[Correspondence] Top ten hyperacusis research priorities in the UK

Hyperacusis involves a reduced tolerance or increased sensitivity to everyday sounds, whereby they become intense and overwhelming. This condition is experienced by 3·7% of children and up to 9·2% of adults in the world, with a higher prevalence in certain populations, such as people who have Williams' syndrome or autism spectrum disorders.1 Hyperacusis-associated problems are many, including fear, pain, avoidance behaviours, and impairments to quality of life, such as reduced ability to work.2 For children with hyperacusis, the classroom can be particularly challenging, and strategies are needed to ensure their wellbeing and educational needs are met.

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Vertebral augmentation in osteoporosis: common procedures for spinal fractures show no benefit

Two common surgical interventions for spinal fractures caused by osteoporosis are no more effective than placebo or sham surgery in bringing lasting relief from pain and disability, a taskforce of...

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Allocation Concealment And Intention-To-Treat Analysis Do Not Influence The Treatment Effects Of Physical Therapy Interventions In Low Back Pain Trials: A Meta-Epidemiological Study

Publication date: Available online 31 January 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Matheus Oliveira de Almeida, Bruno Tirotti Saragiotto, Chris Maher, Leonardo Oliveira Pena Costa

Abstract

Objective

To evaluate if allocation concealment and intention-to-treat (ITT) analysis influence the treatment effects of physical therapy interventions in low back pain trials.

Data sources

We searched on PubMed, Embase, Cochrane Database of Systematic Reviews, PEDro and CINAHL up to February 2017.

Study selection

We included low back pain trials that compared physical therapy interventions to placebo or no intervention or minimal intervention with pain or disability outcomes.

Data extraction

Information about allocation concealment and ITT analysis was extracted from PEDro and pain and disability outcomes converted to a 0-100 scale. A meta-regression was performed to evaluate the influence of these methodological features of interest on treatment effects. Other covariates included in the meta-regression were sample size and sequence generation.

Data Synthesis

We identified 128 eligible trials (pooled n = 20555 participants). A total of 44.5% of the trials achieved allocation concealment, while 32% performed ITT analysis. Meta regression analyses showed no influence of allocation concealment on treatment effects for pain (regression coefficient 0.009; 95% CI -2.91 to 2.91) and disability (regression coefficient 1.13; 95% CI -1.35 to 3.62), and no influence of ITT analysis for pain (regression coefficient 1.38; 95% CI -1.73 to 4.50) or disability (regression coefficient 1.27; 95% CI -1.39 to 3.64). For the other covariates, there was also no clinically significant influence on the treatment effects.

Conclusion

There is no influence of allocation concealment and/or ITT analysis on treatment effects of physical therapy interventions for pain and disability in low back pain trials.

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Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model

Objective Chronic pain is a significant health problem that is increasing in prevalence, and advances in treatment are needed. Methods We briefly review the leading evidence-based psychological therapies for chronic pain—cognitive-behavioral and acceptance/mindfulness-based therapies—and examine several limitations and missing perspectives of these approaches. We review six lesser-known interventions that address these limitations, and we describe our integrative model for psychological assessment and treatment of centralized pain. We present a typical patient and describe how we apply this approach, along with challenges to its implementation and possible solutions to these challenges. Results Greater pain treatment efficacy may be possible if clinicians: (a) distinguish patients with primarily centralized (i.e., somatoform or nociplastic) pain from those with primarily peripheral (nociceptive, inflammatory, or neuropathic) pain; (b) acknowledge the capacity of the brain not only to modulate pain but also generate as well as attenuate or eliminate centralized pain; (c) consider the powerful role that adverse life experiences and psychological conflicts play in centralized pain; and (d) integrate emotional processing and interpersonal changes into treatment. Our integrative treatment involves delivering a progression of interventions, as needed, to achieve pain reduction: tailored pain neuroscience education, cognitive and mindfulness skills to decrease the pain danger alarm mechanism, behavioral engagement in avoided painful and other feared activities, emotional awareness and expression to reverse emotional avoidance and overcome trauma or psychological conflict, and adaptive communication to decrease interpersonal stress. Conclusions This integrative assessment and treatment model has the potential to substantially reduce and sometimes eliminate centralized pain by changing the cognitive, behavioral, emotional, and interpersonal processes that trigger and maintain centralized pain.

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Altered Brain Structure and Functional Connectivity and Its Relation to Pain Perception in Girls With Irritable Bowel Syndrome

Objective Imaging studies in adults with irritable bowel syndrome (IBS) have shown both morphological and resting state (RS) functional connectivity (FC) alterations related to cortical modulation of sensory processing. Because analogous differences have not been adequately investigated in children, this study compared gray matter volume (GMV) and RS-FC between girls with IBS and healthy controls (HC) and tested the correlation between brain metrics and laboratory-based pain thresholds (Pth). Methods Girls with Rome III criteria IBS (n = 32) and matched HCs (n = 26) were recruited. In a subset of patients, Pth were determined using a thermode to the forearm. Structural and RS scans were acquired. A voxel-based general linear model, adjusting for age, was applied to compare differences between groups. Seeds were selected from regions with group GMV differences for a seed-to-voxel whole brain RS-FC analysis. Significance for analyses was considered at p < .05 after controlling for false discovery rate. Significant group differences were correlated with Pth. Results Girls with IBS had lower GMV in the thalamus, caudate nucleus, nucleus accumbens, anterior midcingulate (aMCC), and dorsolateral prefrontal cortex. They also exhibited lower RS-FC between the aMCC and the precuneus, but greater connectivity between the caudate nucleus and precentral gyrus. Girls with IBS had higher Pth with a moderate effect size (t(22.81) = 1.63, p = .12, d = 0.64) and lower thalamic GMV bilaterally was correlated with higher Pth (left: r = −.62, p(FDR) = .008; right: r = −.51, p(FDR) = .08). Conclusions Girls with IBS had lower GMV in the PFC, basal ganglia, and aMCC, as well as altered FC between multiple brain networks, suggesting that structural changes related to IBS occur early in brain development. Girls with IBS also showed altered relationships between pain sensitivity and brain structure.

