Effectiveness of opioids for chronic noncancer pain: a two-year multicenter, prospective cohort study with propensity score matching

Chronic pain (CP) is a major and debilitating health problem.9 It has an estimated prevalence of 20% in the European population and is an important cause of direct and indirect healthcare costs, quality of life impairment and has a significant impact on patients’ and their families’ lives.8,51

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Cannabidiol modulates serotonergic transmission and reverses both allodynia and anxiety-like behavior in a model of neuropathic pain

Clinical studies indicate that cannabidiol (CBD), the primary nonaddictive component of cannabis that interacts with the serotonin (5-HT)1A receptor, may possess analgesic and anxiolytic effects. However, its effects on 5-HT neuronal activity, as well as its impact on models of neuropathic pain are unknown. First, using in vivo single-unit extracellular recordings in rats, we demonstrated that acute intravenous (i.v.) increasing doses of CBD (0.1-1.0 mg/kg) decreased the firing rate of 5-HT neurons in the dorsal raphe nucleus, which was prevented by administration of the 5-HT1A antagonist WAY 100635 (0.3 mg/kg, i.v.) and the TRPV1 antagonist capsazepine (1 mg/kg, i.v.) but not by the CB1 receptor antagonist AM 251 (1 mg/kg, i.v.). Repeated treatment with CBD (5 mg/kg/day, subcutaneously [s.c.], for 7 days) increased 5-HT firing through desensitization of 5-HT1A receptors. Rats subjected to the spared nerve injury model for 24 days showed decreased 5-HT firing activity, mechanical allodynia, and increased anxiety-like behavior in the elevated plus maze test, open-field test, and novelty-suppressed feeding test. Seven days of treatment with CBD reduced mechanical allodynia, decreased anxiety-like behavior, and normalized 5-HT activity. Antiallodynic effects of CBD were fully prevented by capsazepine (10 mg/kg/day, s.c., for 7 days) and partially prevented by WAY 100635 (2 mg/kg/day, s.c., for 7 days), whereas the anxiolytic effect was blocked only by WAY. Overall, repeated treatment with low-dose CBD induces analgesia predominantly through TRPV1 activation, reduces anxiety through 5-HT1A receptor activation, and rescues impaired 5-HT neurotransmission under neuropathic pain conditions.

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Do pain measurement instruments detect the effect of pain-reducing interventions in neonates? A systematic review on responsiveness

Worldwide, more than 15 million children a year are born prematurely and this number is rising.43 In the NICU setting they are at risk of acute pain; one study reported a mean number of 11.4 painful procedures per day during the first 14 day.35 They are also at risk of prolonged or chronic pain from, for example, skin conditions, gastro-intestinal conditions, inflammation and the aftermath of surgery.2,3

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Effectiveness of Exercise Interventions for Pain Reduction in People With Multiple Sclerosis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Publication date: January 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 1

Author(s): Thibaut Demaneuf, Zoe Aitken, Amalia Karahalios, Teng Ieng Leong, Alysha M. De Livera, George A. Jelinek, Tracey J. Weiland, Claudia H. Marck

Abstract

Objective

To systematically review the evidence of the effect of exercise compared with passive control on pain in people with multiple sclerosis.

Data Source and Study Selection

Five electronic databases were searched for randomized controlled trials published up to March 2017 that recruited people with multiple sclerosis where exercise was the intervention and pain was an outcome (PROSPERO registration number CRD42017060489).

Statistical Analysis

A random-effects meta-analysis was conducted to estimate the standardized mean difference of the effect of exercise on pain between treatment and control groups. We assessed risk of bias, fitted meta-regression models to explore heterogeneity between studies, and assessed small study effects.

Data Synthesis

Ten studies met the inclusion criteria (total sample size=389), and all studies were at high risk of bias. We found that exercise interventions were associated with less pain compared with passive control groups (standardized mean difference=−.46; 95% CI, −.92 to .00). There was high between-study heterogeneity (I²=77.0%), which was not explained by the prespecified study characteristics. There was also some evidence of small study effects.

Conclusion

This is the first systematic review of the effect of exercise interventions on pain in people with multiple sclerosis, a chronic neurological disorder that affects 2.5 million people. We found some evidence that exercise compared with passive control alleviates pain in this population, but there were limitations in reporting and study quality with high risk of bias of individual studies and heterogeneity between studies.

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Ability of Patient-Reported Outcomes to Characterize Patient Acceptable Symptom State (PASS) After Attending a Primary Care Physical Therapist and Medical Doctor Collaborative Service: A Cross-Sectional Study

Publication date: January 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 1

Author(s): Jeff Houck, Daniel Kang, Tyler Cuddeford, Sarah Rahkola

Abstract

Objectives

To determine if the Patient-Reported Outcome Measurement Information System (PROMIS) physical function, pain interference, self-efficacy, and global rating of normal function (GRNF) scales are able to accurately characterize a patient’s acceptable symptom state (PASS).

Design

A cross-sectional analysis, using receiver operator curves and chi-square analysis to explore criteria to determine thresholds (80% and 95% sensitivity/specificity) for PASS that are applicable to PROMIS and GRNF scales.

Setting

Phone survey after primary care.

Participants

Patients (N=94) attending primary care for musculoskeletal problems.

Interventions

Not applicable.

Main Outcomes Measures

Accuracy and proportion of patients classified as PASS Yes or No.

Results

Receiver operator curve analysis showed significant area under the curve (AUC) values for each PROMIS scale (AUC>.72) and the GRNF rating (AUC=.74). Identified PROMIS thresholds suggested PASS was achieved when scores were at or slightly worse than the US population average. A score of ≥7 and ≤4 characterized patients that were PASS Yes and No, respectively, on the GRNF rating. A moderate (80%) specificity/sensitivity criteria yielded 72.3%-73.5% accuracy for a majority of participants (>69.9%).

Conclusion

This analysis suggests the PROMIS and GRNF scales are able to characterize PASS status with moderate accuracy (∼70%) for a large portion of patients (∼70%). New to this study is the association of self-efficacy with PASS status. PROMIS scales at or slightly worse than the US population average characterized PASS status.

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Building a Rehabilitative Care Measurement Instrument to Improve the Patient Experience

Publication date: January 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 1

Author(s): Josephine McMurray, Heather McNeil, Alicia Gordon, Jacobi Elliott, Paul Stolee

Abstract

Objective

To develop and test face and content validity, and user interface design of a rehabilitative care patient experience measure.

Design

Mixed methods, cross-sectional validation study that included subject matter expert input. Cognitive interviewing tested user interface and design.

Setting

Outpatient rehabilitative care settings.

Participants

Subject matter experts (n=3), health care providers (n=137), and patients and caregivers (n=5) contributed to the question development. Convenience and snowball sampling were used to recruit rehabilitative care patients postdischarge (n=9) for cognitive interviews to optimize survey design and user interface (N=154).

Interventions

Not applicable.

Main Outcome Measure

This novel survey instrument measures 6 concepts previously identified as key to outpatient rehabilitative care patients’ experience: ecosystem issues, client and informal caregiver engagement, patient and health care provider relations, pain and functional status, group and individual identity, and open-ended feedback.

Results

502 survey questions from psychometrically tested instruments, secondary data from a related ethnographic study, and consultations with health care providers, patients, caregivers, and subject matter experts, were analyzed to create a 10-item questionnaire representing 6 key constructs that influence patient experience quality. Cognitive interviewing with 9 patients (3 rounds of 3 participants each), produced 3 progressively edited versions of the survey instrument. A final version required no further modifications.

Discussion

Rehabilitative care clients have characteristics that differentiate their experience from that of other sectors and patient groups, warranting a distinct experience measure. The survey instrument includes a parsimonious set of questions that address strategic issues in the ongoing improvement of care delivery and the patient experience in the rehabilitative care sector.

