Opposite associations between the rs3845446 single-nucleotide polymorphism of the CACNA1E gene and postoperative pain-related phenotypes in gastrointestinal surgery versus previously reported orthognathic surgery

Perspective: Carriers of the minor allele of the rs3845446 single-nucleotide polymorphism of the CACNA1E gene required more opioid or reported higher pain scores after gastrointestinal surgery, while requiring less opioid after orthognathic surgery. The difference may result from the presence of visceral inflammatory pain stimulus that activates Cav2.3 voltage-activated Ca2+ channels-mediated antinociception.

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Effects of prolonged and acute muscle pain on the force control strategy during isometric contractions

Persistent movement-evoked pain changes force direction from the pain-free direction. Acute pain leads to increase variation in force direction irrespective of persistent movement-evoked pain preceding the acutely painful event. These differences provide novel insight into the search and consolidation of new motor strategies in the presence of pain.

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A content review of cognitive process measures used in pain research within adult populations

Abstract

Background and objective

Previous research suggests that measures of cognitive process may be confounded by the inclusion of items that also assess cognitive content. The primary aims of this content review were to: (1) identify the domains of cognitive processes assessed by measures used in pain research; and (2) determine if pain-specific cognitive process measures with adequate psychometric properties exist.

Databases and data treatment

PsychInfo, CINAHL, PsycArticles, MEDLINE, and Academic Search Complete databases were searched to identify the measures of cognitive process used in pain research. Identified measures were double coded and the measure's items were rated as: (1) cognitive content; (2) cognitive process; (3) behavioural/social; and/or (4) emotional coping/responses to pain.

Results

A total of 319 scales were identified; of these, 29 were coded as providing an un-confounded assessment of cognitive process, and 12 were pain-specific. The cognitive process domains assessed in these measures are Absorption, Dissociation, Reappraisal, Distraction/Suppression, Acceptance, Rumination, Non-Judgment, and Enhancement. Pain-specific, un-confounded measures were identified for: Dissociation, Reappraisal, Distraction/Suppression, and Acceptance. Psychometric properties of all 319 scales are reported in supplementary material.

Conclusions

To understand the importance of cognitive processes in influencing pain outcomes as well as explaining the efficacy of pain treatments, valid and pain-specific cognitive process measures that are not confounded with non-process domains (e.g., cognitive content) are needed. The findings of this content review suggest that future research focused on developing cognitive process measures is critical in order to advance our understanding of the mechanisms that underlie effective pain treatment.

Significance

Many cognitive process measures used in pain research contain a ‘mix’ of items that assess cognitive process, cognitive content, and behavioural/emotional responses. Databases searched: PsychInfo, CINAHL, PsycArticles, MEDLINE and Academic Search Complete. This review describes the domains assessed by measures assessing cognitive processes in pain research, as well as the strengths and limitations of these measures.

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Table of Contents

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Editorial Board

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Masthead

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Erratum

Complete information about one author's name did not appear in the following article:

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Response to Ruan et al. Letter to the Editor: Increased Risk of Depression Recurrence After Initiation of Prescription Opioids in Noncancer Pain Patients

We appreciate the thoughtful comments of Ruan et al,1 regarding the definition of depression used in our recent study on the association between opioid use and depression recurrence.2 The authors argue that using International Classification of Diseases, Ninth Revision (ICD-9) code 311 is not an appropriate measure for major depression. Selecting an ICD-9 code for depression is multifactorial and partly influenced by whether patients were treated in specialty mental health care or primary care. We do not have enough information to distinguish between major depressive episode and the less specific clinical features of sadness and depressed mood related to ICD-9 code 311.

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Increased Risk of Depression Recurrence After Initiation of Prescription Opioids in Noncancer Pain Patients

We read with interest the article by Scherrer and colleagues3 published in The Journal of Pain. The authors conducted a retrospective study using data from Veterans Health Administration (VA; n = 5,400), and Baylor Scott & White Health (n = 842). They reported that patients exposed to an opioid compared with those unexposed had a significantly greater risk of depression recurrence in both patient populations. They conclude that their results suggest opioid use doubles the risk of depression recurrence even after controlling for pain, psychiatric disorders, and opioid misuse.

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Prediction of postoperative opioid analgesia using clinical-experimental parameters and electroencephalography

Abstract

Background

Opioids are often used for pain treatment, but the response is often insufficient and dependent on e.g. the pain condition, genetic factors and drug class. Thus, there is an urgent need to identify biomarkers to enable selection of the appropriate drug for the individual patient, a concept known as personalized medicine. Quantitative sensory testing (QST) and clinical parameters can provide some guidance for response, but better and more objective biomarkers are urgently warranted. Electroencephalography (EEG) may be suitable since it assesses the central nervous system where opioids mediate their effects.

Methods

Clinical parameters, QST and EEG (during rest and tonic pain) was recorded from patients the day prior to total hip replacement surgery. Postoperative pain treatment was performed using oxycodone and piritramide as patient-controlled analgesia. Patients were stratified into responders and non-responders based on pain ratings 24 h post-surgery. Parameters were analysed using conventional group-wise statistical methods. Furthermore, EEG was analysed by machine learning to predict individual response.

Results

Eighty-one patients were included, of which 51 responded to postoperative opioid treatment (30 non-responders). Conventional statistics showed that more severe pre-existing chronic pain was prevalent among non-responders to opioid treatment (p = 0.04). Preoperative EEG analysis was able to predict responders with an accuracy of 65% (p = 0.009), but only during tonic pain.

Conclusions

Chronic pain grade before surgery is associated with the outcome of postoperative pain treatment. Furthermore, EEG shows potential as an objective biomarker and might be used to predict postoperative opioid analgesia.

Significance

The current clinical study demonstrates the viability of EEG as a biomarker and with results consistent with previous experimental results. The combined method of machine learning and electroencephalography offers promising results for future developments of personalized pain treatment.

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Stress reactivity in childhood functional abdominal pain or irritable bowel syndrome

Abstract

Background

Frequent abdominal pain (AP) in childhood has been shown to be associated with elevated experience of stress and with deficits in stress coping, but psychophysiological stress reactivity has been studied rarely.

Methods

We examined whether children with frequent AP show altered reactions of the parasympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis during and following an afternoon laboratory social stress task in comparison to healthy children and children with anxiety disorders. Twenty-four children with frequent AP (18 with functional AP and six with irritable bowel syndrome; M = 9.9 years), and 24 healthy controls underwent stressful free speech and arithmetic tasks. Twelve children with anxiety disorders served as second comparison sample. Groups were compared regarding parasympathetic reaction and saliva cortisol concentration.