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Differences in neuronal representation of mental rotation in CRPS patients and healthy controls

Complex regional pain syndrome (CRPS) affects about 7% of patients after limb trauma4 and leads to chronic pain in the affected limb. There is growing evidence for a pathophysiological involvement of the central nervous system in maintaining CRPS symptoms by altered central sensorimotor processing22,53 and pathological cortical reorganization31,32,43. In addition, neuropsychological pathologies have been described in CRPS, such as impairment in integrating objects spatially in reference to the own body, and a neglect-like mechanism has been controversially discussed36,56.

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Back pain management: patients receive {pound}10.5m of “limited value” inȷections

Patients with lower back pain are still receiving injections of local anaesthetic or steroids with “limited clinical value” rather than physical and psychological rehabilitation as recommended by the...

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Blockade of NMDA receptors and nitric oxide synthesis potentiated morphine-induced anti-allodynia via attenuating pain-related amygdala pCREB/CREB signaling pathway

Neuropathic pain develops in response to injuries or diseases which affect the somatosensory nervous system.31 The symptoms include hyperalgesia and allodynia, which are defined as increased responsiveness to painful stimuli and painful response to non-noxious stimuli.79 Morphine, as a powerful analgesic drug, is commonly used to alleviate different types of pain.46 Due to the development of tolerance, dependence and addiction following morphine administration,55 it seems that combination of morphine with other drugs may be a strategy to potentiate the effect of its low doses without producing the serious side effects associated with pain treatment.

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A brain short on sleep dials up pain intensity

A brain short on sleep dials up pain intensity

A brain short on sleep dials up pain intensity, Published online: 29 January 2019; doi:10.1038/d41586-019-00305-8

Brain region that naturally dampens pain falls short in those running an acute sleep deficit.

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Effectiveness of Physical Therapy Combined with Epidural Steroid Injection for Patients with Lumbar Spinal Stenosis: A Randomized Parallel-Group Trial

Publication date: Available online 29 January 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Amy Hammerich, Julie Whitman, Paul Mintkin, Thomas Denninger, Venu Akuthota, Eric E. Sawyer, Melissa Hofmann, John D. Childs, Joshua Cleland

Abstract

Objective

To examine the effectiveness of epidural steroid injection (ESI) and back education with and without physical therapy (PT) in patients with lumbar spinal stenosis (LSS).

Design

Randomized clinical trial.

Setting

Orthopaedic spine clinics.

Participants

390 patients were screened with 60 eligible and randomly selected to receive ESI and education with or without PT.

Interventions

54 patients received 1-3 injections and education in a 10 week intervention period with 31 receiving injections and education only (ESI) and 23 additionally receiving 8-10 sessions of multi-modal PT (ESI+PT).

Main Outcome Measures

Disability, pain, quality of life, and global rating of change were collected at 10 weeks, 6 months, and 1 year and analyzed using linear mixed model analysis.

Results

No significant difference was found between ESI and ESI+PT in the Oswestry Disability Index at any time point although the sample had significant improvements at 10 weeks (p < .001; 95% CI: -18.01, -5.51) and 1 year (p = .01; 95% CI: -14.57, -2.03) above MCID. Significant differences in SF36 were found for ESI+PT at 10 weeks with higher emotional role function (p = .03; 95% CI: -49.05, -8.01), emotional well-being (p = .02; 95% CI:-19.52, 2.99), and general health perception (p = .05; 95% CI: -17.20, -.78).

Conclusions

ESI plus PT was not superior to ESI alone for reducing disability in people with LSS. Significant benefit was found for the addition of PT related to quality of life factors of emotional function, emotional well-being, and perception of general health.

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The association of pain intensity and suicide attempts among patients initiating pain specialty services

Suicide accounts for over 44,000 deaths per year in the United States and suicide rates have risen 33% since 1999.8,9 Military veterans are a particularly vulnerable group, who are more than twice as likely to die by suicide relative to the general population.14 A recent executive report from the U.S. Department of Veterans Affairs (VA) synthesizing data obtained from family member interviews, chart reviews, and clinician opinion found that pain was the most common factor experienced by veteran suicide decedents prior to their death.

