Health Care Utilization and Costs Associated with Pediatric Chronic Pain

• In a 2016 survey of the United States population, 6% of children had chronic pain• Chronic pain was associated with greater odds of using emergency care in past year• Chronic pain was also associated with higher out-of-pocket medical expenses• Chronic pain was not associated with increased odds of using mental health services

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Pain Neuroimaging in Humans: a Primer for Beginners and Non-Imagers

The field of human pain neuroimaging has exploded in the last two decades. During this time, the broader neuroimaging community has continued to investigate and refine methods. Another key to progress is exchange with clinicians and pain scientists working with other model systems and approaches. These collaborative efforts require that non-imagers be able to evaluate and assess the evidence provided in these papers. Likewise, new trainees must design rigorous and reliable pain imaging experiments.

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Catastrophizing, Solicitous Responses From Significant Others and Function in Individuals with Neuropathic Pain, Osteoarthritis or Spinal Pain in the General Population

• Pain catastrophizing is associated with less psychological and physical function• Solicitous responding to pain is associated with less insomnia severity• A neuropathic pain diagnosis is associated with higher levels of insomnia severity• Neuropathic or spinal pain is associated with higher levels of psychological distress

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A Controlled Pilot Trial of PainTracker Self-Manager, a Web-Based Platform Combined with Patient Coaching, to Support Patients' Self-Management of Chronic Pain

• PainTracker Self-Manager improved patients' confidence in chronic pain self-management• This intervention also improved patients' satisfaction with pain treatment• In study completers, the intervention also improved activity engagement and pain• The intervention included web-based assessment and education plus clinician coaching

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A woman with a 10 year history of abdominal pain

A 64 year old woman with a history of Still’s disease presented with more than 10 years of abdominal pain and bloating. Her symptoms were initially intermittent, but over the last six months they had...

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Does Pain Impact Preference? the Effect of Tonic Laboratory Pain on Discounting of Delayed Rewards

• Capsaicin/heat manipulation led to elevated pain and negative affect over time.• Tonic laboratory pain did not influence delay discounting behavior.• Greater pain sensitivity predicted less discounting of delayed rewards.• Despite less discounting of rewards, the effect sizes were very small.

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Qualitative and Quantitative Aspects of Pain in Patients with Myotonic Dystrophy Type 2

• Pain is a frequent and important symptom in patients with DM2• Pain affects quality of life in patients with DM2• Mechanical hyperalgesia is present in patients with DM2• A peripheral mechanism of pain is likely to be present in DM2• Central sensitization is at least less pronounced in DM2 than in fibromyalgia

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Assessment of Responsiveness to Everyday Non-Noxious Stimuli in Pain-Free Migraineurs with vs Without Aura

• Migraineurs demonstrate sensory over-responsiveness to everyday sensations• Sensory over-responsiveness is more common in migraineurs with aura (MWA)• Attack frequency correlates with sensory over-responsiveness and pain summation

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Traumatic Brain Injury and Receipt of Prescription Opioid Therapy for Chronic Pain in Iraq and Afghanistan Veterans: Do Clinical Practice Guidelines Matter?

• Veterans with more severe TBI symptoms were most likely to receive opioid therapy.• Veterans with moderate to severe TBI were more likely to be prescribed opioids.• Veterans with TBI and mental health comorbidity were at highest risk for opioids.

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Individual Variation in Pain Sensitivity and Conditioned Pain Modulation in Acute Low Back Pain: Impact of Stimulus Type, Sleep, Psychological and Lifestyle Factors.

• Enhanced sensitivity consistent with generalized hyperalgesia was observed• Acute back pain includes four subgroups with sensitivity and modulation profiles• Various factors including sleep and alcohol explain some variation in presentation

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A Comparison of the Assay Sensitivity of Average and Worst Pain Intensity in Pharmacologic Trials: an ACTTION Systematic Review and Meta-Analysis

• Average vs worst pain intensity assay sensitivity not statistically different• Numerically smaller mean and standard deviation for average vs worst pain intensity• No relationship observed between pain condition and difference in assay sensitivity• Many articles ineligible because WPI results not reported

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Prevalence and Pharmaceutical Treatment of Plantar Fasciitis in United States Adults

• Plantar fasciitis pain prevalence is presented for U.S. adults by demographic group• Most individuals with plantar fasciitis report a least moderate daily pain.• Disease severity was associated with pharmaceutical therapy• Blacks and individuals diagnosed by medical specialists had more severe disease• These two groups were also more likely to receive pharmaceutical therapy

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Pain Adaptability in Individuals with Chronic Musculoskeletal Pain is Not Associated with Conditioned Pain Modulation

• The dichotomy of pain adaptability exists in individuals with chronic musculoskeletal pain.• Pain adaptability is dissociated with the potency of conditioned pain modulation.• Pain adaptability could reflect the temporal aspect of pain inhibition.