Results

We found no differences in parasympathetic withdrawal between the groups. Concerning the HPA axis, we detected an attenuated cortisol reactivity in children with AP compared to both other groups.

Conclusions

This study provides preliminary evidence that childhood AP is not associated with altered parasympathetic withdrawal during stress. It seems to be related to a down-regulated reactivity of the HPA axis. This pattern was ascertained in comparison to healthy children and also in comparison to children with anxiety disorders.

Significance

• Childhood abdominal pain could be related to down-regulated HPA axis reactivity to stress but not to altered parasympathetic reaction.
• Children with abdominal pain and children with anxiety disorders exhibit a divergent stress-related HPA axis reaction.

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Towards an integrative view of cognitive biases in pain

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Functional and structural assessment of patients with and without persistent pain after thoracotomy

Abstract

Background

Persistent pain is frequent after thoracotomy, with a reported prevalence of up to 60%. It remains unclear why some patients develop pain, whereas others do not. We therefore examined patients with and without pain after thoracotomy to identify pathophysiological contributors to persistent pain.

Methods

Twenty patients with persistent pain, 12 patients without pain and 20 healthy controls underwent detailed functional and structural assessment including psychometric and neuropathic pain questionnaires, bedside examination for pinprick hyperalgesia and brush allodynia, quantitative sensory testing according to the protocol of the German Research Network on Neuropathic Pain, measurement of capsaicin-evoked flare response, intradermal nerve density as determined by skin biopsies and laser- and heat-evoked potentials.

Results

Bedside testing revealed evoked pain in 16 of 20 patients with pain, but only in 2 of 12 patients without pain (p < 0.001). Quantitative sensory testing showed increased mechanical pain sensitivity (p = 0.018) on the operated side in patients with pain, but there were no differences between the two patient groups with regard to intradermal nerve fibre density, area and flux following capsaicin application and laser- and heat-evoked potentials.

Conclusion

Different and individual pathophysiological mechanisms of pain may obscure the clinical picture and thus preclude identification of a specific pain profile in patients with persistent post-thoracotomy pain.

Significance

Evoked pain is more frequent in patients with pain. Assessment of intradermal nerve density, capsaicin-induced flare response and contact and laser heat-evoked potentials revealed no differences between pain patients and pain-free patients.

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Child attention to pain and pain tolerance are dependent upon anxiety and attention control: An eye-tracking study

Abstract

Background

Pain is common and can be debilitating in childhood. Theoretical models propose that attention to pain plays a key role in pain outcomes, however, very little research has investigated this in youth. This study examined how anxiety-related variables and attention control interacted to predict children's attention to pain cues using eye-tracking methodology, and their pain tolerance on the cold pressor test (CPT).

Methods

Children aged 8–17 years had their eye-gaze tracked whilst they viewed photographs of other children displaying painful facial expressions during the CPT, before completing the CPT themselves. Children also completed self-report measures of anxiety and attention control.

Results

Findings indicated that anxiety and attention control did not impact children's initial fixations on pain or neutral faces, but did impact how long they dwelled on pain versus neutral faces. For children reporting low levels of attention control, higher anxiety was associated with less dwell time on pain faces as opposed to neutral faces, and the opposite pattern was observed for children with high attention control. Anxiety and attention control also interacted to predict pain outcomes. For children with low attention control, increasing anxiety was associated with anticipating more pain and tolerating pain for less time.

Conclusions

This is the first study to examine children's attention to pain cues using eye-tracking technology in the context of a salient painful experience. Data suggest that attention control is an important moderator of anxiety on multiple outcomes relevant to young people's pain experiences.

Significance

This study uses eye tracking to study attention to pain cues in children. Attention control is an important moderator of anxiety on attention bias to pain and tolerance of cold pressor pain in youth.

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Activation of ephrinB–EphB receptor signalling in rat spinal cord contributes to maintenance of diabetic neuropathic pain

Abstract

Background

Diabetic neuropathic pain (DNP) is severe and intractable in clinic. The specific cellular and molecular mechanisms underlying DNP remain elusive and its treatment are limited. We investigated roles of EphB1 receptor in the development of DNP.

Methods

Diabetic neuropathic pain was produced in male, adult, Sprague-Dawley rats by a single i.p. streptozotocin (STZ) or alloxan. Western blot analysis and immunohistochemistry were used to analyse expression of EphB1 receptor as well as the activation of the glial cells and the pro-inflammatory cytokines in the spinal cord. DNP manifested as mechanical allodynia, which was determined by measuring incidence of foot withdrawal in response to mechanical indentation of the hind paw by an electro von Frey filament.

Results

Diabetic neuropathic pain and high blood glucose were exhibited simultaneously in around 70% of animals that received i.p. STZ or alloxan. Phosphorylation of EphB1, activation of the astrocytes and microglial cells, and level of tumour necrosis factor (TNF)-α and interleukin (IL)-1β in the spinal cord were significantly increased in rats with DNP. Spinal blocking EphB1 receptor activation in the late phase after STZ injection significantly suppressed the established mechanical allodynia as well as activation of the astrocytes and microglial cells and activity of TNF-α and IL-1β. However, spinal treatment of EphB1-Fc in the early phase after STZ injection did not prevent the induction of DNP.

Conclusions

EphB1 receptor activation in the spinal cord is critical to the maintenance, but not induction of diabetic pain. EphB1 receptor may be a potential target for relieving the established diabetic pain.

Significance

Activation of EphB1 receptor in the spinal cord is critical to maintaining the established diabetic neuropathic pain, but not to diabetic pain induction. Spinal blocking EphB1 receptor activation suppresses ongoing diabetic neuropathic pain.

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Chronic postsurgical pain in patients 5 years after cardiac surgery: A prospective cohort study

Abstract

Background

Chronic postsurgical pain (CPSP) is a common complication after many surgical procedures, including cardiac surgery. The prevalence of CPSP after cardiac surgery ranges from 9.5% to 56%. Most studies on CPSP after cardiac surgery are retrospective and long-term prospective studies are scarce. The aim of this study was to follow CPSP and health-related quality of life (HRQOL) prospectively in a cohort of patients, emphasizing the prevalence from 12 months to 5 years.

Methods

A total of 534 patients (23% ≥75 years, 67% men) were consecutively included before surgery. Study-specific questionnaires and the Brief Pain Inventory (BPI) were used to measure CPSP at baseline, 12 months and 5-year follow-up. Short-Form Health Survey (SF-36) was used to measure HRQOL.

Results

Among 458 patients who were alive after 5 years, 82% responded (n = 373). The majority, 89.8% (335/373), did not report CPSP, neither 12 months nor 5 years after surgery. Among the 38 patients who reported CPSP after 12 months, 24 (63%) patients did not report CPSP after 5 years. The overall prevalence of CPSP after 5 years was 3.8% (14/373). Patients reporting CPSP and resolved CPSP had lower scores on HRQOL and more pain preoperatively than patients who did not report CPSP.