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Reward for pain. Hyperalgesia and allodynia induced by operant conditioning: systematic review and meta-analysis

Learning processes and pain have been linked for decades. The pioneer work by B.F. Skinner69 has been applied to pain science by Wilbert Fordyce who suggested that operant conditioning, one of the basic learning processes, may explain the chronification of pain by external contingencies of reinforcement28,30. In this framework, pain behaviour – when reinforced – persists beyond the period in which it is biologically required to support healing processes. In contrast to Pavlovian conditioning – previously suggested as a mechanism of chronic pain60 – operant conditioning controls behaviors by their consequences rather than their antecedents, and can be driven by positive or negative punishment as well as positive or negative reinforcement delivered in varied schedules, such as partial or continuous19.

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Pills to pot: observational analyses of cannabis substitution among medical cannabis users with chronic pain

Chronic pain affects >100 million Americans, and costs an estimated $635 billion dollars per year in the US alone.22 However, treating chronic pain is difficult, and many pharmacological options only work in a subset of patients due to inadequate pain relief or side effects that preclude use.10,17 In the context of the ongoing opioid crisis, which claimed ∼42,000 lives in 2016,19 many individuals with chronic pain are seeking alternative medications for pain management. Cannabis is a promising analgesic for many chronic pain conditions, with recent meta-analyses of clinical trials suggesting that cannabis or cannabinoids may be effective for chronic pain management,46 though this effect was mostly seen in neuropathic pain.

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Development of the Revised Opioid Risk Tool to Predict Opioid Use Disorder in Patients with Chronic Non-Malignant Pain

Both chronic pain, and the harms associated with prescription opioid abuse, including serious adverse events and fatalities, ae enormous public health problems. In parallel with a rise in long-term opioid use for chronic nonmalignant pain (CNMP), abuse of prescription opioids in the U.S. escalated more than 113% between 2004 and 2013.20 Safe and effective administration of opioid therapy is recognized as requiring initial and ongoing assessment of the risks related to prescription drug abuse and potential for developing an opioid use disorder (OUD).

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Impact of Sequential Opioid Dose Reduction Interventions in a State Medicaid Program between 2002 and 2017

Opioid misuse and overdose deaths continue to be a serious public health crisis in the United States and prescription opioids have significantly contributed to these deaths.3 A significant increase in prescription opioids correlates with a 15-year increase in overdose deaths.18 The overall national opioid prescribing rate steadily increased from 2006 with a peak in 2012 of 255 million in the number of prescriptions dispensed and a rate of 81.3 prescriptions per 100 persons.4 A 2015 National Survey on Drug Use and Health showed that more than one third of U.S.

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Shoulder pain: physiotherapy patients who believe in their ability to move show better recovery

Patients’ belief in their ability to move despite having shoulder pain and their expectation of a positive outcome are associated with recovery from musculoskeletal pain with physiotherapy, an...

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[Comment] Offline: On scientific leadership

“Weakness is the only fault that we are incapable of correcting” (François de La Rochefoucauld). What is the responsibility of scientists and physicians in the face of political adversities that damage societies? In recent days, the President of the UK's Royal Society has observed that “A no-deal Brexit would be a disaster for British science and innovation and I urge our elected representatives to put the interests of the country first and get a new plan to prevent this catastrophic outcome.” Robert Lechler, President of the Academy of Medical Sciences, noted that “I am at pains to once again stress that leaving the EU without a deal is a grave threat to biomedical research and the patients and public who rely on our currently collaborative and world-class science.” Paul Nurse, Director of the Francis Crick Institute, commented that “Our scientists unanimously agree that no-deal would be a disaster.” UK scientific leaders seem united in their resistance to a calamitous exit from the European Union.

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Effectiveness of Nonsurgical Interventions for Managing Adhesive Capsulitis in Patients With Diabetes: A Systematic Review

Publication date: February 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 2

Author(s): Sana'a A. Alsubheen, Goris Nazari, Pavlos Bobos, Joy C. MacDermid, Tom J. Overend, Kenneth Faber

Abstract

Objective

This systematic review evaluated the effectiveness of nonsurgical interventions for managing adhesive capsulitis (AC) in patients with diabetes on pain, function, and range of motion.

Data Sources

MEDLINE and other databases were searched for studies published in the last 20 years.

Study Selection

Randomized controlled trials (RCTs) that assessed AC in people with diabetes and implemented 1 or a combination of physiotherapeutic interventions, corticosteroids, and manipulation under anesthesia (MUA) were eligible for inclusion.

Data Extraction

The Cochrane Risk of Bias was used by 2 independent raters who met to achieve consensus. The quality of trials was assessed using Grading of Recommendations, Assessment, Development and Evaluations. Data extracted from the eligible studies included study design, participant characteristics and duration of symptoms, type of intervention, outcome measures, follow-up intervals, and research findings.

Data Synthesis

Because of the lack of similar interventions, a narrative synthesis was conducted, and meta-analyses were not performed. The effect sizes or between-group differences of the interventions were reported. A total of 8 RCTs met the inclusion criteria: 4 addressed physiotherapeutic interventions, 3 corticosteroid injections, and 1 MUA. The effect sizes for physiotherapeutic interventions were 0.8-2.0, 0.9-2.0, and 1.0 for ROM, function, and pain, respectively, with the largest effect size (2.0) being reported for joint mobilization plus exercises. The effect sizes for corticosteroids were 0.2-0.5 and 0.1 for ROM and pain. The between-group improvement for MUA was 5.6 points on Constant Shoulder Score.

