US opioid epidemic: FDA demands studies of whether opioids do control chronic pain

Two decades into an opioid epidemic that has killed more US people than the second world war, the US Food and Drug Administration has said that it will require drug companies to conduct research to...

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How an understanding of our ability to adhere to verbal rules can increase insight into (mal)adaptive functioning in chronic pain

Chronic pain is a common health problem in adults8 as well as in children42. Although many people seem to function well despite chronic pain, a considerable number experience restrictions in their daily functioning, from lower levels of physical activity, isolation from social activities, to increased absence from school or work1,46,66,88. Research has mainly focused on those risk factors that give rise to and exacerbate chronic pain-related disability, focusing on both intrapersonal, cognitive (e.g., catastrophic thoughts/worries about pain19,82), attentional (e.g., hypervigilance/selective attention to pain 18,83), affective (e.g., fear of pain78,88), behavioral (e.g., pain avoidance1,88), and interpersonal factors (e.g., spousal solicitousness, parental overprotective behavior28,60).

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Conditioned Pain Modulation in Sexual Assault Survivors

Sexual assault (SA), defined as exposure to any nonconsensual sexual act72, occurs in 1-in-4 women and 1-in-100 men, with a new incident occurring every 98 seconds in the U.S.16. SA has been linked to many negative outcomes, including chronic pain27. Indeed, many people with chronic pain report experiencing SA (7-91%)74, but only a minority of SA survivors report sustaining a physical injury during the SA40,73. Thus, injuries from SA are not likely responsible for chronic pain risk.

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A woman with recurrent anaemia and jaundice

A 41 year old white woman presented to the emergency department. She described fever, cough, and exercise intolerance, yellowish discolouration of her eyes, and pain in the left upper quadrant that...

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Response to Wolfe. Letter to the Editor, “Fibromyalgia Criteria”

We thank the Journal of Pain for the opportunity to respond to Dr. Wolfe.2 We would like to emphasize several main points in response to Dr. Wolfe.

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Self referral to physiotherapy for back pain reduces pressure on GP appointments

Allowing patients with back pain, arthritis, and other musculoskeletal conditions to self refer to physiotherapists based in GP practices cut the proportion needing a GP consultation for back pain...

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Activation of sphingosine-1-phosphate receptor 1 in the spinal cord produces mechano-hypersensitivity through the activation of inflammasome and IL-1β pathway

Dysregulation of sphingolipid metabolism in the dorsal horn of the spinal cord (DH-SC) has been linked to the development of nociceptive behaviors arising from chemotherapy,19,43 traumatic nerve injuries,10 cancer17 and opioids.28 The bioactive sphingolipid sphingosine-1-phosphate (S1P) is formed by phosphorylation of sphingosine by the two isoforms of sphingosine kinases (SphKs; SphK1 and SphK2),42 which are expressed throughout the central nervous system (CNS) including the spinal cord.5,50 S1P can act both as an intracellular mediator and an extracellular ligand to its five cognate G protein-coupled receptors, S1PR1-5, in an autocrine/paracrine manner to produce so-called “inside-out signaling”.

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The role of perceived stress and life stressors in the development of chronic musculoskeletal pain disorders: a systematic review

Musculoskeletal pain disorders (MDs), such as osteoarthritis, low back pain and neck pain, are common health problems and a major cause of disease burden worldwide.10,13 MDs are the second most frequent cause of disability, accounting for 21.3% of the total years lived with disability, second only to mental health conditions.47,67 Psychological factors are strongly associated with MDs,6,13,24,48 and are thought to play a role in the development of chronic MDs (defined as pain lasting longer than three months).

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Sensory, Affective, and Catastrophizing Reactions to Multiple Stimulus Modalities: Results from the Oklahoma Study of Native American Pain Risk (OK-SNAP)

Native Americans (NAs) have a higher prevalence of chronic pain than any other U.S. racial/ethnic group,4,35,83 yet little has been done to understand what contributes to this pain disparity. Access to health care,1,46 difficulties assessing/treating pain cross-culturally,78 and/or provider biases31,32 may contribute to this disparity; but, it could also stem from differences in the way that pain is processed and experienced.37

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Assisted dying methods can lead to “inhumane” deaths

Methods for assisting death in countries where the practice is legal do not reliably achieve unconsciousness at the time of death to ensure that the patient experiences no pain or distress, a review...