Conclusions

The prevalence of CPSP was lower in this study than previously reported. Among the patients reporting CPSP at 12 months, 63% did not report CPSP after 5 years. Hence, the observed decline in CPSP is in line with studies evaluating CPSP in noncardiac surgery.

Significance

The prevalence of chronic postsurgical pain (CPSP) at 5 years after surgery of 3.8% is lower than previously reported. The majority of patients reporting CPSP after 12 months did not report CPSP after 5 years.

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Predictors for future clinically significant pain in patients with temporomandibular disorder: A prospective cohort study

Abstract

Background

Up to 30% of patients with temporomandibular disorder (TMD) run the risk of progressing to chronic pain with significant disability. This prospective cohort study assessed the effects of baseline pain and general health and psychosocial factors on the presence of clinically significant pain in patients with TMD pain at 1 year after initial consultation.

Methods

263 primary care patients with TMD pain were included. At the baseline, patients completed a pain questionnaire including a wide range of putative prognostic factors, which were assessed using validated self-report scales. The outcome, clinically significant pain at 1 year was defined as grades IV and III and grades II and I with any disability points on the Graded Chronic Pain Scale (GCPS). Multivariable logistic regression was used to study the association between the outcome and each predictor variable.

Results

At 1 year, 26.9% of the patients reported clinically significant pain. The number of previous healthcare visits (OR 1.19, 95% CI 1.02–1.39), pain intensity/dysfunction of other pain conditions (OR 1.35, 95% CI 1.07–1.69), the number of other pain conditions (OR 1.31, 95% CI 0.98–1.74), the number of disability days (OR 1.05, 95% CI 1.00–1.12), and perceived ability to control pain (OR 0.79, 95% CI 0.61–1.01) were associated with the outcome. The area under the curve (AUC) for the whole model indicated acceptable discriminative ability (0.74, 95% CI 0.66–0.82).

Conclusions

Reporting several previous healthcare visits and comorbid pains with high pain intensity and disability signal increased risk for poor prognosis of TMD pain.

Significance

About 27% of primary care TMD pain patients reported clinically significant pain at 1 year after initial consultation. Reporting several previous healthcare visits and comorbid pains with high pain intensity and disability were associated with poor prognosis of TMD pain.

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Audiovisual distraction for pain relief in paediatric inpatients: A crossover study

Abstract

Background

Pain is a stressful experience that can have a negative impact on child development. The aim of this crossover study was to examine the efficacy of audiovisual distraction for acute pain relief in paediatric inpatients.

Method

The sample comprised 40 inpatients (6–11 years) who underwent painful puncture procedures. The participants were randomized into two groups, and all children received the intervention and served as their own controls. Stress and pain-catastrophizing assessments were initially performed using the Child Stress Scale and Pain Catastrophizing Scale for Children, with the aim of controlling these variables. The pain assessment was performed using a Visual Analog Scale and the Faces Pain Scale-Revised after the painful procedures. Group 1 received audiovisual distraction before and during the puncture procedure, which was performed again without intervention on another day. The procedure was reversed in Group 2. Audiovisual distraction used animated short films. A 2 × 2 × 2 analysis of variance for 2 × 2 crossover study was performed, with a 5% level of statistical significance.

Results

The two groups had similar baseline measures of stress and pain catastrophizing. A significant difference was found between periods with and without distraction in both groups, in which scores on both pain scales were lower during distraction compared with no intervention. The sequence of exposure to the distraction intervention in both groups and first versus second painful procedure during which the distraction was performed also significantly influenced the efficacy of the distraction intervention.

Conclusion

Audiovisual distraction effectively reduced the intensity of pain perception in paediatric inpatients.

Significance

The crossover study design provides a better understanding of the power effects of distraction for acute pain management. Audiovisual distraction was a powerful and effective non-pharmacological intervention for pain relief in paediatric inpatients. The effects were detected in subsequent acute painful procedures.

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Glucose solution is more effective in relieving pain in neonates than non-nutritive sucking: A randomized clinical trial

Abstract

Background

Few studies have compared the analgesic effect of 25% glucose and non-nutritive sucking. We compared the analgesic effect of 25% glucose and non-nutritive sucking in newborns undergoing hepatitis B vaccination. Our hypothesis is that 25% glucose is more effective in relieving pain than non-nutritive sucking.

Methods

A randomized clinical trial with 78 healthy newborns was performed. Neonates were assigned randomly to receive 25% glucose (G25) and non-nutritive sucking (NNS). Pain was assessed using the Neonatal Infant Pain Scale (NIPS) before and during the immunization procedure. In addition, we evaluated various physiological parameters and crying time.

Results

Neonates who received 25% glucose registered lower NIPS scores than those from the NNS group [mean (SD), 3.3 (2.1) vs. 5.6 (1.6), p < 0.001]. The crying time was shorter among newborns in the G25 group than in the NNS and control groups.

Conclusion

The use of 25% glucose before the vaccination procedure was more effective in relieving acute pain, with newborns in the G25 group registering scores two times lower on the NIPS scale. The clinical practice of administering 25% glucose is therefore a suggested nondrug measure for pain relief during painful procedures.

Significance

Neonates who received 25% glucose registered lower NIPS scores than those from the NNS group; the crying time was shorter among newborns in the G25 group than in the NNS and control groups; the use of 25% glucose before the vaccination procedure was more effective in relieving acute pain.

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Thalamic Functional Connectivity in Mild Traumatic Brain Injury: Longitudinal Associations With Patient-Reported Outcomes and Neuropsychological Tests

Swimming Improves Pain and Functional Capacity of Patients With Fibromyalgia: A Randomized Controlled Trial

Relative Importance of Baseline Pain, Fatigue, Sleep, and Physical Activity: Predicting Change in Depression in Adults With Multiple Sclerosis

Comparison of the Effectiveness of Suprascapular Nerve Block With Physical Therapy, Placebo, and Intra-Articular Injection in Management of Chronic Shoulder Pain: A Meta-Analysis of Randomized Controlled Trials

Systematic Review of Pharmacologic Treatments of Pain After Spinal Cord Injury: An Update

Temporal summation of the nociceptive withdrawal reflex involves deactivation of posterior cingulate cortex

Abstract

Background

Temporal summation of pain sensation is pivotal both in physiological and pathological nociception. In humans, it develops in parallel with temporal summation of the nociceptive withdrawal reflex (NWR) of the lower limb, an objective representation of the temporal processing of nociceptive signals into the spinal cord.

