Ziconotide for spinal cord injury‐related pain

Abstract

Background

Central neuropathic pain related to spinal cord injury is notoriously difficult to treat. So far most pharmacological and surgical options have shown but poor results. Recently ziconotide has been approved for use both neuropathic and non‐neuropathic pain. In this cohort study, we assessed responder rate and long‐term efficacy of intrathecal ziconotide in patients with pain related to spinal cord injury.

Methods

Patients presenting chronic neuropathic related to spinal cord lesions that was refractory to medical pain management were considered for inclusion. Those accepting were tested by lumbar puncture injection of ziconotide or continuous intrathecal infusion and if a significant decrease in pain scores (>40%) was noted they were implanted with a continuous infusion pump. They were then followed up for at least 1 year with constant assessment of the evolution of pain and side effects.

Results

Out of the 20 patients tested 14 had a decrease in pain scores of more than 40% but only 11 (55%) were implanted with permanent pumps due to side effects and patient choice. These were followed up on average for 3.59 years (±1.94) and in eight patients an above threshold decrease in pain scores was maintained. Overall in patients that responded to the test baseline VAS was 7.91 and 4.31 at last follow‐up with an average dose of 7.2 μg of ziconotide per day. Six patients (30%) did not respond to any test and in three patients side effects precluded pump implantation. No significant long‐term effects of the molecule were noted.

Conclusion

This study shows response to intrathecal ziconotide test in 40% of the patients of a very specific population in whom other therapeutic options are not available. This data justifies the development further studies such as a long‐term randomized controlled trial.

Significance

Intrathecal Ziconotide is a posible alternative for the treatment of pain in patients with spinal cord injury and below level neuropathic pain.

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William “Ed” Kois: whistleblower who exposed substandard care at a US veterans hospital

bmj;366/aug30_4/l5325/FAF1faPeter Biello/New Hampshire Public RadioA specialist in rehabilitation and pain management, William “Ed” Kois was not your typical doctor. He swore a lot,1 he wore a goatee...

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Risk and Prognostic Factors of Low Back Pain: Repeated Population-based Cohort Study in Sweden

Study Design. Prospective longitudinal cohort study. Objective. To determine the associations for workload and health-related factors with incident and recurrent low back pain (LBP), and to determine the mediating role of health-related factors in associations between physical workload factors and incident LBP. Summary of Background Data. It is not known whether the risk factors for the development of LBP are also prognostic factors for recurrence of LBP and whether the associations between physical workload and incident LBP are mediated by health-related factors. We used data from the Swedish Longitudinal Occupational Survey of Health study. Those responding to any two subsequent surveys in 2010 to 2016 were included for the main analyses (N = 17,962). Information on occupational lifting, working in twisted positions, weight/height, smoking, physical activity, depressive symptoms, and sleep problems were self-reported. Incident LBP was defined as pain limiting daily activities in the preceding three months in participants free from LBP at baseline. Recurrent LBP was defined as having LBP both at baseline and follow-up. For the mediation analyses, those responding to three subsequent surveys were included (N = 3516). Methods. Main associations were determined using generalized estimating equation models for repeated measures data. Mediation was examined with counterfactual mediation analysis. Results. All risk factors at baseline but smoking and physical activity were associated with incident LBP after adjustment for confounders. The strongest associations were observed for working in twisted positions (risk ratio  = 1.52, 95% CI 1.37, 1.70) and occupational lifting (risk ratio  = 1.52, 95% CI 1.32, 1.74). These associations were not mediated by health-related factors. The studied factors did not have meaningful effects on recurrent LBP. Conclusion. The findings suggest that workload and health-related factors have stronger effects on the development than on the recurrence or progression of LBP, and that health-related factors do not mediate associations between workload factors and incident LBP. Level of Evidence: 3

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Intrathecal dexmedetomidine versus magnesium sulfate for postoperative analgesia and stress response after cesarean delivery; randomized controlled double‐blind study

Abstract

Background

Various adjuvants were added to intrathecal anesthetics to improve quality of the block and postoperative analgesia. We hypothesized that intrathecal dexmedetomidine and magnesium sulfate (MgSO₄) may add similar effects. Our objectives were to compare their effects as adjuvants to intrathecal bupivacaine on postoperative analgesia, stress hormones, sedative properties and the neonatal outcome after cesarean section.

Methods

A randomized double‐blind controlled study; ninety parturients were divided into three groups. All patients received intrathecal hyperbaric bupivacaine 12.5mg. NaCl 0.9% was added to intrathecal block in group C, 5μg dexmedetomidine in the group D and 50mg MgSO₄ in group M. Visual analogue scale (VAS) score, stress hormones were assessed within the first 12 postoperative hours, sensory block, and neonatal outcome were also assessed.

Results

VAS scores were significantly lower in groups D & M. Onset of postoperative pain was significantly prolonged in group D. Time to peak sensory level was shorter in group D. Sedation score was significantly higher in group D only after 30 minutes of intrathecal block. Although stress hormones increased in all groups during intraoperative and postoperative periods, their levels were significantly lower in group D compared to other groups. No differences were noted regarding neonatal outcomes.

Conclusion

Intrathecal dexmedetomidine is superior to intrathecal MgSO₄ during cesarean section with regard to duration of analgesia, pain severity, and stress hormone levels. Dexmedetomidine has a rapid onset and longer duration of sensory block compared to MgSO₄. No significant adverse effects to the parturients or newborns.

This article is protected by copyright. All rights reserved.

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Effect of local infiltration with oxytocin on hemodynamic response to surgical incision and postoperative pain in patients having open laparoscopic surgery under general anesthesia

Abstract

Background

Preemptive analgesia encompasses different perioperative interventions that have the final aim of decreasing postoperative pain and improving recovery. Recently, peripheral analgesic effects of oxytocinergic modulation have been suggested. In this regard, we tested the potential analgesic effects of subcutaneous oxytocin (OT) infiltration in patients submitted to laparoscopic cholecystectomy.

Methods

Thirty patients with similar general characteristics and medical physical conditions were evaluated. The patients were assigned by simple random selection to one of three groups: (a) OT group (n = 10), which received preincisional subcutaneous OT (4 µg/4 ml saline) in the surgical sites for trocar placements; (b) Lidocaine group (n = 10), which received subcutaneous lidocaine 1% (4 ml) in the surgical sites; and (c) Control group (n = 10), which did not receive any treatment. Then we measured the effect of those treatments on the hemodynamic variations produced as responses to the surgical incisions and trocar insertions (open port placements using the Hasson technique). Moreover, we assessed the intensity of postoperative pain with the visual analogue scale during recovery and 24 hr after surgery.

Results

Hemodynamic parameters were stable in both intervention groups (subcutaneous OT and lidocaine) during the surgical incisions and trocar placements, whereas a most likely sympathetic activation due to trocar insertions (open port placements) was not blunted in the placebo group. Furthermore, postoperative pain was diminished in both OT and lidocaine groups when compared to the control group.

Conclusions

Preincisional subcutaneous OT administration reduced the hemodynamic response produced by the latter. Furthermore, OT also diminished postoperative pain.

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Visual attention to pain cues for impending touch versus impending pain: An eye tracking study

Abstract

Background

In this eye tracking study, we evaluated pain‐related biases in orienting and maintenance of gaze within impending touch versus impending pain tasks and examined features of pain resilience as individual difference influences on potential biases.

Methods

Gaze preferences of healthy adults (25 women and 39 men) were assessed during standardized pain‐neutral (P‐N) image pair presentations (2,000 ms) of an impending touch task versus an impending pain task whereby image pair offsets were followed by potential non‐painful touch and potential pain stimulation, respectively.

Results

Within each task, participants were significantly more likely to fixate first upon pain images in P‐N pairs and maintain gaze on these images for longer overall durations during trials. Between task comparisons indicated pain‐related biases in orienting and maintenance were significantly stronger when image pairs signalled potential pain rather than impending touch. Finally, within the impending pain task, higher scores on the behaviour perseverance dimension of pain resilience were related to shorter first fixation durations and overall gaze durations towards pain images.

Conclusions

Supporting specific threat interpretation model premises, comparatively more threatening external pain cues for impending pain were characterized by gaze biases reflecting pronounced early attentional capture and subsequent prolonged vigilance. However, elevations in self‐reported behavioural perseverance in spite of pain corresponded to an increased capacity to disengage from pain images that signalled potential pain.

Significance

Gaze biases were assessed within a comparatively benign “impending touch” paradigm versus a higher threat, impending pain task. Early capture and maintenance of gaze towards pain images were more pronounced on the latter task, although pain resilient participants were able to disengage more easily from pain images signalling possible pain.

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Discharged and dismissed: A qualitative study with back pain patients discharged without treatment from orthopaedic consultations

Abstract

Background

Consultation‐based reassurance for patients with low back pain (LBP) in primary care has been shown to be associated with patients' outcomes. Little is known about the role of reassurance in people with LBP consulting with orthopaedic spinal care teams. Reassurance may be important, especially in cases where surgery is not indicated and patients are discharged without treatment.

Methods

Semi‐structured interviews were conducted with 30 patients with chronic disabling musculoskeletal LBP who had recently consulted with spinal orthopaedic care teams. Interviews were audio recorded, transcribed, coded and analysed.

