat and cold pain responses. Pressure pain threshold was not modified by insular stimulation (ipsilateral: p = 0.1123; contralateral: p = 0.1192; n = 6). Two of the three subjects who had a postero-superior operculo-insulectomy developed central pain with contralateral thermal nociceptive deficit.

Conclusions

High frequency inhibitory postero-superior insular stimulation may have the potential to decrease thermal nociception. Together with previous studies, our data support the notion that the integrity of this brain region is necessary for thermal but not pressure nociceptive processing.

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[Perspective] Restoring the sense of touch

Amputation of damaged tissue is one of the oldest surgical techniques, reaching prevalence in the 16th century (1). Improved emergency medicine has allowed more individuals to survive traumatic injuries as amputees, but prosthetic limbs remain the only means to restore any degree of function to these patients. Inadequate tactile feedback is a leading shortcoming of prosthetic limbs, but for artificial hands, just a few sensors that relay grasp pressure back to the user can provide the functionality needed to enable delicate tasks (2). In addition to improved motor control, sensory stimulation could alleviate phantom limb pain, which affects ~80% of amputees (2). On page 314 of this issue, Tee et al. (3) report a Digital Tactile System (“DiTact”) based on a low-power flexible organic transistor circuit that transduces pressure stimuli into oscillating signals like those generated by skin mechanoreceptors. Mammalian skin is a multilayered viscoelastic material that can stretch up to ~125% from its resting dimensions without any apparent loss in sensitivity to external stimuli such as pressure or temperature. Replicating skin mechanical and functional properties remains an elusive engineering challenge. Meanwhile, the rapidly expanding field of flexible electronics has made substantial strides, and complex circuits can now be produced on soft substrates. Advances in microcontact printing, inkjet deposition, and organic electronics have delivered stretchable and flexible, wearable, and even epidermal sensors (4–6). Authors: Polina Anikeeva, Ryan A. Koppes

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Quantification of Myofascial Taut Bands

Chronic back pain is associated with decreased prefrontal and anterior insular gray matter. Results from a population-based cohort study

Chronic back pain (CBP) is associated with circumscribed atrophy in gray matter (GM) predominantly localized in areas of the so called “pain matrix” and the prefrontal cortex (PFC). Previous studies applying voxel-based morphometry (VBM) for identifying structural brain alterations related to CBP have reported inconsistent results, are limited to small sample sizes and often did not control for medication. We therefore used VBM for high resolution magnetic resonance images to investigate the association of CBP and regional GM volume in 111 individuals with CBP und 432 pain free controls derived from the representative Study of Health in Pomerania (SHIP), while controlling for effects of medication.

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The impact of opioid risk reduction initiatives on high-dose opioid prescribing for chronic opioid therapy patients

Avoiding high opioid doses may reduce chronic opioid therapy (COT) risks, but the feasibility of reducing opioid doses in community practice is unknown. Washington State and a health plan’s group practice implemented initiatives to reduce high dose COT prescribing. The group practice physicians were exposed to both initiatives, while its contracted physicians were exposed only to statewide changes. Using interrupted time series analyses, we assessed whether these initiatives reduced opioid doses among COT patients in group practice (N=16,653) and contracted care settings (N=5,552).

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Impact of alexithymia and emotional repression on postsurgical pain in women with breast cancer: a prospective longitudinal 12 months study

Alexithymia, the inability to identify and express emotions, and emotional repression, a defensive mechanism aiming to avoid unpleasant emotional experience, have been associated with chronic pain and medical illness including breast cancer, but whether these constructs may predict pain after breast cancer surgery has not been assessed. The present study assessed the predictive value of alexithymia and emotional repression in postoperative pain. Anxiety, depression, catastrophizing and psychological adjustment were also assessed.

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Cognitive-behavioral based physical therapy for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial

The purpose of this study was to determine the efficacy of a cognitive-behavioral based physical therapy (CBPT) program for improving outcomes in patients following lumbar spine surgery. A randomized controlled trial was conducted in 86 adults undergoing a laminectomy with or without arthrodesis for a lumbar degenerative condition. Patients were screened preoperatively for high fear of movement using the Tampa Scale for Kinesiophobia. Randomization to either CBPT or an Education program occurred at 6 weeks after surgery.

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Neck muscle endurance and head posture: a comparison between adolescents with and without neck pain

The main aims of this study were to compare the neck flexor and extensor endurance and forward head posture between adolescents with and without neck pain. The secondary aims were to explore potential associations between muscles endurance, head posture and neck pain characteristics and to assess intra-rater reliability of the measurements used.

