Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations

Publication date: Available online 31 January 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Patrick Doiron-Cadrin, Simon Lafrance, Marie Saulnier, Émie Cournoyer, Jean-Sébastien Roy, Joseph-Omer Dyer, Pierre Frémont, Clermont Dionne, Joy C. MacDermid, Michel Tousignant, Annie Rochette, Véronique Lowry, Nathalie J. Bureau, Martin Lamontagne, Marie-France Coutu psy, Patrick Lavigne, François Desmeules

Abstract

Objectives

To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of specific clinical recommendations for the management of rotator cuff disorders in adults.

Data sources

A systematic bibliographic search was conducted up until May 2018 in Medline, Embase and PeDro databases, in addition to twelve clinical guidelines search engines listed on the AGREE Thrust website.

Study selection

Nine CPGs on the management of rotator cuff disorders in adults and/or workers, available in English or French and published from January 2008 onward, were included and screened by two independent reviewers.

Data extraction

CPGs methodology was assessed with the AGREE II tool. A semantic analysis was performed to compare the strength of similar recommendations based on their formulation. The recommendations were categorized in a standardized manner considering the following four levels: “Essential”, “Recommended”, “May be recommended” and “Not recommended”.

Data synthesis

Methodological quality was considered high for three CPGs and low for six. All CPGs recommended active treatment modalities, such as an exercise program in the management of rotator cuff disorders. Acetaminophen and/or NSAIDs prescription and corticosteroid injections were presented as modalities that may be recommended to decrease pain. Recommendations related to medical imagery and surgical opinion varied among the guidelines. The most commonly recommended return to work strategies included intervening early, use of a multidisciplinary approach and adaptation of work organization.

Conclusions

Only three CPGs were of high quality. The development of more rigorous CPGs is warranted.

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Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta‐analysis

Abstract

Background

Sciatica can be a debilitating condition and there is limited guidance on the use of glucocorticoids administered via the oral, intramuscular or intravenous route for this condition. These represent viable treatment options in the primary care setting.

Objective

To evaluate the evidence on efficacy and harms of oral, IM and IV glucocorticoid administration for sciatica.

Databases and data treatment

MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO (inception to October 2018) were searched for randomised placebo‐controlled trials evaluating oral, IV or IM glucocorticoid administration for sciatica. Two authors extracted outcomes data. Continuous pain and disability outcomes were converted to a 0 (no pain/disability) to 100 (worst pain/disability) scale. Data were pooled using a random effects model. Overall quality of evidence was assessed using GRADE. Primary outcomes were leg pain and disability. Primary follow‐up period was the immediate‐term (<2 weeks from administration). We also considered adverse events.

Results

Nine trials were eligible. One study [n = 27] provided low quality evidence of a small reduction in disability with early administration of oral prednisone (within 1 week); MD −13.4 [−23.3, −3.5] but not for pain MD −2.5 [−16.9, 11.9]. There was low quality evidence from one study [n = 78] of moderate reduction in disability and small reduction in pain with early (within 72 hr of symptom onset) single intramuscular administration of methylprednisolone acetate; MD −24.5 [−38.8, −10.2] and −14.0 [−27.4, −0.6], respectively. There were no immediate‐term benefits with IV administration.

Conclusion

The effects of glucocorticoids on immediate‐term leg pain or disability are uncertain. Future large high quality trials are needed to resolve this uncertainty.

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Prognostic factors for pain and functional disability in children and adolescents with persisting pain: a systematic review and meta‐analysis

Abstract

Background and Objective

The aim of this study was to investigate prognostic factors for pain and functional disability in children and/or adolescents with persisting pain.

Databases and Data Treatment

To be included, studies had to be published, peer‐reviewed prospective cohort studies of children and/or adolescents with persisting pain at baseline, that reported at least one baseline prognostic factor and its relationship with pain or functional disability at least one month after baseline. Two reviewers independently assessed study eligibility, completed data extraction, and undertook quality assessment. Meta‐analyses were performed when a prognostic factor was reported in two or more studies.

Results

Of 10992 studies identified from electronic database searches, 18 were included, investigating 62 potential prognostic factors. In clinical settings, insufficient data were available for meta‐analysis. Some positive associations with pain and/or disability were reported by single studies for older age, baseline pain intensity, and baseline functional disability across multiple combinations of follow‐up times and outcomes. In community settings, meta‐analyses of two studies found that prognostic factors for the ongoing presence of pain at medium‐term (1‐year) follow‐up were older age (OR 1.25; 95% CI = 1.05‐1.47), weekly day tiredness (OR 1.69; 95% CI = 1.14‐2.51), weekly abdominal pain (OR 1.44; 95% CI = 1.03‐2.02), and waking during the night (OR 1.49; 95% CI = 1.05‐2.13). No studies in community settings reported on prognostic factors for functional disability.

Conclusions

Prognostic factors having significant associations with future pain and disability were identified; however, as few were investigated in more than one comparable study, the results need to be interpreted with caution.

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Electroacupuncture Alleviates Mechanical Allodynia in a Rat Model of Complex Regional Pain Syndrome Type-I via Suppressing Spinal CXCL12/CXCR4 Signaling

Complex regional pain syndrome (CRPS) is a chronic neurological dysfunction that usually affects the extremities of the patients 30. Trauma, bone fractures, nerve lesions and ischemia are usually among the major reasons that lead to CRPS 2,7,32. CRPS can be subdivided into two categories: type-I CRPS (CRPS-I), without overt nerve damage and type-II CRPS (CRPS-II), with identifiable nerve damage 32. CRPS patients usually suffer from excruciating and chronic pain in affected areas, leading even to disabilities 31.

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Biased partner perceptions of women's pain self-efficacy in postpartum pain during intercourse: A dyadic longitudinal examination

Childbirth is a significant risk factor for the development of persistent pain problems (e.g., 9, 28, 85), including pain during intercourse 14, 17, 34, 53, 62. Approximately 37% of women report pain during intercourse at three months postpartum, which persists for 31% at six months postpartum 73. Pain during intercourse substantially interferes with couples’ sexual functioning, and in turn, their quality of life (e.g., 63, 73, 81). Biomedical factors such as mode of delivery and severity of delivery pain have been implicated in the persistence of this pain in the first six months postpartum73.

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Evolution of Analgesic Tolerance and Opioid-Induced Hyperalgesia over 6 months: Double-blind randomized trial incorporating experimental pain models

Contributors to the ongoing epidemic of prescription opioid abuse, addiction, and death include opioid tolerance, withdrawal symptoms, and possibly opioid-induced hyperalgesia (OIH). Thirty stable chronic non-malignant pain patients entered a six-month long, randomized, double-blind, dose-response, two-center trial of the potent opioid levorphanol, conducted over a decade ago during an era of permissive opioid prescribing. Eleven were taking no opioids at study entry and eleven were taking between 35-122 morphine equivalents (MEQ).

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AAAPT Diagnostic Criteria for ACUTE ABDOMINAL AND PERITONEAL PAIN AFTER SURGERY

Abdominal and peritoneal pain after surgery is common and burdensome, yet the lack of standardized diagnostic criteria for this type of acute pain impedes basic, translational, and clinical investigations. The collaborative effort among the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM) Pain Taxonomy (AAAPT) provides a systematic framework to classify acute painful conditions.

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ChrOnic pain self-ManagementMent support with pain science EducatioN and exerCisE (COMMENCE) for people with chronic pain and multiple comorbidities: A randomized controlled trial

Publication date: Available online 29 January 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Jordan Miller, Joy C. MacDermid, David M. Walton, Julie Richardson

Abstract

Objective

To investigate the effectiveness chronic pain self-management support with pain science education and exercise (COMMENCE) on improving function, pain interference, work status, pain intensity, fatigue, psychological factors associated with pain, health care visits, satisfaction, and perceived change compared to usual care.