Conclusion

Low-quality evidence suggests large effects of joint mobilization plus exercises on AC in people with diabetes, although confidence in this conclusion is limited due to the high risk of bias. Even weaker support was available for corticosteroid and MUA. Future high-quality RCTs are needed to determine the best intervention for managing AC in patients with diabetes.

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Comparative Effectiveness of Injection Therapies in Rotator Cuff Tendinopathy: A Systematic Review, Pairwise and Network Meta-analysis of Randomized Controlled Trials

Publication date: February 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 2

Author(s): Meng-Ting Lin, Ching-Fang Chiang, Chueh-Hung Wu, Yi-Ting Huang, Yu-Kang Tu, Tyng-Guey Wang

Abstract

Objective

To compare the effectiveness of diverse injections in patients with rotator cuff tendinopathy using pairwise and network meta-analysis.

Data Sources

PubMed, EMBASE, Scopus, and Cochrane Library were searched for studies published up to September 31, 2017.

Study Selection

We included all published or unpublished randomized controlled trials (RCTs) comparing diverse injections including corticosteroid, nonsteroidal anti-inflammatory drugs, hyaluronic acid, botulinum toxin, platelet-rich plasma (PRP), and prolotherapy in patients with rotator cuff tendinopathy. Among the 1495 records screened, 18 studies were included in the meta-analysis.

Data Extraction

The quality of RCTs was assessed with Cochrane Risk of Bias Tool by 2 independent raters. The primary outcome was pain reduction, and the secondary outcome was functional improvement.

Data Synthesis

Standardized mean difference (SMD) was used for pairwise and network meta-analysis. In pairwise meta-analysis, corticosteroid was more effective only in the short term in both pain reduction and functional improvement. Network meta-analysis indicated that prolotherapy significantly reduced pain compared with placebo in the long term (over 24wk; SMD: 2.63; 95% confidence interval [CI], 1.88-3.38); meanwhile PRP significantly improved shoulder function compared with placebo in the long term (over 24wk; SMD: 0.44; 95% CI, 0.05-0.84).

Conclusions

For patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6wk) but not in long-term (over 24wk) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long term (over 24wk). On account of heterogeneity, interpreting these results with caution is warranted.

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Immediate Effects of Transcutaneous Electrical Nerve Stimulation on Pain and Physical Performance in Individuals With Preradiographic Knee Osteoarthritis: A Randomized Controlled Trial

Publication date: February 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 2

Author(s): Kanako Shimoura, Hirotaka Iijima, Yusuke Suzuki, Tomoki Aoyama

Abstract

Objective

To investigate the effect of transcutaneous electrical nerve stimulation (TENS) on knee pain and comprehensive physical function in preradiographic knee osteoarthritis.

Design

A single, participant-blinded, randomized controlled trial (RCT) with pre-post design.

Setting

University research laboratory.

Participants

Patients with knee pain belonging to Kellgren–Lawrence grade 0 or 1 (N=50; aged 50-69y) were randomly assigned to the TENS (n=25) and sham-TENS groups (n=25).

Interventions

All participants wore the TENS device under the patella of the symptomatic knee. After measurement, the TENS devices in the TENS group were turned on, and those in the sham-TENS group were not connected.

Main Outcome Measures

The primary outcome measures included the stair climb test, timed Up and Go (TUG) test, 6-minute walk test (6MWT), and knee pain evaluated using the visual analog scale (VAS) for stair climb test, TUG test, and 6MWT. Secondary outcomes included knee extensor strengths and the 2-step test and stand-up test from the locomotive syndrome risk test.

Results

Multiple regression analysis revealed that TENS intervention significantly improved the walk distance and VAS score of the 6MWT, after adjusting for premeasurement data (distance; P=.015, VAS; P=.030).

Conclusions

Use of TENS improved the VAS score for pain and the distance walked in the 6MWT for individuals with Kellgren–Lawrence grade 0 or 1 of the knee. Thus, TENS may be effective for long-distance walking in patients with preradiographic knee osteoarthritis.

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Added Value of Isolated Core Postural Control Training on Knee Pain and Function in Women With Patellofemoral Pain Syndrome: A Randomized Controlled Trial

Publication date: February 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 2

Author(s): Forouzan Foroughi, Sobhan Sobhani, Amin Kordi Yoosefinejad, Alireza Motealleh

Abstract

Objectives

To evaluate the added value of isolated core postural control training on knee pain and function in women with patellofemoral pain syndrome (PFPS).

Design

Randomized controlled trial.

Setting

Rehabilitation sciences research center.

Participants

Women (N=33) between 18 and 30 years of age with PFPS were randomly assigned to a control group (n=16) or the experimental group (n=17).

Interventions

Participants in both groups received the same stretching and strengthening exercises during 4 weeks (12 sessions 3 days per week). The experimental group also received isolated core postural training with an unstable seat apparatus.

Main Outcome Measures

Center of pressure (CoP) trajectories in sitting postural control, pain intensity, and function were recorded before and after the 4-week intervention period. Functional capacity and pain intensity were reassessed 3 months after the intervention.

Results

After treatment, both groups had significant improvements in pain, function (P<.001), and CoP trajectories in sitting postural control (control group P<.05, experimental group P<.001). Between-group comparisons demonstrated greater improvements in pain, function, and CoP trajectories in the experimental group (P<.001). This group also had significantly greater improvements in pain and Kujala Anterior Knee Pain Scale score at 3-month follow-up compared to the control group (P<.001).