Results

Most patients reported feeling dismissed and discouraged. Patients perceived that they needed specific behaviours from practitioners in order to feel sufficiently reassured to commit to self‐management. These behaviours group into four domains: “Knowing my whole story” (evidence that practitioners read the case notes; were familiar with the patients' previous health care history; carried out tests and a physical examination and gathered information about the patients' lifestyle), “Seeing the right person” (showing empathy; listening; building rapport and demonstrating that they are qualified and experienced), “Nothing to worry about” (reducing generic reassuring statements but increasing validating statements recognizing suffering) and “Getting to grips with my problem” (providing explanations and a clear management plan). In the absence of these behaviours, patients rejected advice to self‐manage, reported distress, anger and intention to re‐consult.

Conclusion

Effective communication with patients attending spinal orthopaedic care settings is important, especially when no active treatment is being offered.

Significance

This study describes narratives from patients discharged without surgery following consultations with orthopaedic professionals for persistent and debilitating lower back pain. Findings suggest that these interactions are distressful to patients, and that patients require comprehensive and specific reassurance to promote self‐management. The findings contribute a unique insight into the special needs of people with complex pain problems and provide guidance to improve consultation‐based reassurance in orthopaedic spinal care settings.

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Associations of co‐occurring psychosocial and lifestyle factors with multisite musculoskeletal pain during late adolescence—A birth cohort study

Abstract

Background

Musculoskeletal (MS) pain is common. It often exists in several sites and is recurrent. Psychosocial difficulties and unhealthy behaviours have been related to multisite MS pain, but no literature has assessed the impact of accumulated psychosocial and lifestyle factors on recurrent multiple MS pain.

Methods

Our data were gathered from two questionnaires of the well‐known Northern Finland Birth Cohort 1986 (NFBC1986), sent to members when they were aged 16 and 18. A total of 1,625 adolescents (712 boys and 913 girls) answered questions on smoking, physical activity, sedentary behaviour, sleeping and emotional and behavioural problems at 16 years and on musculoskeletal pain at 16 and 18 years. Weight and height measurements were taken at a health examination at baseline. A latent class analysis and multinomial regression analysis were conducted.

Results

We identified four clusters among both sexes. “Externalizing behavior” among both genders (OR 2.98, CI 1.73–5.13 among boys; OR 2.38, CI 1.38–4.11 among girls), “Multiple risk behaviors” among girls (OR 2.73, CI 1.30–5.71) and a “Sedentary” cluster among boys (OR 1.85, CI 1.21–2.82) were associated to recurrent multisite MS pain. “Obese” clusters had no significant associations with recurrent multiple MS pain.

Conclusions

Adolescents with psychosocial difficulties and/or several adverse health behaviours were at an increased risk of recurrent multisite MS pain, which emphasizes the importance of simultaneously studying multiple rather than single factors. The identification of risk groups may help more accurately target preventive interventions.

Significance

This study found subgroups of adolescents at risk of recurrent multisite musculoskeletal pain during late adolescence. The accumulation of multiple adverse behaviours is likely to provide new perspectives for understanding the multidimensional nature of multiple MS pains.

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Pain and posttraumatic stress disorder in refugees who survived torture: The role of pain catastrophizing and trauma‐related beliefs

Abstract

Background

Traumatized refugees with comorbid pain report more severe posttraumatic stress disorder (PTSD), respond less well to PTSD‐focused treatments and exhibit greater disability. A mutually maintaining relationship may exist between pain and PTSD, that may be partly accounted for by depression, but no prior studies have tested this assumption in traumatized refugees.

Method

Self‐report measures of pain, PTSD, depression, disability, pain catastrophizing (PC) and trauma‐related beliefs (TRBs) were administered to 197 refugees referred to the Danish Institute Against Torture (DIGNITY) prior to treatment. The contribution of pain, depression, PC, and TRBs to the overall variance in PTSD severity was examined. We also examined whether the relationship between pain and PTSD was mediated by PC and TRBs, after controlling for depression.

Results

Depression, pain severity, PC and TRBs together accounted for 66% of the overall variance in PTSD, with depression being the primary contributor (57%). In univariate tests, both PC and TRBs significantly mediated the relationship between pain interference/severity and PTSD. However, after controlling for depression only PC mediated this relationship.

Conclusions

Negative beliefs about pain and the trauma made small, but additive contributions to the relationship between pain and PTSD severity, after controlling for depression. Longitudinal studies with refugees, involving tests of more complex mutual maintenance models, are warranted.

Significance

After controlling for symptoms of depression, pain catastrophizing and negative trauma‐related beliefs partly mediated the relationship between pain and PTSD in tortured refugees. The results suggest that all three variables are important in a mutual mediation model of pain and PTSD, and as targets for treatment, in traumatized refugees.

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The relation of self‐compassion to functioning among adults with chronic pain

Abstract

Background

Previous research has shown that self‐compassion is associated with improved functioning and health outcomes among multiple chronic illnesses. However, the role of self‐compassion in chronic pain‐related functioning is understudied. The present study sought to understand the association between self‐compassion and important measures of functioning within a sample of patients with chronic pain.

Methods

Treatment‐seeking individuals (N = 343 with chronic pain) that were mostly White (97.9%) and female (71%) completed a battery of assessments that included the Self‐Compassion Scale (SCS), as well as measures of pain‐related fear, depression, disability, pain acceptance, success in valued activity and use of pain coping strategies.

Results

Cross‐sectional multiple regression analyses that controlled for age, sex, pain intensity and pain duration, revealed that self‐compassion accounted for a significant and unique amount of variance in all measures of functioning (r² range: 0.07–0.32, all p < 0.001). Beta weights indicated that higher self‐compassion was associated with lower pain‐related fear, depression and disability, as well as greater pain acceptance, success in valued activities and utilization of pain coping strategies.

Conclusions

These findings suggest that self‐compassion may be a relevant adaptive process in those with chronic pain. Targeted interventions to improve self‐compassion in those with chronic pain may be useful.

Significance

Self‐compassion is associated with better functioning across multiple general and pain‐specific outcomes, with the strongest associations among measures related to psychological functioning and valued living. These findings indicate that self‐compassion may be an adaptive process that could minimize the negative impact of chronic pain on important areas of life.

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Does changing weight change pain? Retrospective data analysis from a national multidisciplinary weight management service

Abstract

Background

Musculoskeletal (MSK) pain is common in obese populations. Multidisciplinary Tier 3 weight management services (WMS) are effective in reducing weight; however, MSK pain as an outcome is not routinely reported post‐WMS interventions.

Methods

Following ethical approval this retrospective design study using anonymized data from a national WMS established changes in anthropometric and pain prevalence and intensity scores as well as establishing variables predictive of achieving clinically significant changes (CSC) in pain scores.

Results

Of the 806 patients registered to the WMS (January 2011–February 2015), 59% (n = 476; CI = 56–62) attended their reassessments at 6 months. The overall mean age was 45.1 ± 12 years and 62% (n = 294) were female. At baseline 70% (n = 281; CI = 65–75) reported low back pain (LBP) and 59% (n = 234; CI = 54–64) had knee pain. At reassessment 37.3% (n = 177) of patients lost ≥5% body weight, 58.7% (n = 279) were weight stable (5% weight loss or gain) and 4.0% (n = 19) gained ≥5% body weight. Low back and knee pain prevalence reduced significantly for those who lost ≥5% body weight. Variables predictive of a CSC in LBP numerical rating scale (NRS) score included a higher baseline NRS score, weighing more, and rating losing weight as being important (p < 0.05). Higher baseline NRS and being younger resulted in higher odds of a CSC in knee pain NRS (p < 0.05).

Conclusions

Overall this WMS was effective for clinical weight loss. For those who lost most weight prevalence of knee and LBP reduced. Imbedding pain management strategies within WMS’s may provide a more holistic approach to obesity management.

Significance

Weight loss can reduce musculoskeletal pain, particularly for those who lose more weight. Imbedding pain management strategies within these services may provide a more holistic approach to obesity management.

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Unveiling the relationship between central parkinsonian pain and motor symptoms in Parkinson's disease

Abstract

Background

Pain in Parkinson's disease (PD) is a common and heterogeneous non‐motor symptom. Although the characteristics and predictors of pain in general and of central pain in particular are still largely unknown.

Methods

A semi‐structured interview, the Brief Pain Inventory and the Pain Disability Index were used to identify and characterize pain in a consecutive series of 292 PD patients. Unified PD Rating Scale‐III, Hoehn & Yahr, Schwab and England Independence Scale and Freezing of Gait Questionnaire were applied to assess motor symptoms and functional independence in off and on conditions. Hospital Anxiety and Depression Scale and Questionnaire of Impulsive‐Compulsive Control Disorders were used to screen for anxiety, depression and impulse control disorders.

Results

Two hundred and twelve patients (73%) reported pain, which was classified as: musculoskeletal (63%), dystonia‐related (27%), central parkinsonian (22%) and/or radicular or neuropathic (9%). Patients with pain had more comorbidities and more severe motor symptoms. Patients with central parkinsonian pain were significantly younger, had earlier disease onset, fewer comorbidities, greater non‐axial motor symptom severity in on, more pain‐related disability and more relief of pain with antiparkinsonian medication than patients with non‐central parkinsonian pain.