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Early Physical Therapy vs Usual Care for Recent-Onset Low Back Pain

This randomized trial evaluates whether early physical therapy is more effective than usual care for improving disability in patients with recent-onset low back pain.

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The Effects of Relaxation Before or After Skin Damage on Skin Barrier Recovery: A Preliminary Study

Objectives: Psychological interventions administered before wounding can reduce stress and improve healing. However, in many cases, it would be more practical for interventions to be delivered after wounding. This preliminary study investigated whether a brief relaxation intervention could improve healing when administered either before or after skin damage produced by tape stripping in comparison to a control group. Methods: One hundred twenty-one healthy adults were randomized into one of three groups: a) relaxation prestripping group, b) relaxation poststripping group, or c) no relaxation. Participants completed measures of stress, fatigue, relaxation, and pain. Relaxation consisted of listening to 20 minutes of guided relaxation, whereas the control condition was quiet reading for 20 minutes. Skin barrier function was measured using transepidermal water loss at baseline, immediately after tape stripping and 25 minutes later. Results: Relaxation either before or after tape stripping improved skin barrier recovery compared with the control group (F(2,92) = 3.58, p = .032, partial η2 = 0.074). Participants who took part in the relaxation intervention were significantly more relaxed and reported greater reductions in pain than the control group did 25 minutes after tape stripping. Perceived stress over the last month was not significantly related to healing. Conclusions: This study showed that a relaxation intervention had a beneficial effect on skin barrier recovery regardless of whether the intervention was administered before or after wounding. Future research needs to replicate these findings in other wound types and in clinical settings, and investigate the biological mechanisms involved.

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Distraction Arthrodesis of the C1–C2 Facet Joint with Preservation of the C2 Root for the Management of Intractable Occipital Neuralgia Caused by C2 Root Compression

Study Design. Prospective observational cohort study. Objective. To compare the outcomes of our new technique, distraction arthrodesis of C1–C2 facet joint with C2 root preservation (Study group), to those of conventional C1–C2 fusion with C2 root transection (Control group) for the management of intractable occipital neuralgia caused by C2 root compression. Summary of Background Data. We are not aware of any report concerning C2 root decompression during C1–C2 fusion. Materials and Methods. Inclusion criteria were visual analogue scale (VAS) score for occipital neuralgia 7 or more; C2 root compression at the collapsed C1–C2 neural foramen; and follow-up 12 months or more. The Study group underwent surgery with our new technique including (1) C1–C2 facet joint distraction and bone block insertion while preserving the C2 root; and (2) use of C1 posterior arch screws instead of conventional lateral mass screws during C1–C2 segmental screw fixation. The Control group underwent C2 root transection with C1–C2 segmental screw fixation and fusion. We compared the prospectively collected outcomes data. Results. There were 15 patients in the Study group and 8 in the Control group. Although there was no significant difference in the VAS score for the occipital neuralgia between the 2 groups preoperatively (8.2 ± 0.9 vs. 7.9 ± 0.6, P = 0.39), it was significantly lower in the Study group at 1, 3, and 6 months postoperatively (P < 0.01, respectively). At 12 months, it was 0.4 ± 0.6 versus 2.5 ± 2.6 (P = 0.01). There was no significant difference in improvement in the VAS score for neck pain and neck disability index and Japanese Orthopedic Association recovery rate, which are minimally influenced by occipital neuralgia. Conclusion. Our novel technique of distraction arthrodesis with C2 root preservation can be an effective option for the management of intractable occipital neuralgia caused by C2 root compression. Level of Evidence: 3

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Functional Limitations Due to Lumbar Stiffness in Adults With and Without Spinal Deformity