Conclusions

Adding isolated core postural control training to physiotherapy exercises was associated with significantly greater improvements in pain, function, and CoP trajectories than physiotherapy exercises alone. Therefore, unstable sitting postural control training is potentially useful to enhance rehabilitation management in patients with PFPS.

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The Impact of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review

Publication date: Available online 24 January 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Elizabeth Arnold, Janna La Barrie, Lisley DaSilva, Meagan Patti, Adam Goode, Derek Clewley

Abstract

Objective

To synthesize literature about the impact of early physical therapy (PT) for acute low back pain (LBP) on subsequent health services utilization (HSU), compared to delayed PT or usual care.

Data Sources

Electronic databases (MEDLINE, CINAHL, and EMBASE) were searched from their inception to May 2018.

Study Selection

Study selection included randomized control trials and prospective and retrospective cohort studies that investigated the association between early PT and HSU compared to delayed PT or usual care. Two independent authors screened titles, abstracts, and full text articles for inclusion based on eligibility criteria, and a third author resolved discrepancies. Eleven out of 1,146 articles were included.

Data Extraction

Two independent reviewers extracted data on participants, timing of PT, comparisons to delayed PT or usual care, and downstream HSU, and a third reviewer assessed the information to ensure accuracy and reach consensus. Risk of bias was assessed with the Downs and Black checklist using the same method.

Data Synthesis

Eleven studies met eligibility criteria. Early PT is within 30 days of the index visit for acute LBP. Five out of six studies that compared early PT to delayed PT found that early PT reduces future HSU. Random effects meta-analysis indicated a significant reduction in opioid use, spine injection, and spine surgery. Five studies compared early PT to usual care and reported mixed results.

Conclusions

Early PT for acute LBP reduces HSU and cost, reduces opioid use, and may improve healthcare efficiency. This review may assist patients, healthcare providers, healthcare systems, and 3^rd party payers in making decisions for the treatment of acute LBP.

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Clarifying our cultural contest about chronic pain

No abstract available

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Morphological and functional properties distinguish the substance P and gastrin-releasing peptide subsets of excitatory interneuron in the spinal cord dorsal horn

Excitatory interneurons account for the majority of neurons in the superficial dorsal horn, but despite their presumed contribution to pain and itch, there is still limited information about their organisation and function. We recently identified 2 populations of excitatory interneuron defined by expression of gastrin-releasing peptide (GRP) or substance P (SP). Here, we demonstrate that these cells show major differences in their morphological, electrophysiological, and pharmacological properties. Based on their somatodendritic morphology and firing patterns, we propose that the SP cells correspond to radial cells, which generally show delayed firing. By contrast, most GRP cells show transient or single-spike firing, and many are likely to correspond to the so-called transient central cells. Unlike the SP cells, few of the GRP cells had long propriospinal projections, suggesting that they are involved primarily in local processing. The 2 populations also differed in responses to neuromodulators, with most SP cells, but few GRP cells, responding to noradrenaline and 5-HT; the converse was true for responses to the μ-opioid agonist DAMGO. Although a recent study suggested that GRP cells are innervated by nociceptors and are strongly activated by noxious stimuli, we found that very few GRP cells receive direct synaptic input from TRPV1-expressing afferents, and that they seldom phosphorylate extracellular signal–regulated kinases in response to noxious stimuli. These findings indicate that the SP and GRP cells differentially process somatosensory information.

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Development of a Modified Cervical Deformity Frailty Index: A Streamlined Clinical Tool for Preoperative Risk Stratification

Study Design. Retrospective review. Objective. Develop a simplified frailty index for cervical deformity (CD) patients. Summary of Background Data. To improve preoperative risk stratification for surgical CD patients, a CD frailty index (CD-FI) incorporating 40 health deficits was developed. While novel, the CD-FI is clinically impractical due to the large number of factors needed for its calculation. To increase clinical utility, a simpler, modified CD-FI (mCD-FI) is necessary. Methods. CD patients (C2-C7 Cobb>10°, CL>10°, cSVA>4 cm, or CBVA>25°) >18 year with preoperative CD-FI component factors. Pearson bivariate correlation assessed relationships between component deficits of the CD-FI and overall CD-FI score. Top deficits contributing to CD-FI score were included in multiple stepwise regression models. Deficits from model with largest R2 were dichotomized, and the mean score of all deficits calculated, resulting in mCD-FI score from 0 to 1. Patients were stratified by mCD-FI: Not Frail (NF, <0.3), Frail (0.3–0.5), Severely Frail (SF, >0.5). Means comparison tests established correlations between frailty category and clinical outcomes. Results. Included: 121 CD patients (61 ± 11 yr, 60%F). Multiple stepwise regression models identified 15 deficits as responsible for 86% of the variation in CD-FI; these factors were used to construct the mCD-FI. Overall, mean mCD-FI was 0.31 ± 0.14. Breakdown of patients by mCD-FI category: NF: 47.9%, Frail: 46.3%, SF: 5.8%. Compared with NF and Frail, SF patients had the longest inpatient hospital stays (P = 0.042), as well as greater baseline neck pain (P = 0.033), inferior Neck Disability Index scores (P<0.001) and inferior EQ-5D scores (P < 0.001). Frail patients had higher odds of superficial infection (OR:1.1[1.0–1.2]), and SF patients had increased odds of mortality (OR:8.3[1.3–53.9]). Conclusion. Increased frailty, assessed by mCD-FI, correlated with increased length of stay, neck pain, and decreased health-related quality of life. Frail patients were at greater risk for infection, and severely frail patients had greater odds of mortality. This relationship between frailty and clinical outcomes suggests that mCD-FI offers clinical utility as a preoperative risk stratification tool. Level of Evidence: 3