Conclusions

PD patients with central parkinsonian pain have some distinctive demographic and clinical features, including lower levodopa responsiveness of motor appendicular/limb symptoms to levodopa, associated with greater responsiveness of pain symptoms to these same medications. These findings suggest the need for a more integrated approach to motor and non‐motor symptoms in these patients' clinical care.

Significance

In a consecutive series of 292 patients with PD, almost three quarters of patients with PD reported pain. The study results revealed that pain was related to more severe motor symptoms, anxiety symptoms and comorbidities. Among patients with pain, those with central parkinsonian subtype had distinct demographic and clinical features, including lower levodopa responsiveness for non‐axial motor symptoms and greater responsiveness of pain to antiparkinsonian treatment.

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A diagnosis of rheumatoid arthritis, endometriosis or IBD is associated with later onset of fibromyalgia and chronic widespread pain

Abstract

Background

Widespread pain is a common comorbidity in several chronic diseases and is suspected to be caused by pain resulting from the underlying disease that has provoked a state of central sensitization. However, this argument is currently limited by evidence that has insufficiently captured the temporal nature of the relationship between diagnosis of the underlying disease and onset of widespread pain. The aim of this study was to investigate if patients with rheumatoid arthritis (RA), endometriosis or inflammatory bowel disease (IBD), have a higher risk of developing widespread pain (fibromyalgia or chronic widespread pain [CWP]).

Methods

Using the Swedish Skåne Healthcare register on health care consultation, a cohort of 889,938 adult patients were followed from 2007 to 2016 and incident cases of RA, endometriosis or IBD and of fibromyalgia and CWP were identified by registered diagnoses. Using Poisson regression, we calculated incidence rate ratios (IRR) adjusted for sex, age, education and propensity to seek health care.

Results

For patients with RA the IRR for later fibromyalgia was 3.64 (95% CI: 2.75–4.81) compared to patients without RA, for CWP it was 2.96 (95% CI: 1.81–4.86). For endometriosis patients the IRR for fibromyalgia was 2.83 (95% CI: 1.96–4.08) and for CWP 5.02 (95% CI: 3.10–8.13). IBD patients had an IRR = 2.32 (95% CI: 1.58–3.42) for fibromyalgia and 1.42 (95% CI: 0.93–2.17) for CWP.

Conclusions

This study shows that RA, endometriosis and IBD are all risk factors for later fibromyalgia and CWP, consistent with a hypothesis of central sensitization as an effect of a painful underlying condition.

Significance

We show that RA, endometriosis and IBD predisposes for later fibromyalgia and CWP, a common hypothesis previously difficult to verify due to lack of longitudinal data. The results inform further research regarding the aetiology of fibromyalgia and CWP and stress the need of clinical focus on the pain itself in chronic diseases with pain as a symptom.

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Predictors of treatment outcome in children with medically unexplained pain seeking primary care: A prospective cohort study

Abstract

Background

Medically unexplained pain in children and adolescents is a common and increasing health care problem. Primary care is usually the first point of contact for these patients. It is the overall objective of this study to investigate treatment outcome of medically unexplained pain in paediatric primary care and to identify predictors of treatment failure.

Method

In a prospective observational cohort study with three assessments over 6 months, N = 266 children (6–17 years) presenting to paediatric primary care due to medically unexplained pain were included. The primary outcome is treatment failure after 6 months defined as disabling chronic pain. Risk factors for treatment failure were identified by means of logistic regression analyses.

Results

At the 6‐months follow‐up, treatment proved unsuccessful in 22.6% of patients. In patients with headaches, high functional impairment and strong emotional pain burden at study inclusion, the risk for treatment failure was increased. However, when also including data on the initial treatment response, pain location and functional impairment were no longer significant. Patients who did not respond to treatment within the first 3 months were more likely to experience treatment failure (OR = 203.7 ; p < 0.001) at 6 months, as were children with a higher emotional pain burden at study inclusion (OR = 1.3; p = 0.007; R ² = 0.781).

Conclusions

This study indicates that paediatric primary care is not sufficient for nearly one‐quarter of the children with medically unexplained pain. Individuals without a positive treatment response after 3 months are at increased risk for treatment failure.

Significance

This study investigates the treatment outcome of medically unexplained pain in paediatric primary care. Individuals with a higher emotional pain burden at the first visit and those without positive treatment response after 3 months are at increased risk for treatment failure. Therefore, a stepped‐care approach seems warranted. After an insufficient primary care trial of 3 months, patients should be transferred to pain specialists for a more intense treatment.

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Differences in long‐term physical activity trajectories among individuals with chronic widespread pain: A secondary analysis of a randomized controlled trial

Abstract

Background

Little is known about long‐term physical activity (PA) maintenance in those with chronic widespread pain (CWP) following an exercise intervention. This study examined PA over time to identify the existence and characteristics of subgroups following distinct PA trajectories.

Methods

Data come from individuals with CWP who took part in a 2 × 2 factorial randomized controlled trial, receiving either exercise or both exercise and cognitive behavioural therapy treatment. Information, including self‐report PA, was collected at baseline recruitment, immediately post‐intervention, 3, 24 and 60+ month post‐treatment. Analyses were conducted on 196 men and women with ≥ 3 PA data points. Group‐based trajectory modelling was used to identify latent PA trajectory groups and baseline characteristics (e.g., demographics, pain, self‐rated health, fatigue, coping‐strategy use and kinesiophobia) of these groups.

Results

The best fitting model identified was one with three trajectories: “non‐engagers” (n = 32), “maintainers” (n = 144) and “super‐maintainers” (n = 20). Overall, mean baseline PA levels were significantly different between groups (non‐engagers: 1.1; maintainers: 4.6; super‐maintainers: 8.6, p < 0.001) and all other follow‐up points. Non‐engagers reported, on average, greater BMI, higher disabling chronic pain, poorer self‐rated health, physical functioning, as well as greater use of passive coping strategies and lower use of active coping strategies.

Conclusions

The majority of individuals with CWP receiving exercise as part of a trial were identified as long‐term PA maintainers. Participants with poorer physical health and coping response to symptoms were identified as non‐engagers. For optimal symptom management, a stratified approach may enhance initiation and long‐term PA maintenance in individuals with CWP.

Significance

Chronic pain can be a major barrier to engaging in exercise, a popular self‐management strategy. Our findings identify three distinct long‐term physical activity trajectories for individuals receiving the same exercise intervention. This suggests an approach by health care providers which identifies individuals who would benefit from additional support to enhance initiation and long‐term physical activity maintenance could deliver better outcomes for such patients.

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Differential perception of sharp pain in patients with borderline personality disorder

Abstract

Background

Cutting is the most common method of non‐suicidal self‐injury (NSSI) to reduce inner tension in patients with Borderline Personality Disorder (BPD). Aim of this study was to compare pain perception induced by an incision and by application of a surrogate model for sharp mechanical pain (a non‐invasive “blade”) in BPD.

Methods

22 female patients and 20 healthy controls (HC) received a small incision into the volar forearm, a 7s‐blade application on the same side, and non‐invasive phasic stimuli (pinprick, blade, laser, tactile). Pain intensity as well as affective versus sensory components were assessed.

Results

Incision was rated similarly by both groups (BPD: 28.6 ± 5.5 vs. HC: 33.9 ± 6.6; mean maximum pain ± SEM; p > 0.8), without significant difference for “7‐s‐blade” (BPD: 18.1 ± 3.8 vs. HC: 25.3 ± 3.6; mean maximum pain ± SEM; p > 0.17) or between “7‐s‐blade” and incision (BPD: p > 0.12; HC: p > 0.84). However, patients’ intensity ratings returned significantly faster to baseline after incision (BPD: 38.9 ± 12.6 s vs. HC: 74.52 ± 11.5 s; p < 0.05), and patients evaluated “blade” and incision without any affective and with different sensory descriptors, indicating an altered evaluation of NSSI‐like stimulation with qualitative in addition to quantitative differences—especially for the sharp pain component.

Conclusions

The reduced perception of suprathreshold nociceptive stimuli is based on a missing affective component and specific loss of the perception of “sharpness” as part of the sensory component of pain. The results further demonstrate the usefulness of the “blade” for the perception of sharpness in patients.

Significance

Patients with Borderline Personality Disorder (BPD) who engage in non‐suicidal self‐injury (NSSI) report less pain in response to phasic nociceptive stimuli. In comparing an invasive pain stimulus to phasic nociceptive stimuli in BPD patients, the “blade” as non‐invasive surrogate model for sharp mechanical pain in psychiatric patients is used. In contrast to healthy volunteers, BPD patients do not report significant affective ratings and specifically display a reduced sensory component for sharpness.

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The role of fatigue in functional outcomes for youth with chronic pain

Abstract

Background

As a complex multidimensional construct, fatigue may play an important role in the physical and psychosocial functioning of youth with chronic pain. Based on a model previously tested in adults, the current study similarly utilized patient‐reported outcomes measurement system (PROMIS) to examine how fatigue contributes to functional outcomes for youth with chronic pain. The model tested self‐reported ratings of pain intensity, depressive symptoms and sleep disturbance as predictors of outcomes (mobility, pain‐related interference and school functioning) as mediated by ratings of fatigue.

Methods

Two hundred and eighty‐five youth with chronic pain ages 8–17 years and their caregivers, completed surveys as part of their initial clinical evaluation at a tertiary paediatric pain clinic. Study measures included: paediatric PROMIS domains (mobility, pain interference, sleep disturbance, fatigue and depressive symptoms), Paediatric Quality of Life school functioning and pain intensity. All mediated effects were calculated via a 1,000‐draw bootstrap estimation method in Mplus.