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[Editorial] Diagnosis of heavy menstrual bleeding: a change in direction

Menorrhagia is a debilitating condition that negatively affects quality of life, with accompanying symptoms sometimes including severe abdominal pain and persistent and irregular bleeding outside the menstrual cycle. The UK's National Institute for Health and Care Excellence (NICE) estimates that menorrhagia affects up to 25% of women of reproductive age, accounting for 12% of all UK gynaecological specialist referrals.

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Impact on Health Care Costs for Adolescents Receiving Adjunctive Internet-Delivered Cognitive-Behavioral Therapy: Results of a Randomized Controlled Trial

• Estimated annual health care costs were $16,443 per child.• Total health care costs significantly decreased across both treatment conditions.• Research to determine patterns and drivers of health care costs is needed.

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Research Agenda for the Prevention of Pain and Its Impact: Report of the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy

Following the 2011 Institute of Medicine report on chronic pain, the Interagency Pain Research Coordinating Committee (IPRCC) was created to enhance research efforts among federal agencies. The IPRCC and Office of Pain Policy at the NIH collaborated to identify gaps in knowledge and address them via a Federal Pain Research Strategy (FPRS). The FPRS appointed Interdisciplinary Work Groups (WGs) to make research recommendations in 5 areas: prevention of acute and chronic pain; acute pain and acute pain management; transition from acute to chronic pain; chronic pain and chronic pain management; and disparities in pain and pain care; cross-cutting issues were also considered.

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Hunger’s curious effect on pain in mice

Hunger’s curious effect on pain in mice

Hunger’s curious effect on pain in mice, Published online: 22 March 2018; doi:10.1038/d41586-018-03780-7

Neurons that drive mice to eat also tamp down pain caused by inflammation.

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Pain Sensitivity and Thermal Detection Thresholds in Young Adults Born Preterm with Very Low Birth Weight or Small for Gestational Age at Term Compared to Controls.

• This is the first QST study on adult preterm or term low birth weight individuals• Thermal detection and pain sensitivity are similar in VLBW and control young adults• Adults born SGA at term do not display altered sensory function• Group-wise prevalences of self-reported chronic pain are not reliably different

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Knee pain after a fall

A 69 year old man slipped in the snow and presented with swelling and pain in the left knee. On examination, he could not extend his knee and had a palpable, visible indentation on the surface of his...

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Movement on pain

Doctors face the challenge of treating more people living more of their lives in ill health, and there is not a lot of good news around. For many people, current treatments for their long term...

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Circuit dissection of the role of somatostatin in itch and pain

Circuit dissection of the role of somatostatin in itch and pain

Circuit dissection of the role of somatostatin in itch and pain, Published online: 19 March 2018; doi:10.1038/s41593-018-0119-z

Huang et al. demonstrate that somatostatin (Sst)-expressing primary afferents are pruriceptors. In spinal cord, they show that Sst potentiates itch by disinhibition involving dynorphin-expressing spinal neurons and that Sst also suppresses pain.

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Neurocognitive Basis of Racial Ingroup Bias in Empathy

Publisher Correction: A craniofacial–specific monosynaptic circuit enables heightened affective pain

Publisher Correction: A craniofacial–specific monosynaptic circuit enables heightened affective pain

Publisher Correction: A craniofacial–specific monosynaptic circuit enables heightened affective pain, Published online: 16 March 2018; doi:10.1038/s41593-018-0103-7

Publisher Correction: A craniofacial–specific monosynaptic circuit enables heightened affective pain

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Transcranial Alternating Current Stimulation at Alpha Frequency Reduces Pain When the Intensity of Pain is Uncertain.