Study Design. Cross-sectional analysis. Objective. To compare Lumbar Stiffness Disability Index (LSDI) scores between asymptomatic adults and patients with spinal deformity. Summary of Background Data. The LSDI was designed and validated as a tool to assess functional impacts of lumbar spine stiffness and diminished spinal flexibility. Baseline disability levels of patients with adult spinal deformity (ASD) are high as measured by multiple validated outcome tools. Baseline lumbar stiffness-related disability has not been assessed in adults with and without spinal deformity. Methods. The LSDI and Scoliosis Research Society-22r (SRS-22r) were submitted to a group of asymptomatic adult volunteers. Additionally, a multicenter cross-sectional cohort analysis of patients with ASD from 10 centers was conducted. Baseline LSDI and SRS-22r were completed for both operatively and nonoperatively treated patients with deformity. Results. The LSDI was completed by 176 asymptomatic volunteers and 693 patients with ASD. Mean LSDI score for asymptomatic volunteers was 3.4 +/− 6.3 out of a maximum score of 100, with significant correlation between increasing age and higher (worse) LSDI score (r = 0.30, P = 0.0001). Of the patients with spinal deformity undergoing analysis, 301 subsequently underwent surgery and 392 were subsequently treated nonoperatively. Operative patients had significantly higher preoperative LSDI scores than both nonoperative patients and asymptomatic volunteers (29.9 vs. 17.3 vs. 3.4, P < 0.0001 for both). For patients with ASD, significant correlations were found between LSDI and SRS-22 Pain and Function subscales (r = −0.75 and −0.76, respectively; P < 0.0001 for both). Conclusion. LSDI scores are low among asymptomatic volunteers, although stiffness-related disability increases with increasing age. Patients with ASD report substantial stiffness-related disability even prior to surgical fusion. Stiffness-related disability correlates with pain- and function-related disability measures among patients with spinal deformity. Level of Evidence: 1

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Surgical Treatment of Congenital Scoliosis Associated With Tethered Cord by Thoracic Spine-shortening Osteotomy Without Cord Detethering

Study Design. Retrospective case series. Objective. To investigate the safety and efficacy of spine-shortening osteotomy for congenital scoliosis with tethered cord. Summary of Background Data. Conventional surgery for congenital scoliosis associated with tethered cord risks the complications of detethering. Spine-shortening osteotomy holds the potential to correct scoliosis and decrease spinal cord tension simultaneously without an extra detethering procedure, but no data on this issue is available. Methods. 21 patients (14 females and 7 males, average age 15.4 yr) underwent spine-shortening osteotomy without detethering. All of the patients had tethered cord. Patients with main curve more than 90° underwent vertebral column resection (VCR), whereas the others had pedicle subtraction osteotomy (PSO) performed. The average postoperative follow-up period was 45.2 months. Results. The mean operation time was 544.5 min with average blood loss of 2769.1 ml. The deformity correction was 61.3% in the coronal plane and 43.9° in the sagittal plane. 10 patients had neurological deficits preoperatively. At the final follow-up, the deficits in 8 (80%) patients were significantly improved, whereas 2 (20%) remained unchanged. At final follow-up, 71.4% (5/7) patients reported improvement in motor function, 100% (3/3) had improved pain scores, and 75% (3/4) reported better sensory function after the spine-shortening osteotomy. Urinary dysfunction and bowel incontinence present preoperatively in 3 patients all recovered by final follow-up. 5 (23.8%) patients incurred complications including temporary neurological deterioration in 1 patient, urinary tract infection in 2 patients, cerebrospinal fluid leakage in 1 patient, and blood loss more than 5000 ml in 1 patient. Conclusion. Spine-shortening osteotomy is a safe and effective procedure for congenital scoliosis associated with tethered cord. Spine-shortening osteotomy at the thoracic apical vertebrae level not only corrects the spine deformity but also simultaneously releases the tension of the tethered cord, resulting in improved neurologic function. Level of Evidence: 4

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Determination of the Optimal Cutoff Values for Pain Sensitivity Questionnaire Scores and the Oswestry Disability Index for Favorable Surgical Outcomes in Subjects With Lumbar Spinal Stenosis

Study Design. Retrospective analysis of prospectively collected data (NCT02134821). Objective. The aim of this study was to elucidate the cutoff values for significant predictors for favorable outcomes after lumbar spine surgery in patients with lumbar spinal stenosis (LSS). Summary of Background Data. Various factors are associated with the surgical outcomes for patients with LSS. However, we did not know the odds ratio and/or cutoff values of a predictive factor for a favorable surgical outcome for LSS. Methods. A total of 157 patients who underwent spine surgery due to LSS between June 2012 and April 2013 were included in this study. The patients were dichotomized into 2 groups on the basis of an Oswestry Disability Index (ODI) score of 22 or less (favorable outcome group) or more than 22 (unfavorable outcome group) at 12 months after surgery. Regarding favorable outcomes, the odds ratio for each preoperative variable including demographic data, preoperative symptom severity, and pain sensitivity questionnaire (PSQ) score was calculated using univariate and multivariate logistic regression analyses. For the significant variables for surgical outcome, receiver operating characteristic (ROC) curve was plotted with calculation of the area under the ROC curve. Results. Multivariate analysis revealed that the ODI and total PSQ scores were significantly associated with a greater likelihood of an unfavorable surgical outcome [odds ratio (95% confidence interval) of ODI, 1.289 (1.028–1.616); odds ratio (95% confidence interval) of total PSQ, 1.060 (1.009–1.113)]. ROC analysis revealed area under the ROC curves for the total PSQ and ODI scores of 0.638 (P = 0.005) and 0.692 (P < 0.001), respectively. Conclusion. Preoperative disability and pain sensitivity can be predictors of the functional level achieved after spine surgery in patients with LSS, and the ideal cutoff values for the total PSQ and ODI scores were 6.6 and 45.0, respectively. Level of Evidence: 3

