Prevalence and associated psychosocial and health factors of chronic pain in adolescents: differences by sex and age

Abstract

Background

Chronic pain is a common issue in adolescents. Prevalence of pain and associated factors present differently in sex and age subgroups, however, the interaction of sex and age combined has not been thoroughly assessed. This study aimed to identify psychosocial and health factors associated with chronic pain in younger and older adolescent girls and boys.

Methods

Students from 5 schools in grades 5‐10 self‐completed a pain survey. Participants were 2280 adolescents (52% female) aged 10‐18 years (M=12.95, SD=1.84). Data were analyzed using multivariate logistic regression models.

Results

Chronic pain was present in 33% of participants. The risk of chronic pain increased by 29% in girls, compared to 16% in boys, per year of age (p=.039). Overall, depression (OR=2.05, p<.001), anxiety (OR=1.51, p<.001), lower school satisfaction (OR=1.41, p=.034) and sleep issues (OR=2.34, p<.001) were associated with chronic pain. Stratified analyses identified unique significant associations between chronic pain and psychosocial factors. In boys aged 10‐13 years, higher socioeconomic status (OR=1.76, p=.024) and poorer school performance (OR=1.60, p=.027) were uniquely important; in girls aged 10‐13 years, lower school satisfaction (OR=2.92, p=.003) was associated with pain, and in older girls aged 14‐18 years, anxiety (OR=1.74, p=.009) was significantly associated with pain. When these differences were assessed statistically, only lower school satisfaction had significant differences between subgroups (p=.049).

Conclusions

Many psychosocial and health factors are similarly important, with few differences, for chronic pain in girls and boys at different stages of adolescence.

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Von Frey testing revisited – provision of an online algorithm for improved accuracy of 50% thresholds

Abstract

Background

In the pain field, it is essential to quantify nociceptive responses. The response to the application of von Frey filaments to the skin measures tactile sensitivity and is a surrogate marker of allodynia in states of peripheral and/or central sensitization. The method is widely used across species within the pain field. However, uncertainties appear to exist regarding the appropriate method for analysing obtained data. Therefore, there is a need for refinement of the calculations for transformation of raw data to quantifiable data.

Methods

Here, we briefly review the fundamentals behind von Frey testing using the standard up‐down method and the associated statistics and show how different parameters of the statistical equation influence the calculated 50% threshold results. We discuss how to obtain the most accurate estimations in a given experimental setting.

Results

To enhance accuracy and reproducibility across laboratories, we present an easy to use algorithm that calculates 50% thresholds based on the exact filaments and their interval using math beyond the traditional methods. This tool is available to the everyday user of von Frey filaments and allows the insertion of all imaginable ranges of filaments and is thus applicable to data derived in any species.

Conclusion

We advocate for the use of this algorithm in order to minimise inaccuracies and to improve internal and external reproducibility.

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Author’s reply to Sharvill

Sharvill raises valid concerns about women accessing early pregnancy care.12 The National Institute for Health and Care Excellence recommends that all women presenting with pain or bleeding in early...

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Evolution in acute pain assessment and treatment in the pediatric emergency department of a tertiary health care center

Abstract

Background

Pediatric pain remains one of the most misunderstood, under‐diagnosed and under‐treated medical problems in children.

Aim

To investigate the accuracy of acute pain assessment and management in the Pediatric Emergency Department in Lithuanian University of Health Sciences Hospital.

Methods

We performed a retrospective record analysis before (the year 2017) and after (the year 2018) pediatric pain training course was conducted. In total, 1000 randomly selected outpatient records were analyzed. We divided all patients into two groups: group A records from 2017, group B – from 2018. Patients were further divided into trauma and non‐trauma and subdivided into 4 different age groups. We collected patient age, the origin of pain, pain characteristics, pain score, and medication.

Results

We compared 500 children in each group. Group A and B consisted of 154 (30.8%) and 116 (23.2%) trauma patients respectively. The pain was scored less in group A (420 children (84%)) compared to group B (94.4% of all 500 patients, p<0.001). In all age groups, the pain was assessed more often, and pain medication was prescribed more often in group B compared to group A (p <0.001). There was a tendency to assess pain more often in group A non‐trauma patients (p=0.054). However, pain relief in trauma patients was less adequate compared to non‐trauma.

Conclusion

Our research showed improvement in pain evaluation and treatment after systemic and local changes in PED. In group B, pain was evaluated more frequently, and patients received pain medication more often than in group A. Teenagers are still less likely to receive analgesics than toddlers. Tendency remains to give fewer painkillers to trauma patients compared to non‐trauma children.

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Learning to fear pain after observing another’s pain: An experimental study in schoolchildren

Abstract

Background

Children of individuals with chronic pain have an increased vulnerability to experience pain problems, possibly through observation of pain in their parents. As pain‐related fear (PRF) is a critical factor in the development and maintenance of chronic pain, the current experimental study examined the acquisition of PRF through observational learning and subsequent extinction after first‐hand experience of the feared stimulus.

Methods

Healthy children (8–16 years) observed either their mother or a stranger performing two cold pressor tasks (CPT) filled with coloured water. In a differential conditioning procedure, one colour (CS+) was combined with genuine painful facial expressions and the other colour (CS‐) with neutral facial expressions. Following this observation phase, children performed both CPTs (10°C) themselves.

Results

Children expected the CS + to be more painful than the CS‐ and they reported being more afraid and hesitant to immerse in the CS + compared to the CS‐. Moreover, this fear was reflected in children's level of arousal in anticipation of CPT performance. This learned association extinguished after performing both CPTs. Effects were not moderated by whether the child observed their mother or a stranger, by the child's pain catastrophizing, trait PRF or trait anxiety. Remarkably, learning effects increased when the child perceived a larger difference between the model's painful and neutral facial expressions.

Conclusions

This study provides evidence for observational learning of PRF and subsequent extinction in schoolchildren. This acquisition of PRF by observing parental pain may contribute to vulnerabilities in children of parents with chronic pain.

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Biopsychosocial Influences on Shoulder Pain: Analyzing the Temporal Ordering of Post-Operative Recovery

Shoulder surgery has become a primary intervention for treating persistent shoulder pain, with the number of procedures now exceeding 500,000 annually.26 However, many patients who undergo shoulder surgery experience persistent post-operative pain.3,35 For musculoskeletal pain conditions, current research initiatives aim to identify phenotypical characteristics that predict variability in treatment outcomes.4,12 Our team used exercised-induced shoulder pain to identify an interaction between psychological distress (pain catastrophizing) and genetics (catechol-O-methyltransferase (COMT) enzyme activity) that predicted elevated pain and disability.

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Quality of Chronic Pain Interventional Treatment guidelines from Pain Societies: Assessment with the AGREE II instrument

Abstract

Background and Objective

Procedures to relieve pain are performed frequently but there are concerns about patient selection, appropriate image‐guidance, frequency, and training for physicians. Patients, healthcare providers, policymakers, and licensing bodies seek evidence‐based recommendations to use these interventions judiciously. In this review we appraised the methodological quality of recent clinical practice guidelines (CPGs) for interventional pain procedures.

Database and Data Treatment

A systematic search of the medical literature was performed. Three trained appraisers independently evaluated the methodological quality of the CPGs using a validated instrument, the Appraisal of Guidelines in Research and Evaluation II (AGREE‐II). Six domains were considered: 1) score and purpose; 2) stakeholder involvement; 3) rigour of development; 4) clarity of presentation; 5) applicability; and 6) editorial independence. A total of 23 items were scored. CPGs were deemed “high quality” if a mean scaled score above 60% for rigour of development and for two other domains was obtained.

Results

Mean scaled domain quality scores ranged from 61.72% to 69.99%. Despite being based on modest levels of evidence, two of the four included CPGs were considered to be of high methodological quality. The AGREE II scores across the four guidelines exhibited good inter‐rater reliability. None of the guidelines involved key stakeholders such as patients, other healthcare providers, and payers.

Conclusions

All four CPGs were limited by a weak execution of the guideline development process. There is a need to develop methodologically‐sound evidence‐based guidelines for use of interventional pain procedures using a rigorous process that involves all relevant stakeholders.