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Development of a Modified Cervical Deformity Frailty Index: A Streamlined Clinical Tool for Preoperative Risk Stratification

Study Design. Retrospective review. Objective. Develop a simplified frailty index for cervical deformity (CD) patients. Summary of Background Data. To improve preoperative risk stratification for surgical CD patients, a CD frailty index (CD-FI) incorporating 40 health deficits was developed. While novel, the CD-FI is clinically impractical due to the large number of factors needed for its calculation. To increase clinical utility, a simpler, modified CD-FI (mCD-FI) is necessary. Methods. CD patients (C2-C7 Cobb>10°, CL>10°, cSVA>4 cm, or CBVA>25°) >18 year with preoperative CD-FI component factors. Pearson bivariate correlation assessed relationships between component deficits of the CD-FI and overall CD-FI score. Top deficits contributing to CD-FI score were included in multiple stepwise regression models. Deficits from model with largest R2 were dichotomized, and the mean score of all deficits calculated, resulting in mCD-FI score from 0 to 1. Patients were stratified by mCD-FI: Not Frail (NF, <0.3), Frail (0.3–0.5), Severely Frail (SF, >0.5). Means comparison tests established correlations between frailty category and clinical outcomes. Results. Included: 121 CD patients (61 ± 11 yr, 60%F). Multiple stepwise regression models identified 15 deficits as responsible for 86% of the variation in CD-FI; these factors were used to construct the mCD-FI. Overall, mean mCD-FI was 0.31 ± 0.14. Breakdown of patients by mCD-FI category: NF: 47.9%, Frail: 46.3%, SF: 5.8%. Compared with NF and Frail, SF patients had the longest inpatient hospital stays (P = 0.042), as well as greater baseline neck pain (P = 0.033), inferior Neck Disability Index scores (P<0.001) and inferior EQ-5D scores (P < 0.001). Frail patients had higher odds of superficial infection (OR:1.1[1.0–1.2]), and SF patients had increased odds of mortality (OR:8.3[1.3–53.9]). Conclusion. Increased frailty, assessed by mCD-FI, correlated with increased length of stay, neck pain, and decreased health-related quality of life. Frail patients were at greater risk for infection, and severely frail patients had greater odds of mortality. This relationship between frailty and clinical outcomes suggests that mCD-FI offers clinical utility as a preoperative risk stratification tool. Level of Evidence: 3

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Comparison of Patient Reported Outcome Measurement Information System With Neck Disability Index and Visual Analog Scale in Patients With Neck Pain

Study Design. A retrospective analysis of a patient-reported outcomes database from a single institution from December 2016 to April 2017. Objective. To validate the association of Patient Reported Outcome Measurement Information System (PROMIS) with Neck Disability Index (NDI) in patients with neck pain and examine each instruments ability to capture concomitant arm pain and concomitant back pain. Summary of Background Data. PROMIS has been increasingly utilized and its computer adapted testing methodology improves assessment of pain and disability. However, literature is lacking regarding how these instruments perform in neck pain patients with concomitant arm pain or back pain. Methods. Inclusion criteria were age >18 years and a primary complaint of neck pain. The NDI; Visual Analog Scale (VAS) back, neck, arm, and leg; and PROMIS physical function, pain intensity, and pain interference questionnaires were administered. Propensity score matching was performed to compare patients with high and low back and arm pain by controlling for neck pain. Bivariate correlations and independent samples t tests were performed to assess linear relationships and compare back and arm pain groups with PROMIS. Results. Approximately, 130 patients were included. NDI correlated strongly to PROMIS physical function (r = −0.771, P < 0.001), pain intensity (r = 0.605, P < 0.001), and pain interference (r = 0.786, P < 0.001). VAS neck and arm pain also correlated to the PROMIS pain intensity instrument (VAS neck: r = 0.642, P < 0.001; VAS arm: r = 0.376, P < 0.001). After matching for neck pain, the high and low back pain groups each included 32 patients. There were significant differences in PROMIS physical function when high and low back pain groups were compared (39.07 vs. 43.68, P = 0.031). No significant difference was found for any outcome metric for high and low arm pain groups. Conclusion. PROMIS instruments are capable of characterizing pain and disability in patients with neck pain and are sensitive to disability in regions adjacent to the neck. Level of Evidence: 3

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Initial Provider Specialty Is Associated With Long-term Opiate Use in Patients With Newly Diagnosed Low Back and Lower Extremity Pain