Conclusion

The rehabilitative care patient experience survey instrument developed has an acceptable user interface, and content and face validity. Psychometric testing of the survey instrument is reported elsewhere.

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Efficacy of Internet-Delivered Mindfulness for Improving Depression in Caregivers of People With Spinal Cord Injuries and Chronic Neuropathic Pain: A Randomized Controlled Feasibility Trial

Publication date: January 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 1

Author(s): Jasmine Heath Hearn, Imogen Cotter, Katherine Anne Finlay

Abstract

Objectives

To explore the feasibility and efficacy of web-based mindfulness training for carers of people with spinal cord injury (SCI).

Design

Randomized controlled feasibility study with 3-month follow-up.

Setting

Community setting.

Participants

Spouses or family caregivers (N=55) of people with SCI and chronic neuropathic pain were recruited via the direct care team and advertisements. Participants were older than 18 years (no upper age limit), with Internet access for the duration of the study. Participants were randomly allocated to an 8-week online mindfulness training intervention (n=28), or to receive 8 weeks of psychoeducational materials on SCI and chronic pain (n=27).

Interventions

An established web-based, mindfulness training course was delivered over 8 weeks. Participants completed 10 minutes of mindfulness practices, twice per day, 6 days per week, totaling 960 minutes. The control group received a weekly e-mail with psychoeducational materials (based on the established elements) on SCI and pain for 8 weeks.

Main Outcome Measure

Depression severity.

Results

Mindfulness reduced depression severity more than psychoeducation at T2 (mean difference= −.891; 95% confidence interval,−1.48 to −.30) and T3 (mean difference=−1.96; 95% confidence interval, −2.94 to −.97). Mindfulness training also reduced anxiety at T2 (mean difference=−.888; 95% confidence interval, −1.40 to −.38) and T3 (mean difference=−2.44; 95% confidence interval, −3.20 to −1.69).

Conclusions

Results indicate that Internet-delivered mindfulness training offers unique benefits and is viable for caregivers of people with SCI and chronic neuropathic pain. Further work should explore the feasibility of combined education and mindfulness training incorporating both patient and caregiver, for optimum benefit.

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Effects of a Patient-Centered Graded Exposure Intervention Added to Manual Therapy for Women With Chronic Pelvic Pain: A Randomized Controlled Trial

Publication date: January 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 1

Author(s): M^a José Ariza-Mateos, Irene Cabrera-Martos, Araceli Ortiz-Rubio, Irene Torres-Sánchez, Janet Rodríguez-Torres, Marie Carmen Valenza

Abstract

Objective

To explore the effects of a 6-week patient-centered graded exposure intervention added to manual therapy in women with chronic pelvic pain (CPP) and fear of movement/(re)injury.

Design

Prospective 3-armed randomized controlled trial.

Setting

Faculty of Health Sciences.

Participants

A total of 49 women with CPP and substantial fear of movement were randomly allocated to 1 of 3 groups: (1) patient-centered graded exposure intervention added to manual therapy; (2) manual therapy; (3) control group.

Interventions

The 6-week intervention consisted of 12 sessions in the group receiving manual therapy and 6 additional sessions of graded exposure therapy in the group receiving both interventions.

Main Outcome Measures

Primary outcomes were fear-avoidance behavior assessed using the Fear-Avoidance Beliefs Questionnaire and pain interference and severity evaluated with the Brief Pain Inventory. The secondary outcome was disability evaluated with the Oswestry Disability Index. All the variables were assessed in a blinded manner at baseline, after the treatment, and at 3-month follow-up.

Results

Our results show interaction effects (P<.05) for all the outcomes. Graded exposure added to manual therapy is distinctly superior to manual therapy alone in maintaining improvements for long-term fear-avoidance behavior and physical functioning.

Conclusions

Graded exposure added to manual therapy is a promising approach with long-term effects for women with CPP and fear of movement/(re)injury.

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Social Influences on Peer Judgements about Chronic Pain and Disability

Chronic pain is a leading cause of decreased work productivity and absenteeism.37,40 This lost productivity is estimated to cost the US upwards of $355 billion annually.21 Nearly 40% of individuals with chronic pain report that pain negatively impacts their job, such that they take more sick days, arrive late or leave early, and distribute work to colleagues.33 Furthermore, patients with chronic pain receive $18.9 billion annually in disability compensation.21

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AAAPT Diagnostic Criteria for Acute Sickle Cell Disease Pain

Acute pain episodes are the most common complication in patients with sickle cell disease (SCD). Classically attributed to vaso-occlusion, recent insights suggest that chronic pain may also contribute to the pathogenesis of acute pain episodes, which adds complexity to their diagnosis and management. A taxonomy, or classification system, for acute pain in patients with SCD would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S.

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Cross-Cultural Adaptation, Validity, and Reliability Study of the Turkish Version of Back Performance Scale

Study Design. Validation of a performance scale. Objective. The purpose of this study is to investigate adaptation, validity, and reliability of the Turkish version of the Back Performance Scale (BPS). Summary of Background Data. Low back pain affects people of all ages and causes pain, disability, and psychosocial problems. BPS is a condition-specific performance measure of activity limitation in patients with low back pain. The purpose of this study is to investigate the cross-cultural adaptation, validity, and reliability of the Turkish version of the BPS. Methods. The study included 180 patients with low back pain. For the reliability assessment of the scale, test-retest, and internal consistency analyses were performed. The results of the test-retest analysis were analyzed by Intraclass Correlation Coefficient (ICC) method. For the internal consistency, Cronbach Alpha value was calculated and to construct validity, total points of the BPS were compared with the total points of Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) using Pearson correlation coefficient analysis. Results. BPS was found to have high internal consistency (Cronbach alpha value 0.827). Test-retest results were found highly correlated (range from 0.723 to 0.899). Factor analysis indicated that the scale had one factor. BPS is well correlated with RMDQ and ODI (Pearson correlation coefficient with RMDQ 0.576 and with ODI 0.603). Conclusion. The Turkish version of BPS is valid and reliable. Level of Evidence: 3

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Determinants of Patient Satisfaction 2 Years After Spinal Deformity Surgery: A Latent Class Analysis

Study Design. Retrospective review of prospective multicenter database. Objective. To investigate the determinants of patient satisfaction with respect to changes in functional limitations 2 years after spinal deformity surgery. Summary of Background Data. For operatively treated adult spine deformity (ASD), patient satisfaction has become an important component of evaluating quality of care. Methods. A total of 430 operative patients with ASD with 2-year follow-up were analyzed. Patient satisfaction was assessed using the Scoliosis Research Society 22-item. Latent class analysis was performed to assign individuals to classes based on the changes in pre- and 2-year postoperative functions, assessed using the Oswestry Disability Index (ODI). An ordered logistic regression was conducted to assess the association of class membership and satisfaction. Results. Latent class analysis identified four classes. The worsened-condition class (WC: 1.4%) consisted of patients who were likely to experience worsened function, particularly in lifting and pain intensity. The remained-same class (RS: 13.0%) included patients who remained the same, because the majority reported approximately no change in walking, standing, and sitting. The mild-improved class (mild-I: 40.2%) included patients with mildly enhanced conditions, specifically, in standing, social life, and employment. The most-improved class (most-I: 45.3%) included patients with great improvement after surgery mainly in standing, followed by social life and employment. The odds of being satisfied were significantly increased by 3.91- (P < 0.001) and 16.99-fold (P < 0.001), comparing patients in mild-I and most-I to the RS/WC class, respectively, after controlling for confounders. Conclusion. Improvement in standing, social life, and employment are the most important determinants of patient satisfaction postsurgery. Reduced pain intensity and enhanced walking ability also help to elevate patient satisfaction. However, lifting, personal care, sitting, sleeping, and travelling may be of less importance. Examining the heterogeneity of patient-reported outcome in patients with ASD allows the identification of classes with different patient characteristics and satisfaction, and thus, help to guide tailored provision of care. Level of Evidence: 4