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Placebo Effects in the Neuroendocrine System: Conditioning of the Oxytocin Responses

Objective There is evidence that placebo effects may influence hormone secretion. However, few studies have examined placebo effects in the endocrine system, including oxytocin placebo effects. We studied whether it is possible to trigger oxytocin placebo effects using a classical conditioning paradigm. Methods Ninety-nine women were assigned to a conditioned, control, or drug control group. In the two-phase conditioning paradigm, participants in the conditioned and drug control groups received an oxytocin nasal spray combined with a distinctive smell (conditioned stimulus [CS]) for three acquisition days, whereas the control group received placebo spray. Subsequently, the conditioned and control groups received placebo spray with the CS and the drug control group received oxytocin spray for three evocation days. Salivary oxytocin was measured several times during each day. Pain sensitivity and facial evaluation tests previously used in oxytocin research were also administered. Results On evocation day 1, in the conditioned group, oxytocin significantly increased from baseline to 5 minutes after CS (B[slope] = 19.55, SE = 5.88, p < .001) and remained increased from 5 to 20 (B = −10.42, SE = 5.81, p = .071) and 50 minutes (B = −0.70, SE = 3.37, p = .84). On evocation day 2, a trend for increase in oxytocin was found at 5 minutes (B = 15.22, SE = 8.14, p = .062). No placebo effect was found on evocation day 3 (B = 3.57, SE = 3.26, p = .28). Neither exogenous nor conditioned oxytocin affected pain or facial tasks. Conclusions Results indicate that oxytocin release can be conditioned and that this response extinguishes over time. Triggering hormonal release by placebo manipulation offers various clinical possibilities, such as enhancing effects of pharmacological treatments or reducing dosages of medications. Trial Registration: The study was registered as a clinical trial on www.trialregister.nl (number NTR5596).

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Opioids for chronic osteoarthritis pain. An updated systematic review and meta‐analysis of efficacy, tolerability and safety in randomized placebo‐controlled studies of at least four weeks double‐blind duration

Abstract

Background and Objective

This updated systematic review evaluated the efficacy and safety of opioids compared to placebo for chronic osteoarthritis pain.

Databases and Data Treatment

Clinicaltrials.gov, CENTRAL, MEDLINE and PsycINFO were searched from October 2013 to July 2019. Randomized controlled trials comparing opioids with placebo and at least four weeks double‐blinded duration were analysed. Primary outcomes were pain relief of 50% or greater, disability, tolerability and safety. Effects were summarized by a random effects model using risk differences or standardized mean differences with 95% confidence intervals. We added two new studies with 397 participants for a total of 22 studies with 8,942 participants. Study duration ranged between four and 24 weeks. Studies with a parallel and cross‐over design: Based on very low to low quality evidence, opioids provided no clinically relevant pain relief of 50% or greater and no clinically relevant reduction of disability compared to placebo. There was a clinically relevant harm related to the dropout rate due to adverse events. The frequency of serious adverse events did not differ from placebo. Enriched enrolment randomized withdrawal design: Based on very low to low quality evidence, opioids provided no clinically relevant pain relief of 50% or greater and no clinically relevant reduction of disability compared to placebo. Dropout rates due to adverse events and frequency of serious adverse events did not differ from placebo.

Conclusions

Tolerability of opioids is low and efficacy is not clinically relevant in controlled studies from four to 24 weeks for osteoarthritis pain.

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Emotional distress: Specifying a neglected part of chronic pain

Abstract

We argue that in all RCTs that investigate treatments for chronic pain emotional distress should be reported. In a majority of cases, pain intensity and pain‐related disability are measured, yet ‐ despite guidelines to the contrary ‐ pain‐related distress is not included. We suggest that the new extension code for chronic pain as incorporated in the ICD‐11 will be well suited to fill this gap at minute additional effort for the participants.

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Temporal aspects of endogenous pain modulation during a noxious stimulus prolonged for one day

Abstract

Background

This study investigated 1) if a prolonged noxious stimulus (24‐hr topical capsaicin) in healthy adults would impair central pain inhibitory and facilitatory systems measured as a reduction in conditioned pain modulation (CPM) and enhancement of temporal summation of pain (TSP) and 2) if acute pain relief or exacerbation (cooling and heating the capsaicin patch) during the prolonged noxious stimulus would affect central pain modulation.

Methods

Twenty‐eight participants (26.2 ± 1.0 years;12 women) wore a transdermal 8% capsaicin‐patch on the forearm for 24 hr. Data were collected at baseline (Day0), 1‐hr, 3‐hr, Day1 (post‐capsaicin application), and Day3/4 (post‐capsaicin removal) that included capsaicin‐evoked pain intensity, heat pain thresholds (HPT), TSP (10 painful cuff‐pressure stimuli on leg), and CPM (cuff‐pressure pain threshold on the leg prior vs. during painful cuff‐pressure conditioning on contralateral leg). After 3‐hr, cold (12°C) and heat (42°C) stimuli were applied to the capsaicin‐patch to transiently increase and decrease pain intensity.

Results

Participants reported moderate pain scores at 1‐hr (2.5 ± 2.0), 3‐hr (3.7 ± 2.4), and Day1 (2.4 ± 1.8). CPM decreased 3‐hr post‐capsaicin (p = .001) compared to Day0 and remained diminished while the capsaicin pain score was reduced (0.4 ± 0.7, p < .001) and increased (6.6 ± 2.2, p < .001) by patch‐cooling and ‐heating. No significant differences occurred for CPM during patch‐cooling or ‐heating compared to initial 3HR, however CPM during patch‐heating was reduced compared with patch‐cooling (p = .01). TSP and HPT did not change.

Conclusions

This prolonged experimental pain model is useful to provide insight into subacute pain conditions and may provide insight into the transition from acute to chronic pain.

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Rescue and concomitant analgesics in placebo-controlled trials of pharmacotherapy for neuropathic pain and low back pain

Rescue medication is commonly offered to participants in placebo-controlled trials of analgesic drugs. The use of pain medication in addition to the placebo or experimental drug may complicate the interpretation of effects and tolerability, but this issue has received little methodological attention. This study examined the handling and reporting of rescue and concomitant analgesic use in trials of pharmacotherapy for neuropathic pain and low back pain. We based our review on 265 trials included in 2 recent systematic reviews: 83 trials of low back pain and 182 of neuropathic pain. In total, 117 (44%) trials permitted rescue medication and 126 (48%) allowed participants to continue all or some of their usual analgesics. The utilization of rescue medication increased over time, occurring in 18% of trials before 2000 compared with 55% after 2000. Forty-one trials (16%) permitted both rescue analgesics and continued use of prestudy analgesics. More than one-third of the trials permitting rescue medication did not report the actual rescue drug consumption, and over half of the trials allowing concomitant analgesics did not report whether intake changed during the trial. Only 22 (19%) of the trials permitting rescue medication included complete information about whether rescue medication was used as an outcome, specified the drugs used, specified how consumption was assessed and measured, and reported and analyzed the use of rescue medication in each trial arm. Our findings suggest that poorly described procedures and incomplete reporting are likely to hinder the interpretation, critical appraisal, and replication of trial results.

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Neurotransmitter systems involved in placebo and nocebo effects in healthy participants and patients with chronic pain: a systematic review

The investigation of neurotransmitter systems in placebo and nocebo effects has improved our understanding of these phenomena. Yet, most studies involve healthy participants. Because the pain modulatory system may differ in healthy participants and patients with chronic pain, it is important to investigate the evidence for neurotransmitter involvement in placebo and nocebo effects in each of these populations. PubMed, Embase, and Scopus databases, and the Cochrane Library were searched for articles investigating the endogenous opioid, endocannabinoid, dopaminergic, oxytocinergic, vasopressinergic, and cholecystokininergic (CCKergic) systems in placebo and nocebo effects in pain. Twenty-eight placebo and 2 nocebo studies were included. Vote counting was used to balance the number of positive vs negative findings. In healthy participants, the endogenous opioid, endocannabinoid, and vasopressinergic systems were involved in placebo effects, whereas findings on the dopaminergic and oxytocinergic systems were mixed. In patients with chronic pain, only 4 studies investigated neurotransmitters showing no involvement of the endogenous opioid system and mixed findings regarding the dopaminergic system. As to nocebo effects, 2 studies suggest that the CCKergic system is involved in nocebo effects in healthy participants. Overall, research has come a long way in specifying the neurotransmitter systems involved in placebo effects in healthy participants. Yet, evidence for the involvement of neurotransmitter systems in placebo effects in patients with chronic pain and in nocebo effects in healthy participants and patients is scarce. Based on the existing evidence, this systematic review suggests that knowledge obtained in healthy participants may not necessarily be transferred to chronic pain.