Study Design. Retrospective longitudinal cohort analysis of patients diagnosed in 2010, with continuous enrollment 6 months prior to and 12 months following the initial visit. Objective. To determine whether provider specialty influences patterns of opiate utilization long after initial diagnosis. Summary of Background Data. Patients with low back pain present to a variety of providers and receive a spectrum of treatments, including opiate medications. The impact of initial provider type on opiate use in this population is uncertain. Methods. We performed a retrospective analysis of opiate-naïve adult patients in the United States with newly diagnosed low back or lower extremity pain. We estimated the risk of early opiate prescription (≤14 d from diagnosis) and long-term opiate use (≥six prescriptions in 12 mo) based on the provider type at initial diagnosis using multivariable logistic regression, adjusting for patient demographics and comorbidities. Results. We identified 478,981 newly diagnosed opiate-naïve patients. Of these, 40.4% received an opiate prescription within 1 year and 4.0% met criteria for long-term use. The most common initial provider type was family practice, associated with a 24.4% risk of early opiate prescription (95% CI, 24.1–24.6) and a 2.0% risk of long-term opiate use (95% CI, 2.0–2.1). Risk of receiving an early opiate prescription was higher among patients initially diagnosed by emergency medicine (43.1%; 95% CI, 41.6–44.5) or at an urgent care facility (40.8%; 95% CI, 39.4–42.3). Risk of long-term opiate use was highest for patients initially diagnosed by pain management/anesthesia (6.7%; 95% CI, 6.0–7.3) or physical medicine and rehabilitation (3.4%; 95% CI, 3.1–3.8) providers. Conclusion. Initial provider type influences early opiate prescription and long-term opiate use among opiate-naïve patients with newly diagnosed low back and lower extremity pain. Level of Evidence: 3

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Point of View: Initial Provider Specialty Is Associated With Long-Term Opiate Use in Patients With Newly Diagnosed Low Back and Lower Extremity Pain

No abstract available

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Comparative Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population: Pre and Post Affordable Care Act

Study Design. A retrospective cohort study of utilization patterns of epidural injections. Objective. The aim of this study was to assess patterns of utilization and variables of in chronic spinal pain in the fee-for-service (FFS) Medicare population, with a comparative analysis of pre- and post-Affordable Care Act (ACA) data from 2000 to 2009 and 2009 to 2016. Summary of Background Data. Over the years, utilization of interventional pain management techniques, specifically epidural injections have increased creating concern over costs and public health policy. Methods. The master data from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2016 was utilized to assess utilization patterns. The descriptive analysis of the database analysis was performed using guidance from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Multiple variables were analyzed based on the procedures, specialties, and geography. Results. Caudal and lumbar interlaminar epidural injections decreased 25% from 2009 to 2016 with an annual decrease of 4% in contrast to lumbosacral transforaminal epidural injection episodes, increasing at an annual rate of 0.3%. In contrast, lumbar interlaminar epidural injections increased 2.4% annually, while transforaminal episodes increased 23% from 2000 to 2009. The ratio of interlaminar epidural injections to transforaminal epidural injection episodes has changed from 7 in 2000 to 1 in 2016, whereas ratio of services changed from 5 to 0.7. From 2009 to 2016, cervical/thoracic interlaminar epidural injections episodes increased at an annual rate of 0.5%, with a decrease of 2.3% for transforaminal epidural injections. Conclusion. Comparative analysis of the utilization of epidural injections from 2000 to 2009 and 2009 to 2016 showed vast differences with overall significant decreases in utilization, specifically for lumbar interlaminar and caudal epidural injections, with a continued, though greatly slowed increase of lumbosacral transforaminal epidural injections. Level of Evidence: 3

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Expectations for Postoperative Improvement in Health-Related Quality of Life in Young Patients With Lumbosacral Spondylolisthesis: A Prospective Cohort Study

Study Design. Prospective multicenter study of the changes in Scoliosis Research Society Outcome Questionaire 22 (SRS-22) scores for 78 patients younger than 25 years old surgically treated for lumbosacral spondylolisthesis Objective. Report the change of health-related quality of life (HRQOL) in patients younger than 25 years after surgical treatment of lumbosacral spondylolisthesis. Summary of Background Data. There is a paucity of data with regard to the influence of surgical treatment on the HRQOL of patients with lumbosacral spondylolisthesis. Large prospective studies are needed to clearly define the benefits of surgery in the young patient population. Methods. A prospective multicenter cohort of 78 patients younger than 25 years (14.8 ± 2.9, range: 7.9–23.6 yr) undergoing posterior fusion for lumbosacral spondylolisthesis were enrolled. There were 17 patients with low-grade (<50%) and 61 with high-grade (≥50%) slips. SRS-22 scores calculated before surgery and after 2 years of follow-up were compared for all patients using two-tailed paired t tests. Subanalyses for low- and high-grade patients were done using two-tailed Wilcoxon signed ranked and paired t tests, respectively. The level of significance was set at 0.05. Results. HRQOL was significantly improved 2 years after surgery for all domains and for the total score of the SRS-22 questionnaire. The individual total score was improved in 66 patients (85%), and 52 patients (67%) improved by at least 0.5 point. All domains and the total score of the SRS-22 questionnaire were significantly improved for high-grade patients, whereas only pain, function, and total score were improved for low-grade patients. Conclusion. This is the largest study comparing the HRQOL before and after surgery in young patients with low- and high-grade lumbosacral spondylolisthesis. HRQOL significantly improves after surgery for the majority of patients, especially for high-grade patients. This study helps clinicians to better counsel patients with regard to the benefits of surgery for lumbosacral spondylolisthesis. Level of Evidence: 2

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Sensorimotor Cortical Activity in Acute Low Back Pain: A Cross-Sectional Study

Individuals who experience low back pain (LBP) for 6 months or more (‘chronic LBP’) display cortical activity and organisation of the primary sensory (S1) and motor (M1) cortices that differs from pain-free individuals.58,61,66 For example, studies demonstrate greater S1 activity and a difference in the location of S1 activation in chronic LBP.16,19 Similarly, there is evidence of different M1 organisation characterised by a more posterior location and greater overlap of representations of the trunk muscles.