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Improving pain and sleep in middle-aged and older adults: the promise of behavioral sleep interventions

Improving pain and sleep in middle-aged and older adults: the promise of behavioral sleep interventions

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Facial muscle movements encoding pain—a systematic review

Facial expressions of pain are not undefined grimaces, but they convey specific information about the internal state of the individual in pain. With this systematic review, we aim to answer the question of which facial movements are displayed most consistently during pain. We searched for studies that used the Facial Action Coding System to analyze facial activity during pain in adults, and that report on distinct facial responses (action units [AUs]). Twenty-seven studies using experimental pain and 10 clinical pain studies were included. We synthesized the data by taking into consideration (1) the criteria used to define whether an AU is pain-related; (2) types of pain; and (3) the cognitive status of the individuals. When AUs were selected as being pain-related based on a “pain > baseline” increase, a consistent subset of pain-related AUs emerged across studies: lowering the brows (AU4), cheek raise/lid tightening (AUs6_7), nose wrinkling/raising the upper lip (AUs9_10), and opening of the mouth (AUs25_26_27). This subset was found independently of the cognitive status of the individuals and was stable across clinical and experimental pain with only one variation, namely that eye closure (AU43) occurred more frequently during clinical pain. This subset of pain-related facial responses seems to encode the essential information about pain available in the face. However, given that these pain-related AUs are most often not displayed all at once, but are differently combined, health care professionals should use a more individualized approach, determining which pain-related facial responses an individual combines and aggregates to express pain, instead of erroneously searching for a uniform expression of pain.

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The migraine eye: distinct rod-driven retinal pathways' response to dim light challenges the visual cortex hyperexcitability theory

Migraine-type photophobia, most commonly described as exacerbation of headache by light, affects nearly 90% of the patients. It is the most bothersome symptom accompanying an attack. Using subjective psychophysical assessments, we showed that migraine patients are more sensitive to all colors of light during ictal than during interictal phase and that control subjects do not experience pain when exposed to different colors of light. Based on these findings, we suggested that color preference is unique to migraineurs (as it was not found in control subjects) rather than migraine phase (as it was found in both phases). To identify the origin of this photophobia in migraineurs, we compared the electrical waveforms that were generated in the retina and visual cortex of 46 interictal migraineurs to those generated in 42 healthy controls using color-based electroretinography and visual-evoked potential paradigms. Unexpectedly, it was the amplitude of the retinal rod-driven b wave, which was consistently larger (by 14%-19% in the light-adapted and 18%-34% in the dark-adapted flash ERG) in the migraineurs than in the controls, rather than the retinal cone-driven a wave or the visual-evoked potentials that differs most strikingly between the 2 groups. Mechanistically, these findings suggest that the inherent hypersensitivity to light among migraine patients may originate in the retinal rods rather than retinal cones or the visual cortex. Clinically, the findings may explain why migraineurs complain that the light is too bright even when it is dim to the extent that nonmigraineurs feel as if they are in a cave.

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Trigger Point Manual Therapy for the Treatment of Chronic Noncancer Pain in Adults: A Systematic Review and Meta-analysis

Publication date: March 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 3

Author(s): Diarmuid Denneny, Helena C. Frawley, Katrine Petersen, Rebecca McLoughlin, Suzanne Brook, Salma Hassan, Amanda C. Williams

Abstract

Objective

To determine the effectiveness of trigger point manual therapy (TPMT) for reducing chronic noncancer pain and associated problems in adults, by analyzing all relevant randomized controlled trials (RCTs).

Data Sources

We searched databases and clinical trials registers from their inception to May 2017.

Study Selection

We included RCTs in any language that recruited patients older than 18, with pain of 3 months’ duration or more. We assessed pain, function, and patient-reported improvement as outcomes.

Data Extraction

Two authors independently extracted and verified data. Meta-analysis was completed where possible, otherwise data were synthesized narratively.

Data Synthesis

We combined all data using a random-effects model and assessed the quality of evidence using GRADE. A total of 19 trials (involving 1047 participants) met inclusion criteria, representing TPMT treatment of musculoskeletal, pelvic, and facial pain. No effect was found for short-term pain relief (mean standardized difference −0.53; 95% confidence interval [CI], −1.08 to 0.02). One small study showed a longer-term benefit for pain (mean standardized difference −2.00; 95% CI, −3.40 to −0.60) but with low confidence in the effect. Significant gains emerged for function (mean standardized difference −0.77; 95% CI, −1.27 to −0.26) and in patient global response (odds ratio 3.79; 95% CI, 1.86-7.71) from 4 studies, but not for health-related quality of life.

Conclusions

Evidence for TPMT for chronic noncancer pain is weak and it cannot currently be recommended.

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Patellar Tendon Reflex and Vastus Medialis Hoffmann Reflex Are Down Regulated and Correlated in Women With Patellofemoral Pain

Publication date: March 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 3

Author(s): Marcella Ferraz Pazzinatto, Danilo de Oliveira Silva, Amanda Schenatto Ferreira, Marina Cabral Waiteman, Evangelos Pappas, Fernando Henrique Magalhães, Fábio Mícolis de Azevedo

Abstract

Objectives

The aims of this study were threefold: (1) to compare the amplitude of patellar tendon reflex (T-reflex) between women with patellofemoral pain (PFP) and pain-free controls; (2) to compare the amplitude of vastus medialis Hoffmann reflex (VM H-reflex) between women with PFP and pain-free controls; (3) to investigate the association between the amplitude of patellar T-reflex and VM H-reflex in women with PFP and pain-free controls.

Design

Cross-sectional observational study.

Setting

Laboratory of biomechanics and motor control.

Participants

Thirty women with PFP and 30 pain-free women aged 18 to 35 years (N=60).