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Systematic review and meta-analysis of placebo/sham controlled randomised trials of spinal cord stimulation for neuropathic pain

The aims of this review were to systematically identify the current evidence base of placebo (or “sham”) randomised controlled trials (RCTs) of spinal cord stimulation (SCS) for neuropathic pain and to undertake a meta-analysis to investigate the effectiveness of SCS when compared with a placebo comparator arm. Electronic databases were searched from inception until January 2019 for RCTs of SCS using a placebo/sham control. Searches identified 8 eligible placebo-controlled randomised trials of SCS for neuropathic pain. Meta-analysis shows a statistically significant reduction in pain intensity during the active stimulation treatment periods compared with the control treatment periods, pooled mean difference −1.15 (95% confidence interval −1.75 to −0.55, P = 0.001) on a 10-point scale. Exploratory study–level subgroup analysis suggests a larger treatment effect in RCTs using a placebo control (defined as studies where the device was inactive and at least one of the study procedures was different between the arms) than a sham control (defined as all study procedures being equal between arms including SCS device behaviour). Our findings demonstrate limited evidence that SCS is effective in reducing pain intensity when compared with a placebo intervention. Our analyses suggest that the magnitude of treatment effect varies across trials and, in part, depends on the quality of patient blinding and minimisation of carryover effects. Improved reporting and further methodological research is needed into placebo and blinding approaches in SCS trials. Furthermore, we introduce a differentiation between placebo and sham concepts that may be generalisable to trials evaluating surgical or medical procedures.

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Upregulation of cortical GABAA receptor concentration in fibromyalgia

An imbalance between excitatory and inhibitory neurotransmission has been linked to fibromyalgia (FM). Magnetic resonance spectroscopy has shown increased levels of glutamate in the insula and posterior cingulate cortex in FM as well as reduced insular levels of gamma-aminobutyric acid (GABA). Both of these changes have been associated with increased pain sensitivity. However, it is not clear whether excitatory and/or inhibitory neurotransmission is altered across the brain. Therefore, the aim of this study was to quantify GABAA receptor concentration on the whole brain level in FM to investigate a potential dysregulation of the GABAergic system. Fifty-one postmenopausal women (26 FM, 25 matched controls) underwent assessments of pain sensitivity, attention and memory, psychological status and function, as well as positron emission tomography imaging using a tracer for GABAA receptors, [18F]flumazenil. Patients showed increased pain sensitivity, impaired immediate memory, and increased cortical GABAA receptor concentration in the attention and default-mode networks. No decrease of GABAA receptor concentration was observed. Across the 2 groups, GABAA receptor concentration correlated positively with functional scores and current pain in areas overlapping with regions of increased GABAA receptor concentration. This study shows increased GABAA receptor concentration in FM, associated with pain symptoms and impaired function. The changes were widespread and not restricted to pain-processing regions. These findings suggest that the GABAergic system is altered, possibly indicating an imbalance between excitatory and inhibitory neurotransmission. Future studies should try to understand the nature of the dysregulation of the GABAergic system in FM and in other pain syndromes.

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Pain as a predictor of frailty over time among older Mexican Americans

The objective of this study was to examine pain as a predictor of frailty over 18 years of follow-up among older Mexican Americans who were nonfrail at baseline. Data were from a prospective cohort study of 1545 community-dwelling Mexican Americans aged ≥67 years from the Hispanic Established Populations for the Epidemiological Study of the Elderly (1995/1996-2012/2013). Frailty was defined as meeting 2 or more of the following: unintentional weight loss of >10 pounds, weakness, self-reported exhaustion, and slowness. The independent predictor was self-reported pain. Covariates included age, sex, marital status, education, comorbid conditions, body mass index, Mini-Mental State Examination, depressive symptoms, and limitation in activities of daily livings. General equation estimation was performed to estimate the odds ratio of frailty as a function of pain. A total of 538 participants (34.8%) reported pain at baseline. The prevalence of frailty among those with pain ranged from 24.4% in wave 3 to 41% in wave 8. The odds ratio of becoming frail over time as a function of pain was 1.71; 95% confidence interval: 1.41 to 2.09 after controlling for all covariates. Older age, hip fracture, high depressive symptoms, and activities of daily living disability were also associated with higher odds of becoming frail over time. Female participants and those with higher levels of education and high Mini-Mental State Examination scores were less at risk. In conclusion, pain was a significantly predictor of frailty. Early assessment and better management of pain may prevent early onset of frailty in older Mexican Americans.

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Machine-learning–based knowledge discovery in rheumatoid arthritis–related registry data to identify predictors of persistent pain

Early detection of patients with chronic diseases at risk of developing persistent pain is clinically desirable for timely initiation of multimodal therapies. Quality follow-up registries may provide the necessary clinical data; however, their design is not focused on a specific research aim, which poses challenges on the data analysis strategy. Here, machine-learning was used to identify early parameters that provide information about a future development of persistent pain in rheumatoid arthritis (RA). Data of 288 patients were queried from a registry based on the Swedish Epidemiological Investigation of RA. Unsupervised data analyses identified the following 3 distinct patient subgroups: low-, median-, and high-persistent pain intensity. Next, supervised machine-learning, implemented as random forests followed by computed ABC analysis–based item categorization, was used to select predictive parameters among 21 different demographic, patient-rated, and objective clinical factors. The selected parameters were used to train machine-learned algorithms to assign patients pain-related subgroups (1000 random resamplings, 2/3 training, and 1/3 test data). Algorithms trained with 3-month data of the patient global assessment and health assessment questionnaire provided pain group assignment at a balanced accuracy of 70%. When restricting the predictors to objective clinical parameters of disease severity, swollen joint count and tender joint count acquired at 3 months provided a balanced accuracy of RA of 59%. Results indicate that machine-learning is suited to extract knowledge from data queried from pain- and disease-related registries. Early functional parameters of RA are informative for the development and degree of persistent pain.

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The metabotropic glutamate receptor 5 negative allosteric modulator fenobam: pharmacokinetics, side effects, and analgesic effects in healthy human subjects

Metabotropic glutamate receptor 5 (mGlu5) has been shown to modulate nociception in animals, but no mGlu5 antagonists have been developed commercially as analgesics. The mGlu5 antagonist fenobam [N-(3-chlorophenyl)-N′-(4,5-dihydro-1-methyl-4-oxo-1H-imidazole-2-yl)urea] was originally evaluated for development as a nonbenzodiazepine anxiolytic. Fenobam is analgesic in numerous mouse pain models, acting exclusively through mGlu5 blockade. Furthermore, fenobam showed no signs of analgesic tolerance with up to 2 weeks of daily dosing in mice. Analgesic effects of fenobam in humans have not been reported. The purpose of this investigation was to evaluate fenobam pharmacokinetics and analgesic effects in humans. We first evaluated single-dose oral fenobam disposition in a parallel-group dose-escalation study in healthy volunteers. A second investigation tested the analgesic effects of fenobam in an established experimental human pain model of cutaneous sensitization using capsaicin cream and heat, in a double-blind placebo-controlled study. The primary outcome measure was the area of hyperalgesia and allodynia around the area applied with heat/capsaicin. Secondary outcome measures included nociception, measured as pain rating on a visual analog scale, heat pain detection threshold, and effects on cognition and mood. Fenobam plasma exposures showed considerable interindividual variability and were not linear with dose. Fenobam reduced sensitization vs placebo at a single timepoint (peak plasma concentration); we found no other difference between fenobam and placebo. Our results suggest highly variable fenobam disposition and minimal analgesic effects at the dose tested. We suggest that future studies testing analgesic effects of mGlu5 blockade are warranted, but such studies should use molecules with improved pharmacokinetic profiles.

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Heightened risk of pain in young adult women with a history of childhood maltreatment: a prospective longitudinal study

A child maltreatment history is reported more frequently among adults with chronic pain compared with the general population; unfortunately, studies have primarily relied upon retrospective maltreatment reports by adults with chronic pain. This prospective study assessed pain symptoms in a cohort of young adult women with a documented history of child maltreatment, compared with a matched cohort of women who did not experience childhood maltreatment. Young women (N = 477) were recruited between ages 14 to 17 years and followed annually to age 19. Of these women, 57% experienced maltreatment (ie, physical, sexual, or emotional abuse, neglect; n = 273) substantiated by child welfare record. Maltreated women were demographically matched to nonmaltreated women, also confirmed by child welfare record. In adolescence, post-traumatic stress was assessed. Women were contacted as young adults (Mage = 24.76; n = 383) and surveyed about their pain experiences, including the presence of pain in the past week, pain severity (0-10), and number of body areas with pain. Mediation path analyses examining the impact of maltreatment and adolescent post-traumatic stress on young adult pain were estimated through structural equation modeling. As adults, women who had experienced child maltreatment reported higher pain intensity, a greater number of pain locations, and were more likely to experience pain in the previous week than nonmaltreated women. Adolescent post-traumatic stress partially explained the effects of maltreatment on pain. Young adult women who experienced child maltreatment are at higher risk of pain, particularly when they also experienced post-traumatic stress as adolescents.