Design

Parallel group randomized controlled trial with 1- and 12-week follow-ups.

Setting

Community health centre.

Participants

Adults (n=102) with chronic non-cancer pain referred for self-management support. Eighty of 102 participants completed 12-week follow-up assessments. No participants withdrew with adverse events.

Interventions

Participants were randomized to COMMENCE or usual care.

Main outcome measures

Primary: Function measured using the Short Musculoskeletal Function Assessment (SMFA) – Dysfunction Index. Secondary: SMFA bother index, PROMIS pain interference, work status, numeric pain and fatigue rating scales, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Pain Self-Efficacy Scale, Neurophysiology of Pain Questionnaire, number of healthcare visits, satisfaction, and global rating of change.

Results

COMMENCE resulted in greater improvements in function [mean difference at 12-week follow-up (MD) = -8.0; 95%CI: -14.7 to -1.3), bother with functional difficulties (MD = -12.0; 95%CI: -20.8 to -3.2), pain intensity (MD = -1.0; 95%CI -2.1 to -0.1), catastrophizing (MD = -8.2; 95%CI: -14.5 to -2.0), self-efficacy (MD 7.0; 95%CI 0.8 to 13.2), knowledge (MD = 2.8; 95%CI: 1.6 to 3.9), satisfaction (MD = 1.2; 95%CI: 0.7 to 1.8) and perceived change (MD = 1.4; 95%CI: 0.8 to 2.1). There were no significant between group differences in pain interference, work, fatigue, depressive symptoms, or healthcare visits.

Conclusion

COMMENCE is more effective than usual care at improving function, pain, catastrophic thinking, self-efficacy, pain knowledge, satisfaction, and perceived change, but not pain interference, work status, fatigue, depressive symptoms, or health care visits.

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Dual‐action ambroxol in treatment of chronic pain in Gaucher Disease

Abstract

A significant number of patients with Gaucher disease (GD) suffer from chronic or acute pain that reduces their quality of life. A mutation in lysosomal enzyme β‐glucosidase (GCase) leads to an accumulation of glucocerebroside in the macrophage‐lineage cells, causing the development of clinical symptoms. Novel studies have revealed that ambroxol (trans‐4‐(2‐amino‐3,5‐dibromobenzylamino)‐cyclohexanol), the well‐known mucolytic drug, acts as a chaperone for the mutant, misfolded enzyme. In addition, as has recently been shown, ambroxol is a Na_v1.8 channel blocker in Aβ, Aδ, and unmyelinated C‐fibers, and therefore reduces the transmission of sensory stimuli from the primary afferent neurons to the dorsal spinal cord. In this way, it can act analgetically. Thus, in addition to broncholytic properties, ambroxol combines two other important functions: it enhances enzyme replacement therapy (ERT) and pain management in patients with GD.

We present a 38‐year‐old female patient with type 3 GD who had reported permanent bone pain in the lumbar‐sacral part of the spine for over a year without any pathology evidenced in the undertaken, recommended diagnostic tests. The pain was partly controlled with standard analgesics, i.e. paracetamol and tramadol. Ambroxol was introduced at a dose of 150mg/d without a noticeable effect. However, when the dose was increased up to 450mg/d, the intensity of pain diminished and subsided within the following months. Two out of three attempts to reduce the dose of ambroxol resulted in a pain relapse within a week, which subsided after resetting the previous, higher dose. This observation of the effects of ambroxol in a GD patient is worth considering for other GD patients with chronic pain.

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Probing the mechanisms underpinning recovery in post‐surgical patients with cervical radiculopathy using Bayesian Networks

Abstract

Background

Rehabilitation approaches should be based on an understanding of the mechanisms underpinning functional recovery. Yet, the mediators that drive an improvement in post‐surgical pain‐related disability in individuals with cervical radiculopathy (CR) is unknown. The aim of the present study is to use Bayesian Networks (BN) to learn the probabilistic relationships between physical and psychological factors, and pain‐related disability in CR.

Methods

We analysed a prospective cohort dataset of 201 post‐surgical individuals with CR. Fifteen variables were used to build a BN model: age, sex, neck muscle endurance, neck range of motion, neck proprioception, hand grip strength, self‐efficacy, catastrophizing, depression, somatic perception, arm pain intensity, neck pain intensity, and disability.

Results

A one point increase in a change of self‐efficacy at six months was associated with a 0.09 point decrease in a change in disability at 12 months (t = ‐64.09, P < 0.001). Two pathways led to a change in disability: a direct path leading from a change in self‐efficacy at six months to disability, and an indirect path which was mediated by neck and arm pain intensity changes at six and 12 months.

Conclusions

This is the first study to apply BN modelling to understand the mechanisms of recovery in post‐surgical individuals with CR. Improvements in pain‐related disability was directly and indirectly driven by changes in self‐efficacy levels. The present study provides potentially modifiable mediators that could be the target of future intervention trials. BN models could increase the precision of treatment and outcome assessment of individuals with CR.

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Perturbing the activity of the superior temporal gyrus during pain encoding prevents the exaggeration of pain memories: a virtual lesion study using single-pulse transcranial magnetic stimulation

Publication date: Available online 27 January 2020

Source: Neurobiology of Learning and Memory

Author(s): Francis Houde, Marylie Martel, Alexia Coulombe-Lévêque, Marie-Philippe Harvey, Vincent Auclair, David Mathieu, Kevin Whittingstall, Philippe Goffaux, Guillaume Léonard

Abstract

Background

Past studies have shown that pain memories are often inaccurate, a phenomenon known as mnemonic pain bias. Pain memories are thought to play an important role on how future pain is felt. Recent evidence from our laboratory suggests that individuals who exaggerate past pain display increased superior temporal gyrus (STG) and parahippocampal gyrus (PHG) activity during the encoding of experimental painful stimulations, suggesting that these brain structures play an important role in pain memories.

Objective

/hypothesis

To determine whether a virtual lesion paradigm, targeting the STG during pain encoding, can affect long-lasting pain memories. We hypothesized that interfering with the activity of the STG (and possibly of the PHG via distant/ remote effects) would attenuate mnemonic bias.

Methods

Randomized double-blind study with two parallel groups. Participants received either sham (n = 21) or real (n = 21) transcranial magnetic stimulation (TMS - virtual lesion paradigm) over the STG during pain encoding (milliseconds after the administration of a painful stimuli). Pain intensity and unpleasantness were evaluated using a visual analog scale (VAS; 0 to 10) immediately after the painful event, and at recall, 2 months later. The mnemonic pain bias (calculated by subtracting the pain scores obtained at recall from the pain score obtained during encoding) was compared between the two groups for both pain intensity and unpleasantness.

Results

Participants in both groups did not differ in terms of age and gender (real TMS = 27 years ± 9, 43% female; sham TMS = 25 years ± 4, 49% female; p > 0.64). The mnemonic bias related to pain intensity was similar in both groups (p = 0.83). However, the mnemonic bias related to pain unpleasantness was lower in the real TMS group (p = 0.04).

Conclusions

Our results provide the first evidence that the STG and/or the PHG, and possibly the PHG, are causally involved in the formation of biased memories of pain unpleasantness.

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Pain assessment for cognitively impaired older adults: do items of available observer tools reflect pain‐specific responses?

Abstract

Background

A number of observational tools is available to assess pain in cognitively impaired older adults, however, none of them can yet be regarded as a ‘gold standard’. An international research initiative has created a meta‐tool compiling the facial, vocalization and body movement items of the majority of available tools. Objective of the present study was to investigate the pain specificity and the validity of these items.