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Bexarotent attenuated CCI-induced spinal neuroinflammation and neuropathic pain by targeting MKP-1

It is widely accepted that neuroinflammation in the spinal cord plays an important role in the development of central sensitization in neuropathic pain. Spinal MAPKs activation contribute to the development of neurinflammation in neuropathic pain.13,15 However, Ndong C et al reported that mitogen-activated protein kinase phosphatase 1(MKP-1), a negative feedback of activated MAPKs, was reduced in the development of neuropathic pain.27 Upregulation of spinal MPK-1 alleviated the behavioral hypersensitivity in neuropathic pain.

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Nicotine-evoked currents in human primary sensory neurons

Data from rodents and humans indicate that activation of peripheral nicotinic acetylcholine receptors (nAChRs) can be either pro- or antinociceptive. Application of nicotine at a variety of superficial and deep tissue sites evokes the sensation of pain in humans7,17 and nociceptive responses in the rat.4,29 Persistent inflammation is associated with increased α3β4 subunit expression3 and an increase in nAChR current density in putative nociceptive DRG neurons.35 Furthermore, inflammatory hypersensitivity appears to be due, at least in part, to nAChR activation.

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The (parental) whole is greater than the sum of its parts: A multifactorial model of parent factors in pediatric chronic pain

Parents are important influencers of symptoms and functioning in youth with chronic pain.37 A number of parental factors are associated with child pain and functioning, including responses to child pain (e.g., protectiveness),10, 33 psychological functioning (e.g., anxiety),4, 34 and chronic pain history.4, 7, 22, 40 However, these parental factors typically have been evaluated as separate domains with few studies examining their interrelations.28, 30, 37, 45, 46, 56 Understanding the extent to which parental factors are interrelated, and exhibit differential associations with child adjustment to chronic pain may help improve interventions for parents of youth with chronic pain.

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18-year Trends in the Prevalence of, and Health Care Use for, Non-Cancer Pain in the United States: Data from the Medical Expenditure Panel Survey

Pain is a major cause of morbidity in the United States, costing billions of dollars annually in conventional28 and complementary44 health care and lost productivity.28 The prevalence of condition-specific pain in the United States is generally estimated using data from national surveys. These surveys have routinely found increases in arthritic conditions,14,45,75,76 headaches7, and spine conditions1616,22,38,40,58 since the 1990s. Increases in the prevalence of spine conditions have also been observed at the state level.

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Discrete trajectories of resolving and persistent pain in people with rheumatoid arthritis despite undergoing treatment for inflammation: Results from three UK cohorts

Arthritis is a common cause of chronic musculoskeletal pain and disability; especially across ageing populations. Arthritis has traditionally been classified as either inflammatory (e.g. rheumatoid arthritis; RA) or non-inflammatory (e.g. osteoarthritis; OA, the commonest reason for joint replacement surgery). RA is a systemic, autoimmune condition with a predilection for synovial joints of the hands and feet. Synovitis (inflammation of the joint lining) contributes to pain, and also leads to joint damage.

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Fetal pain debate may weaken the fight for newborns’ analgesia

Dr Apkar V. Apkarian recently dealt with the controversial issue of fetal pain;2 he argued that “pain perception by humans or other animals requires the ability to evaluate the environment and form a subjective judgment about the value of the incoming flow of nociceptive information. Therefore, pain requires consciousness,”. Thus, he concludes that fetuses are immune from feeling pain because of their lack of awareness, according with the official definition of the word pain given by the IASP, that requires a full consciousness to feel pain.

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[Clinical Picture] Hyperphosphataemic tumoral calcinosis

An 18-year-old man presented to our department with a 1-year history of pain in the region of his left hip and difficulty in squatting. He reported no history of any local trauma. There was no history suggestive of an autoimmune disorder. Clinical examination found a tender, hard mass in the left greater trochanteric region with painful, restricted rotation and abduction movements of the hip. Both his medical history and family history were unremarkable. Plain x-ray and CT scans of the pelvis (figure) showed bilateral—left greater than the right—and periarticular, lobulated, calcific, soft tissue masses.

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The ACTTION–APS–AAPM Pain Taxonomy (AAAPT) Diagnostic Criteria for Acute Pain Conditions: An Introduction

In 2013, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration and the American Pain Society (APS) collaborated to address the ongoing need for a systematic, standardized, and evidence based diagnostic framework applied to chronic pain conditions. This effort, termed the ACTTION-APS Pain Taxonomy (AAPT), created a 5-dimensional framework whereby chronic pain conditions could be classified in a multidimensional manner while embracing the biopsychosocial variables associated with each condition.

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Herpes zoster infection

What you need to knowA typical history for herpes zoster might include neuropathic pain for around three days followed by a vesicular rash in a dermatomal distributionConsider treatment with an...

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