Results

Fatigue was found to be a statistically significant mediator of the effects of pain intensity, sleep disturbance and depressive symptoms on outcomes of pain interference, mobility and school functioning. While pain intensity was found to independently contribute to mobility and pain interference, depressive symptoms did not show significant effects on any outcome beyond its association with fatigue. Sleep disturbance predicted pain interference while fatigue predicted school functioning.

Conclusions

Findings suggest that fatigue is an important intervening factor for functional outcomes among youth with chronic pain. Targeting fatigue may be effective in optimizing school functioning and reducing the deleterious effects of depressive symptoms.

Significance

This cross‐sectional study highlights fatigue as a potential clinical target by applying a path analytic model to understand its possible significance and distinction from overlapping constructs such as pain intensity, depression and sleep disturbance. Further study of fatigue may be important in understanding its importance in treatment of paediatric chronic pain.

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The European epidemic: Pain prevalence and socioeconomic inequalities in pain across 19 European countries

Abstract

Background

Using data from the European Social Survey (ESS) 2014, this study presents an update of pain prevalence amongst men and women across Europe and undertakes the first analysis of socioeconomic inequalities in pain.

Methods

Data from the ESS 2014 survey were analysed for three pain variables: back/neck pain (n = 11,032), hand/arm pain (n = 5,954) and foot/leg pain (n = 6,314). Education was used as the indicator of socioeconomic status (SES). Age‐adjusted risk differences and age‐adjusted risk ratios were calculated from predicted probabilities generated by means of binary logistic regression. These analyses compared the lower education group with the higher education group (the socioeconomic gap), and the medium education group with the higher education group (the gradient).

Results

High prevalence rates were reported for all three types of pain across European countries. At a pan‐European level, back/neck pain was the most prevalent with 40% of survey participants experiencing pain; then hand/arm pain at 22%, and then foot/leg pain at 21%. There was considerable cross‐national variation in pain across European counties, as well as significant socioeconomic inequalities in the prevalence of pain—with social gradients or socioeconomic gaps evident for both men and women; socioeconomic inequalities were most pronounced for hand/arm pain, and least pronounced for back/neck pain. The magnitudes of the socioeconomic pain inequalities differed between countries, but were generally higher for women.

Conclusions

Future strategies to reduce the burden of pain should acknowledge and consider the associated socioeconomic inequalities of pain to ensure the “pain gap” does not widen.

Significance

This is a pan European study that has explored socioeconomic inequalities in pain. Across Europe, pain is more prevalent in people of lower socioeconomic position; these pain inequalities were most significant for hand/arm pain, and least significant for back/neck pain.

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Cognitive functional therapy in patients with non‐specific chronic low back pain—a randomized controlled trial 3‐year follow‐up

Abstract

Objectives

This randomized controlled trial investigated the efficacy of cognitive functional therapy (CFT) compared with manual therapy and exercise (MT‐EX) for people with non‐specific chronic low back pain (NSCLBP) at 3‐year follow‐up.

Methods

Hundred and twenty‐one patients were randomized to CFT (n = 62) or MT‐EX (n = 59). Three‐year data were available for 30 (48.4%) participants in the CFT group, and 33 (55.9%) participants in the MT‐EX group. The primary outcomes were disability (Oswestry disability Index [ODI]) and pain intensity (numerical rating scale) and secondary outcomes were anxiety/depression (Hopkins Symptoms Checklist) and pain‐related fear (Fear‐Avoidance Belief Questionnaire). A full intention to treat analysis was conducted using linear mixed models.

Results

Significantly greater reductions in disability were observed for the CFT group, with ODI scores at 3 years 6.6 points lower in the CFT than the MT‐EX group (95%CI:‐10.1 to −3.1, p < 0.001, standardized effect size = 0.70). There was no significant difference in pain intensity between the groups at 3 years (0.6 points 95%CI:‐1.4–0.3, p = 0.195). Significantly greater reductions were also observed for the CFT group for Hopkins Symptoms Checklist and Fear‐Avoidance Belief Questionnaire (Work).

Conclusions

CFT is more effective at reducing disability, depression/anxiety and pain‐related fear, but not pain, at 3‐year follow‐up than MT‐EX.

Significance

Cognitive functional therapy (CFT) was more effective than manual therapy and exercise (MT‐EX) in reducing disability at 3‐year follow‐up, in people with non‐specific chronic low back pain. The sustained reduction in disability without concomitant reductions in pain intensity in the CFT group suggests a de‐coupling of the pain—disability relationship.

CFT resulted in long‐lasting reductions in anxiety and depression, and pain‐related fear regarding work compared to MT‐EX. The findings support the long‐term benefits of a individualized behaviourally orientated intervention that targets pain beliefs, functional restoration and lifestyle factors.

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Commentary on “Cognitive Functional Therapy in Patients with Non‐Specific Chronic Low Back Pain”

European Journal of Pain, Volume 23, Issue 8, Page 1401-1402, September 2019.

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Weight management and musculoskeletal pain: Does sleep mediate the connection?

European Journal of Pain, Volume 23, Issue 8, Page 1578-1579, September 2019.

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Comment on the paper “Cognitive functional therapy in patients with non specific chronic low back pain”, by Vibe Fersum et al.

European Journal of Pain, Volume 23, Issue 8, Page 1574-1575, September 2019.

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Sándor Márai and his account of painful Guillain‐Barré syndrome

European Journal of Pain, Volume 23, Issue 8, Page 1580-1581, September 2019.

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Authors’ Reply to the Letter to the Editor from Filho et al.

European Journal of Pain, Volume 23, Issue 8, Page 1576-1577, September 2019.

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Issue Information

European Journal of Pain, Volume 23, Issue 8, Page 1399-1400, September 2019.

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New insight to the characteristics and clinical course of clusters of patients with imaging confirmed disc‐related sciatica

Abstract

Background

Referral to secondary care is common for a considerable proportion of patients with persistent sciatica symptoms. It is unclear if information from clinical assessment can further identify distinct subgroups of disc‐related sciatica, with perhaps different clinical courses.

Aims

This study aims to identify and describe clusters of imaging confirmed disc‐related sciatica patients using latent class analysis, and compare their clinical course.

Methods

The study population were 466 patients with disc‐related sciatica. Variables from clinical assessment were included in the analysis. Characteristics of the identified clusters were described and their clinical course over two years, was compared.

Results

A four cluster solution was optimal. Cluster 1 (n=110) had mild back and leg pain; cluster 2 (n=59) had moderate back and leg pain, cluster 3 (n=158) had mild back pain and severe leg pain; cluster 4 (n=139) had severe back and leg pain. Patients in cluster 4 had the most severe profile in terms of disability, distress and comorbidity and the lowest reported global change and the smallest proportion of patients with a successful outcome at two years. Of the 135 patients who underwent surgery, 42% and 41% were in clusters 3 and 4 respectively.

Conclusions

Using a strict diagnosis of sciatica, this work identified four clusters of patients primarily differentiated by back and leg pain severity. Patients with severe back and leg pain had the most severe profile at baseline and follow‐up irrespective of intervention. This simple classification system may be useful when considering prognosis and management with sciatica patients.

This article is protected by copyright. All rights reserved.

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A common ground for pain and depression

Nature Neuroscience, Published online: 27 August 2019; doi:10.1038/s41593-019-0499-8

Chronic pain is associated with anxio-depressive comorbidities, but the neuroanatomical substrates remain unknown. A specific serotonergic pathway from the dorsal raphe nucleus to the lateral habenula via the central amygdala is now uncovered as a key neural circuit governing comorbid depressive symptoms in chronic pain.

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A neural circuit for comorbid depressive symptoms in chronic pain

Nature Neuroscience, Published online: 26 August 2019; doi:10.1038/s41593-019-0468-2

Zhou et al. report a novel 5-HT circuit from the dorsal raphe nucleus to somatostatin-expressing neurons in the central nucleus of the amygdala that partially mediates depressive-like behavior in a mouse model of chronic pain.

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The Effectiveness of Instrument-Assisted Soft Tissue Mobilization in Athletes, Participants Without Extremity or Spinal Conditions, and Individuals with Upper Extremity, Lower Extremity, and Spinal Conditions: A Systematic Review

Publication date: September 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 9

Author(s): Goris Nazari, Pavlos Bobos, Joy C. MacDermid, Trevor Birmingham

Abstract

Objective

To assess the effectiveness of instrument-assisted soft tissue mobilization (IASTM) to other treatments or placebo in athletes or participants without extremity or spinal conditions and individuals with upper extremity, lower extremity, and spinal conditions.

Data Sources

The MEDLINE, EMBASE, CINAHL, and PEDro electronic databases were searched from January 1998 to March 2018.

Study Selection

Randomized controlled trials of participants without extremity or spinal conditions or athletes and people with upper extremity, lower extremity, or spinal conditions, who revived IASTM vs other active treatment, placebo, or control (no treatment), to improve outcome (function, pain, range of motion).

Data Extraction

Two independent review authors extracted data, assessed the trials for risk of bias using the Cochrane Risk of Bias tool in included studies, and performed the rating of quality of individual trials per outcome across trials was also performed using the Grading of Recommendations, Assessment, Development, and Evaluations guidelines.