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Effectiveness of Kinesio Taping in Patients With Chronic Nonspecific Low Back Pain: A Systematic Review With Meta-analysis

Study Design. Systematic review. Objective. To investigate the effects of Kinesio Taping (KT) in patients with nonspecific low back pain. Summary of Background Data. KT is widely used in patients with low back pain. Methods. We conducted searches on PubMed, EMBASE, PEDro, SciELO, and LILACS up to February 26, 2018. We included only randomized controlled trials (RCTs) in adults with chronic nonspecific low back pain that compared KT to no intervention or placebo as well as RCTs that compared KT combined with exercise against exercise alone. The methodological quality and statistical reporting of the eligible trials were measured by the 11-item PEDro scale. The quality of the evidence was assessed using the GRADE classification. We considered pain intensity and disability as the primary outcomes. Whenever possible, the data were pooled through meta-analysis. Results. We identified 11 RCTs for this systematic review (pooled n = 743). Two clinical trials (pooled n = 100) compared KT to no intervention at the short-term follow-up. Four studies compared KT to placebo (pooled n = 287) at short-term follow-up and two trials (pooled n = 100) compared KT to placebo at intermediate-term follow-up. Five trials (pooled n = 296) compared KT combined with exercises or electrotherapy to exercises or spinal manipulation alone. No statistically significant difference was found for most comparisons. Conclusion. Very low to moderate quality evidence shows that KT was no better than any other intervention for most the outcomes assessed in patients with chronic nonspecific low back pain. We found no evidence to support the use of KT in clinical practice for patients with chronic nonspecific low back pain. Level of Evidence: 1

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Comparison of Two Posterior Three-Point Fixation Techniques for Treating Reducible Atlantoaxial Dislocation

Study Design. Retrospective comparative study. Objective. To compare the outcomes of C1–C2 transarticular screw combined with C1 laminar hook (TAS+C1H) and C1–C2 transarticular screw combined with modified Gallie technique (TAS+G) for treating reducible atlantoaxial dislocation (AAD). Summary of Background Data. Both TAS+C1H and TAS+G fixation were 3-point fixation techniques for AAD. TAS+C1H technique was comparable to TAS+G technique in biomechanics. However, it is unknown whether it can achieve same outcomes as TAS+G technique. Methods. Data of the 63 patients who underwent TAS+C1H or TAS+G fixation and fusion because of AAD were retrospectively reviewed. Bone fusion time was recorded. The outcomes evaluated by visual analog scale score for neck pain (VASSNP), Nurick scale, neck stiffness (none/mild/severe), patient satisfaction, and Neck Disability Index (NDI) were compared between two groups. Results. At the final follow-up, bone graft fusion rates were 100% in both groups (P > 0.05). Nurick scales were significantly improved in both groups (P < 0.05), but with no significant differences between groups (P > 0.05). There were no significant differences between two groups in VASSNP, neck stiffness, patient satisfaction, or NDI (all P > 0.05). There were no complications related to the surgical approach and instrumentation in either group. Conclusion. Both TAS+C1H and TAS+G fixation were effective in the treatment of reducible AAD. TAS+C1H was safer than TAS+G because it could potentially reduce the risk of spinal cord and venous plexus injury associated with sublaminar cables. Level of Evidence: 3

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Decreasing pain ratings in chronic arm pain through changing a virtual body: different strategies for different pain types

Immersive virtual reality (IVR or just VR) technology is an effective tool for reducing pain sensation in subjects with acute pain. Through presence,54,60 interaction with the virtual environment, and engagement, VR can act as a powerful distractor by gathering attentional resources. This strategy has been used in previous studies for decreasing the attention to acute pain both in patients12,21–23 and in healthy subjects receiving acutely painful stimuli in laboratory settings (e.g. thermal), thereby decreasing pain perception19,24 (reviewed in 25).

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[Correspondence] Low back pain

The Lancet Low Back Pain Series Working Group (June 9, p 2384)1 is to be commended for its call for action on low back pain. Unmet needs in health care, public health, and clinical research must be highlighted. However, the implication that patients with a common symptom of low back pain can adequately be lumped together under a homogeneous biopsychosocial umbrella conflicts with the WHO International Classification of Functioning, Disability and Health, which focuses on body function and structure, in addition to activity, participation, and personal and environmental factors.

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[Correspondence] Low back pain

We are not convinced that the proposals made by the Lancet Low Back Pain Series Working Group,1 which broadly reflect current national guidance,2 are rational or supported by sufficient evidence. Pain is a symptom, not a diagnosis. Without a diagnosis there is little rationale for intervention. Only with a meaningful diagnosis can there be discussion of the risks and benefits of potential interventions. Interventions not based on diagnosis risk being dishonest.

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[Correspondence] Low back pain

The Lancet Series papers on low back pain (June 9, p 2356)1,2 provide a comprehensive review of the causes, prevention, and treatment of low back pain. One possible cause of low back pain often missed by physicians is abdominal aortic aneurysm rupture (or impending rupture).3–5 Ruptured abdominal aortic aneurysms are associated with mortality rates as high as 80% and are often misdiagnosed because of non-specific presenting symptoms, including shock, syncope, low back pain, and nausea or vomiting.

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[Correspondence] Low back pain

We read with interest the Lancet Series on low back pain1,2 outlining the causes, consequences, and challenges associated with low back pain. However, the authors might have collectively missed a valuable opportunity to acknowledge the emerging link between chronic pain, accelerated cognitive decline, and dementia given that there are over 46 million people worldwide living with dementia at a cost of US$818 billion, with the number of people projected to almost double every 20 years.3 Dementia is, after all, Britain's single biggest killer.

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[Correspondence] Low back pain

The Lancet Series on low back pain1 gives a comprehensive overview of strategies to prevent and treat low back pain. The treatment of low back pain remains challenging, as is the interpretation of the evidence. We would like to comment on two statements made by Nadine E Foster and colleagues.1

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[Correspondence] Low back pain – Authors' reply

Christelle Nguyen and colleagues, Tim Germon and colleagues, and Kosmas I Paraskevas argue that we did not pay sufficient attention to the specific nociceptive causes of low back pain in our Lancet Series on low back pain. We were quite explicit that low back pain is a symptom not a disease and can result from several different known or unknown abnormalities or diseases.1 When it is possible to define additional specific nociceptive causes for low back pain with effective treatments then we will be able to address this major health issue, as Germon and colleagues suggest.

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Exercise therapy in addition to an orthosis reduces pain more than an orthosis alone in patients with thumb base osteoarthritis: a propensity score matching study

Publication date: Available online 11 December 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): R.M. Wouters, J. Tsehaie, H.P. Slijper, S.E.R. Hovius, R. Feitz, Hand-Wrist Study Group, R.W. Selles

Abstract

Objective

To compare the effect of exercises and orthotics with orthotics alone on pain and hand function in patients with thumb base (CMC-1) osteoarthritis (OA) and to predict outcomes on pain and hand function of exercises and orthotics.

Design

Prospective cohort study with propensity score matching

Setting

Data collection took place in thirteen outpatient clinics for hand surgery and hand therapy in the Netherlands.

Participants

A consecutive, population-based sample of 173 patients with CMC-1 OA was included in this study of which 84 were matched on baseline demographics and baseline primary outcomes.

Interventions

Exercises and orthotics versus orthotics alone.