Method

N = 34 older adults with or without cognitive impairment were videotaped in three different conditions (one reference, two painful conditions) in their nursing homes. They were further asked to self‐report their pain in each condition. The occurrence of non‐verbal behaviors was coded as present or absent using the items of the meta‐tool.

Results

The majority of non‐verbal behaviors was not pain sensitive as they occurred less than three times across participants and conditions. Of the remaining items, two facial items (‘pained expression’ and ‘raising upper lip’), one vocalization item (‘using pain related words’) and one body movement item (‘guarding’) were found to be pain specific and valid. One additional item, the vocalization item ‘gasping’, was pain‐specific, but not associated with pain self‐report, and three additional items, the facial items ‘frowning’ and ‘narrowing eyes’ and the vocalization item ‘mumbling’ were correlated with pain self‐report but did not help to separate pain from non‐pain conditions.

Conclusions

Systematic evaluation of items of existing observational pain assessment tools under naturalistic conditions seems a promising approach in the process of further investigating and improving tools.

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Blockade of BDNF Signaling Attenuates Chronic Visceral Hypersensitivity in an IBS‐like Rat Model

Abstract

Background

Irritable bowel syndrome (IBS) is a common functional disease characterized by chronic abdominal pain and changes in bowel movements. Effective therapy for visceral hypersensitivity in IBS patients remains challenging. This study investigated the roles of brain‐derived neurotrophic factor (BDNF) and tyrosine kinase receptor B (TrkB) and the effect of ANA‐12 (a selective antagonist of TrkB) on chronic visceral hypersensitivity in an IBS‐like rat model.

Methods

An IBS‐like rat model was established through neonatal maternal separation (NMS), and visceral hypersensitivity was assessed by electromyographic (EMG) responses of the abdominal external oblique muscles to colorectal distention (CRD). Different doses of ANA‐12 were injected intrathecally to investigate the effect of that drug on visceral hypersensitivity, and the open field test was performed to determine whether ANA‐12 had side effects on movement. Thoracolumbar spinal BDNF, TrkB receptor and PKMζ expression were measured to investigate their roles in chronic visceral hypersensitivity. Whole‐cell recordings were made from thoracolumbar superficial dorsal horn (SDH) neurons of lamina II.

Results

The expression of BDNF and TrkB was enhanced in the thoracolumbar spinal cord of the NMS animals. ANA‐12 attenuated visceral hypersensitivity without side effects on motricity in NMS rats. PKMζ expression significantly decreased after the administration of ANA‐12. The frequency of spontaneous excitatory postsynaptic currents (sEPSCs) increased in the thoracolumbar SDH neurons of lamina II in NMS rats. The amplitude and frequency of sEPSCs were reduced after perfusion with ANA‐12 in NMS rats.

Conclusions

NMS caused visceral hypersensitivity and increased synaptic activity by activating BDNF‐TrkB‐PKMζ signaling in the thoracolumbar spinal cord of adult rats. PKMζ was able to potentiate AMPA receptor (AMPAR)‐mediated sEPSCs in NMS rats. ANA‐12 attenuated visceral hypersensitivity and synaptic activity by blocking BDNF/TrkB signaling in NMS rats.

Significance

ANA‐12 attenuates visceral hypersensitivity via BDNF‐TrkB‐PKMζ signaling and reduces synaptic activity through AMPARs in NMS rats. This knowledge suggests that ANA‐12 could represent an interesting novel therapeutic medicine for chronic visceral hypersensitivity.

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Regional Increases in Brain Signal Variability Are Associated with Pain Intensity Reductions Following Repeated Eccentric Exercise Bouts

Abstract

Background

Traditional pain interventions limit fluctuations in pain sensation, which may paradoxically impair endogenous pain modulatory systems (EPMS). However, controlled exposures to clinically relevant pain (e.g. delayed onset muscle soreness, DOMS) may build capacity in the EPMS. Emerging evidence suggests regional signal variability (RSV) may be an important indicator of efficiency and modulatory capacity within brain regions. The present study sought to determine the role of RSV in both susceptibility to and trainability of pain response following repeated DOMS inductions.

Methods

Baseline and follow‐up resting‐state fMRI was performed on 12 healthy volunteers ~40 days apart. Between scanning visits, participants received four weekly DOMS inductions in alternating elbow flexors and supplied seven days of post‐induction pain ratings. Voxel‐wise standard deviation of signal intensity was calculated to measure RSV. Associations among DOMS‐related pain and RSV were assessed with regression. Relationships among baseline and change measurements were probed (i.e. susceptibility to DOMS; trainability following multiple inductions).

Results

Significant association between baseline RSV in left MFG and right cerebellum and reductions in DOMS‐related pain unpleasantness were detected. Furthermore, increases in RSV were associated with reduced DOMS pain intensity (left lingual gyrus, right MTG, left MTG, left precuneus) and unpleasantness (left MTG, right SFG).

Discussion

Findings suggest that RSV may be an indicator of EPMS resilience and responsivity to training, as well as an indicator that is responsive to training. Involved regions underlie cognitive, affective, and representation processes. Results further clarify the potential role of RSV as an indicator of pain modulation and resilience.

Significance

Regional signal variability may be an important indicator of endogenous pain modulatory system responsivity to training following repeated bouts of clinically relevant pain and may in fact be responsive to training itself.

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Conservative Interventions Reduce Fear in Individuals With Chronic Low Back Pain: A Systematic Review

Publication date: February 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 2

Author(s): Javier Martinez-Calderon, Mar Flores-Cortes, Jose Miguel Morales-Asencio, Alejandro Luque-Suarez

Abstract

Objective

To systematically review and critically appraise the effectiveness of conservative and surgical interventions to reduce fear in studies of people with chronic low back pain, based on the analysis of randomized controlled trials for which fear was a primary or secondary outcome.

Data Sources

Electronic databases PubMed, CINAHL, PsycINFO, PEDro, and CENTRAL, as well as manual searches and grey literature were searched from inception until May 2019.

Study Selection

Randomized controlled trials analyzing the effectiveness of conservative and surgical interventions to reduce fear were included.

Data Extraction

Two reviewers independently conducted the search strategy, study selection, data extraction, risk of bias assessment, and quality of the evidence judgment.

Data Synthesis

Sixty-one studies (n=7201) were included. A large number of fear-related search terms were used but only 3 fear constructs (kinesiophobia, fear-avoidance beliefs, fear of falling) were measured in the included studies. Multidisciplinary and psychological interventions as well as exercise reduced kinesiophobia. Fear-avoidance beliefs were reduced by the aforementioned interventions, manual therapy, and electrotherapy. A multidisciplinary intervention reduced the fear of falling. There was moderate evidence of multidisciplinary interventions and exercise to reduce kinesiophobia. There was moderate evidence of manual therapy and electrotherapy to reduce fear-avoidance beliefs.

Conclusions

The present systematic review highlights the potential effectiveness of conservative interventions to reduce kinesiophobia and fear-avoidance beliefs in individuals with chronic low back pain. This information can help health professionals to reduce fear when treating patients with this condition.

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Effect of Pilates Intervention on Physical Function of Children and Youth: A Systematic Review

Publication date: February 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 2

Author(s): Elizabeth Hornsby, Leanne M. Johnston

Abstract

Objective

To conduct a systematic review to evaluate the effectiveness of Pilates intervention on physical function in children and youth.

Data Sources

Six electronic databases were searched from inception to June 2018 using the term Pilates.

Study Selection

Articles were included if they (1) reported original data for a Pilates-only intervention; (2) involved children or youth aged up to 22 years; (3) reported a musculoskeletal, pain, or function study outcome. Searches identified 2565 papers and 11 studies fulfilled the inclusion criteria.