Data Synthesis

Nine trials with 43 reported outcomes (function, pain, range of motion, grip strength), compared the addition of IASTM over other treatments vs other treatments. Six trials with 36 outcomes reported no clinically important differences in outcomes between the 2 groups. Two trials with 2 outcomes displayed clinically important differences favoring the other treatment (without IASTM) group. Six trials with 15 reported outcomes (pressure sensitivity, pain, range of motion, muscle performance), compared IASTM vs control (no treatment). Three trials with 5 outcomes reported no clinically important differences in outcomes between the 2 groups. Furthermore, in 1 trial with 5 outcomes, IASTM demonstrated small effects (standard mean difference range 0.03-0.24) in terms of improvement muscle performance in physically active individuals when compared to a no treatment group.

Conclusion

The current evidence does not support the use of IASTM to improve pain, function, or range of motion in individuals without extremity or spinal conditions or those with varied pathologies.

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Effectiveness of Botulinum Toxin Treatment for Upper Limb Spasticity Poststroke Over Different ICF Domains: A Systematic Review and Meta-Analysis

Publication date: September 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 9

Author(s): Aukje Andringa, Ingrid van de Port, Erwin van Wegen, Johannes Ket, Carel Meskers, Gert Kwakkel

Abstract

Objective

To provide a comprehensive overview of reported effects and scientific robustness of botulinum toxin (BoNT) treatment regarding the main clinical goals related to poststroke upper limb spasticity, using the International Classification of Functioning, Disability and Health.

Data Sources

Embase, PubMed, Wiley/Cochrane Library, and Ebsco/CINAHL were searched from inception up to May 16, 2018.

Study Selection

We included randomized controlled trials comparing upper limb BoNT injections with a control intervention in patients with a history of stroke. A total of 1212 unique records were screened by 2 independent reviewers. Forty trials were identified, including 2718 patients with history of stroke.

Data Extraction

Outcome data were pooled according to assessment timing (ie, 4-8wk and 12wk after injection), and categorized into 6 main clinical goals (ie, spasticity-related pain, involuntary movements, passive joint motion, care ability, arm and hand use, and standing and walking performance). Sensitivity analyses were performed for the influence of study and intervention characteristics, involvement of pharmaceutical industry, and publication bias.

Data Synthesis

Robust evidence is shown for the effectiveness of BoNT in reducing resistance to passive movement, as measured with the (Modified) Ashworth Score, and improving self-care ability for the affected hand and arm after intervention (P<.005) and at follow-up (P<.005). In addition, robust evidence is shown for the absence of effect on arm-hand capacity at follow-up. BoNT was found to significantly reduce involuntary movements, spasticity-related pain, and caregiver burden, and improve passive range of motion, while no evidence was found for arm and hand use after intervention.

Conclusions

In view of the robustness of current evidence, no further trials are needed to investigate BoNT for its favorable effects on resistance to passive movement of the spastic wrist and fingers, and on self-care. No trials are needed to further confirm the lack of effects of BoNT on arm-hand capacity, whereas additional trials are needed to establish the suggested favorable effects of BoNT on other body functions, which may result in clinically meaningful outcomes at activity and participation levels.

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A Randomized Controlled Trial on the Effects of Low-Dose Extracorporeal Shockwave Therapy in Patients With Knee Osteoarthritis

Publication date: September 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 9

Author(s): Zongye Zhong, Bangzhong Liu, Guanghua Liu, Jun Chen, Yun Li, Jianxin Chen, Xinxin Liu, Yiwen Hu

Abstract

Objective

To test the efficacy of low-dose extracorporeal shockwave therapy (ESWT) on osteoarthritis knee pain, lower limb function, and cartilage alteration for patients with knee osteoarthritis.

Design

Randomized controlled trial with placebo control.

Setting

Outpatient physical therapy clinics within a hospital network.

Participants

Eligible volunteers (N=63) with knee osteoarthritis (Kellgren-Lawrence grade II or III) were randomly assigned to 2 groups.

Interventions

Patients in the experimental group received low-dose ESWT for 4 weeks while those in the placebo group got sham shockwave therapy. Both groups maintained a usual level of home exercise.

Main Outcome Measures

Knee pain and physical function were measured using a visual analog scale (VAS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Lequesne index at baseline, 5 weeks, and 12 weeks. Cartilage alteration was measured analyzing the transverse relaxation time (T2) mapping.

Results

The VAS score, WOMAC, and Lequesne index of the ESWT group were significantly better than those of the placebo group at 5 and 12 weeks (P<.05). Both groups showed improvement in pain and disability scores over the 12-week follow-up period (P<.05). In terms of imaging results, there was no significant difference in T2 values between groups during the trial, although T2 values of the ESWT group at 12 weeks significantly increased compared to those at baseline (P=.004). The number and prevalence of adverse effects were similar between the 2 groups, and no serious side effects were found.

Conclusions

A 4-week treatment of low-dose ESWT was superior to placebo for pain easement and functional improvement in patients with mild to moderate knee osteoarthritis but had some negative effects on articular cartilage.

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Efficacy of Topical Vibratory Stimulation for Reducing Pain During Trigger Point Injection to the Gastrocnemius: A Randomized Controlled Trial

Publication date: September 2019

Source: Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 9

Author(s): Young-Eun Moon, Sang-Hyun Kim, Hyun Seok, Seung Yeol Lee

Abstract

Objective

To evaluate the efficacy of topical vibratory stimulation for reducing pain during trigger point injection (TPI).

Design

Double-blind randomized placebo-controlled clinical trial.

Setting

Tertiary care university hospital.

Participants

A total of 136 participants were randomly recruited from among patients with myofascial pain syndrome who were scheduled for TPI. Of these, 65 were excluded because they met the exclusion criteria, and 11 because they refused to participate. Finally, 60 participants were enrolled. No participants dropped out of the study.

Intervention

Participants were randomly assigned to the vibration group or control group. TPI was performed with 0.5% lidocaine using a 25-gauge needle. A vibrator was applied to the popliteal fossa for 3 to 5 seconds prior to and during TPI to the gastrocnemius; 100-Hz vibration was turned on for the vibration group and turned off for the control group.

Main Outcome Measures

Pain intensity during TPI was assessed using a 100-mm visual analog scale (VAS) as a primary outcome, and participant satisfaction and preference for repeated use were measured using 5-point Likert scales as a secondary outcome. These parameters were evaluated immediately after TPI. The primary outcome was evaluated using analysis of covariance and secondary outcome using the Mann-Whitney U test.

Results

VAS scores for pain during TPI were significantly lower in the vibration group (30.30; 95% confidence interval [CI], 22.65-39.26) compared with the control group (47.58; 95% CI, 38.80-56.52; F=7.74; P< .01). The mean difference in VAS scores between the 2 groups was 17.27 (95% CI, 5.24-29.30). Participant satisfaction and preference for repeated use were significantly higher in the vibration group than in the control group (P<.05). No participant showed any side effects.

Conclusion

Topical vibratory stimulation significantly decreased pain during TPI of the gastrocnemius.

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[Comment] Defining primary palliative care for universal health coverage

Much has been achieved in advancing palliative care on the global health agenda, but there is more to do. The 2014 World Health Assembly (WHA) committed countries to integrating palliative care into their health systems and WHO was tasked with monitoring progress.1 By 2017, WHO had updated the definition of universal health coverage (UHC)—Sustainable Development Goal 3.8—to include palliation along with promotion, prevention, treatment, and rehabilitation.2 A Lancet Commission in 2017 highlighted the global need to take action when 61 million people are living with serious health-related suffering due to uncontrolled pain and without access to an affordable essential package for palliative care.

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Managing a patient with pain and facial swelling

A 32 year old man presented to the emergency department with trismus and a painful swollen right side of his face. He was intoxicated and unable to provide a clear history, but he mentioned an...

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The impact of ultrasound‐guided continuous serratus anterior plane block versus intravenous patient‐controlled analgesia on the incidence and severity of post‐thoracotomy pain syndrome: A randomized, controlled study

Abstract

Objective

The aim of this randomized controlled trial is to evaluate U/S guided serratus anterior plane catheter block (SAPB) versus patient‐controlled analgesia (PCA) on the emergence of post‐thoracotomy pain syndrome (PTPS) after thoracotomies for thoracic tumors.

Methods

This trial included 89 patients with chest malignancies, scheduled for thoracotomy were randomly allocated into two groups: Group A "PCA–group N=44" receiving patient‐controlled analgesia and group B "SAPB group N=45" where analgesia was provided by serratus anterior plane catheter block. The primary outcome measure was the assessment for the possible emergence of PTPS at 12 weeks. The secondary outcome measures were pain relief measured by visual analog scale (VAS) score, Quality of life was assessed by Flanagan Quality of Life Scale (QOLS) and Activity level was assessed by Barthel Activity of daily living (ADL) score.