Main Outcome Measure(s)

Primary outcomes included pain and hand function at three months, measured using Visual Analogue Scales (0-100, VAS) and the Michigan Hand outcomes Questionnaire (0-100, MHQ).

Results

A larger decrease in VAS pain at rest (11.1 points difference, 95% Confidence interval(CI): 1.9, 20.3, p=0.002) and during physical load (22.7 points difference, 95% CI: 13.6, 31.0, p<0.001,) was found in the exercise + orthotic group compared to the orthotic group. Additionally, larger improvement was found for the MHQ subscales pain, work performance, aesthetics and satisfaction in the exercise + orthotic group. No differences were found on other outcomes. Baseline scores of metacarpophalangeal flexion, presence of scapho-trapezio-trapezoid OA, VAS pain at rest, heavy physical labor and MHQ total predicted primary outcomes for the total exercise + orthotic group (N=131).

Conclusions

Conservative treatment for patients with CMC-1 OA should include exercises, since there is a relatively large treatment effect compared to using an orthosis alone. Future research should study exercises and predictors in a more standardized setting to confirm this finding.

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Racial-Ethnic Differences in Osteoarthritis Pain and Disability: A Meta-Analysis

Osteoarthritis (OA) affects 32.5 million individuals and is among the leading causes of pain and disability in the United States, with annual direct (i.e., medical expenditure) and indirect (i.e., loss earnings) costs estimated at $16,000 per patient and an annual societal economic impact of $486 billion.134 OA is a significant cause of musculoskeletal pain, stiffness, swelling, and restricted range of motion,37 and adversely impacts mobility,15 activities of daily living,127 quality of life,2 and psychological functioning.

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Identifying the pathways required for coping behaviours associated with sustained pain

Identifying the pathways required for coping behaviours associated with sustained pain

Identifying the pathways required for coping behaviours associated with sustained pain, Published online: 10 December 2018; doi:10.1038/s41586-018-0793-8

In mice, the ablation of spinal neurons that co-express TAC1 and LBX1 leads to the loss of coping responses to sustained pain without affecting reflexive defensive reactions to external threats.

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Differential predictors of pain severity over 12 months following non-catastrophic injury sustained in a road traffic crash

The incidence of non-catastrophic injuries sustained in a road traffic crash has increased over the last three decades.39 These injuries can lead to substantial personal, social, and economic health burden in the longer term.5, 13, 25 Australian data on mild to moderate injuries sustained in a road traffic crash show that nearly 70% of related costs was associated with disability, costs of medical services, lost productivity and insurance administration.2 Despite the high prevalence and substantial burden, little is known about the factors hindering recovery following these traffic-related injuries.

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The pain dynamics of small fiber neuropathy

Small fiber neuropathy (SFN) is a condition in which the thinly myelinated Aδ- and unmyelinated C-fibers are affected. The clinical picture is dominated by neuropathic pain, but other sensory symptoms and autonomic complaints may also be present.19 SFN is not a rare disorder, but has mainly been underdiagnosed. There is a conservative minimum incidence estimation of 12/100,000 per year, and a minimum prevalence of 53/100,000.25 The diagnosis SFN is based on the clinical picture in combination with an abnormal intraepidermal nerve fiber density (IENFD) in skin biopsy, and/or abnormal temperature thresholds levels in quantitative sensory testing (QST).

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Tropomyosin receptor kinase B receptor activation in the locus coeruleus restores impairment of endogenous analgesia at a late stage following nerve injury in rats

Insufficient endogenous analgesia is reported in human patients with various types of chronic pain.3,10,13,22,25,29 Endogenous analgesia in humans can be evaluated by measuring conditioned pain modulation.41 In experimental animals, conditioned pain modulation is assessed based on noxious stimuli-induced analgesia (NSIA).28 The noxious stimulus in NSIA is a subcutaneous injection of capsaicin, and the resulting endogenous analgesia is heterosegmental, i.e., antinociception can be observed at sites remote from the site of stimulation.

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Comparative Responsiveness of the PROMIS Pain Interference Short Forms with Legacy Pain Measures: Results from Three Randomized Clinical Trials

The National Institutes of Health-funded Patient-Reported Outcomes Measurement Information System (PROMIS®) provides researchers and clinicians with outcome measures that are reliable, valid, and publicly accessible.1,3 In contrast to legacy measures, PROMIS® emerged from state-of-art psychometric methodologies including item response theory.3 Item response theory supports computerized adaptive testing and development of fixed-length short forms containing the most informative items.1

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Adjacent Disc Degeneration After Lumbar Total Disc Replacement or Nonoperative Treatment: A Randomized Study with 8-year Follow-up

Study Design. A randomized controlled multicenter trial with 8-year follow-up. Objective. The aim of this study was to assess the long-term development of adjacent disc degeneration (ADD) after lumbar total disc replacement (TDR) or nonoperative treatment, and to analyze the association between ADD development and clinical outcome. Summary of Background Data. TDR was introduced as a motion-preserving alternative to spinal fusion, which has been reported to increase the risk of ADD. However, ADD may develop naturally regardless of any surgery, and no randomized study has assessed the long-term development of ADD after TDR versus nonoperative treatment. Methods. The study included 126 of the 173 patients with chronic low back pain (LBP) originally included in a randomized study comparing TDR with multidisciplinary rehabilitation. Magnetic resonance imaging (MRI) of the lumbar spine was performed before treatment and at 8-year follow-up. ADD was categorized as increased or not increased based on an evaluation of Modic changes, disc height reduction, disc contour, herniation size, nucleus pulposus signal, and posterior high intensity zones. We used a χ2 test or a Fisher exact test to compare crude proportions, and multiple linear regressions to analyze the association between increased ADD (yes/no) and change in Oswestry Disability Index (ODI) from pre-treatment to follow-up. Results. ADD increased (for at least one ADD variable) in 23 of 57 patients (40%) treated nonoperatively, and 29 of 69 patients (42%) treated with TDR (P = 0.86). We found no significant associations between ADD increase and the change in ODI. Conclusion. Increased ADD occurred with similar frequency after TDR and after nonoperative treatment, and was not related to the clinical outcome at 8-year follow-up. Level of Evidence: 1

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Proprioceptive Weighting Ratio for Balance Control in Static Standing Is Reduced in Elderly Patients With Non–Specific Low Back Pain

MINI Elderly patients older than 65 years were divided into non-specific low back pain (NSLBP) and non-LBP (NLBP) groups. The postural control study of the relative contributions of different proprioceptive signals (relative proprioceptive weighting ratio [RPW]) revealed lower leg proprioceptive decreases (RPW 240 Hz) in NSLBP compared to NLBP. Study Design. A cross-sectional, observational study. Objective. The aim of this study was to determine a specific proprioceptive control strategy during postural balance in elderly patients with non-specific low back pain (NSLBP) and non-LBP (NLBP). Summary of Background Data. Proprioceptive decline is an important risk factor for decreased balance control in elderly patients with NSLBP. The resulting reduction in proprioception in the trunk or lower legs may contribute to a reduction in postural sway. This study aims to determine the specific proprioceptive control strategy used during postural balance in elderly patients with NSLBP and NLBP and to assess whether this strategy is related to proprioceptive decline in NSLBP. Methods. Pressure displacement centers were determined in 28 elderly patients with NSLBP and 46 elderly patients with NLBP during upright stances on a balance board without the benefit of vision. Gastrocnemius and lumbar multifidus muscle vibratory stimulations at 30, 60, and 240 Hz, respectively, were applied to evaluate the relative contributions of the different proprioceptive signals (relative proprioceptive weighting ratio, RPW) used in postural control. Results. Compared to elderly patients with NLBP, those with NSLBP had a lower RPW at 240 Hz and significantly higher RPW at 30 Hz. A logistic regression analysis showed that RPW at 240 Hz was independently associated with NSLBP after controlling for confounding factors. Conclusion. Elderly patients with NSLBP decreased their reliance on ankle strategy (RPW at 240 Hz) and hip strategy (RPW at 30 Hz) proprioceptive signals during balance control. The inability to control hip and ankle strategies indicates a deficit of postural control and is hypothesized to result from proprioceptive impairment. Moreover, elderly patients with NSLBP are at higher risk for lower leg proprioceptive decrease (240 Hz) through the NSLBP exacerbation. Level of Evidence: 4