Data Extraction

The 2 authors independently screened and assessed all studies and any discrepancies were resolved by consensus.

Data Synthesis

Level of evidence was classified using the Oxford Centre for Evidence Based Medicine. Study quality was assessed using the Physiotherapy Evidence Database for randomized controlled trials and Risk of Bias in N-of-1 Trials scale for single case experimental design studies. Four studies were high quality, 3 were fair quality, and 4 were of low quality. Findings showed that Pilates does appear to improve flexibility (n=6); muscle strength, power and movement speed (n=3); postural control, orientation and balance (n=3); metabolic cost (n=1); functional ability (n=1) and health related quality of life (n=1) and reduce pain (n=2) in children with musculoskeletal pathology, the majority with a large effect size. Pilates content varied from group-based mat classes to individualized programs using specialized equipment. Intervention dose and frequency varied widely.

Conclusions

This is the first systematic review of the effect of Pilates intervention for children and youth. Research is in the preliminary stages; however, Pilates does appear to improve flexibility, strength and postural control, and reduce pain in children with musculoskeletal pathology. Further research is warranted to determine the potential effectiveness of Pilates for children and youth for various population groups and to develop comprehensive treatment guidelines.

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PROMIS Physical Function Short Forms Display Item- and Scale-Level Characteristics at Least as Good as the Roland Morris Disability Questionnaire in Patients With Chronic Low Back Pain

Publication date: February 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 2

Author(s): Alessandro Chiarotto, Leo D. Roorda, Martine H. Crins, Maarten Boers, Raymond W. Ostelo, Caroline B. Terwee

Abstract

Objective

To compare dimensionality, item-level characteristics, scale-level reliability, and construct validity of PROMIS Physical Function short forms (PROMIS-PF) and 24-item Roland Morris Disability Questionnaire (RMDQ-24) in patients with chronic low back pain (LBP).

Design

Cross-sectional study.

Setting

Secondary care center for rehabilitation and rheumatology.

Participants

Patients with nonspecific LBP ≥3 months (N=768). Mean age was 49±13 years, 77% were female, and 54% displayed pain for more than 5 years.

Interventions

Not applicable.

Main Outcome Measures

Dutch versions of the 4-, 6-, 8-, 10-, and 20-item PROMIS-PF and of the RMDQ-24.

Results

PROMIS-PF-6, PROMIS-PF-8, and RMDQ-24 exhibited sufficient unidimensionality (confirmatory factor analysis: comparative fit index>0.950, Tucker-Lewis index>0.950, root means square error of approximation<0.060), whereas the other instruments did not. All instruments were free of local dependence except PROMIS-PF-20 with 4 item pairs with clear residual correlations. Mokken scale analysis found 1 nonmonotone item for PROMIS-PF-20 and 8 for RMDQ-24 (ie, the probability of endorsing these items was not increasing with increasing level on the underlying construct). PROMIS-PF-20 displayed 2 misfitting items (S-χ² P value>.001). Two-parameter item response theory models found 2 items with low discrimination for RMDQ-24. All other instruments had adequate fit statistics and item parameters. PROMIS-PF-20 displayed the best scale-level reliability. Construct validity was sufficient for all instruments as all hypotheses on expected correlations with other instruments and differences between relevant subgroups were met.

Conclusions

PROMIS-PF-6, PROMIS-PF-8, and RMDQ-24 exhibited better unidimensionality, whereas PROMIS-PF-4, PROMIS-PF-6, PROMIS-PF-8, and PROMIS-PF-10 showed superior item-level characteristics. PROMIS-PF-20 was the instrument with the best scale-level reliability. This study warrants assessment of other measurement properties of PROMIS-PF short forms in comparison with disease-specific physical functioning instruments in LBP.

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Added Value of Gluteus Medius and Quadratus Lumborum Dry Needling in Improving Knee Pain and Function in Female Athletes With Patellofemoral Pain Syndrome: A Randomized Clinical Trial

Publication date: February 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 2

Author(s): Hanieh Zarei, Soha Bervis, Soraya Piroozi, Alireza Motealleh

Abstract

Objective

To compare the effects of exercise therapy alone and exercise therapy plus gluteus medius (GM) and quadratus lumbarum (QL) dry needling on pain and function in female athletes with patellofemoral pain (PFP).

Design

Single-blind randomized controlled trial with follow-up.

Setting

Physiotherapy clinic.

Participants

Convenience sample of female athletes with PFP (N=40), who were randomly assigned to the exercise therapy (Ex group) or exercise-therapy+dry needling (Ex+DN group) group.

Interventions

The Ex group received exercise therapy for 4 weeks, and the Ex+DN group received exercise therapy in combination with dry needling directed at GM and QL trigger points for 4 weeks.

Main Outcome Measures

In all participants, pain intensity, function (Kujala score, modified star excursion balance test, step-down test), and QL and GM pressure pain threshold (PPT) were recorded at baseline and at 4 and 6 weeks after the start of treatment. Analysis of variance (2 groups×3 times) was used to compare within- and between-group differences.

Results

The group versus time interaction effect was significant for all variables (P<.05). Both groups showed significant improvements in pain, function, and PPT at weeks 4 and 6 compared to baseline (P<.05). Between-groups comparisons showed significantly greater improvements in pain, function, and PPT in the Ex+DN group (P<.05).

Conclusions

Targeting intervention to treat trigger points in the GM and QL muscles combined with exercise therapy had superior beneficial effects compared to exercise alone in managing PFP. Therefore, adding GM and QL muscle dry needling to exercise therapy may be advisable to enhance the effects of PFP rehabilitation.

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Acute and Chronic Pain in Children and Adolescents With Cerebral Palsy: Prevalence, Interference, and Management

Publication date: February 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 2

Author(s): Katarina Ostojic, Simon Paget, Maria Kyriagis, Angela Morrow

Abstract

Objective

To determine the prevalence, interference, and management of acute and chronic pain among youth with cerebral palsy (CP) aged 5-18 years attending outpatient rehabilitation services.

Design

A cross-sectional study using the Faces Pain Scale-Revised, Patient Reporting Outcomes Measurement Information System Pediatric Pain Interference Scale, and the Cerebral Palsy Quality of Life questionnaire. Where children were unable to self-report, parent or caregiver proxy was obtained.

Setting

Outpatient rehabilitation.

Participants

Participants (N=280) with CP aged 5-18 years and their parent or caregiver. Self-report was obtained by 45.7% (n=128) and proxy-report was obtained by 54.3% (n=152) of the cohort.

Interventions

Not applicable.

Main Outcome Measures

Presence or absence of acute pain and chronic pain. Secondary measures were pain intensity, pain interference, pain management, and quality of life.

Results

Acute pain and chronic pain were reported by 67.1% and 31.4% of participants, respectively. Of those reporting acute pain, 42% also experienced chronic pain. Factors that increased the odds of chronic pain were: predominately dyskinesia (odds ratio [OR]=3.52; 95% confidence interval [CI], 1.64-7.55); mixed spasticity-dyskinesia (OR=1.93; 95% CI, 1.07-3.47); bilateral involvement (OR=3.22; 95% CI, 1.844-5.61) and Gross Motor Function Classification System level IV (OR=2.32; 95% CI, 1.02-5.25), and V (OR=3.73; 95% CI, 1.70-8.20). Pain frequently interferes with sleep, attention, ability to have fun, and quality of life. Short-acting pharmacologic analgesics, thermotherapy, hydrotherapy, and massage were commonly used for pain management.

Conclusions

Routine screening for pain is critical for early identification and intervention. Multimodal interventions are needed to address the biopsychosocial model of pain, and should be tailored for all abilities across the CP spectrum.