Results

At week 8, PTPS incidence was significantly (P=0.037) higher in the PCA group (45%) than in the SAPB group (24%) with a relative risk of 1.38 and 95 % CI (1.01 to 1.9) while the incidence of PTPS at week 12 was significantly (P= 0.035) higher in the PCA group (43%) than in the SAPB group (22%) with a relative risk of 2.38 and 95 % CI (1.23 to 4.57). The need for pain therapy in PTPS patients was significantly lower in the SAPB group (17.7%) than PCA group (38.6%) (P= 0.028) at week 12. Pain intensity: VAS‐R and VAS‐D (pain scores at rest and with activity, respectively) were comparable (P > 0.05) between both groups at 6, 12, 18 and 24 hours, however VAS was significantly higher in the PCA group at week 8 (P = 0.046) and week 12 (P = 0.032) . Both groups were comparable regarding ADL and QOL scores (P > 0.05).

Conclusion

SAPB is assumed to be a good alternative for post‐thoracotomy analgesia following thoracotomies. The current work hypothesized that SAPB for a week postoperatively, may reduce the emergence of PTPS and may reduce the demand for pain therapy in those patients.

This article is protected by copyright. All rights reserved.

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Risk factors for episodes of back pain in emerging adults. A systematic review

Abstract

Background and Objective

The transition from adolescence to adulthood is a sensitive period in life for health outcomes, including back pain. The objective was to synthesize evidence on risk factors for new episodes of back pain in emerging adults (18‐29 years).

Methods

The protocol was registered in PROSPERO (CRD42016046635). We searched Medline; EMBASE; AMED and other databases up to September 2018 for prospective cohort studies that estimated the association between risk factor(s) and self‐reported back pain. Risk factors could be measured before or during the age range 18‐29 years, and back pain could be measured during or after this age range, with at least 12 months between assessments. Risk factors assessed in ≥3 studies were summarized. Risk of bias was assessed using a 6‐item checklist.

Results

Forty‐nine studies were included with more than 150 different risk factors studied. Nine studies had low risk of bias, 26 had moderate, and 14 had high risk of bias. Age, sex, height, body mass index (BMI), smoking, physical activity level, a history of back pain, job satisfaction and structural imaging findings were investigated in 3 or more studies. History of back pain was the only risk factor consistently associated with back pain after adjustment (9 studies).

Conclusion

There is moderate quality evidence that a history of back pain is a risk factor for back pain. There are inconsistent associations for age, sex, height, BMI, smoking, and activity level. No associations were found between job satisfaction and structural imaging findings and back pain.

This article is protected by copyright. All rights reserved.

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Premorbid and Concurrent Predictors of TMD Onset and Persistence

Abstract

Background

Multiple risk factors predict temporomandibular disorders (TMD) onset, but temporal changes in risk factors and their contribution to risk of TMD have not been evaluated. The study aims were to (1) describe changes occurring in premorbid TMD risk factors when re‐measured at TMD onset and six months later; and (2) determine if measures of change improve accuracy in predicting TMD incidence compared to premorbid measures alone.

Methods

In this observational prospective cohort study at 4 university research clinics, 3258 community‐based, 18‐44 year‐olds without TMD were enrolled. During the 3‐year median follow‐up, 260 incident cases of first‐onset TMD were identified, and 196 TMD‐free subjects were selected as matched controls. Six‐months later, 147/260 incident cases (56.6%) were re‐examined revealing 72 (49%) with “persistent TMD” and 75 (51%) whose condition had resolved (“transient TMD”). Virtually all (126) of the 127 re‐examined controls remained without TMD. Questionnaires and clinical measurements evaluated risk factors from clinical, health, psychological and behavioral, and neurosensory domains.

Results

Most risk factors across all 4 domains increased with TMD onset, remained elevated in the persistent group, and declined in the transient group (i.e., significant ANOVA interactions, p<0.05). Accuracy in predicting first‐onset TMD, quantified as area under the receiver operating characteristic curve was 0.71 (95%CL 0.68, 0.73) using only premorbid measures of risk factors, which increased to 0.91 (95%CL 0.89, 0.94) after addition of change measures.

Conclusions

TMD pain onset and persistence appear to be determined by enduring characteristics of the person as well as mutually interactive with temporally evolving variables.

This article is protected by copyright. All rights reserved.

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The association between the weight of schoolbags and low back pain among schoolchildren. A systematic review, meta‐analysis and individual patient data meta‐analysis

Abstract

Background

The objective of this study was to determine whether carrying a heavy schoolbag is associated to a higher prevalence of low back pain (LBP).

Methods

A systematic review and meta‐analysis was conducted (PROSPERO, CRD42018077839). Observational studies analyzing the relationship between schoolbag weight and LBP, were searched for in 20 electronic databases and 12 specialized journals until February 28th, 2019, without date or language restrictions. All studies which included ≥ 50 subjects aged 9 to 16, were reviewed. Methodological quality was assessed by two reviewers separately, using validated tools. A meta‐analysis and an individual patient data (IPD) meta‐analysis were conducted to examine the relationship between schoolbag weight and LBP. Certainty of evidence was assessed using an adapted GRADE methodology.

Results

5,524 citations were screened, 21 studies (18,296 subjects) were reviewed and 11 studies (9,188 subjects) were included in the meta‐analysis. The IPD meta‐analysis included 9,188 subjects from 7 studies. Among the 21 studies reviewed, the mean score for methodological quality was 78.3 out of 100. Only one study suggested an association between heavier schoolbags and LBP. Neither the meta‐analysis nor the IPD meta‐analysis found an association between carrying schoolbags weighing > 10% of bodyweight, and LBP. No differences based on age, sex or sport activity were found.

Discussion

Available evidence does not support that schoolbags weighing > 10% of bodyweight are associated with a higher prevalence of LBP among schoolchildren aged 9‐16. The certainty of evidence is low. Further research is required on the relationship between schoolbag weight and LBP.

This article is protected by copyright. All rights reserved.

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Usefulness of Ramp & Hold Procedures for Testing of Pain Facilitation in Human Participants: Comparisons with Temporal Summation of Second Pain

Quantitative sensory testing (QST) is often used for the study of sensory function including pain mechanisms in basic and clinical research. QST methods range from simple threshold testing to complex multi-modal test procedures of hyperalgesia, allodynia, and pain modulation (spatial and temporal).39 The application of precise experimental pain stimuli has been used extensively for the evaluation of pain mechanisms in animals6,11,25,55 and humans16,39,50 with help of mechanical, thermal, and electrical stimuli.

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Unilateral Osteotomy of Lumbar Facet Joint Induces a Mouse Model of Lumbar Facet Joint Osteoarthritis

Study Design. The lumbar facet joint (LFJ) osteoarthritis (OA) model that highly mimics the clinical conditions was established and evaluated. Objective. Here, we innovatively constructed and evaluated the aberrant mechanical loading-related LFJ OA model. Summary of Background Data. LFJ is the only true synovial joint in a functional spinal unit in mammals. The LFJ osteoarthritis is considered to contribute 15% to 45% of low back pain. The establish of animal models highly mimicking the clinical conditions is a useful tool for the investigation of LFJ OA. However, the previously established animal models damaged the LFJ structure directly, which did not demonstrate the effect of aberrant mechanical loading on the development of LFJ osteoarthritis. Methods. In the present study, an animal model for LFJ degeneration was established by the unilateral osteotomy of LFJ (OLFJ) in L4/5 unit to induce the spine instability. Then, the change of contralateral LFJ was evaluated by morphological and molecular biological techniques. Results. We showed that the OLFJ induced instability accelerated the cartilage degeneration of the contralateral LFJ. Importantly, the SRμCT elucidated that the three-dimensional structure of the subchondral bone changed in contralateral LFJ, indicated as the abnormity of bone volume/total volume ratio (BV/TV), trabecular pattern factor (Tb. Pf), and the trabecular thickness (Tb. Th). Immunostaining further demonstrated the uncoupled osteoclastic bone resorption, and bone formation in the subchondral bone of contralateral LFJ, indicated as increased activity of osteoclast, osteoblast, and Type H vessels. Conclusion. We develop a novel LFJ OA model demonstrating the effect of abnormal mechanical instability on the degeneration of LFJ. This LFJ degeneration model that highly mimics the clinical conditions is a valuable tool to investigate the LFJ osteoarthritis. Level of Evidence: N/A

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Motor and Sensory Impairments of the Lower Extremities After L2 Nerve Root Transection During Total en Bloc Spondylectomy

Study Design. Retrospective study. Objective. The purpose of this study was to examine motor and sensory impairments of the lower extremities after L2 nerve root transection during total en bloc spondylectomy (TES) for spinal tumors. Summary of Background Data. At our institute, for TES at L3 to L5 lumbar levels, the nerve roots are preserved. However, at the level of L1 and L2, the vertebral resection and spinal reconstruction via a posterior approach is employed with transection of the nerve roots during dissection and resection of the vertebra. Methods. This study included 13 patients who had undergone TES for spinal tumors involving L2 between 2007 and 2016. Postoperative motor function of the lower extremities was quantified using the Manual Muscle Testing grade for the iliopsoas (IP) and quadriceps femoris (QF) muscles, and a grade of the modified Frankel Classification. Postoperative sensory impairment was quantified by the sites of lower extremity pain and numbness. Results. An initial decrease in strength of the IP and QF muscles in more than 60% of the patients, with a decline in the modified Frankel grade in 76.9%, was observed at 1-week after surgery. All patients recovered by the final follow-up, with 12 of the 13 patients walking without a gait aid. The other patient, who had undergone a bilateral dissection of L3 nerve root during TES of L2 and L3, had a mild QF muscle weakness, requiring a cane for walking. Eleven of 13 patients developed pain or numbness in the groin or thigh area after surgery, with the most common area being the anterior aspect of the thigh. Conclusion. Although IP and QF weakness was observed in the majority of patients who underwent bilateral transection of L2 nerve roots during TES, these deficits recovered over time and did not finally affect activities of daily living. Level of Evidence: 4