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Considering Spine Surgery: A Web-Based Calculator for Communicating Estimates of Personalized Treatment Outcomes

Study Design. Prospective evaluation of an informational web-based calculator for communicating estimates of personalized treatment outcomes. Objective. To evaluate the usability, effectiveness in communicating benefits and risks, and impact on decision quality of a calculator tool for patients with intervertebral disc herniations, spinal stenosis, and degenerative spondylolisthesis who are deciding between surgical and nonsurgical treatments. Summary of Background Data. The decision to have back surgery is preference-sensitive and warrants shared decision making. However, more patient-specific, individualized tools for presenting clinical evidence on treatment outcomes are needed. Methods. Using Spine Patient Outcomes Research Trial data, prediction models were designed and integrated into a web-based calculator tool: https://ift.tt/2y3da9Z. Consumer Reports subscribers with back-related pain were invited to use the calculator via email, and patient participants were recruited to use the calculator in a prospective manner following an initial appointment at participating spine centers. Participants completed questionnaires before and after using the calculator. We randomly assigned previously validated questions that tested knowledge about the treatment options to be asked either before or after viewing the calculator. Results. A total of 1256 consumer reports subscribers and 68 patient participants completed the calculator and questionnaires. Knowledge scores were higher in the postcalculator group compared to the precalculator group, indicating that calculator usage successfully informed users. Decisional conflict was lower when measured following calculator use, suggesting the calculator was beneficial in the decision-making process. Participants generally found the tool helpful and easy to use. Conclusion. Although the calculator is not a comprehensive decision aid, it does focus on communicating individualized risks and benefits for treatment options. Moreover, it appears to be helpful in achieving the goals of more traditional shared decision-making tools. It not only improved knowledge scores but also improved other aspects of decision quality. Level of Evidence: 2

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Opioid Dependence and Prolonged Length of Stay in Lumbar Fusion: A Retrospective Study Utilizing the National Inpatient Sample 2003–2014

Study Design. Retrospective cohort utilizing the National Inpatient Sample (NIS) 2003 to 2014. Objective. To investigate the association of opioid dependence with prolonged length of stay (LOS), costs, and surgical complications in elective one-to-two level lumbar fusion. Summary of Background Data. Opioids are the most commonly prescribed drug class to treat back pain. Few studies have examined the impact of opioid dependence on spinal fusion outcomes. The data available show inconsistent conclusions regarding the association between opioid dependence and LOS. Methods. Data from 1,826,868 adult elective one-to-two level lumbar fusion discharges in the NIS from 2003 to 2014 were included. Discharges were categorized into an opioid-dependent or unaffected cohort based on the presence or absence of an International Classification of Disease, Ninth Revision-Clinical Modification (ICD-9-CM) code for opioid dependence. Incidence of opioid dependence was compared between 2003 and 2014 via adjusted Wald tests. Patient and surgical characteristics, costs, and complications were compared between cohorts via chi-square tests or adjusted Wald tests for categorical and continuous variables, respectively. Patient and surgical factors were tested for association with prolonged LOS via univariable logistic regressions, and significant (P ≤ 0.01) factors were included in a multivariable logistic regression. Results. Seven thousand nine hundred sixty-four (0.44%) discharges included a diagnosis of opioid dependence. The incidence of opioid dependence increased from 2003 to 2014. Opioid dependence was associated with an adjusted 2.11 times higher odds of prolonged LOS. Opioid-dependent discharges accrued higher costs and had higher frequencies of infection, device-related complications, hematoma- or seroma-related complications, acute posthemorrhagic anemia, and pulmonary insufficiency. Conclusion. This nationally-representative study suggests that opioid dependence is associated with prolonged LOS in lumbar fusion, as well as higher costs and higher frequencies of surgical complications. Further investigations are needed to determine the optimal method to treat opioid-dependent patients who require lumbar fusion. Level of Evidence: 3

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Highly Cited Works in Spinal Disorders: The Top 100 Most Cited Papers Published in Spine Journals

Study Design. Bibliometric analysis. Objective. To identify, and summarize the key findings of, the top 100 most highly cited works published in spinal disorder topic-specific journals. Summary of Background Data. There is an abundance of published articles pertaining to spine surgery and spinal disorders. The number of citations a work receives provides a useful measure of its scientific impact. An understanding of the most cited works in spine surgery can identify literature that surgeons and researchers should be familiar with, point to the most active areas of research, inform the design of educational curricula, and help guide future research efforts. Methods. Journals relating to spinal disorders were identified using the Journal Citation Reports database. We then searched the Web of Science database for articles appearing in each of these journals. The top 100 most cited works were selected for analysis. Results. The top 100 most cited articles appeared in seven of eight journals dedicated to spinal disorders, with 84 in Spine and seven in the European Spine Journal. The citation count for individual articles ranged from 343 to 1949. Most works (73) were published between 1990 and 2004. The greatest number of articles (22) focused on low back pain, followed by biomechanics (13), degenerative disc disease (12), and lumbar spinal stenosis/lumbar fusion (9). With regard to study design, laboratory investigations were the most common (12), followed by guideline documents (11), reviews (10), and retrospective cohort studies (10). Conclusion. The most cited works in spinal disorder journals are guidelines for low back pain, descriptions of quality of life (QOL) metrics, or laboratory investigations into spinal biomechanics. A gap exists for work relating to neck pain or cervical spinal pathology (e.g., cervical myelopathy), representing opportunity for future work. Time of publication, topic of study, study design, and journal are possible determinants of likelihood of citation. Level of Evidence: N/A

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Efficacy and Safety of Full-endoscopic Decompression via Interlaminar Approach for Central or Lateral Recess Spinal Stenosis of the Lumbar Spine: A Meta-analysis

Study Design. A meta-analysis of five retrospective cohort studies. Objective. The aim of the study was to delineate the efficacy and safety of full-endoscopic decompression via the interlaminar approach for central or lateral recess spinal stenosis of the lumbar spine using a meta-analysis. Summary of Background Data. The paradigm of spinal endoscopy is shifting from treatment of soft disc herniation to that of lumbar spinal stenosis. Technical advancements have enabled full-endoscopic decompression in spinal stenosis surgery. There is few strong evidence supporting this surgical technique, and clinicians usually rely on their own opinions and experiences. Methods. A systematic search of electronic databases, including PubMed, EMBASE, Cochrane Library, Web of science, and KoreaMed, up to August 2017 was performed to identify studies concerning full-endoscopic decompression via the interlaminar approach for lumbar spinal stenosis. Changes in clinical outcomes [Oswestry Disability Index (ODI) and Visual Analog Scales (VAS) for back and leg pain] were compared with the minimal clinically important difference (MCID) for each item. We then calculated the mean differences and 95% confidence intervals (95% CIs) using random-effects models. Results. We included data from five studies involving 156 patients at 6- and 12-month follow-ups. The majority of enrolled papers included patients with neurogenic claudication due to central stenosis refractory to conservative management and excluded patients with significant instability or previous surgery. The overall mean difference of patients with ODI and VAS scores for leg and back pain exceeded the criteria for MCID. ODI scores improved by 41.71 (95% CI, 39.80–43.62) after the surgery, which was twice the MCID. The VAS leg and back pain scores improved by 5.95 (95% CI, 5.70–6.21) and 4.22 (95% CI, 3.88–4.56), respectively, indicating statistically significant improvement over the MCID. Conclusion. Successful clinical outcomes can be achieved with full-endoscopic decompression via the interlaminar approach for lumbar central spinal stenosis in patients for the defined indications. Level of Evidence: 2