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Is transcranial direct current stimulation (tDCS) effective for the treatment of pain in fibromyalgia? A systematic review and meta-analysis

Fibromyalgia is a debilitating chronic pain condition affecting approximately 5.4% of the UK population.19 Its primary symptoms include: chronic widespread muscle pain, fatigue, sleep disturbances, tenderness (allodynia) and hyperalgesia to pressure over tender points.53,54 Its pathogenesis is uncertain but may be due to dysfunction of the central nervous system (CNS)31, possibly related to abnormal processing of pain expectation amongst other CNS abnormalities.8 Current treatments include: antidepressant and antiepileptic medication, exercise, cognitive behavioral therapy (CBT) and patient education.

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Cupping for patients with chronic pain: a systematic review and meta-analysis

Low back pain, neck pain and other musculoskeletal disorders are among the ten leading causes of years lived with disability worldwide in 2016.12 Despite the wide range of treatments and health care resources devoted to low back pain, back-related disability and population burden have increased 10,11,14 and this development has recently called for international action.2 Since the US opioid crisis, the value of analgesics in general and of opioids in particular in the treatment of chronic pain is under discussion.

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Duchenne muscular dystrophy

What you need to knowConsider Duchenne muscular dystrophy in boys with delayed motor milestones, positive Gowers’ sign, abnormal gait, muscle pains, calf hypertrophy, unexplained elevated liver...

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Five-year Pain Intensity and Treatment Trajectories of Post-9/11 Veterans with Mild Traumatic Brain Injury

Patterns of multimorbidity exist in Post-9/11 Veterans deployed in support of the Global War on Terror.30 In 2009, approximately 40% of Post-9/11 Veterans were diagnosed with some type of pain, but only half of those individuals had pain without traumatic brain injury (TBI) or posttraumatic stress disorder (PTSD).7 Among those with diagnosed TBI, over 60% had one or more comorbid pain diagnoses demonstrating the co-occurrence of pain and TBI.7 Pain in the context of TBI can be due to physical trauma or overuse injuries and may be driven by musculoskeletal, neuropathic, and central mechanisms.

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The influence of visual experience and cognitive goals on the spatial representations of nociceptive stimuli

Localizing pain is crucial because it allows for detecting which part of the body is being hurt and identifying in its surrounding which stimulus is producing the damage. Nociceptive inputs should therefore be mapped according to somatotopic (“which limb is stimulated?”) and spatiotopic representations (“where is the stimulated limb?”). Because the body posture constantly changes, the brain has to realign the different spatial representations, for instance when the arms are crossed with the left hand in the right space and vice versa, to adequately guide actions towards the threatening object. Such ability is thought to be dependent on past sensory experience and contextual factors. We compared performances of early blind and normally sighted participants during temporal order judgement tasks. Two nociceptive stimuli were applied, one on each hand, with the hands either uncrossed or crossed. Participants reported which stimulus they perceived as first presented, according to either its location on the body or the position of the stimulated hand, respectively, prioritizing anatomy or external space as task-relevant reference frame. Relative to the uncrossed posture, sighted participants' performances were decreased when the hands were crossed, whatever the instruction be. Early blind participants' performances were affected by crossing the hands during spatial instruction, but not during anatomical instruction. These results indicate that nociceptive stimuli are automatically coded according to both somatotopic and spatiotopic representations, but the integration of the different spatial reference frames depends on early visual experience and ongoing cognitive goals, illustrating the plasticity and the flexibility of the nociceptive system.

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Can slow deep breathing reduce pain? An experimental study exploring mechanisms

Slow deep breathing (SDB) is a common complementary treatment strategy to manage pain.2 Despite its wide use and some promising findings, evidence for its efficacy remains equivocal. Also the exact working mechanisms remain unestablished.28 Distraction, emotion modulation, and expectations induced by voluntary SDB have been proposed among the most viable potential top-down mechanisms.28 Another class of potential mechanisms relate to the profound impact of SDB on the cardiovascular system, including an augmentation of cardiac vagal activity and the baroreflex.

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Ultrasound‐Guided Continuous Deep Serratus Anterior Plane Block Versus Continuous Thoracic Paravertebral Block for Perioperative Analgesia in Videoscopic‐Assisted Thoracic Surgery

Abstract

Background

The deep serratus anterior plane blockade (SAPB) is a promising novel regional anaesthesia technique for blockade of the anterolateral chest wall. Evidence for the efficacy of SAPB versus other analgesic techniques in thoracic surgery remains inadequate.

Aims

This study compared ultrasound‐guided continuous SAPB with a surgically‐placed continuous thoracic paravertebral block (SPVB) technique in patients undergoing videoscopic‐assisted thoracic surgery (VATS).

Methods

In a single‐centre, double‐blinded, randomised, non‐inferiority study we allocated 40 patients undergoing VATS to either SAPB or SPVB, with both groups receiving otherwise standardised treatment, including multimodal analgesia. The primary outcome was 48‐hour opioid consumption. Secondary outcomes included numerical rating scores (NRS) for postoperative pain, patient‐reported “worst pain score” (WPS) as well as functional measures (including mobilisation distance and cough strength).

Results

48‐hour opioid consumption for the SAPB group was non‐inferior compared with SPVB. SAPB was associated with improved NRS pain scores at rest, with cough and with movement at 24‐hours postoperatively (p=0.007, p=0.001 and p=0.012 respectively). SAPB was also associated with a lower “worst pain score” (p=0.008). Day 1 walking distance (D1WD) was improved in the SAPB group (p=0.012), whereas the difference in cough strength did not reach statistical significance (p=0.071). There was no difference in haemodynamics, opioid side‐effects, length of hospital stay, or patient satisfaction between the two groups.

Conclusions

The SAPB, as part of a multimodal analgesia regimen, is non‐inferior in terms of 48‐hour opioid consumption compared to SPVB and is associated with improved functional measures in thoracic surgical patients.

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Issue Information

European Journal of Pain, Volume 24, Issue 2, Page 263-264, February 2020.

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Nerve growth factor‐induced muscle hyperalgesia facilitates ischaemic contraction‐evoked pain

European Journal of Pain, Volume 24, Issue 2, Page 470-472, February 2020.

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Relative Effectiveness of Electroacupuncture and Biofeedback in Treatment of Neck and Upper Back Myofascial Pain: a Randomized Clinical Trial"

Publication date: Available online 16 January 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Fariba Eslamian, Fatemeh Jahanjou, Neda Dolatkhah, Alireza Pishgahi, Ali Pirani

Abstract

Objective

To determine the differences between clinical effects of electro-acupuncture and biofeedback therapy in addition to conventional treatment in patients with cervical Myofascial Pain Syndrome (MPS).

Design

Randomized clinical trial.

Setting

Physical medicine and rehabilitation clinic of a university hospital.

Participants

50 patients aged 25-55 years old of both genders with chronic neck pain diagnosed to have MPS (characterized by trigger points within taut bands) were randomly assigned into two equal groups of 25 individuals.

Interventions

The patients in electroacupuncture group were treated with standard acupuncture concomitant electrical stimulation and those in biofeedback group received visual EMG-biofeedback therapy for muscle activity and relaxation. Both groups received the intervention 2 times a week for a total of 6 sessions. Basic exercise trainings and medicines were administered for all the patients.

Outcome Measures

Pain severity based on Visual Analogue Scale (VAS), functional status using Neck Disability Index (NDI), cervical Range of Motion (ROM) using inclinometer and Pressure Pain Threshold (PPT) using algometer were evaluated before and at 3 and 12 weeks after the treatment. Primary outcome was defined as 20% reduction in the 3-month neck pain and dysfunction compared to baseline, assessed through NDI.