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Health Care Costs and Opioid Use Associated With High-impact Chronic Spinal Pain in the United States

Study Design. A descriptive analysis of secondary data. Objective. The aim of this study was to estimate health care costs and opioid use for those with high-impact chronic spinal (back and neck) pain. Summary of Background Data. The US National Pain Strategy introduced a focus on high-impact chronic pain—that is, chronic pain associated with work, social, and self-care restrictions. Chronic neck and low-back pain are common, costly, and associated with long-term opioid use. Although chronic pain is not homogenous, most estimates of its costs are averages that ignore severity (impact). Methods. We used 2003 to 2015 Medical Expenditures Panel Survey (MEPS) data to identify individuals with chronic spinal pain, their health care expenditures, and use of opioids. We developed prediction models to identify those with high- versus moderate- and low-impact chronic spinal pain based on the variables available in MEPS. Results. We found that overall and spine-related health care costs, and the use and dosage of opioids increased significantly with chronic pain impact levels. Overall and spine-related annual per person health care costs for those with high-impact chronic pain ($14,661 SE: $814; and $5979 SE: $471, respectively) were more than double that of those with low-impact, but still clinically significant, chronic pain ($6371 SE: $557; and $2300 SE: $328). Those with high-impact chronic spinal pain also use spine-related opioids at a rate almost four times that of those with low-impact pain (48.4% vs. 12.4%), and on average use over five times the morphine equivalent daily dose (MEDD) in mg (15.3 SE: 1.4 vs. 2.7 SE: 0.6). Opioid use and dosing increased significantly across years, but the increase in inflation-adjusted health care costs was not statistically significant. Conclusion. Although most studies of chronic spinal pain do not differentiate participants by the impact of their chronic pain, these estimates highlight the importance of identifying chronic pain levels and focusing on those with high-impact chronic pain. Level of Evidence: 3

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Full-Endoscopic Visualized Foraminoplasty and Discectomy Under General Anesthesia in the Treatment of L4-L5 and L5-S1 Disc Herniation

Study Design. Retrospective analysis of clinical records. Objective. The aim of this study is to evaluate the clinical outcomes and neurological complications of full-endoscopic visualized foraminoplasty and discectomy under general anesthesia for the treatment of L4-L5 and L5-S1 disc herniation. Summary of Background Data. Full-endoscopic visualized foraminoplasty and discectomy, which is our newly developed technique, has been used in the treatment of lumbar disc herniation and lumbar spinal stenosis. While the clinical effect, safety, and neurological complications of full-endoscopic visualized foraminoplasty and discectomy under general anesthesia are still uncertain. Methods. Between May 2015 and April 2017, 84 patients with lumbar disc herniation were included, and categorized into L4-L5 group and L5-S1 group according to the discectomy segment. Full-endoscopic visualized foraminoplasty and discectomy was performed under general anesthesia. Operative time, fluoroscopy time, hospitalization time, and complications were recorded. Each patient included was followed for at least 12 months. Visual analog scale score for leg and back pain and Oswestry Disability Index score were evaluated preoperatively and at 3, 6, and 12 months postoperatively. The modified MacNab criteria were also used to evaluate surgical effectiveness. Results. The mean operative time, fluoroscopy time, and hospitalization time at L4-L5 and L5-S1 were of no significant difference. The mean visual analog scale and Oswestry Disability Index postoperative scores were significantly improved over the preoperative scores. Intraoperative nerve injury occurred in one case at L4-L5, with a neurological complication rate of 2.1% in L4-L5 group. One case at L4-L5 suffered recurrence 2 weeks after the surgery, resulting in a recurrence rate of 2.1% in L4-L5 group. This recurrence case was treated by a second full-endoscopic visualized foraminoplasty and discectomy under general anesthesia. Conclusion. Full-endoscopic visualized foraminoplasty and discectomy under general anesthesia is efficient and safe for the treatment of L4-L5 and L5-S1 disc herniation. Level of Evidence: 4

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A cross-sectional study to investigate the effects of perceived discrimination in the healthcare setting on pain and depressive symptoms in wheelchair users with spinal cord injury.

Publication date: Available online 15 August 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Nathan Hogaboom, Denise C. Fyffe, Amanda L. Botticello, Lynn A. Worobey, Michael L. Boninger

Abstract

Objectives

In a sample of wheelchair users with spinal cord injury (SCI), the objectives were to investigate which subject characteristics are associated with greater perceived discrimination in the healthcare setting, and how such discrimination relates to health outcomes of pain and depressive symptoms.

Design

Survey, cross-sectional.

Setting

Spinal Cord Injury Model Systems Centers (SCIMS).

Participants

410 full-time wheelchair users with SCI from 9 SCIMS centers, with data collected between 2011 and 2016.

Interventions

N/A.

Main Outcomes

7-item questionnaire inquiring about perceived discrimination by hospital staff; self-reported pain severity over the past month using a 0-10 Numerical Rating Scale; depressive symptoms using the 2-question Patient Health Questionnaire screener.

Results

Participants who were Black or from the lowest income group were more likely to report experiencing more discrimination than those who were White or from the highest income group, respectively (IRR=2.2-2.6, p<.01). Those who reported more perceived discrimination had greater risk of severe pain compared to no pain (RR=1.11, 95% CI=1.01-1.23, p<.05), mild depressive symptoms (RR=1.09, 95%CI=1.02-1.17, p<.05), and severe depressive symptoms (RR=1.12, 95% CI=1.04-1.21, p<.05) compared to no symptoms.

Conclusions

Wheelchair users with SCI who were from more disadvantaged groups (Black, lower income levels) reported experiencing more discrimination in their healthcare setting. Furthermore, those who reported more discrimination were more likely to report worse mental and physical health outcomes. Attempts to reduce discrimination in healthcare settings may lead to better outcomes for people with SCI. These observations were correlational and not causal; a prospective analysis is necessary to prove causation. Future investigations should further explore the impact of discrimination on the many facets of living with a SCI.

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Proposal for Improvement of the Hospital Anxiety and Depression Scale for the Assessment of Emotional Distress in Patients with Chronic Musculoskeletal Pain: a Bifactor and Item Response Theory Analysis

The link between chronic pain and mental health has long been recognized.22,29 Their association can be acknowledged at a biological, psychological and social level, as they are thought to share common neural mechanisms,36,70 interact in their development over time18,80 and have a bidirectional relationship with environmental factors (e.g. social support, work-related factors).6,24,45 In particular, states of emotional distress in the form of anxiety or depression seem to be associated with the development and maintenance of chronic musculoskeletal pain,7,50 as well as with the outcomes of surgery34,78 or rehabilitation programs.

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The responsiveness and interpretability of psychosocial patient‐reported outcome measures in chronic musculoskeletal pain rehabilitation

Abstract

Background

For several widely‐used patient‐reported outcome measures (PROMs) in chronic musculoskeletal pain (CMSP) rehabilitation, it is still not known whether they are responsive to change, and what the smallest detectable change (SDC) and minimal clinically important change (MCIC) are. Knowledge of these values can be used to accurately interpret change scores in research and clinical practice.

Methods

In this retrospective cohort study, the responsiveness, the SDC, and the MCIC of the mental components of the Research and Development 36‐Item Health Survey (RAND‐36), the Pain Catastrophizing Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK) were investigated in CMSP patients. Responsiveness, the SDC, and MCIC were determined by using both anchor and distribution‐based methods.

Results

For all outcome measures, there was a progression from smallest to largest mean change scores between participants who did not perceive change and those who reported change after treatment. However, correlations of the Global Perceived Effect (GPE) with the change scores on the outcome measures were low. For all outcome measures, the SDC was larger than the MCIC.

Conclusions

For this population, the questionnaires were shown not to be responsive. Furthermore, the questionnaires appeared not to be able to distinguish clinically important change from measurement error in individual patients. The finding of large measurement errors of PROMs is in line with previous research in pain rehabilitation. Using generic PROM s only, to examine changes in psychosocial status due to a pain rehabilitation programme, is therefore questionable.

This article is protected by copyright. All rights reserved.

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Comment on “Sándor Márai and painful Guillain‐Barré syndrome” by Alamos et al

Abstract

Alamos et al. (2019) discuss Hungarian author Sándor Márai's description of pain in Guillain‐Barré syndrome (GBS) in his novel “The Sister” (1946) and claim that it significantly predates published medical descriptions of the painful component in some cases of GBS. I would like to add to the picture by referring to Márai's personal experience with polyneuritis that he suffered in early 1943 and described in the first volume of his diary, begun that year.

This article is protected by copyright. All rights reserved.

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Exercise in Parkinson′s disease: experimental‐induced pain sensitivity is reduced already after short term training

Abstract

This journal recently published a paper by Nguy et al. titled 'Exercise induced hypoalgesia is present in people with Parkinson′s disease: two observational cross‐sectional studies' (Nguy et al. 2019). In this study the authors compare the immediate effects of two different forms of exercise on exercise induced hypoalgesia (EIH) by measuring pressure pain thresholds after a single intervention in two studies (isometric exercise vs. aerobic exercise).