Methods

To study the contribution of cortical and subcortical structures in temporal summation of pain reflex responses, we compared the fMRI signal changes related to the temporal summation threshold (TST) of the NWR with that related to the single NWR response. We studied 17 healthy subjects using a stimulation paradigm previously determined to evoke both the TST of the NWR (SUMM) and the NWR single response (SING).

Results

We found a significant activation in left (contralateral) primary somatosensory cortex (SI), bilateral secondary somatosensory cortex (SII), bilateral insula, anterior cingulate cortex (ACC) and bilateral thalamus during both SUMM and SING conditions. The SUMM versus SING contrast revealed a significant deactivation in the posterior cingulate cortex (PCC) and bilateral middle occipital gyrus in SUMM when compared to SING condition.

Conclusions

Our data support the hypothesis that temporal summation of nociceptive reflex responses is driven through a switch between activation and deactivation of a specific set of brain areas linked to the default mode network. This behaviour could be explained in view of the relevance of the pain processing induced by temporal summation, recognized as a more significant potential damaging condition with respect to a single, isolated, painful stimulation of comparable pain intensity.

Significance

The study demonstrated that TST of the NWR involves a selective deactivation of PCC.

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The presence of respiratory disorders in individuals with low back pain: a systematic review

Inspiratory muscles, such as the diaphragm, play a key role in both respiration and spinal control. Therefore, diaphragm dysfunctions are often related to low back pain (LBP). However, few is known on the association between the presence of LBP and the presence of respiratory disorders (RD).

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Negative neurodynamic tests do not exclude neural dysfunction in patients with entrapment neuropathies

Pain by association? Experimental modulation of human pain thresholds using classical conditioning

A classical conditioning framework is often used for clinical reasoning about pain that persists after tissue healing. However, experimental studies demonstrating classically conditioned pain in humans are lacking. The current study tested whether non-nociceptive somatosensory stimuli can come to modulate pain threshold after being paired with painful nociceptive stimuli in healthy humans. We used a differential simultaneous conditioning paradigm in which one non-painful vibrotactile conditioned stimulus (CS+) was simultaneously paired with an unconditioned painful laser stimulus (US), while another vibrotactile stimulus (CS-) was paired with a non-painful laser stimulus.

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Effects of Dry Needling to the Symptomatic versus Control Shoulder in Patients with Unilateral Subacromial Pain Syndrome

Initial reports suggest that treating myofascial trigger points in the infraspinatus with dry needling may be effective in treating patients with shoulder pain. However, to date, high quality clinical trials and thorough knowledge of the physiologic mechanisms involved is lacking.

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Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review

Excessive thoracic kyphosis is considered a predisposing factor for shoulder pain, though there is uncertainty about the nature of the relationship between shoulder pain and thoracic spine posture. The aim of this systematic review was to investigate the relationship between thoracic kyphosis and shoulder pain, shoulder range of motion (ROM) and function.

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The neuromotor effects of transverse friction massage

Transverse friction massage (TFM), as an often used technique by therapists, is known for its effect in reducing the pain and loosing the scar tissues. Nevertheless, its effects on neuromotor driving mechanism including the electromechanical delay (EMD), force transmission and excitation-contraction (EC) coupling which could be used as markers of stiffness changes, has not been computed using ultrafast ultrasound (US) when combined with external sensors.

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Use of Rasch analysis to investigate structural validity of a set of movement control tests for the neck

Movement control abilities are often reduced in persons with neck pain. In physiotherapeutic practice observational tests are frequently used to assess the impaired abilities. Several tests for movement control abilities are available, but no evidence exists on how to combine and interpret them.

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Subjective and clinical assessment criteria suggestive for five clinical patterns discernible in nonspecific neck pain patients. A Delphi-survey of clinical experts

Nonspecific neck pain patients form a heterogeneous group with different musculoskeletal impairments. Classifying nonspecific neck pain patients into subgroups based on clinical characteristics might lead to more comprehensive diagnoses and can guide effective management.

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Now you see it, now you don’t

A 40 year old black British man with known sickle cell anaemia presented to the emergency department with a nine hour history of left-sided pleuritic chest pain. The patient also had pain in both...

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The forebrain medial septal region and nociception

Examining Committed Action in Chronic Pain: Further Validation and Clinical Utility of the Committed Action Questionnaire

Psychosocial treatments for chronic pain conditions, such as Acceptance and Commitment Therapy (ACT), have highlighted minimizing pain avoidance behaviors and increasing engagement in valued activities as key treatment targets. In terms of salient processes within ACT, committed action is considered essential to the pursuit of a meaningful life, as it entails a flexible persistence over time in living consistently with one’s values. To date, however, only one study has examined the association between measures of committed action and important aspects of pain-related functioning.

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Severely obese teens who have bariatric surgery show improved mobility and less pain

Severely obese teenagers who undergo bariatric surgery show improved mobility and reduced musculoskeletal pain from walking as much as two years after surgery, a study published in JAMA Pediatrics...

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Ultrasonographic measures of the acromiohumeral distance and supraspinatus tendon thickness in manual wheelchair users with spinal cord injury

Subacromial anaesthetics increase asymmetry of scapular kinematics in patients with subacromial pain syndrome

Subacromial pain syndrome (SAPS) and scapular dyskinesis are closely associated, but the role of pain is unknown. We hypothesized that pain results in asymmetrical scapular kinematics, and we expected more symmetrical kinematics after infiltration of subacromial anaesthetics.

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Complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a chronic pain condition that can occur after a minor trauma or surgery. It is a multifactorial condition with a complex cause and even more complex pathophysiology. There are disturbances and changes in the sympathetic, somatosensory and motor nervous system, resulting in severe pain and disability. Patients with CRPS can have their quality of life and functional ability greatly affected and they need appropriate and interdisciplinary interventions.