Results

50 patients (39 women, 11 men) with an average age of 39.0 (5.5) years old and neck pain duration of 6.0(2.2) weeks were analyzed. All parameters, except for PPT of lower trapezius and paravertebral muscles were improved significantly in both groups, while baseline values were controlled. Achieving primary outcome was significantly more in acupuncture group compared to biofeedback group: 20 (80.0%) versus 10 (40.0%); RR = 2 with 95% CI = 1.19 to 3.36; NNT = 2.5 with 95% CI = 1.54 to 6.58. Advantages of the acupuncture over biofeedback were observed according to values obtained from NDI,VAS, extension and left lateral bending ROM and PPT on left upper trapezius after the last session of intervention until 3 months (P < 0.05).

Conclusion

Both electroacupuncture and biofeedback therapies were found to be effective in management of MPS when integrated with conventional treatment. However, intergroup differences showed priority of acupuncture in some parameters versus biofeedback. Thus, electro-acupuncture seems to be a better complementary modality for treatment of MPS in neck and upper back area.

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[Comment] Offline: After 2000 years, an answer arrives

The fabric of humanity is unravelling. That is not a 21st-century diagnosis of our collective ills. It was the conclusion drawn by Lucretius, a Roman poet whose epic De Rerum Natura (The Nature of Things) was published in the first century BCE. Divided into six books, Lucretius described the “architects of Death” as Disease and Pain. But he rooted his analysis of human life in the wider predicaments facing his society—“our land in her hour of need”. Lucretius linked prospects for the human condition to the state of Nature and the Earth, to the natural and physical systems on which human existence depended.

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Daily briefing: Cell that kicked off complex life grown in the lab for the first time

Nature, Published online: 16 January 2020; doi:10.1038/d41586-020-00123-3

‘Asgard archaea’ isolated from deep-sea sediment and painstakingly grown over 12 years. Plus: a damning survey of scientific careers and a proposal for a Human Screenome Project.

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Is there a place for intra-articular corticosteroid injections in the treatment of knee osteoarthritis?

What you need to knowIntra-articular corticosteroid injections possibly improve pain and function in the short term (<8 weeks) in patients with osteoarthritis of the knee, but the evidence is of low...

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Dynorphin and Enkephalin Opioid Peptides and Transcripts in Spinal Cord and Dorsal Root Ganglion During Peripheral Inflammatory Hyperalgesia and Allodynia

Opioids are among the most effective analgesics in use, acting at receptors for endogenous opioid neuropeptides in spinal cord and in higher brain regions. These opioid peptides are also regulated in response to persistent pain states, participating in the complex plasticities that induce hyperalgesia, guarding, and other alterations associated with sustained nociceptive input. Enhancement of the opioid peptide precursor prodynorphin (Pdyn) mRNA levels31,38,62 in the dorsal spinal cord has been extensively described in response to persistent painful conditions,47,67 and is preceded by activation of transcriptional mechanisms regulating the Pdyn promoter.

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The Anatomical Study and Clinical Significance of the Sinuvertebral Nerves at the Lumbar Levels

Study Design. A dissection-based study of 10 embalmed human cadavers. Objective. The purpose of this study was to describe the sinuvertebral nerves at the lumbar level and to discuss their possible clinical significance. Summary of Background Data. Discogenic low-back pain is mediated by the sinuvertebral nerves. However, the detailed descriptions of the sinuvertebral nerves at the lumbar level are lacking. Methods. One hundred L1-L5 intervertebral foramina from 10 embalmed cadavers were studied. The presence of the sinuvertebral nerves was noted. The quantity, origin, pathway, innervation range, and spatial orientations of the sinuvertebral nerves in the L1-L5 intervertebral foramina were examined. Results. A total of 450 sinuvertebral nerves were identified in the 100 lumbar intervertebral foramina; sinuvertebral nerves were observed in 100.00% of the intervertebral foramina. The sinuvertebral nerves were routinely divided into the following two types: the sinuvertebral nerve deputy branch and sinuvertebral nerve main trunk. Three hundred twelve sinuvertebral nerve deputy branches were found; on average, there were approximately 3.12 (range, 1–8) branches in each intervertebral foramen. One hundred thirty-eight sinuvertebral nerve main trunks were found, and sinuvertebral nerve main trunks were observed in 97.00% of the intervertebral foramina. The initial portion of the sinuvertebral nerve was located along the posterior-lateral edge of the disc to the spinal canal. Sixty-one (44.20%) sinuvertebral nerve main trunks originated from the starting point of the gray ramus communicans of the nerve root; 77 (55.80%) sinuvertebral nerve main trunks originated from the anterior surface of the spinal ganglia of the nerve root. Conclusion. This is a systematic anatomy study that describes the sinuvertebral nerve at the lumbar level and may be of clinical importance to spinal surgeons. A comprehensive understanding of the distribution of sinuvertebral nerves may lead to significant benefits for patients undergoing percutaneous endoscopic treatment for discogenic low-back pain. Level of Evidence: 4

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Surgical Management of Enneking Stage 3 Aggressive Vertebral Hemangiomas With Neurological Deficit by One-stage Posterior Total En Bloc Spondylectomy: A Review of 23 Cases

Study Design. Clinical case series. Objective. The aim of this study was to describe the treatment of aggressive vertebral hemangiomas (VHs) with neurological deficit treated with total en bloc spondylectomy (TES) in a single institute. Summary of Background Data. Despite increasing utilization of surgery to treat aggressive VHs, owing to the rarity, the diagnosis and treatment protocols of aggressive VHs are still questionable and disputable. Methods. All patients with Enneking stage 3 aggressive thoracic or lumbar VHs with neurological deficit and treated with TES from January 2005 to January 2013 were included. Clinical characteristics and surgery outcomes of patients, including Tomita classification, operation time, blood loss, pre- and postoperative American Spinal Injury Association (ASIA) impairment scale, visual analogue score (VAS), and Spinal Instability Neoplastic Score (SINS), were retrospectively reviewed. Results. A total of 23 VHs patients were enrolled in this study, including 17 in the thoracic spine and six in the lumbar spine. All patients suffered neurological deficits caused by direct spinal cord compression with or without associated mechanical instability. The average SINS score was 9.78 ± 1.51. The mean operation time of patients with preoperative embolization was 426.6 ± 104.3 minutes and the mean blood loss was 1883.3 ± 932.1 mL. There were no technical difficulties or serious complications. After surgery, all patients recovered to ASIA-E levels. The VAS pain score decreased from 8.0 ± 0.9 to 2.8 ± 0.8 (P <� .05). Conclusion. TES is a good treatment option for patients with aggressive VHs with bony destruction and neurological deficit. Level of Evidence: 4

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Health-Related Quality of Life in Nonoperated Patients With Adolescent Idiopathic Scoliosis in the Middle Years: A Mean 25-Year Follow-up Study

Study Design. A retrospective long-term follow-up study. Objective. To investigate the health-related quality of life (HRQOL) status in middle-aged patients with adolescent idiopathic scoliosis (AIS) treated non-surgically. Summary of Background Data. The HRQOL status using various established questionnaires for non-operated AIS patients has not been fully investigated in long-term follow-up surveys. Methods. Inclusion criteria were non-surgical treatment for AIS, more than or equl to 30° major scoliosis at skeletal maturity (Risser grade ≥4), and age more than or equl to 30 years at the time of the survey. A total of 107 AIS patients were included and divided into three groups (single main thoracic [MT] curve group; n = 50, single thoracolumbar/lumbar [TL/L] curve group; n = 19, and double-major [DM] curve group; n = 38) based on curve location at skeletal maturity. Age- and sex-matched volunteers were selected as the control group. Results. There were no significant differences in age at survey, body mass index, bone mineral density of the femoral neck, and skeletal muscle mass index among the groups. In all groups, major scoliosis progressed by approximately 0.5°/yr from the time of skeletal maturity to the survey. The thoracolumbar (TL/L) and double-major (DM) groups showed significantly worse visual analog scale scores for low back pain compared with the main thoracice (MT) group (P <� 0.05). The all-scoliosis groups showed significantly worse scores for self-image domain of the Scoliosis Research Society Outcome Instrument-22 (SRS-22) than the control group (P <� 0.0001). The TL/L group showed significantly worse scores for walking ability and social function domains of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) (P <� 0.05). There were no significant differences in Oswestory Disability Index and Short-Form-12 among the four groups. Conclusion. AIS patients with single MT curve maintain equal HRQOL status compared with healthy controls. Patients with structural TL/L curves are likely to experience greater annual TL/L curve progression and have substantial low back pain or worse low back pain-specific HRQOL status during middle age. Level of Evidence: 4

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The Fear Avoidance Beliefs Questionnaire (FABQ) Does it Really Measure Fear Beliefs?