This article is protected by copyright. All rights reserved.

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Punishing the Self: Posttraumatic Guilt mediates the link between trauma and deficient pain modulation

Torture is a highly devastating traumatic event. Individuals are often subjected to severe physical pain (e.g., beating, burning, suspension, electric shock, among other methods) alongside isolation, humiliation and other forms of psychological torture (e.g.,46) as a way to obtain information, as well as to inflict intimidation and punishment.9 As a result, torture survivors often suffer from long-term mental46 and somatic pathologies (e.g.,35).

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Pain is Associated with Increased Physical and Psychosocial Impairment in Youth with a History of Burn Injuries

Burn injuries are a commonly occurring injury in youth6,34 and often require extensive medical intervention surrounding wound healing and pain management.14 Burn injuries can also be significantly traumatic for many youth,7,40,41 with symptoms of posttraumatic stress (PTSS), anxiety, and/or depression commonly reported after the initial incident.7,38 Although rates of physical recovery are high following burn injury, youth may require continued treatment, including surgeries to address skin contractures, nerve regrowth, etc., which can be significantly painful and prolonged up to several years after their initial burn injury.

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A painful shoulder after a seizure

A 25 year old man presented to the emergency department with pain and reduced movement in his left shoulder following a generalised tonic clonic seizure. He had no medical history and no history of...

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Sympathetic efferent neurons are less sensitive than nociceptors to 4 Hz sinusoidal stimulation

Abstract

Background

Sinusoidal current stimuli preferentially activate C‐nociceptors. Sodium channel isoforms NaV1.7 and NaV1.8 have been implicated in this. Sympathetic efferent neurons lack NaV1.8 and were explored upon sinusoidal activation.

Methods

Quantitative Sudomotor Axon Reflex Test (QSART) was performed in hairy (n=16) and glabrous (n=12) skin. Responses of sympathetic efferents (n=10) and nociceptive afferents (n=21) to sinusoidal current stimulation (4 Hz, 0.05 ‐ 0.15 mA) were recorded in humans by microneurography (n=11). Activation of sympathetic units upon supra‐threshold sinusoidal currents (> 0.8 mA) was recorded in pigs (n=8).

Results

Sinusoidal stimuli (4 Hz, 0.4 mA) evoked weak sweat output (30 ml/h/m²) in hairy skin compared to rectangular pulses (4 Hz, 5 mA, 53 ml/h/m², p < 0.00001, ANOVA). No change in sweat output was recorded from glabrous skin to sine wave stimuli. Sinusoidal current at intensities ranging from 0.05 – 0.15 mA activated almost all (85%) nociceptors but only 40% of sympathetic units in human. Stimuli lead to a significantly lower activation in sympathetic vs. nociceptive fibers as measured by activity dependent slowing (ADS) of conduction (sympathetic efferents average ADS 100 ± 0.2% vs. C‐nociceptors average ADS 113 ± 4%, p < 0.003, ANOVA).

Conclusions

Sympathetic efferent neurons are less apt to convert slow depolarizations into action potentials as compared to nociceptors. Distinctive sodium channel expression patterns between nociceptors and sympathetic efferent neurons may account for this difference. Sinusoidal stimulation therefore provokes weak sweat responses and provides no alternative for clinical assessment of autonomic function.

This article is protected by copyright. All rights reserved.

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Exercise‐induced hypoalgesia in young adult females with long‐standing patellofemoral pain – A randomized crossover study

Abstract

Background

Patellofemoral pain (PFP) is a common knee pain condition where hip and knee exercises help improve treatment outcomes. This study compared the acute effect of hip versus knee exercises on anti‐nociceptive and pro‐nociceptive mechanisms in young females with long‐standing PFP.

Methods

In this randomized cross‐over study, 29 females with PFP performed hip and knee exercises in randomized order during a single day. Pressure pain thresholds (PPTs) were assessed by handheld pressure algometry at the patella, the tibialis anterior muscle, and the contralateral elbow. Cuff pressure algometry at the lower legs was used to assess pain detection threshold (cPDT) and tolerance (cPTT) as well as conditioned pain modulation (CPM: change in cPDT during contralateral cuff pain conditioning) and temporal summation of pain (TSP: ten painful cuff stimulations assessed on a visual analogue scale [VAS]).

Results

PPTs at the tibialis anterior muscle but not at the patella increased compared with baseline following both exercises (p < .002). Compared with baseline, the cPDTs and cPTTs increased after both types of exercises (p < .001). The cPTTs increased more after knee compared to hip exercises (p < .007). VAS scores for TSP were increased following hip exercises (p < .001) although the rate of VAS increase over repeated stimulations was not significantly affected by exercises. The CPM‐effect was reduced after both types of exercises (p < .001).

Conclusion

A general hypoalgesic response to slowly increasing pressure stimuli was observed following both hip and knee exercises as well as decreased conditioned pain modulation, potentially indicating an attenuated ability from exercise to inhibit pain.

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Altered spontaneous activity and functional connectivity in the posterior pons of patients with migraine without aura

Migraine is a complex and multifaceted brain disorder, and its clinical manifestations are moderate to severe intensity headaches in combination with nausea, vomiting, and hypersensitivities to visual, auditory, olfactory and somatosensory stimuli 13, 15. This disorder has caused a huge public health burden 9. However, the exact neurological mechanisms contributing to this complex disorder remain unclear. The brainstem has been discussed as the main contributor to the pathogenesis of migraine1, 27.

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AMP-Activated Protein Kinase Activation in Dorsal Root Ganglion Suppresses mTOR/p70S6K Signaling and Alleviates Painful Radiculopathies in Lumbar Disc Herniation Rat Model

Study Design. Animal experiment: a rat model of lumbar disc herniation (LDH) induced painful radiculopathies. Objective. To investigate the role and mechanism of AMP-activated protein kinase (AMPK) in dorsal root ganglia (DRG) neurons in LDH-induced painful radiculopathies. Summary of Background Data. Overactivation of multiple pain signals in DRG neurons triggered by LDH is crucial to the development of radicular pain. AMPK is recognized as a cellular energy sensor, as well as a pain sensation modulator, but its function in LDH-induced pain hypersensitivity remains largely unknown. Methods. The LDH rat model was established by autologous nucleus pulposus transplantation into the right lumbar 5 (L5) nerve root. At different time points after AMPK agonist metformin (250 mg/kg/d) or mammalian target of rapamycin (mTOR) inhibitor rapamycin (5 mg/kg) intraperitoneal administration, thermal and mechanical sensitivity were evaluated by measuring paw withdrawal latency (PWL) and 50% paw withdrawal thresholds (PWT). The levels of AMPK, mTOR, and p70S6K phosphorylation were determined by Western blot. We also investigated the proportion of p-AMPK positive neurons in the right L5 DRG neurons using immunofluorescence. Results. LDH evoked persistent thermal hyperalgesia and mechanical allodynia on the ipsilateral paw, as indicated by the decreased PWL and 50% PWT. These pain hypersensitive behaviors were accompanied with significant inhibition of AMPK and activation of mTOR in the associated DRG neurons. Pharmacological activation of AMPK in the DRG neurons not only suppressed mTOR/p70S6K signaling, but also alleviated LDH-induced pain hypersensitive behaviors. Conclusion. We provide a molecular mechanism for the activation of pain signals based on AMPK-mTOR axis, as well as an intervention strategy by targeting AMPK-mTOR axis in LDH-induced painful radiculopathies. Level of Evidence: N/A

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ERRFI1 Inhibits Proliferation and Inflammation of Nucleus Pulposus and Is Negatively Regulated by miR-2355-5p in Intervertebral Disc Degeneration

Study Design. In vivo and in vitro studies of the role of miR-2355-5p and its possible targets in intervertebral disc degeneration (IVDD). Objective. To elucidate the regulatory role of miR-2355-5p in IVDD and the underlying mechanisms. Summary of Background Data. IVDD, which is caused by multiple factors, is the main cause of lower back pain with or without extremity pain. However, the underlying cellular mechanisms of IVDD pathogenesis are not well elucidated. Cell hyper-proliferation, inflammation, and epidermal growth factor receptor activation have been implicated in IVDD. Up-regulated miR-2355-5p level was identified to associate with IVDD. ERRFI1 (the product of mitogen-inducible gene 6 [MIG6]) was known to inhibit epidermal growth factor receptor activation. Methods. We monitored the expression of miR-2355-5p and ERRFI1 in IVDD tissues and lipopolysaccharides (LPS)-treated nucleus pulposus (NP) cells. We explored the effects of ERFFI1 on NP cells proliferation and LPS-induced pro-inflammatory cytokines production. We searched the targets of miR-2355-5p and explored the effects of miR-2355-5p on NP cells proliferation and cytokines production. Results. We identified the up-regulation of miR-2355-5p and down-regulation of ERFFI1 in IVDD samples and LPS-treated NP cells. ERFFI1 inhibited NP cells proliferation and LPS-induced pro-inflammatory cytokine production. MiR-2355-5p targeted ERFFI1 and negatively regulated ERFFI1 expression. MiR-2355-5p regulated IVDD by targeting ERFFI1. Conclusion. MiR-2355-5p negatively regulated ERFFI1 and prevented the effects of ERRFI1 on inhibiting NP cells proliferation and inflammation. Level of Evidence: N/A

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