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Vastus medialis H-reflex excitability is associated with pain level, self-reported function and chronicity in women with patellofemoral pain

Poor Radiological and Good Functional Long-term Outcome of Surgically Treated Scheuermann Patients

Study Design. Cohort study. Objective. To analyze long-term clinical and radiological outcomes of surgically treated Scheuermann patients. Summary of Background Data. Long-term clinical and radiological outcomes of surgery for Scheuermann kyphosis are unknown. A single-center cohort of 33 consecutive, surgically treated (between 1991 and 1998) Scheuermann patients was studied. Methods. Clinical and radiological data of 29 surgically treated Scheuermann patients were collected (posterior approach n = 13; combined anterior-posterior procedure n = 16), after a mean follow-up of 18 years. Oswestry Disability Index (ODI) scores were measured preoperatively (PRE) and twice postoperatively: 2 to 8 years postoperative (FU 1) and 14 to 21 years postoperative (FU 2). Visual Analog Score pain, Short Form-36 (SF-36), and EQ-5d scores were recorded at FU 2 only. Radiographs were analyzed for correction, distal and proximal junctional kyphosis, and implant failures. Results. Mean preoperative kyphosis of the corrected levels was 76° (range 60°–105°) and decreased to a Cobb of 58°(range 30°–105°) at FU 2. Median Visual Analog Score was 2.5 points (range 0–8) and median ODI score was 12 (range 0–62) at FU 2. The ODI score at FU 1 was significantly better as compared to PRE (P < 0.001) and FU 2 (P < 0.001). Also, anterior-posterior treated group had a significantly better ODI score as compared to the posterior-only group (P = 0.023). EQ-5d scores on mobility, usual activities, and pain/discomfort were worse compared to an age-matched population control group; however, SF-36 outcome scores were comparable. Proximal junctional kyphosis was present in 53% of patients, distal junctional kyphosis did not occur, and implant failure/removal had occurred in 69% of patients. Radiological complications do not relate with the ODI, EQ-5d, and SF-36 and 72% of the patients were satisfied. Conclusion. Radiological results of this cohort were disappointing but did not relate to clinical outcome scores. Even lumbar pain could not prevent a high patient satisfaction and quality of life. Patients treated with a combined anterior-posterior approach tended to perform better. Level of Evidence: 3

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Correlation of PROMIS Physical Function and Pain CAT Instruments With Oswestry Disability Index and Neck Disability Index in Spine Patients

Study Design. A prospective and retrospective cross-sectional cohort analysis. Objective. The aim of this study was to show that Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT) assessments for physical function and pain interference can be efficiently collected in a standard office visit and to evaluate these scores with scores from previously validated Oswestry Disability Index (ODI) and Neck Disability Index (NDI) providing evidence of convergent validity for use in patients with spine pathology. Summary of Background Data. Spinal surgery outcomes are highly variable, and substantial debate continues regarding the role and value of spine surgery. The routine collection of patient-based outcomes instruments in spine surgery patients may inform this debate. Traditionally, the inefficiency associated with collecting standard validated instruments has been a barrier to routine use in outpatient clinics. We utilized several CAT instruments available through PROMIS and correlated these with the results obtained using “gold standard” legacy outcomes measurement instruments. Methods. All measurements were collected at a routine clinical visit. The ODI and the NDI assessments were used as “gold standard” comparisons for patient-reported outcomes. Results. PROMIS CAT instruments required 4.5 ± 1.8 questions and took 35 ± 16 seconds to complete, compared with ODI/NDI requiring 10 questions and taking 188 ± 85 seconds when administered electronically. Linear regression analysis of retrospective scores involving a primary back complaint revealed moderate to strong correlations between ODI and PROMIS physical function with r values ranging from 0.5846 to 0.8907 depending on the specific assessment and patient subsets examined. Conclusion. Routine collection of physical function outcome measures in clinical practice offers the ability to inform and improve patient care. We have shown that several PROMIS CAT instruments can be efficiently administered during routine clinical visits. The moderate to strong correlations found validate the utility of computer adaptive testing when compared with the gold standard “static” legacy assessments. Level of Evidence: 4

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[Perspectives] Irene Tracey: seeing pain for what it is

Reflecting on the tension between clinicians and scientists that still makes occasional appearances in medical research circles, Professor Irene Tracey speaks dismissively of what she calls “badge-wearing”. This October will see her taking up a post as Head of the Nuffield Department of Clinical Neurosciences at the University of Oxford. The job is one that might traditionally have been expected to go to a clinician; Tracey's background is in the science of biochemistry and she is already Head of Oxford's Nuffield Division of Anaesthetics, another job for which the spec might well have read “clinical”.

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Do we need a third mechanistic descriptor for chronic pain states?

No abstract available

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Effect of Kinesio Taping on Pain and Functional Disability in Chronic Nonspecific Low Back Pain: A Randomized Clinical Trial

Study Design. A randomized controlled trial with 2-week Kinesio taping intervention. Objective. The aim of the study was to investigate the effectiveness of Kinesio taping application on pain, functional disability, and trunk flexion range of motion (ROM) in patients with chronic nonspecific low back pain (chronic NSLBP). Summary of Background Data. Kinesio taping is a therapeutic tool used for treatment of chronic NSLBP. However, there is little scientific evidence that describes its clinical efficacy. Methods. Forty-four patients with chronic NSLBP were randomized into experimental group (n = 21) and placebo group (n = 23). The experimental group was treated with Erector Spinae Taping, whereas the placebo group was treated with placebo taping. The primary endpoint was pain intensity on visual analog scale. Secondary endpoints were functional disability on Arabic version of Oswestry disability index (ODI) and trunk flexion ROM on Modified Schober's test. All measurements were recorded at baseline (W0), after 2-week intervention (W2), and at 4-week (W4) follow-up. Results. Both group were comparable at baseline (P > 0.05). The experimental group had a greater decrease in pain than the placebo group after W2 of intervention (mean between-group difference 2.05 cm, 95% confidence interval [CI] = 1.38–2.71 points). This was maintained to W4 follow-up (2.25 cm, 95% CI = 1.67–2.82 points). At W2, the experimental group had significantly greater improvement in disability, by 3.90 points (95% CI = 1.68–8.54 points). This effect was significant at W4 follow-up (5.6, 95% CI = 2.65–8.54 points). Similarly trunk flexion ROM was significantly better at W2 (−0.71 cm, 95% CI = −0.85 to −0.56) and W4 follow-up (−0.73 cm, 95% CI = −0.88 to −0.58). Conclusion. Kinesio taping reduces pain and disability and improves trunk flexion ROM after 2 weeks of application. However, thesis effects were very small to be considered clinically relevant and meaningful when compared with placebo taping. Level of Evidence: 2

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Developing a Reliable Core Stability Assessment Battery for Patients with Nonspecific Low Back Pain