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The Safety and Feasibility of Exoskeletal-Assisted Walking in Acute Rehabilitation After Spinal Cord Injury

Publication date: January 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 1

Author(s): Kyle McIntosh, Rebecca Charbonneau, Yassine Bensaada, Urchit Bhatiya, Chester Ho

Abstract

Objective

To assess safety and feasibility for persons with acute spinal cord injury (SCI) using the robotic exoskeleton.

Design

Case series observational study.

Setting

A level-1 trauma center in Canada with both acute and tertiary inpatient SCI rehabilitation units.

Participants

Eight male and 3 female (N=11) participants were recruited with a mean age of 41 years and with neurologic level of injury (C6-L2) and severity (American Spinal Injury Association Impairment Scale [AIS] A-D). The time since injury is a range of 3-15 weeks at the onset of training.

Interventions

Up to 25 one-hour sessions of exoskeletal-assisted walking gait training, with participants less than 6 months from initial SCI.

Main Outcome Measures

Cardiopulmonary outcomes including blood pressure, heart rate, and peripheral oxygen saturation; and perceived physical exertion using the Borg CR10 Scale were recorded. Gait parameters were measured by 6-minute walk test (6MWT) and 10-meter walk test (10MWT). Up Time, walk time, and number of steps were detailed longitudinally. Safety was assessed with regard to pain, falls, and skin integrity.

Results

No serious adverse events occurred. Blood pressure decreased following initial sit to stand and increased during walking. Symptoms of hypotension were rare and improved with increased number of sessions. Perceived exertion was reported on average to be moderate (mean of 3.1). There was no significant increase in pain scores by Visual Analog Scale. On 6MWT, participants covered more distance (mean [m] ± SD, 117.1±11.7) in session 25 compared to session 2 (mean [m] ± SD, 47.6±6.6). On the 10MWT, all participants showed consistently improved gait speed; with participants traveling an average of 3.2 times faster during their last training session (mean [m/s] ± SD, 0.40±0.04) in comparison to session 2 (mean [m/s] ± SD, 0.12±0.01).

Conclusions

Exoskeletal-assisted walking in acute rehabilitation (<6mo) following SCI appears to be both safe and feasible.

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Frequency of Primary Neck Pain in Mild Traumatic Brain Injury/Concussion Patients

Publication date: January 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 1

Author(s): Jeffrey A. King, Michael A. McCrea, Lindsay D. Nelson

Abstract

Objectives

To determine (1) the frequency of neck pain overall and relative to other symptoms in patients presenting to a level I trauma center emergency department (ED) with mild traumatic brain injury (mTBI) and (2) the predictors of primary neck pain in this population.

Design

Cohort study.

Setting

Level I trauma center ED.

Participants

Patients presenting to the ED with symptoms of mTBI having been exposed to an event that could have caused mTBI (N=95).

Interventions

Not applicable.

Main Outcome Measures

Frequency of self-reported neck pain as measured by Sport Concussion Assessment Tool 3 (SCAT3) symptom questionnaire at <3, 8, 15, and 45 days post injury. Primary neck pain was defined in 2 ways: (1) neck pain rated as equal or greater in severity than all other SCAT3 symptoms and (2) neck pain worse than all other symptoms.

Results

The frequency of any reported neck pain was 68.4%, 50.6%, 49%, and 41.9% within 72 hours and at 8, 15, and 45 days, respectively. Frequency of primary neck pain (equal or worse/worse definitions) was 35.8%/17.9%, 34.9%/14.5%, 37%/14.8%, and 39.2%/10.8% across the 4 follow-up assessments. Participants who sustained their injuries in motor vehicle collisions had a higher rate of primary neck pain than those with other mechanisms of injury.

Conclusions

A sizable percentage of patients who present to level I trauma center EDs with mTBI report neck pain, which is commonly rated as similar to or worse than other mTBI-related symptoms. Primary neck pain is more common after motor vehicle collisions than with other mechanisms of injury. These findings support consensus statements identifying cervical injury as an important potential concurrent diagnosis in patients with mTBI.

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Conceptual Structure of Health-Related Quality of Life for Persons With Traumatic Brain Injury: Confirmatory Factor Analysis of the TBI-QOL

Publication date: January 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 1

Author(s): Mark Sherer, Julia M.P. Poritz, David Tulsky, Pamela Kisala, Luis Leon-Novelo, Esther Ngan

Abstract

Objective

To determine the factor structure of the Traumatic Brain Injury–Quality of Life (TBI-QOL) measurement system.

Design

Observational.

Setting

3 TBI Model Systems rehabilitation centers.

Participants

Twenty TBI-QOL item banks were administered to a sample of community-dwelling adults with TBI (N=504) as part of a study of TBI classification. A subsample of participants (n=200) was randomly selected for exploratory factor analyses, while data from the remaining participants (n=304) were used for the confirmatory factor analysis. To examine a wide range of conceptual models, confirmatory factor analyses were conducted on a total of 16 models, ranging from 1 to 7 factors.

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

Initial exploratory factor analysis yielded support for a 5-factor model (negative emotion, cognitive impairment, functioning and participation, positive emotion, pain). Confirmatory factor analysis results, however, indicated a 7-factor model including physical function, physical symptoms, cognition, negative emotion, positive emotion, sense of self, and social participation (model 16; robust fit statistics root mean square error of approximation =.063, standardized root mean square residual =.035, comparative fit index =.955, Tucker-Lewis Index =.943, Bayes Information Criterion =40059.44).

Conclusions

The complex 7-factor model of the TBI-QOL provides a more nuanced framework for understanding health-related quality of life for persons with TBI than the commonly used 3-factor model including physical health, mental health, and social health.

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Measuring Pain in TBI: Development of the TBI-QOL Pain Interference Item Bank and Short Form

Publication date: January 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 1

Author(s): Noelle E. Carlozzi, Pamela A. Kisala, Aaron J. Boulton, Elliot Roth, Anna L. Kratz, Mark Sherer, Angelle M. Sander, Allen W. Heinemann, Nancy D. Chiaravalloti, Tamara Bushnik, David S. Tulsky

Abstract

Objective

To develop a pain interference item bank, computer adaptive test (CAT), and short form for use by individuals with traumatic brain injury (TBI).

Design

Cross-sectional survey study.

Setting

Five TBI Model Systems rehabilitation hospitals.

Participants

Individuals with TBI (N=590).

Interventions

Not applicable.

Outcome Measures

Traumatic Brain Injury–Quality of Life (TBI-QOL) Pain Interference item bank.

Results

Confirmatory factor analysis provided evidence of a single underlying trait (χ² [740]=3254.030; P<.001; Comparative Fix Index=0.988; Tucker-Lewis Index=0.980; Root Mean Square Error of Approximation=0.076) and a graded response model (GRM) supported item fit of 40 Pain Interference items. Items did not exhibit differential item functioning or local item dependence. GRM calibration data were used to inform the selection of a 10-item static short form and to program a TBI-QOL Pain Interference CAT. Comparative analyses indicated excellent comparability and reliability across test administration formats.

Conclusion

The 40-item TBI-QOL Pain Interference item bank demonstrated strong psychometric properties. End users can administer this measure as either a 10-item short form or CAT.

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Factors Affecting Employment After Burn Injury in the United States: A Burn Model System National Database Investigation

Publication date: January 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 1, Supplement

Author(s): Gretchen J. Carrougher, Alyssa M. Bamer, Samuel P. Mandell, Sabina Brych, Jeffrey C. Schneider, Colleen M. Ryan, Karen Kowalske, Peter C. Esselman, Nicole S. Gibran

Abstract

Objective

To investigate the effect of patient and injury characteristics on employment for working-age, adult survivors of burn injury using the multicenter Burn Model System national database.

Design

Longitudinal survey.

Setting

Multicenter regional burn centers.