• Application of alpha tACS over somatosensory regions influences perceived pain• Alpha tACS compared to sham lowers both perceived pain intensity and unpleasantness• However, uncertainty about pain intensity moderates this effect• Perceived pain was lower during alpha tACS, only when pain intensity was uncertain• Alpha tACS has the potential to alleviate pain, particularly when pain is uncertain

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The Psychometric Properties of the FLACC Scale Used to Assess Procedural Pain.

• The FLACC scale is reliable and sensitive to procedural pain in young children• The FLACC scale may not be specific for procedural pain assessment• Circumstances of procedure interfere with application of the FLACC scale

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Bradyarrhythmias and pacemakers

What you need to knowSuspect bradyarrhythmia in patients with symptoms of fainting, shortness of breath, chest pain, or lethargy, and a heart rate <60 beats/min on examinationRequest 12-lead...

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Evidence for the improvement of fatigue in fibromyalgia: a 4-week left dorsolateral prefrontal cortex repetitive transcranial magnetic stimulation randomised-controlled trial

Abstract

Background

Fibromyalgia is a complex chronic disorder with few effective treatments currently available. One promising treatment option is repetitive Transcranial Magnetic Stimulation (rTMS), a non-invasive brain stimulation technique that has shown promise in disorders effecting the central nervous system.

Methods

We assessed the efficacy of a course of high-frequency (10Hz) left-hemisphere dorsolateral prefrontal cortex (DLPFC) rTMS in 26 patients (14 active; 12 sham) with a diagnosis of fibromyalgia. Participants underwent a double-blind stimulation protocol of daily (Monday-Friday) rTMS sessions over 4 consecutive weeks (total of 20 sessions; 75 x 4-second 10Hz trains at 120% resting motor threshold). Assessments were conducted at baseline, 4 weeks and at 1 month follow-up.

Results

Using mixed-model analysis we did not identify a group difference for our primary outcome measures. However, we found that patients in the active compared to sham treatment group had significantly greater improvement in the Physical Fatigue (p = .045) and General Fatigue (p = .023) scales of the Multidimensional Fatigue Iventory-20 at the 1 month follow up. In a responder analysis, we also found the active group was significantly more likely (2.84 times) to achieve a minimum 30% improvement in pain intensity ratings. (p = .024).

Conclusions

High-frequency rTMS applied daily for 4 weeks to the left DLPFC induces significant relief from fatigue and a greater chance of clinically meaningful improvement in pain intensity in patients with fibromyalgia. These results suggest DLPFC rTMS may be a relevant therapy for fibromyalgia.

This article is protected by copyright. All rights reserved.

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MIS Single-position Lateral and Oblique Lateral Lumbar Interbody Fusion and Bilateral Pedicle Screw Fixation: Feasibility and Perioperative Results

Study Design. Retrospective review of prospectively collected data of the first 72 consecutive patients treated with single-position one- or two-level lateral (LLIF) or oblique lateral interbody fusion (OLLIF) with bilateral percutaneous pedicle screw and rod fixation by a single spine surgeon. Objective. To evaluate the clinical feasibility, accuracy, and efficiency of a single-position technique for LLIF and OLLIF with bilateral pedicle screw and rod fixation. Summary of Background Data. Minimally-invasive lateral interbody approaches are performed in the lateral decubitus position. Subsequent repositioning prone for bilateral pedicle screw and rod fixation requires significant time and resources and does not facilitate increased lumbar lordosis. Methods. The first 72 consecutive patients (300 screws) treated with single-position LLIF or OLLIF and bilateral pedicle screws by a single surgeon between December 2013 and August 2016 were included in the study. Screw accuracy and fusion were graded using computed tomography and several timing parameters were recorded including retractor, fluoroscopy, and screw placement time. Complications including reoperation, infection, and postoperative radicular pain and weakness were recorded. Results. Average screw placement time was 5.9 min/screw (standard deviation, SD: 1.5 min; range: 3–9.5 min). Average total operative time (interbody cage and pedicle screw placement) was 87.9 minutes (SD: 25.1 min; range: 49–195 min). Average fluoroscopy time was 15.0 s/screw (SD: 4.7 s; range: 6–25 s). The pedicle screw breach rate was 5.1% with 10/13 breaches measured as < 2 mm in magnitude. Fusion rate at 6-months postoperative was 87.5%. Two (2.8%) patients underwent reoperation for malpositioned pedicle screws with subsequent resolution of symptoms. Conclusion. The single-position, all-lateral technique was found to be feasible with accuracy, fluoroscopy usage, and complication rates comparable with the published literature. This technique eliminates the time and staffing associated with intraoperative repositioning and may lead to significant improvements in operative efficiency and cost savings. Level of Evidence: 4