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Epidural Abscess: A Propensity Analysis of Surgical Treatment Strategies

Study Design. Observational analysis of retrospectively collected data. Objective. A retrospective study was performed in order to compare the surgical profile of risk factors and perioperative complications for laminectomy and laminectomy with fusion procedures in the treatment of spinal epidural abscess (SEA). Summary of Background Data. SEA is a highly morbid condition typically presenting with back pain, fever, and neurologic deficits. Posterior fusion has been used to supplement traditional laminectomy of SEA to improve spinal stability. At present, the ideal surgical strategy—laminectomy with or without fusion—remains elusive. Methods. Thirty-day outcomes such as reoperation and readmission following laminectomy and laminectomy with fusion in patients with SEA were investigated utilizing the American College of Surgeons National Quality Improvement Program database. Demographics and clinical risk factors were collected, and propensity matching was performed to account for differences in risk profiles between the groups. Results. Seven hundred thirty-eight patients were studied (608 laminectomy alone, 130 fusion). The fusion population was in worse health. The fusion population experienced significantly greater rate of return to the operating room (odds ratio [OR] 1.892), with the difference primarily accounted for by cervical spine operations. Additionally, fusion patients had significantly greater rates of blood transfusion. Infection was the most common reason for reoperation in both populations. Conclusion. Both laminectomy and laminectomy with fusion effectively treat SEA, but addition of fusion is associated with significantly higher rates of transfusion and perioperative return to the operating room. In operative situations where either procedure is reasonable, surgeons should consider that fusion nearly doubles the odds of reoperation in the short-term, and weigh this risk against the benefit of added stability. Level of Evidence: 3

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AAPT Diagnostic Criteria for Peripheral Neuropathic Pain: Focal and Segmental Disorders

Peripheral neuropathic pain is among the most prevalent types of neuropathic pain. No comprehensive peripheral neuropathic pain classification system that incorporates contemporary clinical, diagnostic, biological, and psychological information exists. To address this need, this article covers the taxonomy for 4 focal or segmental peripheral neuropathic pain disorders, as part of the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership and the American Pain Society (APS) collaborative to develop a standardized, evidence-based taxonomy initiative: the ACTTION-APS Pain Taxonomy (AAPT).

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The effect of spinal mobilization with leg movement in patients with lumbar radiculopathy – A double blind randomized controlled trial

Publication date: Available online 3 December 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Kiran Satpute, Toby Hall, Richa Bisen, Pramod Lokhande

Abstract

Objectives

To evaluate the effect of spinal mobilization with leg movement (SMWLM) on low back and leg pain intensity, disability, pain centralization and patient satisfaction in subjects with lumbar radiculopathy.

Design

A double blind randomized controlled trial.

Setting

General Hospital

Participants

Sixty adults (mean age 44 years) with sub-acute lumbar radiculopathy

Interventions

Subjects were randomly allocated to receive SMWLM, exercise and electrotherapy (n = 30) or exercise and electrotherapy alone (n = 30). All subjects received 6 sessions over 2 weeks.

Main Outcome Measures

The primary outcomes were leg pain intensity and Oswestry disability index score. Secondary variables were low back pain intensity, global rating of change (GROC), straight leg raise (SLR) and lumbar range of motion (ROM). Variables were evaluated blind at base line, post intervention, and 3 and 6 months follow-up.

Results

Significant and clinically meaningful improvement occurred in all outcome variables. At 2 weeks the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.4, 95% CI 2.0 to 2.7) and disability (MD 3.9 (5.5 to 2.2). Similarly at 6 months the SMWLM group had significantly greater improvement than the control group in leg pain (MD 4.4, 95% CI 4.0 to 4.8) and disability (MD 4.7 (6.3to 3.1). The SMWLM group also reported greater improvement in the GROC and in SLR ROM.

Conclusion

In patients with lumbar radiculopathy, the addition of SMWLM provided significantly improved benefits in terms of leg and back pain, disability, SLR ROM and patient satisfaction in the short-and long-term.

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ENLARGED AREAS OF PAIN AND PRESSURE HYPERSENSITIVITY BY SPATIALLY DISTRIBUTED INTRAMUSCULAR INJECTIONS OF LOW-DOSE NERVE GROWTH FACTOR

Nerve growth factor (NGF) is a neurotrophic factor involved in pain sensitization22 and associated with chronic pain conditions20. Elevated NGF levels have been found in the cerebrospinal fluid of patients with chronic headache and fibromyalgia25, and linked to increased pain intensity in patients with an inflammatory condition22. An early study in healthy volunteers and patients assessing the therapeutic potential of NGF showed that the dose-limiting effect of NGF was pain and hyperalgesia at the site of injection2.

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Trait perceived injustice is associated with pain intensity and pain behaviour in participants undergoing an experimental pain induction procedure

Over the past decade, numerous investigations have examined the role of justice-related appraisals as determinants of health and mental health outcomes of individuals with chronic pain conditions 40, 41. In the context of pain and pain-related disability, perceived injustice has been conceptualized as an appraisal process characterized by a tendency to construe injury or illness as a violation of justice principles, to view one's losses as severe and irreparable, and to attribute blame to others for one's suffering 39.

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Pan-Canadian estimates of chronic pain prevalence from 2000 to 2014: A Repeated Cross-Sectional Survey Analysis

The prevalence of chronic pain in Canada increased between 1996 and 2006, from 15.3% to 19.5%.20 This increase parallels changes reported in other western countries, including the United States,9,13 and is of major concern because chronic pain is associated with substantial costs to the individual and society (i.e., decreased quality of life, lost productivity, and increased health care expenses).16,14 However, since 2008, there has been a paucity of information on the prevalence of chronic pain in Canada.

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Alleviation of mechanical allodynia by 14,15-EET in a central post-stroke pain model: possible role of allopregnanolone and δGABAAR

Central post-stroke pain (CPSP) is a neuropathic pain syndrome arising after lesion of the central nervous system (CNS) due to cerebrovascular insult. This syndrome is characterised by somatosensory abnormalities including spontaneous pain, hyperalgesia and allodynia, which localized to body areas corresponding to the injured brain region.2 These conditions are constant and could impair activities of daily living, consequently undermine quality of life and rehabilitation process. However, CPSP is probably the least recognized complication of stroke and the mechanism of which has not been adequately studied to date.

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Trait mindfulness is associated with lower pain reactivity and connectivity of the default mode network

Mindfulness training reduces pain in clinical and laboratory settings.10,24,34,41,53,60 Similarly, long term meditative practice mitigates sensory17–19 and emotional8,16,37 components of pain. Several studies have shown that mindfulness attenuates pain by enhancing attentional focus on the present moment and regulating associated emotional responses.4,31,43 A growing body of work documents neural activations associated with the effects of mindfulness training on pain. Decreases in pain following mindfulness-based training are frequently associated with greater activation in brain areas associated with sensory and/or salience processing,16,32,61 alongside decreases in the prefrontal cortical regions linked to evaluative and/or emotional responses.