Main Outcome Measures

Peak-to-peak amplitudes of maximal VM H-reflex (elicited via electrical stimulation on the femoral nerve) and patellar T-reflex (elicited via mechanical percussion on the patellar tendon) were estimated.

Results

Women with PFP had significant lower amplitude of patellar T-reflex (mean difference=0.086; 95% confidence interval=0.020 to 0.151; P=.010; moderate effect) and VM H-reflex (mean difference=0.150; 95% confidence interval =0.073 to 0.227; P<.001; large effect) compared to pain-free controls. The VM H-reflex was strongly correlated with patellar T-reflex in both PFP group (r=0.66; P<.001) and control group (r=0.72; P<.001).

Conclusions

As the T-reflex is easier to perform than H-reflex assessments in a clinical setting, it represents a feasible option to assess the impaired excitability of the stretch reflex pathway associated with PFP.

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Return-to-Work Barriers Among Manual Workers After Hand Injuries: 1-Year Follow-up Cohort Study

Publication date: March 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 3

Author(s): Batia S. Marom, Navah Z. Ratzon, Rafael S. Carel, Moshe Sharabi

Abstract

Objective

To determine time of return to work (TRTW) in relation to multivariable predictors among male manual workers after hand injury (HI) over a 12-month follow-up.

Design

A cohort study with baseline medical information, functional evaluation, and 3-, 6-, 9-, and 12-month follow-up telephone interviews.

Setting

Seven physical rehabilitation community occupational therapy clinics.

Participants

Participants (N=178) with acute HI aged 22-65. Two participants were lost to follow-up.

Intervention

Not applicable.

Main Outcome Measure

The dependent variable was TRTW. The independent variables originated from 4 domains: personal factors, environmental factors, body function and structure, and activity limitation and participation restriction. The proportion of return to work (RTW) at each time point was calculated. Multiple Cox regressions established a predictive model for TRTW.

Results

At the end of the study, 75.3% participants returned to work. The median TRTW was 94 days. In the final model, only compensation factors and education contributed significantly to overall RTW, but when separate analyses were performed, decreased level of self-efficacy, higher workplace demands, level of pain, level of emotional response to trauma, reduced physical capability of the hand, and higher level of disability were significantly associated with delayed TRTW.

Conclusions

TRTW was determined by the physical capability of the hand, pain, and psychosocial factors, but it was also affected by legal factors. Participants who did not return to work during the first 9 months are at risk for long-term disability. Developing treatment programs for those who are at risk for not returning to work, taking into consideration these factors, is recommended.

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The Effects of M2M and Adapted Yoga on Physical and Psychosocial Outcomes in People With Multiple Sclerosis

Publication date: March 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 3

Author(s): Hui-Ju Young, Tapan S. Mehta, Cassandra Herman, Fuchenchu Wang, James H. Rimmer

Abstract

Objective

To investigate the effects of two 12-week exercise training interventions, movement-to-music (M2M) and adapted yoga (AY), on physical and psychosocial outcomes in people with multiple sclerosis (MS).

Design

Three-arm randomized controlled proof-of-concept trial.

Setting

A community-based fitness facility.

Participants

Participants (N=81) with MS (Patient Determined Disease Steps [PDDS] self-reported disease status scores: 0-6) between ages of 18 and 65 years were randomized to M2M (n=27), AY (n=26), or waitlist control (n=28).

Interventions

Both M2M and AY completed three 60-minute exercise sessions per week for 12 weeks. Waitlist controls received biweekly newsletters via mail that contained educational information on living with MS.

Main Outcome Measures

Primary measures were timed Up and Go (TUG, s) test, 6-minute walk test (6MWT, m), and 5 times sit-to-stand test (FTSST, s). Secondary measures were self-reported outcomes assessed using Patient-Reported Outcomes Measurement Information System Fatigue and Pain Interference Short Form 8a. Participants were evaluated at baseline and postintervention. Primary analyses were performed using an intent-to-treat mixed model analysis of covariance.

Results

Comparisons across all 3 groups revealed significant group differences in TUG and 6MWT. Post hoc analyses indicated significant improvements in TUG (least square mean difference [95% confidence interval] = −1.9s [−3.3 to −0.5], P=.01, d=0.7) and 6MWT (41.0m [2.2-80.0], P=.04, d=0.6; controlled for PDDS) in M2M compared to controls, while no significant differences were observed when compared AY to controls. No significant group differences were found in FTSST, fatigue, and pain interference.

Conclusions

M2M may be a useful and enjoyable exercise form for people with MS in improving mobility and walking endurance and merits long-term study in larger study populations.

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Classify viruses — the gain is worth the pain

Classify viruses — the gain is worth the pain

Classify viruses — the gain is worth the pain, Published online: 20 February 2019; doi:10.1038/d41586-019-00599-8

Viruses hold solutions to a lot of problems, so let’s fund and reward cataloguing, urge Jens H. Kuhn and colleagues.

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Helen Salisbury: The perils of deprescribing

Imagine that my next patient is a 78 year old who’s come about her back pain—it’s no better, and she won’t get the physiotherapy she needs for many weeks yet. She’d also like me to look at a funny...

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