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Suppression of Sympathetic Nerve Sprouting by Local Administration of an α-antagonist Around the Dorsal Root Ganglion in a Lumbar Radiculopathy Model

Study Design. Animal experimental study with intervention. Objective. The purpose of this study was to elucidate whether local administration of an α-antagonist around the dorsal root ganglion (DRG) suppressed sympathetic nerve sprouting, from the acute to the chronic pain development phase, in a lumbar radiculopathy model using immunohistochemical methods. Summary of Background Data. The abnormal sympathetic-somatosensory interaction may underlie some forms of neuropathic pain. There were several reports suggesting α-antagonists are effective to treat neuropathic pain. However, its pathophysiological mechanisms remain obscure. Methods. We used 70 male Sprague-Dawley rats. After root constriction (RC), rats received a series of three local injections of the nonselective α-antagonist phentolamine around the DRG for 3 days. There were three groups of rats: those that were injected from the day of surgery and those injected from day 4 and third group injected from day 11. The control rats were subjected to RC but equal-volume normal saline injections, and the naïve rats were not subjected to any surgical procedures. At the 14th postoperative day, the left L5 DRG was removed, embedded in paraffin, and sectioned. Sections were then immunostained with antibodies to tyrosine hydroxylase (TH). To quantify the extent of the presence of sympathetic nerve fibers, we counted TH-immunoreactive fibers in the DRG using a light microscope equipped with a micrometer graticule. We counted the squares of the graticule, which contained TH-immunoreactive fibers for each of five randomly selected sections of the DRG. Results. In the naïve group, TH-immunoreactive fibers were scarce in the DRG. α-antagonist injections from postoperative day 0 and 4 suppressed sympathetic nerve sprouting compared with the control group. α-antagonist injections from postoperative day 11 had no suppressant effect compared with the control group. Conclusion. The α-antagonist administered around the DRG could suppress neural plastic changes in the early phase after nerve injury. Level of Evidence: N/A

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Posterior-only Hemivertebra Resection for Congenital Cervicothoracic Scoliosis: Correcting Neck Tilt and Balancing the Shoulders

Study Design. A retrospective study. Objective. To evaluate radiographic and cosmetic outcomes after posterior-only cervicothoracic hemivertebra resection and instrumentation. Summary of Background Data. Cervicothoracic hemivertebra is a rare congenital deformity. It locates between the mobile cervical spine and the fixed thoracic spine, leading to rapid curve progression, shoulder imbalance, fixed torticollis, and facial asymmetry. Methods. This study reviewed a consecutive series of 18 patients with cervicothoracic hemivertebra. All received posterior-only hemivertebra resection and instrumentation and had a minimum follow up of 2 years. Assessments on radiographic and cosmetic outcomes were based on changes in measurements of scoliosis, shoulder balance, neck tilt, head shift, and sagittal profiles. Results. There were 24 hemivertebrae, consisting of 16 fully segmented and 8 semisegmented. Mean age at surgery was 9.5 ± 3.1 years, and mean follow up was 32 ± 10 months. Mean fusion segments were 4.8 ± 0.6 segments. Operation time averaged 208 ± 33 minutes, with an average blood loss of 384 ± 40 mL. Local scoliosis was corrected from 39 ± 5° to 16 ± 4° (P < 0.001). The distal curve had a spontaneous correction of 41 ± 18%. With regards to shoulder balance, both T1 tilt and clavicle angle were significantly improved, with a correction rate of 55 ± 22% and 47 ± 32%, respectively. Accordingly, neck tilt was improved from 20 ± 7° to 11 ± 7°, and head shift from 22 ± 9 mm to 13 ± 8 mm. A remarkable pedicle screw malpositioning rate (20%) was observed, but no neurovascular injuries. One case developed with Horner syndrome, and another one had transient radicular pain on the right arm after surgery. Conclusion. For patients with congenital cervicothoracic scoliosis, posterior-only hemivertebra resection with instrumentation allows for excellent scoliosis correction and cosmetic improvement. Great care should be taken to reduce the rate of pedicle screw malpositioning. Level of Evidence: 4

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Evolution of Surgery for Adolescent Idiopathic Scoliosis Over 20 Years: Have Outcomes Improved?