Participants

Adult burn survivors (N=967) age≥18 years with known employment status prior to injury were included in the analysis at 12 months after injury.

Interventions

Not applicable.

Main Outcome Measures

Employment status at 12 months after injury.

Results

The analyses determined that those employed preinjury had higher odds of being employed (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.9-13.1). White, non-Hispanic individuals were also more likely to be employed (OR=1.49; 95% CI, 1.0-2.1). Older individuals, females, those with longer hospitalizations, amputation during the acute hospitalization, and those with high pain interference at hospital discharge had lower odds of working after injury. Preinjury living situation, preinjury alcohol and drug misuse, number of acute operations and burn size (total body surface area, %) were not significant predictors of employment status at 12 months after burn injury.

Conclusion

Preinjury employment remains the most significant predictor for postburn employment. Although past reports have focused on predictors for postburn employment, we believe that we need to seek greater understanding of modifiable risk factors for unemployment and examine issues related to work retention, performance, accommodations, and career trajectories for the working-age survivor of burn injury.

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The promotion of policy changes restricting access to codeine medicines on Twitter: what do national pain organizations say?

Widespread use of opioids has contributed to what has been called an “opioid epidemic”.26,41,49,64,66 Codeine is one of the most commonly used opioid analgesics globally for treating mild to moderate pain.65 In Australia, codeine has remained the dominant opioid medicine that has been dispensed over the past 25 years.24,38,39 It is one of the most widely available opioids, accessible without prescription (over-the-counter; OTC) in a number of countries (e.g., United Kingdom, New Zealand).30,67

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Improving study conduct and data quality in clinical trials of chronic pain treatments: IMMPACT recommendations

The late stage failure of drug development programs is a significant problem. Successful phase 2 trial results do not guarantee a successful phase 3 program. The estimated probability of progressing from phase 3 analgesic clinical trials to regulatory approval is approximately 57%, suggesting that a considerable number of treatments with phase 2 trial results deemed sufficiently successful to progress to phase 3 do not yield positive phase 3 results.33 Potential explanations for this high rate of failure in late stage development include (1) false positive phase 2 trial results, (2) incorrect dosage selection based on phase 2 trial data, (3) phase 2 and 3 clinical trial design features that compromise assay sensitivity (i.e., the ability of a trial to detect a true treatment effect); for example, entry criteria that are too heterogeneous or inappropriate outcome measures, (4) insufficient increase in sample size between phase 2 and 3 to accommodate potential increased heterogeneity in the target population in larger, phase 3 trials, and (5) low quality execution of the phase 2 or phase 3 trial.

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Directional discrimination is better for noxious laser stimuli than for innocuous laser stimuli

Abstract

Background

The directional discrimination is lower for painful laser heat compared to non‐painful mechanical stimulation. The aim of the current study was to investigate how the directional discrimination of radiant heat stimulation depends on stimulation intensity and displacement velocity.

Methods

Fifteen healthy subjects were stimulated in the right volar forearm with a CO₂ laser at intensities that were expected to be either painful (46 ⁰C) or non‐painful (39 ⁰C). The laser beam was continuously displaced distal‐proximally along the arm during the stimulation. After the stimulation, subjects indicated the perceived direction and intensity (NRS: 0: perception 3: pain 10: maximum pain). Stimulations were delivered with five lengths (20, 40, 60, 80, 100 mm) and three velocities (10, 30 and 100 mm/s). To estimate the directional discrimination threshold (DDT) the data was fitted to a sigmoidal curve.

Results

For the lower intensity (39 ⁰C) the DDT was 81.8 mm for the slowest velocity, and above 100 mm for the two faster velocities. For the higher intensity (46 ⁰C) the DDT was 58.8 and 69.6 mm for the slowest velocity and middle velocity, respectively, and above 100 mm for the fastest velocity. The perceived intensity increased with stimulation length, stimulation intensity and decreasing velocity (LMM, p < .001).

Conclusions

This study shows how the DDT for thermal stimuli is shorter for higher intensity and lower displacement velocities. Additionally, it was shown that for the velocity where directional discrimination is optimal for mechanical stimuli it is not possible to discriminate a thermal stimulus.

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The use of Quantitative Sensory Testing (QST) in cancer pain assessment: A systematic review

Abstract

Objective

To summarises the literature on the use of quantitative sensory testing (QST) in the assessment of pain in people with cancer and to describe which QST parameters consistently demonstrate abnormal sensory processing in patients with cancer pain.

Databases and Data Treatment

Medline, EMBASE, AMED, CINAHL, SCOPUS and CENTRAL were searched for observational or experimental studies using QST in patients with a cancer diagnosis and reporting pain. Search strategies were based on the terms ‘quantitative sensory testing’, ‘cancer’, ‘pain’, ‘cancer pain’ and ‘assessment’. Databases were search from inception to January 2019. Data were extracted and synthesised narratively, structured around the different QST modalities and sub‐grouped by cancer pain aetiology (tumour‐ or treatment‐related pain).

Results

Searches identified 286 records of which 18 met the eligibility criteria for inclusion. Three studies included patients with tumour‐related pain, and 15 studies included patients with pain from chemotherapy induced peripheral neuropathy (CIPN). Across all studies, 50% (9/18) reported sensory abnormities using thermal detection thresholds (cool and warm), 44% (8/18) reported abnormal mechanical detection thresholds using von‐Frey filaments and 39% (7/18) found abnormal pin‐prick thresholds. Abnormal vibration and thermal pain (heat/cold) thresholds were each reported in a third of included studies.

Conclusion

This systematic review highlights the lack of published data characterising the sensory phenotype of tumour‐related cancer pain. This has implications for our understanding of the underlying pathophysiological mechanisms of cancer pain. Understanding the multiple mechanisms driving cancer pain will help to move towards rational individualised analgesic treatment choices.

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Opioids for chronic low back pain. An updated systematic review and meta‐analysis of efficacy, tolerability and safety in randomized placebo‐controlled studies of at least four weeks double‐blind duration

Abstract

Background and Objective

This updated systematic review evaluated the efficacy, tolerability and safety of opioids compared to placebo in non‐malignant chronic low back pain.

Databases and Data Treatment

Clinicaltrials.gov, CENTRAL, MEDLINE and

PsycINFO were searched from October 2013 to May 2019. Randomized controlled trials comparing opioids with placebo and at least four weeks double‐blinded duration were analysed. Primary outcomes were pain relief of 50% or greater, disability, tolerability and safety. Effects were summarized by a random effects model using risk differences or standardized mean differences. We added nine new studies with 2980 participants for a total of 21 studies with 7650 participants. Study duration ranged between four and 15 weeks. Studies with a parallel and cross‐over design: Based on very low to low quality evidence, opioids provided no clinically relevant pain relief of 50% or greater, but a clinically relevant reduction of disability compared to placebo. Enriched enrolment randomized withdrawal (EERW) design: Based on very low to low quality evidence, opioids provided a clinically relevant pain relief of 50% or greater, but not a clinically relevant reduction of disability compared to placebo. There was no clinically relevant harm with regards serious adverse events by opioids compared to placebo in studies with parallel/cross‐over and EERW designThere was a relevant harm with regards to drop out rates due to adverse events in studies with parallel/cross‐over, but not in studies with EERW design

Conclusions

Opioids may provide a safe and clinically relevant pain relief for four to 15 weeks in highly selected patients.

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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 < .00001, ANOVA). No change in sweat output was recorded from glabrous skin to sine wave stimuli. Sinusoidal current at intensities ranging from 0.05 to 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 versus nociceptive fibres as measured by activity‐dependent slowing (ADS) of conduction (sympathetic efferents average ADS 100 ± 0.2% vs. C‐nociceptors average ADS 113 ± 4%, p < .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.

Significance

C‐nociceptors in hairy skin are activated by 4 Hz sinusoidal current stimulation at lower intensities than myelinated fibres. Sympathetic efferent neurons—albeit also unmyelinated—are less responsive to sinusoidal activation than nociceptors within the same skin area. Cutaneous sympathetic efferent neurons apparently are less apt than nociceptors to convert slow depolarization into action potentials.

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Change in fatigue in acceptance and commitment therapy‐based treatment for chronic pain and its association with enhanced psychological flexibility

Abstract

Purpose

Fatigue is commonly reported by people with chronic pain. The purpose of the current study was to examine Acceptance and Commitment Therapy (ACT), based on the Psychological Flexibility (PF) model, for fatigue in chronic pain.