Study Design. A cohort study with 12 months of follow-up. Objective. To assess (1) the unidimensionality of the Fear-Avoidance Beliefs Questionnaire (FABQ) and (2) whether single questions in the FABQ predict future sickness absence as well as the whole scale. Summary of Background Data. The fear-avoidance model is a leading model in describing the link between musculoskeletal pain and chronic disability. However, reported measurement properties have been inconsistent regarding the FABQ. Methods. Individuals (n = 722) sick listed due to musculoskeletal, unspecified or common mental health disorders undergoing rehabilitation was included. A Rasch analysis was applied to evaluate the measurement properties of FABQ and its two subscales (physical activity and work). Linear regression was used to assess how well single items predicted future sickness absence. Results. The Rasch analysis did not support the FABQ or its two subscales representing a unidimensional construct. The 7-point scoring of the items was far too fine meshed and in the present population the data only supported a yes or no or a 3-point response option. The items were invariant to age, whereas two of the items revealed sex differences. The item “I do not think that I will be back to my normal work within 3 months” was the best predictor of future sickness absence. Adding the item “I should not do my regular work with my present pain” improved the prediction model slightly. Conclusion. The FABQ is not a good measure of fear-avoidance beliefs about work or physical activity, and the predictive property of the FABQ questionnaire is most likely related to expectations rather than fear. Based on these results we do not recommend using the FABQ to measure fear-avoidance beliefs. Level of Evidence: 1

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Trends and Characteristics of Spine Research From 2006 to 2015: A Review of Spine Articles in a High Impact General Orthopedic Journal

Study Design. Literature review. Objective. To determine characteristics and trends in published spine research over a recent decade in a high impact, general orthopedic surgery journal. Summary of Background Data. Recent trends in published spine research in a high-impact orthopedic surgery journal are unknown. Such knowledge could guide future research in the field. Methods. A comprehensive literature review of clinical and basic science spine articles published in The Journal of Bone & Joint Surgery from 2006 to 2015 was conducted. Articles were assessed for: title, year of publication, authorship, academic degrees of the authors, number of citations, institution of origin, and spine topic. Clinical articles were evaluated for: sex and race/ethnicity of the human subjects, level of evidence, and inclusion of patient-reported outcome measures (PROMs). Basic science articles were evaluated for: type of study (animal, cadaver, cell-based), sex of the animals, cadavers or cells studied (male, female, or male and female), and presence of sex-based reporting (defined as reporting of results by sex). Results. A total of 203 spine articles were evaluated from the 10-year study period. At least 35 validated or nonvalidated patient-reported outcome measures were utilized in clinical spine research. The most commonly reported PROMs were the Oswestry Disability Index (24.4%), Short Form-36 Health Survey (23.7%), and Visual Analog Scale for Pain (19.3%). The average level of evidence improved from 3.25 in 2006 to 2.60 in 2015. Only 13.2% of clinical spine articles reported the race/ethnicity of the subjects. Conclusion. A consensus regarding validated PROMs in spine research would be valuable. From 2006 to 2015, the level of evidence of spine articles in The Journal of Bone & Joint Surgery improved. Accurate and complete reporting of patient demographics is an area for improvement in spine research in light of studies demonstrating sex and race/ethnicity-related differences in clinical outcome after spine surgery. Level of Evidence: 5

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Surgical Management and Adjuvant Therapy for Patients With Neurological Deficits From Vertebral Hemangiomas: A Meta-Analysis

Study Design. Meta-analysis. Objective. To understand the benefits and limitations of surgical management and adjuvant therapies for patients presenting with neurological deficits from vertebral hemangiomas (VH). Summary of Background Data. VH is the most common benign spine tumor but rarely causes symptoms. Patients with back pain alone are treated with conservative management (kyphoplasty and radiation therapy), while those with neurological deficits require complex multi-modal treatment plans. Methods. A PubMed literature search for “symptomatic vertebral hemangioma with spinal cord compression” identified 47 articles. From these articles and their references, 19 observational studies on patients who underwent surgery for VH met inclusion criteria. Meta-analyses were performed comparing outcomes of the surgical and adjuvant therapies using Stata13 software. For those with insufficient data for meta-analyses, descriptive analyses of variables were completed. Results. One hundred ninety seven surgical cases of VH with neurologic deficits were identified. Surgery provided a complete remission of symptoms in 84% of patients, however 18% of patients had recurrence of hemangioma. Adjuvant interventions included radiation, embolization, and kyphoplasty. Radiation therapy (XRT) was associated with a lower recurrence rate and an increase in minor transient adverse effects. Preoperative embolization performed in 98 patients was associated with improved symptoms, reduced complications, lower recurrence rate, less blood loss, and higher incidence of pathologic vertebral fractures. Meta-analyses did not yield statistically significant results, likely due to the heterogeneity amongst the studies and small sample sizes, but the results compiled together provide insight on potential benefits of preoperative embolization for symptomatic relief and reduced risk of recurrence with XRT that deserves further study. Conclusion. For patients with neurologic deficits from spinal cord or nerve root compression, surgery provides improvement in symptoms. Recurrence of VH and symptoms refractory to surgery can be further reduced by adjuvant therapies such as embolization, kyphoplasty, and radiation with some unique risks to each therapy. Level of Evidence: 2

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The importance of cognitive executive functions in gait recovery after total hip arthroplasty

Publication date: Available online 7 January 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Francesco Negrini, Matteo Preti, Eleonora Zirone, Daniele Mazziotti, Marco Biffi, Catia Pelosi, Giuseppe Banfi, Laura Zapparoli

Abstract

Objective

To determine the influence of cognitive functioning on gait recovery after total hip arthroplasty.

Design

Prospective cohort study.

Setting

Rehabilitation hospital.

Participants

40 patients who underwent a total hip arthroplasty, with normal cognitive functioning and without any other relevant medical condition were recruited and studied before surgery and at the beginning and the end of the rehabilitation program.

Main Outcome Measures

Gait speed (10-Meter Walk Test, 10MWT) and functional mobility (Timed Up and Go test, TUG), measured at the time of discharge from the rehabilitation unit, were the primary outcomes. The candidate predictors were the cognitive and psychological variables collected in the pre-surgery phase, together with other potentially informative measures such as age, education, perceived pain, body mass index, pre-surgical gait speed and functional mobility.

Results

The results suggest the existence of a direct relationship between cognitive functioning, with specific reference to high-level frontal executive functions, and the post-operative progress: the better the cognitive functioning in the pre-operative phase, the better the course of recovery in terms of gait speed and functional mobility. In particular, the performance at the Frontal Assessment Battery test, together with age, perceived pain and pre-surgical gait speed/functional mobility was the best predictor of recovery of walking measured by 10MWT and TUG.