Study Design. Test-retest design. Objective. The objective was to examine the intrarater (test-retest) reliability of the core stability related tests and to develop a reliable core stability assessment battery. Summary of Background Data. Studies suggest that core stability exercises may improve function and decrease pain in patients with nonspecific low back pain (LBP). Reliable clinical tests are required to implement adequate rehabilitation and to evaluate results of these interventions. Methods. The study had a test-retest design. Thirty-three different tests that might relate to core stability were identified with their mostly used protocols. Five different components of core stability including endurance, flexibility, strength, functional performance, and motor control were assessed in 38 patients with nonspecific LBP. The same testing procedure was performed again after 48 to 72 hours. Intraclass correlation coefficients (ICCs), standard error of measurement, and minimal detectable change were calculated to assess the intrarater reliability. Results. The intrarater reliability of the tests ranged from little to very high (ICC = 0.08–0.98). Partial curl-up (ICC = 0.90), lateral bridge (ICC = 0.95–0.96), trunk flexor endurance (ICC = 0.97), sit and reach (ICC = 0.98), single-legged hop (ICC = 0.98–0.97), lateral step-down (ICC = 0.93–0.92), eyes open right and left leg unilateral stance (ICC = 0.97 and 0.91) tests had the highest intrarater reliability for each core stability component. Conclusion. The results indicated that the partial curl-up test (strength), side bridge and trunk flexor tests (endurance), sit-and-reach test (flexibility), single-legged hop, and lateral step-down (functional), unilateral stance test with eyes open (motor control) had very high intrarater reliability. A core stability assessment battery involving these tests can be used in patients with nonspecific LBP to assess all components of core stability. Level of Evidence: 3

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Surgical Versus Nonsurgical Treatment for Lumbar Spinal Stenosis

Study Design. A systematic review. Objectives. The aim of this study is to evaluate the effectiveness of different types of surgery compared with different types of nonsurgical interventions in adults with symptomatic lumbar spinal stenosis (LSS). Summary of Background Data. LSS is a debilitating condition associated with degeneration of the spine with aging. People with LSS experience a range of symptoms, including back pain, leg pain, numbness and tingling in the legs, and reduced physical function. Main treatment options are surgery, physical therapy, exercise, braces, and injections into the spine. Methods. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, five other databases, and two trials registries up to February 2015, reference lists, and conference proceedings related to treatment of the spine. Randomized controlled trials (RCTs) compared surgical versus nonoperative treatments in participants with LSS. Outcomes included quality of life, disability, function, pain, complication rates, and side effects. Results. From the 12,966 citations screened, we included five RCTs (643 participants). Three studies compared spine surgery versus various types of nonsurgical treatment. It is difficult to draw conclusions from these studies because nonsurgical treatments were inadequately described. One study that compared surgery versus bracing and exercise found no differences in pain. Another study compared surgery versus spinal injections and found better physical function with injections, and better pain relief with surgery at six weeks. Still another trial compared surgery with an implanted device versus nonsurgical care. This study reported favorable outcomes of surgery for symptoms and physical function. Conclusion. We cannot conclude on the basis of this review whether surgical or nonsurgical treatment is better for individuals with LSS. Nevertheless, we can report on the high rate of effects reported in three of five surgical groups, ranging from 10% to 24%. No side effects were reported for any of the conservative treatment options. Level of Evidence: 1

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Fifty shades of pain

Fifty shades of pain

Nature 535, 7611 (2016). doi:10.1038/535200a

Measuring hurt is harder than inflicting it.

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Treat signs of sepsis with same urgency as chest pain, says NICE

Doctors should treat patients with suspected sepsis with the same urgency as those who present with chest pains, says new UK guidance from the National Institute for Health and Care...

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Restoring movement representation and alleviating phantom limb pain through short-term neurorehabilitation with a virtual reality system

Abstract

Background and Objective

We developed a quantitative method to measure movement representations of a phantom upper limb using a bimanual circle-line coordination task (BCT). We investigated whether short-term neurorehabilitation with a virtual reality (VR) system would restore voluntary movement representations and alleviate phantom limb pain (PLP).

Methods

Eight PLP patients were enrolled. In the BCT, they repeatedly drew vertical lines using the intact hand and intended to draw circles using the phantom limb. Drawing circles mentally using the phantom limb led to the emergence of an oval transfiguration of the vertical lines (‘bimanual-coupling’ effect). We quantitatively measured the degree of this bimanual-coupling effect as movement representations of the phantom limb before and immediately after short-term VR neurorehabilitation. This was achieved using an 11-point numerical rating scale (NRS) for PLP intensity and the Short-Form McGill Pain Questionnaire (SF-MPQ). During VR neurorehabilitation, patients wore a head-mounted display that showed a mirror-reversed computer graphic image of an intact arm (the virtual phantom limb). By intending to move both limbs simultaneously and similarly, the patients perceived voluntary execution of movement in their phantom limb.

Results

Short-term VR neurorehabilitation promptly restored voluntary movement representations in the BCT and alleviated PLP (NRS: p = 0.015; 39.1 ± 28.4% relief, SF-MPQ: p = 0.015; 61.5 ± 48.5% relief). Restoration of phantom limb movement representations and reduced PLP intensity were linearly correlated (p < 0.05).

Conclusions

VR rehabilitation may encourage patient's motivation and multimodal sensorimotor re-integration of a phantom limb and subsequently have a potent analgesic effect.

Significance

There was no objective evidence that restoring movement representation by neurorehabilitation with virtual reality alleviated phantom limb pain. This study revealed quantitatively that restoring movement representation with virtual reality rehabilitation using a bimanual coordination task correlated with alleviation of phantom limb pain.

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Response to Letter to the Editor: Reliability of lumbar movement dysfunction tests for chronic low back pain patients; Methodological concerns to avoid misinterpretation

We are pleased to have the opportunity to respond to the letter to the editor from Prof. Dr. S. Sabour regarding our recent publication (Bauer et al., 2016). We will attempt to address the issues raised in this letter. Our study assessed the reliability of interval-scaled outcome measures of eleven different movement dysfunction tests (Bauer et al. 2016). As stated by Prof. S. Sabour, the reproducibility of such outcome measures is generally quantified by intraclass correlation (ICC) coefficients.

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Resident macrophages in muscle contribute to development of hyperalgesia in a mouse model of non-inflammatory muscle pain

Macrophages play a role in innate immunity within the body, are located in muscle tissue, and can release inflammatory cytokines that sensitize local nociceptors. Here we investigate the role of resident macrophages in the non-inflammatory muscle pain model induced by 2 pH 4.0 injections 5 days apart in the gastrocnemius muscle. We demonstrate that injecting 2 pH 4.0 injections into the gastrocnemius muscle increased the number of local muscle macrophages, and depleting muscle macrophages with clodronate liposomes prior to acid injections attenuated the hyperalgesia produced by this model.

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United States National Pain Strategy for Population Research: Concepts, Definitions and Pilot Data

National Pain Strategy (NPS) population research objectives include: estimating chronic pain prevalence; studying pain treatment with electronic health care data; and, developing metrics to assess progress in reducing chronic pain impact. In this paper, the NPS Population Research Workgroup reviews concepts relevant to achieving these aims. High impact chronic pain was defined as persistent pain with substantial restriction of life activities lasting six months or more. In pilot work, we tested a brief assessment of high impact chronic pain, and employed electronic health records data to describe pain-related health care.