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Factors Affecting the Outcome of Surgical Versus Nonsurgical Treatment of Cervical Radiculopathy: A Randomized, Controlled Study

Study Design. Prospective randomized controlled trial. Objective. To analyze factors that may influence the outcome of anterior cervical decompression and fusion (ACDF) followed by physiotherapy versus physiotherapy alone for treatment of patients with cervical radiculopathy. Summary of Background Data. An understanding of patient-related factors affecting the outcome of ACDF is important for preoperative patient selection. No previous prospective, randomized study of treatment effect modifiers relating to outcome of ACDF compared with physiotherapy has been carried out. Methods. 60 patients with cervical radiculopathy were randomized to ACDF followed by physiotherapy or physiotherapy alone. Data for possible modifiers of treatment outcome at 1 year, such as sex, age, duration of pain, pain intensity, disability (Neck Disability Index, NDI), patient expectations of treatment, anxiety due to neck/arm pain, distress (Distress and Risk Assessment Method), self-efficacy (Self-Efficacy Scale) health status (EQ-5D), and magnetic resonance imaging findings were collected. A multivariate analysis was performed to find treatment effect modifiers affecting the outcome regarding arm/neck pain intensity and NDI. Results. Factors that significantly altered the treatment effect between treatment groups in favor of surgery were: duration of neck pain less than 12 months (P = 0.007), duration of arm pain less than 12 months (P = 0.01) and female sex (P = 0.007) (outcome: arm pain), low EQ-5D index (outcome: neck pain, P = 0.02), high levels of anxiety due to neck/arm pain (outcome: neck pain, P = 0.02 and NDI, P = 0.02), low Self-Efficacy Scale score (P = 0.05), and high Distress and Risk Assessment Method score (P = 0.04) (outcome: NDI). No factors were found to be associated with better outcome with physiotherapy alone. Conclusion. In this prospective, randomized study of patients with cervical radiculopathy, short duration of pain, female sex, low health quality, high levels of anxiety due to neck/arm pain, low self-efficacy, and a high level of distress before treatment were associated with better outcome from surgery. No factors were found to be associated with better outcome from physiotherapy alone. Level of Evidence: 2

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A qualitative exploration of people's experiences of Pain Neurophysiological Education for chronic pain: the importance of relevance for the individual

Pain neurophysiology education (PNE) is a distinct form of patient education in pain management. The aims of this study were to explore the experience of PNE for people with chronic pain and to gain insight into their understanding of their pain after PNE. This was a qualitative study, based on Interpretive Phenomenology Analysis, using individual semi-structured interviews to collect data. We recruited a purposive sample of 10 adults with chronic musculoskeletal pain (men and women; mean age 48 years; with a mean pain duration of 9 years) who had recently completed PNE delivered as a single two-hour group session.

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Pain-Contingent Interruption and Resumption of Work Goals: A Within-Day Diary Analysis

Daily pain-related attributions for and negative affective reactions to the non-pursuit of work goals and individual differences in chronic pain severity and stress were used to predict work goal resumption in a sample of 131 adults with chronic pain. Variables were assessed via questionnaires and a 21-day diary. On days when participants reported non-pursuit of work goals in the afternoon, increases in pain-related attributions for goal interruption were positively associated with higher negative affective reactions which, in turn, were associated with an increased likelihood of same-day work goal resumption.

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Level of troponin needed to rule out MI in patients with chest pain is identified

Researchers have identified the level of the protein troponin below which it is highly unlikely that someone presenting with chest pain has had a myocardial infarction (MI).Routine use of the test in...

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