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Preoperative Psychosocial and Psychophysical Phenotypes as Predictors of Acute Pain Outcomes after Breast Surgery

The effective and safe management of postsurgical pain is an important clinical goal, as an estimated 240 million surgeries are performed each year worldwide.60 Despite increased recognition of acute41 and chronic34 postsurgical pain, and much excellent study of the mechanistic underpinnings of postsurgical pain,7 acute postsurgical pain remains a problem21 for a significant minority of patients. In a recent large study in a variety of surgical types, 28% of patients (of 22,000 patients studied) still experienced moderate-severe acute pain after surgery,24 and a sizable number of patients remain on long-term opioids months after orthopedic surgery.

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The Influence of Chronic Neck Pain on Explicit Sequence Learning

Publication date: December 2018

Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 12

Author(s): Michael Brown, Zhengxiong Li, Baicheng Chen, Wenyao Xu, Jeanne Langan

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[Clinical Picture] Kidneys are key in secondary hypertension: a case of fibromuscular dysplasia

A 29-year-old woman was referred to our renal clinic because of pain in her right flank and severe hypertension; her blood pressure was more than 180/110 mm Hg. She was diagnosed as having treatment-resistant-hypertension because her blood pressure remained high at 157/105 mm Hg despite being treated with three antihypertensive drugs, including a diuretic, at maximum doses. 24-h ambulatory monitoring showed increased daytime and nocturnal (non-dipper pattern) blood pressures. She had no history of previous medical difficulties.

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A tired young man with a dysmorphic thumb

A 23 year old man with short stature, congenital malformation of the left thumb and both ears, and a single kidney presented with back pain, shortness of breath, fatigue, and easy bruising that had...

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Monoclonal Antibody Targeting the Matrix Metalloproteinase 9 Prevents and Reverses Paclitaxel-Induced Peripheral Neuropathy in Mice

Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse effect associated with anticancer drugs.45 Nearly 70% of cancer patients experience neuropathic pain symptoms due to the administration of anticancer drugs such as platinum compounds, proteasomes inhibitors, and antitubulins (e.g., vinca alkaloids and taxanes).11,59 Paclitaxel is the frontline chemotherapeutic agent used to treat many solid tumors, but it is also associated with a high incidence of CIPN leading to dose reduction or termination of an otherwise potential life-saving treatment.

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Incident chronic spinal pain and depressive disorders: Data from the National Comorbidity Survey

Chronic spinal pain and depression are common conditions associated with a good deal of morbidity and healthcare utilization. In the US, low back pain, neck pain, and major depressive disorder comprise three of the top four leading causes of years lived with disability.51 The point-prevalence or past-year prevalence of chronic neck and back pain has been estimated at 8.1%-19% in large population-based studies.15,19,25,49,52 The lifetime prevalence of major depressive disorder (MDD) was 17.1% and 16.2% and dysthymic disorder (DD) was 6.4% and 6.9% in the original National Comorbidity Survey (NCS) and its replication (NCS-R), respectively.

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Activation of KCNQ channels prevents paclitaxel-induced peripheral neuropathy and associated neuropathic pain

Paclitaxel is a commonly used chemotherapeutic agent for the treatment of breast and other cancers12. Unfortunately, its use is often associated with significant neurotoxicity, especially resulting in sensory peripheral neuropathies that are often accompanied by neuropathic pain and are frequently severe and resistant to intervention. Paclitaxel-induced peripheral neuropathy (PIPN) results from damage to, or dysfunction of, peripheral nerves, including sensory, autonomic, and motor neurons. The incidence and severity of PIPN is duration- and dose-related, such that more than 60% of patients receiving paclitaxel-based chemotherapy experience peripheral neuropathy in first 3 months58.

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Long-Term Results of Surgery Compared With Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis in the Spine Patient Outcomes Research Trial (SPORT)

Study Design. Randomized trial with a concurrent observational cohort study. Objective. To compare 8-year outcomes between surgery and nonoperative care and among different fusion techniques for symptomatic lumbar degenerative spondylolisthesis (DS). Summary of Background Data. Surgical treatment of DS has been shown to be more effective than nonoperative treatment out to 4 years. This study sought to further determine the long-term (8-year) outcomes. Methods. Surgical candidates with DS from 13 centers with at least 12 weeks of symptoms and confirmatory imaging were offered enrollment in a randomized controlled trial (RCT) or observational cohort study (OBS). Treatment consisted of standard decompressive laminectomy (with or without fusion) versus standard nonoperative care. Primary outcome measures were the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and yearly up to 8 years. Results. Data were obtained for 69% of the randomized cohort and 57% of the observational cohort at the 8-year follow up. Intent-to-treat analyses of the randomized group were limited by high levels of nonadherence to the randomized treatment. As-treated analyses in the randomized and observational groups showed significantly greater improvement in the surgery group on all primary outcome measures at all time points through 8 years. Outcomes were similar among patients treated with uninstrumented posterolateral fusion, instrumented posterolateral fusion, and 360° fusion. Conclusion. For patients with symptomatic DS, patients who received surgery had significantly greater improvements in pain and function compared with nonoperative treatment through 8 years of follow-up. Fusion technique did not affect outcomes. Level of Evidence: 1

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Activity of Daily Living After Long Level Fusion in Adult Spinal Deformity: Compared With Over 60-Year-Old Degenerative Spine Patients Without Adult Spinal Deformity

Study Design. Prospective single center study. Objective. The aim of this study was to evaluate 1) the activity of daily living (ADL) of three categorized patients group; over 60-year-old degenerative spine patients without adult spinal deformity (ASD), nonoperative ASD patients, and operative ASD patients, 2) what kinds of activities would be impaired, and 3) how the ADL changes over time after long level fusion. Summary of Background Data. There is still debate how surgeons could decide treatment methods for old-aged adult spinal deformity, operatively or not. There was lack of information how long level fusion impacts daily activities, especially sedentary Asian lifestyle. In Asia, impaired ADL is much more important issue because of different lifestyle. Methods. Patients were categorized into three groups; Group 1 was over 60-year old aged degenerative spine disease without deformity, Group 2 was ASD patients who did not have surgery, and Group 3 was ASD patients who had surgery for deformity correction. Patients were evaluated using answer Oswestry Low Back Pain Disability Questionnaire, and Assessment activities of daily living for sedentary Asian culture (ADL-SA) questionnaire. Results. Group 1 showed nearly full functions in every activity (ADL-SA: 41.4). ADL-SA scores of Group 2 were similar to Group 1 (P = 0.452). However, get up from bottom (P < 0.001), and pick up object (P < 0.001) were impaired. After long level fusion, ADL was impaired but gradually improved by time. From postoperative 1 year, total ADL score recovered to acceptable range. However, among ADL, activities associated sedentary lifestyle (get up from bottom, wipe floor, pick up object, and sit cross-legged) were still impaired after 2 years postoperatively. Conclusion. ADL was impaired after long level fusion; however it would improve as time goes by. However, among ADL, activities associated sedentary lifestyle was still impaired. Hence give enough information to patients about limited activities before deciding operation. Level of Evidence: 3

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Predicting Factors at Skeletal Maturity for Curve Progression and Low Back Pain in Adult Patients Treated Nonoperatively for Adolescent Idiopathic Scoliosis With Thoracolumbar/Lumbar Curves: A Mean 25-year Follow-up