Methods

This study included 354 adults attending an interdisciplinary ACT‐oriented treatment for chronic pain. T‐tests and analyses of clinically meaningful change were used to investigate participant improvements in fatigue interference after the treatment. Pearson's correlations and hierarchical regressions were conducted to investigate associations between improvement in fatigue interference and improvements in PF processes. Finally, mixed effects models were used to explore associations between baseline fatigue interference and changes in treatment outcome measures.

Results

Participants improved in fatigue interference (d = 0.37), pain, some PF processes and daily functioning (d = 0.18–1.08). 39.7% of participants demonstrated clinically meaningfully improvements in fatigue interference. Changes in fatigue interference was associated with changes in pain, PF processes and daily functioning, |r| = 0.20–0.46. Change in fatigue interference was associated with change in pain acceptance independent of change in pain, β = −0.36, p < .001. However, baseline fatigue interference did not predict any treatment outcome. Overall, people with fatigue appeared to benefit from the ACT‐oriented interdisciplinary treatment for chronic pain, and relatively higher levels of fatigue did not appear to impede this benefit.

Conclusion

ACT‐based treatments may benefit people with chronic pain and fatigue. Future studies including experimental designs, and studies investigating other PF processes, are needed to better understand the utility of ACT for comorbid fatigue and pain.

Significance

This study investigates the association between fatigue interference and psychological flexibility processes in chronic pain, and the first one investigating fatigue interference as a predictor of functioning in chronic pain following Acceptance and Commitment Therapy (ACT)‐based treatment. Findings of the study provide preliminary evidence for the association between ACT and fatigue in people with chronic pain and support the potential benefit of ACT for people with comorbid chronic pain and fatigue.

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How and for whom does a positive affect intervention work in fibromyalgia: An analysis of mediators and moderators

Abstract

Objectives

Psychological interventions designed to enhance positive affect are promising ways to promote adaptive functioning in people with chronic pain. However, few studies have addressed the efficacy of positive affect interventions in chronic pain populations and examined which patients can benefit more from them. The aim of the present study was to identify mediators and moderators of the best possible self intervention (BPS) in fibromyalgia patients.

Methods

We used data from a previous randomized controlled trial that examined changes in pain interference, depression, self‐efficacy and quality of life after the BPS intervention.

Results

Mediation analyses showed that depression mediated changes in pain interference. Positive and negative affect were significant mediators of the change in depression and quality of life. No significant mediators of the change in self‐efficacy were found. Baseline levels of quality of life, emotion regulation strategies of negative and positive affect, and rumination moderated the effects of the intervention on depressive symptomatology.

Discussion

In fibromyalgia patients, the effects of the BPS on the outcomes seem to be more related to changes in affect than to changes in future expectations.

Significance

This study presents evidence about who can benefit from an intervention designed to augment positive affect and promote positive functioning in FMS patients and how these changes occur. It extends previous findings on patient characteristics associated with the response to pain management interventions.

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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 PROMs only, to examine changes in psychosocial status due to a pain rehabilitation programme, is therefore questionable.

Significance

This study shows that widely used generic psychosocial PROMs might not be responsive and not able to distinguish clinically important change from measurement error in individual chronic musculoskeletal pain patients. It therefore seems reasonable to reconsider the (compulsory) use of these PROMs for assessing the quality of pain rehabilitation programmes, and necessary to consider other, more objective, outcome measures for this purpose in this population.

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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 was 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 tumours.

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 SAPB. The primary outcome measure was the assessment for the possible emergence of PTPS at 12 weeks. The secondary outcome measures were pain relief measured using visual analog scale (VAS) score, Quality of life was assessed using Flanagan Quality of Life Scale (QOLS) and Activity level was assessed using Barthel Activity of daily living (ADL) score.

Results

At week 8, PTPS incidence was significantly (p = .037) higher in the PCA group (45%) than in the SAPB group (24%) with a relative risk of 1.38 and 95% CI (1.01–1.9) while the incidence of PTPS at week 12 was significantly (p = .035) higher in the PCA group (43%) than in the SAPB group (22%) with a relative risk of 2.38 and 95% CI (1.23–4.57). The need for pain therapy in PTPS patients was significantly lower in the SAPB group (17.7%) than the PCA group (38.6%) (p = .028) at week 12. Pain intensity: VAS‐R and VAS‐D (pain scores at rest and with activity, respectively) was comparable (p > .05) between both groups at 6, 12, 18 and 24 hr, however VAS was significantly higher in the PCA group at week 8 (p = .046) and week 12 (p = .032) . Both groups were comparable regarding ADL and QOL scores (p > .05).

Conclusion

Serratus anterior plane block 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.

Significance statement

The current work hypothesized that SAPB for a week postoperatively, is a good loco‐regional alternative for post‐thoracotomy analgesia following thoracotomies for chest malignancies, it may reduce the emergence of PTPS and the demand for pain therapy in these patients.

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

Abstract

Background

Various adjuvants were added to intrathecal anaesthetics to improve quality of the block and postoperative analgesia. We hypothesized that intrathecal dexmedetomidine and magnesium sulphate (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 caesarean section.

Methods

A randomized double‐blind controlled study; 90 parturients were divided into three groups. All patients received intrathecal hyperbaric bupivacaine 12.5 mg. NaCl 0.9% was added to intrathecal block in group C, 5 μg dexmedetomidine in the group D and 50 mg 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 and 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 min 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 caesarean 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.

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Metacognition, perseverative thinking, and pain catastrophizing: A moderated‐mediation analysis

Abstract

Background

Pain catastrophizing is linked to a range of negative health and treatment outcomes, although debate continues about how best to define and treat it, since most interventions produce only modest benefit. This study aimed to contribute to theory‐driven development of these treatments by exploring the role of perseverative thinking in pain catastrophizing, along with the higher order beliefs, called metacognitions that might shape it.

Methods

An Internet sample of 510 people with chronic pain (≥3 months), who mostly (54.9%) had clinical levels of catastrophizing, completed self‐report measures of pain intensity, disability, perseverative thinking, pain catastrophizing, depression, anxiety, and pain metacognition. Regression‐based moderated mediation analysis tested the conditional indirect effect of pain intensity on pain catastrophizing via perseverative thinking at varying levels of unhelpful pain metacognition.

Results

Perseverative thinking partially mediated the effect of pain intensity on pain catastrophizing, accounting for 20% of the total effect. This indirect effect was conditional on both positive and negative metacognition. Higher levels of both forms of unhelpful metacognition strengthened the indirect effect, which was not significant below the 50th percentile for positive metacognitions or below the 60th percentile for negative metacognitions.

Conclusions

Strongly believing that thinking about pain helps you solve problems or cope with pain (positive metacognition), or that it is harmful and uncontrollable (negative metacognition), can increase the amount you worry or ruminate as pain increases. This is associated with increased pain catastrophizing. Identifying and modifying these unhelpful pain metacognitions may improve treatments for pain catastrophizing and thereby chronic pain generally.

Significance

This study shows that perseverative thinking (worry and rumination) mediates the relationship between pain intensity and catastrophizing. Consistent with metacognitive theory, this association is also moderated by unhelpful beliefs about worry and rumination. Pain metacognitions could become new therapeutic targets to help improve psychological treatments for pain‐related distress, which are currently only modestly effective.

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The COX‐2 inhibitor etoricoxib reduces experimental osteoarthritis and nociception in rats: The roles of TGF‐β1 and NGF expressions in chondrocytes

Abstract

Background

Osteoarthritis (OA) is the most common joint disease, especially affecting the knee joint. Etoricoxib, a highly selective cyclooxygenase (COX)‐2 inhibitor which can reduce postoperative pain after orthopaedic surgery. The aim of this study was to investigate the effects of oral etoricoxib on the development of OA and to examine concomitant changes in the nociceptive behaviour of rats.

Method

OA was induced in wistar rats by anterior cruciate ligament transection (ACLT) of the right knee. The ACLT + etoricoxib groups received 6.7 or 33.3 mg/kg of oral etoricoxib three times a week for 12 consecutive weeks, starting at week 8 after ACLT. Nociceptive behaviours and changes in knee joint width during OA development were analyzed. Histopathological studies were then performed on the cartilage. Immunohistochemical analysis was performed to examine the effect of etoricoxib on the expression of transforming growth factor‐beta (TGF‐β) and nerve growth factor (NGF) in articular cartilage chondrocytes.