Study Design. Retrospective review of a prospective adolescent idiopathic scoliosis (AIS) registry. Objective. To study the evolution of the operative approach, outcomes, and complication rates in AIS surgery over the past 20 years. Summary of Background Data. Surgical techniques in AIS surgery have evolved considerably over the past 20 years. We study the trends in the operative management of AIS over this period and their impact on perioperative outcomes. Methods. A total of 1819 AIS patients (1995–2013) with 2-year F/U were studied. Operative approach, perioperative parameters, major complication rates, and SRS outcomes were assessed. Linear regression was used to assess the trend of changes over 5-year quartiles. Results. Mean age at surgery was 14.6 ± 2.1 years, 80.2% were females, and this remained consistent throughout. Operative time, EBL/level, and LOS decreased over the 20 years (P < 0.0001). The use of antifibrinolytic (AF) increased from 6.7% to 68.8% in the past 10 years (P < 0.0001). Number of levels fused increased and LIV was more distal (in relation to stable vertebrae) over time in Lenke 1 and 2 curves (levels fused 7.97−9.94, P < 0.0001 and 9.8−11.0, P=0.0134, respectively). Anterior spinal fusion (ASF) in Lenke 1 curves decreased from 81% in the first quartile to 0% in the last (P = 0.0429). ASF for Lenke 5 curves evolved from 78% in the second quartile to 0 in the last. Thoracoplasty performance decreased from 76% to 20.3% (P = 0.1632). All screw constructs in PSF cases increased from 0% to 98.4% (P = 0.0095). Two-year major complication rates decreased over time (18.7%−5.1%; P = 0.0173). Increased improvement in SRS scores were observed in pain, image, function, and total domains. Conclusion. Evolution of surgical technique in AIS over the past 20 years has resulted in a cessation of anterior only surgery, increasing use of all screw constructs, less blood loss, greater use of AF, shorter operative times and LOS, lower major complications rates, and greater improvements in SRS scores. Level of Evidence: 2

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Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?: A Longitudinal Case-Crossover Feasibility Study

Study Design. Prospective, longitudinal case-crossover study. Objective. The aim of this study was to determine whether physical activities trigger flare-ups of pain during the course of acute low back pain (LBP). Summary of Background Data. . There exist no evidence-based estimates for the transient risk of pain flare-ups associated with specific physical activities, during acute LBP. Methods. Participants with LBP of duration <3 months completed frequent, Internet-based serial assessments at both 3- and 7-day intervals for 6 weeks. At each assessment, participants reported whether they had engaged in specific physical activity exposures, or experienced stress or depression, during the past 24 hours. Participants also reported whether they were currently experiencing a LBP flare-up, defined as “a period of increased pain lasting at least 2 hours, when your pain intensity is distinctly worse than it has been recently.” Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for associations between potential triggers during the past 24 hours, and the risk of LBP flare-ups, using conditional logistic regression. Results. Of 48 participants followed longitudinally, 30 participants had both case (“flare”) and control periods and contributed data to the case-crossover analysis. There were 81 flare periods and 247 control periods, an average of 11 periods per participant. Prolonged sitting (>6 hours) was the only activity that was significantly associated with flare-ups(OR 4.4, 95% CI 2.0–9.7; P < 0.001). Having either stress or depression was also significantly associated with greater risk of flare-ups (OR 2.5, 95% CI 1.0–6.0; P = 0.04). In multivariable analyses, prolonged sitting (OR 4.2, 95% CI 1.9–9.1; P < 0.001), physical therapy (PT) (OR 0.4, 95% CI 0.1–1.0; P = 0.05), and stress/depression (OR 2.8, 95% CI 1.2–6.7; P = 0.02) were independently and significantly associated with LBP flare-up risk. Conclusion. Among participants with acute LBP, prolonged sitting (>6 hours) and stress or depression triggered LBP flare-ups. PT was a deterrent of flare-ups. Level of Evidence: 2