Study Design. A retrospective, long-term follow-up study. Objective. We aimed to clarify the predicting factors at skeletal maturity for future curve progression and low back pain (LBP) in adolescent idiopathic scoliosis (AIS) with thoracolumbar/lumbar (TL/L) curve. Summary of Background Data. TL/L curves are likely to progress after skeletal maturity and cause LBP. Methods. Of 147 patients treated nonoperatively for AIS with TL/L curve, 56 (55 females; average age at the time of survey, 39.5 ± 7.1 years; average follow-up duration after maturity, 24.9 ± 6.9 years) completed questionnaires, including the visual analogue scale (VAS) for LBP and Oswestry disability index (ODI). Forty-nine patients underwent a radiological examination, and 48 underwent lumbar magnetic resonance imaging (MRI). Results. The mean Cobb angle of the TL/L curve increased from 37.3° ± 7.5° to 47.8° ± 12.6° (0.41° ± 0.39° per year). The factors at skeletal maturity that were associated with the annual progression of the TL/L curve included a cranially located apical vertebra, and great apical vertebral translation and L3 tilt. In addition, the VAS for LBP was positively correlated with L4 tilt, and the ODI was positively correlated with L4 tilt and apical vertebral rotation. Multivariate analyses and receiver-operating characteristic curves demonstrated that L3 tilt at skeletal maturity independently predicted a curve progression ≥0.5° per year (odds ratio [OR], 1.17), while L4 tilt at skeletal maturity independently predicted a VAS ≥3 cm (OR, 1.20) and ODI ≥21% (OR, 1.25) in adulthood, with a cutoff value of approximately 16° for each factor. Moreover, lumbar disc degeneration on MRI was associated with L4 tilt at skeletal maturity and LBP in adulthood. Conclusion. Great L3 and L4 tilt at skeletal maturity, especially those >16°, are predictors of future curve progression and LBP in adulthood, respectively. For adolescent patients with these risk factors, periodic follow-ups into adulthood should be considered. Level of Evidence: 4

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The Relationship Between Fear-Avoidance and Neuromuscular Measures of Function in Patients With Adult Degenerative Scoliosis

Study Design. A prospective cohort study. Objective. To examine the relationship of fear-avoidance beliefs and neuromuscular activity during gait in adult degenerative scoliosis (ADS) patients. Summary of Background Data. Among patients with chronic spine pain, fear-avoidance beliefs are predictive of poor surgical outcomes. Fear-avoi occurs when patients perceive that movement will worsen underlying physical problems. This process leads them to restrict activity, which further heightens emotional distress. Patients with ADS have previously been shown to have an altered gait pattern. Electromyography is evolving into a useful tool to further our understanding of the pathologic manifestations of ADS during gait. Methods. Fifty ADS patients completed the Tampa Scale for Kinesiophobia (TSK) questionnaire and the Fear Avoidance Beliefs Questionnaire (FABQ). Surface electromyography electrodes were bilaterally placed on trunk and lower extremity muscles. Each patient performed a series of over-ground gait trials at a self-selected comfortable speed. Pearson Product Correlation analysis was used to determine the relationship between the self-reported fear of movement measures and the neuromuscular gait analysis biomechanical data. Results. The TSK total score and the FABQ physical were correlated with muscle onset of the External Oblique (P = 0.005), Gluteus Maximus (P = 0.018), Multifidi (P = 0.017), Erector Spinae (P = 0.014), Rectus Femoris (i = 0.008), Semitendinosus (P = 0.012), Tibilais Anterior (P = 0.012), and Medial Gastrocnemius (P = 0.010). Furthermore, the TSK total score, FABQ physical portion were correlated with muscle peak activity of Medial Gastrocnemius (P = 0.007), Multifidi (P = 0.014), and Tibilais Anterior (i = 0.050) and time to peak muscle activity of the Medial Gastrocnemius (P = 0.006) and Semitendinosus P = 0.038. Conclusion. This study demonstrates a strong correlation between neuromuscular gait parameters and fear-avoidance of movement which may reflect ADS patient experiences during ambulation. Further, it demonstrates that there are different aspects of fear-avoidance that may influence gait parameters. This study extends previous research on the role of fear-avoidance to include patients with spinal deformity. Level of Evidence: 3

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Course and Contributors to Back Pain in Middle-aged Women Over 9 Years: Data From the Australian Longitudinal Study on Women's Health

Study Design. Community-based, cohort study. Objective. Our aim was to determine the course of back pain in middle-aged women over a 9-year period, and assess whether obesity and physical inactivity are associated with more frequent back pain. Summary of Background Data. Back pain is the leading cause of disability worldwide. With minimal effective therapies and rising financial burden, identifying modifiable risk factors remains a key priority. Methods. The Australian Longitudinal Study on Women's Health is a cohort study of community-based, middle-aged women who completed questionnaires every 3 years between 2004 and 2013. Approximately, 10,530 women completed the survey in 2004 (mean age 55.5 yrs), and 9020 completed follow-up 9 years later. Self-reported data on back pain in the last 12 months and other sociodemographic factors were collected at all four surveys. ‘Frequent back pain’ was defined as back pain reported at ≥ three surveys. Results. Back pain was common and persistent, with 48% having back pain in ≥ three out of four surveys. Baseline obesity (relative risk [RR] 1.18, 95% confidence interval [CI] 1.12–1.25), lack of vigorous physical activity (RR 1.17, 95% CI 1.10–1.25), depressive symptoms (RR 1.40, 95% CI 1.33–1.47), and low-education status (RR 1.17, 95% CI 1.12–1.24), were independently associated with an increased risk of frequent back pain (all P < 0.001). Overall, 28% of the risk of frequent back pain could be attributed to these factors, equating to one extra case of frequent back pain for every five women with depressive symptoms, for every 11 obese women, for every 12 women with low-education status, and for every 13 women who do not do vigorous physical activity, at baseline. Conclusion. Obesity, depressive symptoms, low-education status, and lack of vigorous physical activity are associated with higher risk of frequent back pain over the following 9 years among women in their mid-50 s. Targeting these risk factors may lessen the burden of back pain. Level of Evidence: 2

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Influence of Abuse History on Concurrent Benzodiazepine and Opioid Use in Chronic Pain Patients

In 2016, more than 42,200 deaths in the United States involved opioids.41 The rate of opioid-related deaths has risen steadily and drastically since 1999. Although public policy has focused on curbing these high rates, the epidemic remains a public health crisis. An important predictor of opioid overdose is the co-use of benzodiazepines.12,22,36 Benzodiazepines are frequently prescribed among patients with chronic pain due to their broad clinical applications, including treatment of anxiety, sleep disorders, and seizures.

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AAPT Diagnostic Criteria for Fibromyalgia

Over many decades, there have been efforts to develop diagnostic criteria for the condition we now recognize as fibromyalgia (FM). The multiple symptoms and comorbidities associated with FM make it difficult to diagnose, and FM is still under-diagnosed and under-treated.7,34,79 The diagnosis of FM might take more than 2 years, with patients seeing an average of 3.7 different physicians during this time.34 Many health care providers, particularly in primary care, report unclear diagnostic criteria, a lack of confidence in using existing criteria for diagnosis, insufficient training or skill in diagnosing FM, and a lack of knowledge of treatment options.

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Experimental Pain Decreases Corticomuscular Coherence in a Force- But Not a Position-Control Task

Neural drive to muscles is altered in pain, but this depends on task type. Acute experimental pain reduces the discharge rate of many active motor units during gentle isometric contractions,12,51,54 but this is less pronounced in position- than force-control tasks.44 Even when tasks are identical in mechanical requirements and muscle torques, neuromotor control during position- and force-control tasks differs. Task-specific differences at the spinal cord and descending inputs are thought to explain this difference.

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Pfizer could owe NHS {pound}500m for extending pregabalin patent for pain

The UK Supreme Court has thrown out an appeal by the drug company Pfizer over its blockbuster drug pregabalin (Lyrica).The court’s ruling that Pfizer’s subsidiary Warner-Lambert was not entitled to a...

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An unusual cause of right iliac fossa pain

A 34 year old woman presented to the emergency department with a history of worsening right iliac fossa pain over several days. She described the pain as alternating dull and sharp, and had found...

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Holding out for an apology

My emotional recovery from surgical complications was unbelievably difficult. The anger became haunting, and the physical pain made it impossible to forget the trauma. It was only when I was able to...

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