Results

OA rats receiving etoricoxib showed a significantly lower degree of cartilage degeneration than the rats receiving placebo. Nociceptive behaviour studies showed significant improvement in the ACLT + etoricoxib groups compared to that in the ACLT group. Moreover, etoricoxib attenuated NGF expression, but increased TGF‐β expression, in OA‐affected cartilage.

Conclusions

Oral etoricoxib in a rat OA model (a) attenuates the development of OA, (b) concomitantly reduces nociception, and (c) modulates chondrocyte metabolism, possibly by inhibiting NGF expression and increasing TGF‐β expression.

Significance

Oral administration of etoricoxib can attenuate the development of OA, with an associated attenuation of nociceptive behaviour in an experimental rat OA model. Moreover, etoricoxib attenuated NGF expression, but enhanced TGF‐β expression in OA‐affected chondrocytes. These findings may pave the way for further investigations of etoricoxib as a potential therapeutic target for the treatment of the inflammatory component in OA.

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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 (a) describe changes occurring in premorbid TMD risk factors when re‐measured at TMD onset and 6 months later, and (b) determine if measures of change improve accuracy in predicting TMD incidence compared to premorbid measures alone.

Methods

In this observational prospective cohort study at four university research clinics, 3,258 community‐based, 18‐ to 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 of 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 behavioural and neurosensory domains.

Results

Most risk factors across all four domains increased with TMD onset, remained elevated in the persistent group and declined in the transient group (i.e., significant ANOVA interactions, p < .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.

Significance

TMD is known to be a complex disorder, in which onset and persistence are associated with disease‐related variables in multiple domains, including environmental exposure, clinical, psychological, health status, and pain processing variables. Using a more dynamic approach in order to capture change across time, many aspects of those domains were found to worsen prior to the reporting of pain, with bidirectional influences between domains and pain emergence likely. TMD onset appears to represent the cumulative effect of multiple system dysregulation.

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Sleep restriction does not potentiate nocebo‐induced changes in pain and cortical potentials

Abstract

Background

The increased pain sensitivity following reduced sleep may be related to changes in cortical processing of nociceptive stimuli. Expectations shape pain perception and can inhibit (placebo) or enhance (nocebo) pain. Sleep restriction appears to enhance placebo responses; however, whether sleep restriction also affects nocebo responses remains unknown. The aim of the present study was to determine whether sleep restriction facilitates nocebo‐induced changes in pain and pain‐evoked cortical potentials.

Methods

In an experimental study with a crossover design, the sensitivity to electrically induced pain was determined in 53 nurses under two sleep conditions, after habitual sleep and after two consecutive nights at work. Nocebo was induced by conditioning one‐third of the pain stimuli. Pain‐elicited cortical event‐related potentials were recorded by electroencephalography (EEG). Data were analysed both in the time domain (N2P2 amplitude) and in the time–frequency domain (ERP magnitude). Sleepiness and vigilance were also assessed.

Results

Both nocebo alone and sleep restriction alone increased the sensitivity to electrically induced pain. However, no interaction effect was found. Moreover, the magnitude of the pain‐elicited responses increased after sleep restriction and decreased after nocebo expectation, suggesting that nocebo is probably not an underlying mechanism for the commonly observed hyperalgesia induced by sleep restriction.

Conclusions

The present work addresses whether sleep restriction, known to increase the sensitivity of the pain system, facilitates nocebo‐induced hyperalgesia. Our findings suggest that this is not the case, indicating that the increased sensitivity of the pain system following nocebo and sleep restriction are mediated by different cortical mechanisms.

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Issue Information

European Journal of Pain, Volume 24, Issue 1, Page 1-2, January 2020.

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Incidence of shoulder pain in 40 years old and over and associated factors: A systematic review

Abstract

Background

Shoulder pain is one of the most frequent musculoskeletal complaints, and its prevalence and consequences increase with age. However, little is known about the incidence of shoulder pain among aging adults. We conducted this review to estimate the incidence of shoulder pain in ageing adults and its associated factors.

Databases and data treatment

We conducted a systematic review of cohort studies in which the incidence of shoulder pain and associated factors were explored in adults aged 40 years and over. PubMed, Embase, and Web of Science databases were consulted.

Results

We retrieved 3332 studies and included six, of which five were prospective cohort studies and one was retrospective. For adults aged 45–64 years, the annual cumulative incidence was 2.4%. The incidence density was estimated at 17.3 per 1,000 person‐years for adults in the 45–64 years age group, at 12.8 per 1000 person‐years for those in the 65–74 years group and at 6.7 per 1000 person‐years among those aged 75 years and over. Occupational factors, notably physical demands of work, were associated with the incidence of shoulder pain. Non‐occupational factors were also linked to the occurrence of shoulder pain.

Conclusion

Few studies have estimated the incidence of shoulder pain and associated factors among ageing adults. From this systematic review, we conclude that studies on the incidence of shoulder pain are scarce, and that both occupational and non‐occupational factors could be associated with the onset of shoulder pain among adults 40 years and over. This very limited evidence calls for more studies on this topic.

Significance

Shoulder pain is one of the most frequent musculoskeletal complaints, and its prevalence and consequences increase with age. However, since the prevalence of a recurring condition is determined by its incidence and the number and duration of episodes, it is important to have valid incidence estimates and to conduct aetiological studies on incidence measures to untangle risk factors of the occurrence of shoulder pain from those affecting the duration and number of episodes . In this systematic review, we sought to estimate the incidence of shoulder pain in ageing adults along with its associated factors. This work could lead to better interventions to prevent shoulder pain in older individuals.

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Predictors of functional outcome in musculoskeletal healthcare: An umbrella review

Abstract

Background

Multiple cohort and systematic review studies exist, reporting independent predictive factors associated with outcome in musculoskeletal populations. These studies have found evidence for a number of “generic” factors that have been shown to predict outcome across musculoskeletal patient cohorts. This review provides a higher level review of the evidence with a focus on generic patient factors associated with functional musculoskeletal outcome with a view to informing predictive modelling.

Objectives

(a) Identify patient factors found to have evidence to support their association with functional outcome, and (b) review these findings across body areas/conditions to identify generic predictive factors.

Databases and Data Treatment

Electronic databases of MEDLINE, AMED, EMBASE, CINAHL and Cochrane were searched for eligible studies. Two reviewers independently extracted data and assessed quality using an established checklist for umbrella reviews.

Results

Twenty‐one systematic reviews met inclusion criteria, all were of moderate/high quality. Six independent predictors were found to have strong evidence of association with worse musculoskeletal functional outcome across anatomical body sites (worse baseline function, higher symptom/pain severity, worse mental well‐being, more comorbidities, older age and higher body mass index). Longer duration of symptoms, worse pain coping, presence of workers compensation, lower vitality and lower education were also found to have moderate evidence of association with worse functional outcome across body sites.

Conclusions

This study identifies a number of factors associated with musculoskeletal functional outcome. The generic predictive factors identified should be considered for inclusion into musculoskeletal prognostic models, including models used for case‐mix‐adjustment of patient reported outcome measure data.

Significance

This article identifies “generic” patient factors that predict functional outcome (measured using Patient Reported Outcome Measures (PROMs)) across musculoskeletal conditions. Findings provide support for the development and content of generic musculoskeletal prognostic models including models used to case‐mix adjust PROM data for baseline complexity. Generic musculoskeletal models and functional PROMs would facilitate more feasible comparison and benchmarking of musculoskeletal services in order to identify variation and address health inequalities.

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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 analysing 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 seven studies. Among the 21 studies reviewed, the mean score for methodological quality was 78.3 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, gender 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.

Significance

This systematic review, with a meta‐analysis and an IPD meta‐analysis, failed to find a link between schoolbags weighing ≥ 10% of body weight and LBP among schoolchildren aged 9 to 16. Further longitudinal studies, with large samples, long follow‐up periods, and rigorous methods taking into account duration of carry and the physical capacity of each subject, are required in this field.

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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 three or more studies. History of back pain was the only risk factor consistently associated with back pain after adjustment (nine 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.

Significance

Emerging adulthood is a transitional period of life with changes in life style, potentially influencing future musculoskeletal health. This systematic review included 49 articles evaluating more than 150 potential risk factors for back pain, one of the most prevalent musculoskeletal disorders. No consistent results were found for life style factors such as physical activity level or BMI, both highlighted as important risk factors in previous literature. Importantly, a previous episode of back pain was a consistent risk factor for a new episode of back pain across several studies, and further investigation of risk factors for the first back pain episode is needed.