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The Difficulty in Identifying Factors Responsible for Pressure Ulcer Healing in Veterans with Spinal Cord Injury

A Prospective, Randomized, Multicenter, Open-label Clinical Trial Comparing Intradiscal Biacuplasty to Conventional Medical Management for Discogenic Lumbar Back Pain

Study Design. This study was a prospective, randomized, crossover, multicenter trial for the evaluation of comparative effectiveness of intradiscal biacuplasty (IDB) versus conventional medical management (CMM) in the treatment of lumbar discogenic pain. Objective. The objective was to demonstrate the superiority of IDB over CMM in the treatment of discogenic pain with respect to the primary outcome measure. Summary of Background Data. Current therapeutic options for the treatment of chronic low back pain of discogenic origin are limited. CMM is often unsatisfactory with regard to the treatment of discogenic pain. IDB offers a minimally invasive treatment that has been demonstrated to be superior to placebo in the past. Methods. A total of 63 subjects with lumbar discogenic pain diagnosed via provocation discography were randomized to IDB + CMM (n = 29) or CMM-alone (n = 34). At 6 months, patients in the CMM-alone group were eligible for crossover if desired. The primary outcome measure was the change in visual analog scale (VAS) from baseline to 6 months. Secondary outcome measures included treatment “responders,” defined as the proportion of subjects with a 2-point or 30% decrease in VAS scores. Other secondary measures included changes from baseline to 6 months in (1) short form (SF) 36-physical functioning, (2) Oswestry Disability Index, (3) Beck Depression Inventory, (4) Patient Global Impression of Change, (5) EQ-5D VAS, and (6) back pain-related medication usage. Results. In the IDB cohort, the mean VAS score reduction exceeded that in the CMM cohort (−2.4 vs. −0.56; P = 0.02), and the proportion of treatment responders was substantially greater (50% vs. 18%). Differences in secondary measures favored IDB. No differences in opioid utilization were noted between groups. Conclusion. Superior performance of IDB with respect to all study outcomes suggests that it is a more effective treatment for discogenic pain than CMM-alone. Level of Evidence: 2

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Efficacy of i-Factor Bone Graft versus Autograft in Anterior Cervical Discectomy and Fusion: Results of the Prospective, Randomized, Single-blinded Food and Drug Administration Investigational Device Exemption Study

Study Design. A prospective, randomized, controlled, parallel, single-blinded noninferiority multicenter pivotal FDA IDE trial. Objective. The objective of this study was to investigate efficacy and safety of i-Factor Bone Graft (i-Factor) compared with local autograft in single-level anterior cervical discectomy and fusion (ACDF) for cervical radiculopathy. Summary of Background Data. i-Factor is a composite bone substitute material consisting of the P-15 synthetic collagen fragment adsorbed onto anorganic bone mineral and suspended in an inert biocompatible hydrogel carrier. P-15 has demonstrated bone healing efficacy in dental, orthopedic, and nonhuman applications. Methods. Patients randomly received either autograft (N = 154) or i-Factor (N = 165) in a cortical ring allograft. Study success was defined as noninferiority in fusion, Neck Disability Index (NDI), and Neurological Success endpoints, and similar adverse events profile at 12 months. Results. At 12 months (follow-up rate 87%), both i-Factor and autograft subjects demonstrated a high fusion rate (88.97% and 85.82%, respectively, noninferiority P = 0.0004), significant improvements in NDI (28.75 and 27.40, respectively, noninferiority P < 0.0001), and high Neurological Success rate (93.71% and 93.01%, respectively, noninferiority P < 0.0001). There was no difference in the rate of adverse events (83.64% and 82.47% in the i-Factor and autograft groups, respectively, P = 0.8814). Overall success rate consisting of fusion, NDI, Neurological Success and Safety Success was higher in i-Factor subjects than in autograft subjects (68.75% and 56.94%, respectively, P = 0.0382). Improvements in VAS pain and SF-36v2 scores were clinically relevant and similar between the groups. A high proportion of patients reported good or excellent Odom outcomes (81.4% in both groups). Conclusion. i-Factor has met all four FDA mandated noninferiority success criteria and has demonstrated safety and efficacy in single-level ACDF for cervical radiculopathy. i-Factor and autograft groups demonstrated significant postsurgical improvement and high fusion rates. Level of Evidence: 1

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Ultrasonographic Evaluation of Anatomic Variations in the Sacral Hiatus: Implications for Caudal Epidural Injections

Study Design. Prospective study Objective. The aim of this study was to evaluate variations in the sacral hiatus based on ultrasonographic images. Summary of Background Data. Caudal epidural injection is commonly used for the treatment of lower back pain, but blind injections commonly lead to mistakes made at the injection site due to anatomic variations in the sacral hiatus. Methods. A total of 339 patients with low back pain or sciatica were studied using a linear-array ultrasound transducer. The transducer was placed at the sacral cornua and the distance between the bilateral cornua and the width of the sacrococcygeal ligament between the bilateral cornua were measured in the transverse view. The transducer was also placed between the two cornua and the distance between the skin and posterior sacral bony surface was measured, including the depth of the subcutaneous fat, in the longitudinal view. The surface distance was then measured from the natal cleft to the apex of the sacral hiatus. Results. The mean distance between the bilateral cornua was 18.1 ± 3.2 mm and mean width of the sacrococcygeal ligament was 10.5 ± 2.6 mm. The mean diameter of the sacral canal was 6.8 ± 2.5 mm but 6 of 339 patients (1.8%) found less than 2 mm. The mean surface distance from the natal cleft to the apex of the sacral hiatus was 29.3 ± 12.3 mm. The distance between the sacral hiatus and the natal cleft ranged from −2.0 to 75.0 mm. Conclusion. We believe that the variations found in the surface distance from the natal cleft to the sacral hiatus are significant for caudal epidural injection. However, the other measurements may also have clinical importance in this area. Level of Evidence: 3

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Cost-effectiveness Analysis of Existing Pedicle Screws Reusing Technique in Extension Revision Operation for Adjacent Segmental Stenosis After Lumbar Posterolateral Fusion