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Impact of Depression on Patient-Reported Outcome Measures After Lumbar Spine Decompression

Study Design. A retrospective cohort study. Objective. The aim of this study was to investigate the effect depression has on the improvement of patient-reported outcome measures (PROMs) following lumbar decompression. Summary of Background Data. Decompression without fusion is a viable treatment option for lumbar spine stenosis. Depression reportedly has a negative impact on PROMs after certain types of spine surgery, though verification of this with new, more precise outcome measures is needed. Methods. We included consecutive adult patients who underwent lumbar decompression for lumbar spine stenosis between 2016 and 2017 who had PROM information system (PROMIS) physical function, pain, depression, and Oswestry Disability Index (ODI) questionnaires completed preoperatively and at 6-month follow-up. Patients with a PROMIS depression score >50 or <50 were allocated to the depressed and not depressed groups, respectively. The cohorts were compared using unpaired t tests and repeated-measures two-way analysis of variance (ANOVA) with statistical significance taken at P < 0.05. Results. The analysis included 55 patients without depression and 56 patients with depression. Depressed patients had worse preoperative PROMIS physical function (30.08 vs. 36.66, P = 0.005), PROMIS pain (69.36 vs. 64.69, P < 0.0001), and ODI scores (51.92 vs. 36.35, P < 0.0001). Similarly, the depressed group had worse postoperative PROMIS physical function (36.29 vs. 40.34, P = 0.005), PROMIS pain (60.16 vs. 54.87, P < 0.0001), and ODI scores (37.01 vs. 23.44, P = 0.0003). We observed a statistically significant interaction between depression status and pre to postoperative improvement in outcome for PROMIS physical function (F[1,109] = 102.5, P < 0.0001) and depression scores (F[1,109] = 15.38, P = 0.0002). No interaction was found for pain and ODI scores. Conclusion. Our results suggest that depressed patients experience a greater magnitude of improvement in PROMIS physical function and depression scores than nondepressed patients. Despite this, depressed patients have worse postoperative outcomes for PROMIS physical function, depression, pain, and ODI. These findings are important for risk stratifying and treating depressed patients before lumbar spine decompression. Level of Evidence: 3

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Simplified Chinese Version of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire: Cross-cultural Adaptation, Reliability, and Validity for Patients With Low Back Pain

Study Design. Cross-cultural adaptation and cross-sectional psychometric testing in a convenience sample of patients with low back pain. Objective. The aim of this study was to translate and adapt the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) into a simplified Chinese version, and assess its reliability and validity. Summary of Background Data. No simplified Chinese version of the JOABPEQ was previously available. Methods. We translated and culturally adapted the original English JOABPEQ to develop a Chinese version, based on cross-cultural adaptation guidelines. Principal component analysis with varimax rotation was used to confirm the factor structure of each subscale. Internal consistency was evaluated with Cronbach alpha. Test-retest reliability was examined in stable patients, who completed the questionnaire again at 4 days to 2 weeks from baseline. The validity of the translated Chinese version was assessed by examining the relationship between the JOABPEQ and Chinese versions of the Roland–Morris Disability Questionnaire (RMDQ), the Oswestry Disability Index (ODI), the Short Form Health Survey (SF-36), and the Numerical Pain Rating Scale. Ceiling and floor effects were considered present if more than 15% of respondents achieved the lowest or highest possible total score. Results. The JOABPEQ showed excellent internal consistency (α = 0.886). The test-retest reliability (intraclass correlation coefficients) ranged from 0.951 to 0.977. The convergent validity of the Chinese version was supported by its high correlation with other physical functional status measures (RMDQ, ODI, and SF-36 Physical Function; r values from −0.645 to −0.726), and moderate correlation with other measures (SF-36 Bodily pain and Social functioning subscales; r values 0.426–0.546). Q5 Mental health was highly correlated with SF-36 items (r values 0.337–0.640). There was a floor effect in Q1 low back pain (38, 20.65%). Conclusion. The results indicate that the simplified Chinese version of the JOABPEQ is a reliable and valid instrument to measure the multidimensional status in patients with low back pain. Level of Evidence: 4

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