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Epigenetic and miRNA expression changes in people with pain: a systematic review

Recent scientific evidence demonstrates how most chronic and degenerative disorders are not determined by genetic mutations or polymorphisms, but are rather consequence of complex gene-environment interactions.22,27 Such evidence has been changing our understanding of both common and complex diseases, and an increasing amount of basic science and clinical research has been trying to determine which mechanisms are responsible for linking environmental and lifestyle factors to changes in gene expression.

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Management of patients with a musculoskeletal pain condition that is likely chronic: Results from a national cross sectional survey

Chronic musculoskeletal pain (e.g. back and neck pain, pain due to arthritis, leg pain, arm pain of >3 months duration) affects between 11 and 24% of the general population,5, 10 with some estimates as high as 48% for chronic musculoskeletal complaints.19 Costs attributable to musculoskeletal pain have risen in the United States between 1996 and 2014 from $400 billion to nearly a trillion dollars (i.e. 3.4% of GDP to 5.8% of GDP) and these will no doubt rise even further as the prevalence of musculoskeletal disorders are expected to increase as the population ages.

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Test-retest and inter-examiner reliability of a novel bedside quantitative sensory testing battery in postherpetic neuralgia patients

Quantitative sensory testing (QST) is a well-established method of psychophysical evaluation of the somatosensory system, based on measurements of responses to calibrated, graded innocuous or noxious stimuli2,31,39.It has been used traditionally in the research setting to phenotype patients with a variety of pain disorders39. QST yields valuable information about the functional status of the somatosensory system from peripheral receptor to the cortex, and it may be used to quantify and monitor the presence and severity of either positive sensory phenomena (such as amplified pain perception reported in allodynia or hyperalgesia) or negative phenomena (e.g., loss of function as in hypoesthesia or hypoalgesia)1,44.

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The “culture” of pain control: A review of opioid-induced dysbiosis (OID) in antinociceptive tolerance

In October 2017, the United States government declared a state of public health emergency in response to the growing prescription opioid epidemic. Social, political, and medical rhetoric has recently demanded improvements in clinical pain control, prompting the publication of the “Guideline for Prescribing Opioids for Chronic Pain” by the Centers for Disease Control and Prevention (CDC) in March, 2016.31 Over the last decade, opioid use in the US has risen dramatically, with the number of prescriptions written by health care providers in 2012 (∼259 million) exceeding the total adult population (∼240 million).

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Two weeks of wearing a knee brace compared to minimal intervention on kinesiophobia at 2 and 6-weeks in people with patellofemoral pain: A randomized controlled trial

Publication date: Available online 10 December 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Liliam B. Priore, Simon Lack, Carmen Garcia, Fabio M. Azevedo, Danilo de Oliveira Silva

Abstract

Objective

To investigate the effect of a knee brace compared with minimal intervention on self-reported kinesiophobia and function, objective function and physical activity level in individuals with patellofemoral pain (PFP).

Design

Single-blind randomized controlled trial [1:1], parallel

Participants

Fifty individuals with PFP.

Main Outcome Measures

Primary: Kinesiophobia (Tampa Scale of Kinesiophobia). Secondary: self-reported function (Anterior Knee Pain Scale), physical activity level (International Physical Activity Questionnaire) and objective function (forward step-down test). Outcomes were assessed at baseline (T₀), at the end of the intervention (2-weeks) (T₁) and at 6-weeks after baseline (T₂).

Intervention

Participants were randomly assigned to one of two interventions groups: (i) use of knee brace for 2 weeks during daily living, sports or painful tasks (brace group); (ii) educational leaflet with information about PFP (leaflet group).

Results

The knee brace reduced kinesiophobia in people with PFP compared to minimal intervention with moderate effect size at T₁ = mean difference (95%CI) -5.56 (-9.18 to -1.93) and T₂ = -5.24 (-8.58 to -1.89). There was no significant difference in self-reported and objective function and physical activity level.

Conclusion

The knee brace improved kinesiophobia immediately after intervention (at 2-weeks) and at 6-weeks follow-up in people with PFP compared to minimal intervention. A knee brace may be considered within clinically reasoned paradigms to facilitate exercise-therapy interventions for people with PFP.

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Effectiveness of platelet rich plasma injections for non-surgical management of carpal tunnel syndrome: a systematic review and meta-analysis of randomized controlled trials

Publication date: Available online 7 December 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Michael Catapano, Joseph Catapano, Gregory Borschel, Seyed Mohammad Alavania, Lawrence R. Robinson, Nimish Mittal

Abstract

Objective

To systematically review and evaluate the efficacy and complication profile of platelet-rich plasma (PRP) injection into the carpal tunnel for management of carpal tunnel syndrome (CTS).

Data Sources

PubMed, MEDLINE, SCOPUS, EMBASE, Google Scholar, Cochrane Central Register of Controlled Trials, and Web of Sciences (from inception to January 1^st, 2019).

Study Selection

Controlled trials addressing PRP for CTS.

Data Extraction

Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. The outcomes of interest were the visual analog score (VAS) for pain and the Boston Carpal Tunnel Questionnaire (BCTQ), including the subscales of the symptom severity scale (SSS) and the functional status scale (FSS). Other reported outcome measures and complications were analyzed descriptively.

Data Synthesis

Four randomized control studies satisfied the inclusion criteria and analyzed a total of 191 cases with a final follow-up of either 3 or 6-months. Control groups included splinting in two studies, corticosteroid injection in one study, and saline injection in one study. There was a statistically and clinically significant improvement in the BCTQ {Std. Mean Difference(95%CI) = -2.06[-3.41, -0.70], p=.003} between groups. Subgroup analysis showed significant improvement in SSS {Std. Mean Difference(95%CI) = -1.95[-3.65, -0.25], p=.02} but not for FSS {Std. Mean Difference(95%CI) = -2.19[-4.77, 0.40], p=.10}. There was a similar improvement in VAS and nerve conduction studies in those receiving PRP compared to controls. Complication rate in the included studies was low with 4/97 participants receiving PRP injections experiencing transient pruritis, burning and/or tingling.

Conclusion

PRP represents a promising therapy for patients with mild to moderate CTS; however, included studies were limited as follow-up was short, included patients were heterogeneous, and the number of included studies was low. Further investigation is necessary to determine its true efficacy and effect and to better delineate the long-term results in patients with CTS.

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Pressure Pain Threshold in Subjects with Piriformis Syndrome: Test-Retest, Intra-, and Inter-Rater Reliability, and Minimal Detectible Changes

Publication date: Available online 7 December 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Abbas Tabatabaiee, Ismail Ebrahimi Takamjani, Javad Sarrafzadeh, Reza Salehi, Maryam Ahmadi.

Abstract

Objective

This study aimed to assess the test-retest, intra-, and interrater reliability of using the pressure pain threshold (PPT) in healthy and affected piriformis muscles and to estimate its absolute reliability. As a secondary objective, the degree of tenderness of the affected piriformis muscles was compared with healthy piriformis muscles.

Study Design

This study used a comparative and reliability-based design.

Setting

Rehabilitation clinic.

Participants

Thirty patients with unilateral piriformis muscle syndrome (30 affected and 30 healthy piriformis muscles) were recruited, and the PPT of both the healthy and affected piriformis muscles was recorded using digital algometry. Measurements of PPT were done by two raters (rater 1 and 2), which have selected at random order. The rater 1 repeated the PPT measurements 24-72 hours after initial assessment.

Interventions

Not applicable.

Main Outcome Measures

PPT.

Results

Excellent intra-rater intra-class coefficient (ICC) values were observed for the PPT of the affected piriformis (ICC: 0.86–0.96) and the healthy piriformis (ICC: 0.88–0.96) in the same session. The PPT measurements using digital algometry showed good-to-excellent inter-rater reliability (ICC: 0.64–0.92) and test-retest reliability (ICC: 0.72–0.95) in both the healthy and affected piriformis muscles. The findings revealed a significant decrease in the PPT of the affected piriformis muscle in comparison to the healthy piriformis muscle (mean difference 12.76 [95% confidence interval [CI]:15.69–9.82], P < 0.001).

Conclusion

Digital algometry is a reliable tool for measuring piriformis PPT, regardless of the testing session and the rater. Patients with unilateral piriformis muscle syndrome have increased tenderness and decreased PPT in the affected piriformis muscle in comparison to the healthy piriformis muscle.

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