Study Design. Retrospective case-control study. Objective. A cost-effectiveness analysis was performed by comparing patients who received extension revision operations for adjacent segment disease (ASD) reusing the pedicle screws extracted from fused segments with patients who received conventional surgery. Summary of Background Data. ASD often required extension revision surgery, and during extension surgery, pedicle screws may be reused by extracting from the fused segments of primary surgery. Methods. Study examined 37 patients who received extension revision surgery for ASD from January 2003 to December 2013. For the fixation of extended segments during revision operation, in 16 cases the pedicle screws extracted from fused segments were reused (group R), and in 21 cases new pedicle screws were used (group C) as a conventional method. Clinical outcomes were evaluated by means of visual analog scale scores for lumbago and leg pain, and the Korean Oswestry Disability Index. Radiologic outcomes were evaluated from the extent of bone union. The total operating costs in the two groups were compared. Results. Visual analog scale scores for lumbago and leg pain, and the Korean Oswestry Disability Index measured at final follow-up averaged 3.6 and 3.8, and 19.9 in group R, and 3.8 and 3.1, and 21.1 in group C, respectively (P = 0.280, P = 0.387, P = 0.751). For radiologic outcomes, there was one case of nonunion in each group. The cost of surgery was 5332 US dollars in group R, and 6109 US dollars in group C, respectively (P = 0.036). Conclusion. Reusing pedicle screws extracted from the fused segments during extension revision operation for ASD can reduce the cost of surgery, and achieves clinical and radiological results similar to those of the conventional operation. Level of Evidence: 4.

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Predicting Extended Length of Hospital Stay in an Adult Spinal Deformity Surgical Population

Study Design. A retrospective review of a prospective multicenter database. Objective. The aim of this study was to identify variables associated with extended length of stay (ExtLOS) and this impact on health-related quality of life (HRQoL) scores in adult spinal deformity (ASD) patients. Summary of Background Data. ASD surgery is complex and associated with complications including extLOS. Although variables contributing to extLOS have been considered, specific complications and pre-disposing factors among ASD surgical patients remain to be investigated. Methods. Inclusion criteria: ASD surgical patients (age >18 years, scoliosis ≥20°, sagittal vertical axis ≥5 cm, pelvic tilt ≥25°, and/or thoracic kyphosis >60°) with complete demographic, radiographic, and HRQoL data at baseline, 6 weeks, and 2 years postoperative. ExtLOS was based on 75th percentile (≥9 days). Univariate and multivariate analyses identified predictors and evaluated effects on outcomes. Repeated-measures mixed models analyzed impact of ExtLOS on HRQoL [Oswestry Disability Index; Short Form-36 physical component summary/mental component summary; SRS22r Activity (AC), Pain (P), Appearance (AP), Satisfaction (S), Mental (M) and Total (T)]. Results. Three hundred eighty patients met inclusion criteria: 105 (27.6%) had extLOS (≥9 days) and 275 (72.4%) did not. Average LOS was 8 days (range: 1–30 days). Age [odds ratio (OR) 1.04], no. of levels fused (OR 1.12), no. of infections (OR 2.29), no. of neurologic complications (OR 2.51), Charlson Comorbidity Index Score (CCI) predicted ExtLOS (OR 3.92), and no. of intraop complications predicted ExtLOS (OR 3.56). ExtLOS patients had more intracardiopulmonary (pleural effusion: 1.9% vs. 0%) and operative complications (dural tear: 13.3% vs. 5.1%; excessive blood loss: 18% vs. 5.8%) (P < 0.022). At 2 years, both groups of patients experienced an overall improvement in all HRQoL scores (P < 0.001). ExtLOS patients had significantly less overall improvement in all HRQoLs (P < 0.01) except for MCS (P = 0.17) and SRS M (P = 0.08). Conclusion. Extended LOS of ASD patients is affected by comorbidities (higher CCI) and number of intraoperative, but not peri-operative, complications. All patients improved overall in HRQoL scores, but extended LOS patients improved less overall at 2 years in comparison. Level of Evidence: 3

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Do Work-Related Mechanical and Psychosocial Factors Contribute to the Social Gradient in Low Back Pain?: A 3-Year Follow-Up Study of the General Working Population in Norway

Study Design. A prospective cohort study. Objective. The aim of the study was to investigate the extent to which work-related factors contribute to the social gradient in low back pain (LBP). Summary of Background Data. A social gradient in LBP is well established, but only a few studies have examined the extent to which exposure to mechanical and psychosocial work environment factors is a pathway for this gradient. Methods. A randomly drawn cohort from the general population in Norway aged 18 to 66 years was followed up for 3 years (n = 12,550, response rate at baseline = 67%). Eligible respondents were in paid work during 2006 and 2009 (n = 6819). Based on administrative register data respondents were coded into five educational levels (university/college ≥4 years was set as the reference group). Outcome of interest was self-reported moderate or severe LBP at follow-up adjusted for baseline LBP. Results. In total, 11.2% (397 individuals) men and 14.5% (461 individual) women reported LBP at follow-up. There was a strong social gradient ranging from 16.4% (elementary) to 6.4% (university/college ≥4 years). The corresponding figures among women were 22.4% and 7.5%. Corrected for age, LBP at baseline and working hours, educational level was a significant predictor of LBP at follow-up (odds ratios 1.8–2.3 in men and 1.7–3.1 in women). Adjusting for mechanical factors reduced the gradient by 39% to 43% in men and 28% to 34% in women. Adjusting for psychosocial factors reduced the gradient by 5% to 12% in men and increased the gradient by 7% to 11% in women. Conclusion. Work-related mechanical factors contributed substantially to the social gradient in LBP among both men and women. The impact of psychosocial factors was modest among men and contributed to an increased gradient among women. Level of Evidence: 3

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Lumbar Spondylolisthesis Progression and De Novo Spondylolisthesis in Elderly Chinese Men and Women: A Year-4 Follow-up Study

Study Design. Longitudinal follow-up study. Objective. This current study aimed to further assess progression, incidence, and risk factors of lumbar spondylolisthesis in these subjects at 4-year follow-up. Summary of Background Data. A survey for osteoporotic fractures in Hong Kong during 2001 to 2003 represented the first large scale prospective population-based study on bone health in elderly (≥65 years) Chinese men and women. A follow-up study was performed at year-4. Methods. The lateral lumbar radiographs of 1519 male and 1546 female subjects at year-4 follow-up were analyzed using the Meyerding classification, and compared with the baseline findings. Results. Spondylolisthesis progressed in 13.0%, and de novo spondylolisthesis appeared in 12.4% in men. Spondylolisthesis progressed in 16.5%, and de novo spondylolisthesis appeared in 12.7% in women. In women, higher weight, body mass index, spine and hip bone mineral density (BMD), lower physical activity and lower grip strength were significant factors associated with spondylolisthesis progression, whereas only higher spine BMD was a marginally significant factor associated with spondylolisthesis progression for men. A weak association was noted between spondylolisthesis and lower back pain incidence in women, but not in men. Conclusion. Lumbar spondylolisthesis progression in elderly Chinese at 4-year follow-up was characterized by this study. Level of Evidence: 3

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