Conclusions

The present study highlights the importance of cognitive functioning, together with clinical and demographic features, in the post-surgical recovery of walking, even in the absence of cognitive decline.In particular, these data show the crucial role of higher-order cognitive processes, such as executive functions, involved in the formulation of motor plans and their integration with proprioceptive and visual cues.

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A knee flexion contracture is associated with a contracture and worse function of the contralateral knee: data from the Osteoarthritis Initiative

Publication date: Available online 7 January 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): T Mark Campbell, Guy Trudel

Abstract

Objective

Patients at-risk of, or those with knee osteoarthritis (OA) may present with a knee flexion contracture (FC). A knee FC can cause pain and can decrease function. By altering lower extremity biomechanics, the impact of a knee FC goes beyond the affected joint. Compensatory movements during gait can chronically affect other joints in both lower limbs. Few studies describe the impact of a knee FC on, or direct assessment toward, the contralateral knee. We investigated the associations between knee FC with range of extension, function, pain, and stiffness of the contralateral knee.

Design

Cross-sectional, using the Osteoarthritis Initiative database.

Setting/Participants

Outpatient cohort study, recruiting from four United States academic health care centers. Two groups were included: those at-risk of (n=3284 knees), and those with (n=1390 knees) radiographic OA.

Main Outcomes Measures

Maximum contralateral knee extension, and Western Ontario and McMaster Osteoarthritis Index (WOMAC) scores. Statistical analysis included a mixed linear model evaluating for independent associations between the index knee FC and contralateral knee outcome measures.

Results

A knee FC was associated with a contralateral knee FC (p<0.001) with contralateral FC severity dependent on severity of the index knee FC (p<0.001). Participants at-risk for OA with moderate FC showed worse function in the contralateral knee compared with mild FC (WOMAC functional subscale: 7.6±10.1 versus 5.5±8.8; p=0.036). Mixed linear analysis confirmed an independent association between knee FC severity and contralateral WOMAC function.

Conclusions

Having a FC in one knee was associated with FC in the contralateral knee for both at-risk and OA participants. For those at-risk of OA, the severity of knee FC was an independent predictor for loss of contralateral knee function. Rehabilitation of patients with, or at-risk of OA should consider the restoration of extension and function for both knees.

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Treatment outcomes in group‐based Cognitive Behavioral Therapy for chronic pain: An examination of PTSD symptoms

Abstract

Background

The relevance of PTSD symptoms to outcomes of Cognitive Behavioral Therapy (CBT) for chronic pain is unclear. This study examines whether (a) traumatic exposure or the severity of PTSD symptoms at pre‐treatment predict outcomes (pain intensity/interference) (b) participation in this treatment is associated with reduced PTSD symptoms, and (c) any observed changes in PTSD symptoms are mediated by changes in psychological mechanisms that have been shown to be of importance to PTSD and chronic pain.

Methods

Participants were 159 chronic pain patients who were consecutively admitted for a multidisciplinary, group‐based CBT program at the Pain Rehabilitation Unit at Skåne University Hospital. A self‐report measure of traumatic exposure and PTSD symptoms was administered before and after treatment, and at a 12‐month follow‐up, along with measures of depression, anxiety, pain intensity, pain interference, psychological inflexibility, life control, and kinesiophobia.

Results

Traumatic exposure and PTSD symptom severity did not predict pain intensity or interference at 12‐month follow‐up. There were no overall significant changes in PTSD symptom severity at post‐treatment or follow‐up, but 24.6% of the participants showed potential clinically significant change at follow‐up. Psychological inflexibility mediated the changes that occurred in PTSD symptoms during treatment.

Conclusions

Neither traumatic exposure nor baseline symptoms of PTSD predicted the treatment outcomes examined here. Despite improvements in both comorbid depression and anxiety, participation in this pain‐focused CBT program was not associated with improvements in comorbid PTSD. To the extent that changes in PTSD symptoms did occur, these were mediated by changes in psychological inflexibility during treatment.

Significance

Pain‐focused CBT programs yield clinically meaningful improvements in pain and comorbid symptoms of depression and anxiety, but may have little effect on comorbid PTSD. This raises the issue of whether current pain‐focused CBT programs can be modified to improve outcomes for comorbid conditions, perhaps by better targeting of psychological flexibility, and/or whether separate treatment of PTSD may be associated with improved pain outcomes.

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Commentary on “Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta‐analysis” by Abdel Shaheed et al

Abstract

This journal recently published a paper by Abdel Shaheed et al., entitled “Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta‐analysis” (Abdel Shaheed et al. 2020). This paper synthesizes published evidence on role of glucocorticoids administered through enteral and parenteral (but not epidural) routes for relieving pain radiating down the leg with or without lower back pain secondary to compression of lumbosacral spinal nerve roots, a condition commonly referred to as sciatica.

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Alternative splicing of Nrcam gene in dorsal root ganglion contributes to neuropathic pain

Neuropathic pain is a very common clinical disorder, usually caused by nerve injury or accompanying some diseases (such as diabetes). It reduces the quality of life in patients due to a lack of effective analgesic strategies. The altered gene/protein expression in primary sensory neurons following injury has been demonstrated as the key component of the pathophysiology of neuropathic pain 16,17,29,40,41. A next generation RNA sequencing analysis revealed the differential expression of thousands of genes in the injured DRG caused by spinal nerve ligation (SNL) 35.

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Multisensorial perception in chronic migraine and the role of medication overuse

Coherent, unambiguous and stable perceptual experiences result from the ability to merge concurrent information provided by different senses26,43,50,72. Multisensory integration occurs when stimuli from different sensory systems are combined in close temporal or spatial proximity, improving their detection2,12,25,50,76. However, we experience illusory percepts whenever sensory inputs from different modalities are incoherent45,53,76,80,90. Crossmodal illusions represent useful paradigms to assess how multisensory integration affects sensory perception in healthy and pathological conditions17,77,78, as shown by the Sound-Induced Flash Illusion (SIFI).

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Doctor recommendations are related to patient interest and use of behavioral treatment for chronic pain and addiction

Chronic pain is one of the most debilitating, difficult to treat, chronic health conditions and affects at least 20% of the American adult population.7 In addition to the direct impact on quality of life via health consequences, chronic pain is widely believed to be causally related to the current opioid epidemic.24

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Parental multi-site chronic pain and the risk of adult offspring developing additional chronic pain sites: family-linkage data from the Norwegian HUNT Study

Musculoskeletal pain is associated with substantial disability and a large financial burden worldwide49,71,5,70. For example, the total yearly costs of musculoskeletal pain in Australia is estimated at $55 billion4, while in Europe, the yearly costs of back pain are estimated as high as €300 billion 71. Low back and neck pain are among the most prevalent and disabling musculoskeletal conditions70 (global point-prevalence of 9.4%27 and 4.9%28, respectively), however, approximately one in ten individuals (during their life) will experience chronic musculoskeletal pain in multiple body areas73,50,3 and report even greater disability22,14.

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The Endogenous Analgesia Signature in The Resting Brain of Healthy Adults and Migraineurs

Imaging studies link migraine pathophysiology to functional abnormalities in pain modulatory brain areas.57,75 When interictal migraineurs are exposed to evoked pain, the pain-modulatory areas become hyperactive, and the level of hyperactivity is associated with attack frequency and pain intensity.56,63,81,96 Migraineurs also exhibit an association between migraine clinical characteristics, and altered resting-state functional connectivity (rsFC) of mesencephalic, cingulate, insular and prefrontal brain areas involved in affective processing and descending inhibition of pain.

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[Comment] Why is laparoscopic surgery underutilised?

Abdominal adhesions resulting from surgery can cause long-term morbidity, including chronic abdominal pain, infertility, and bowel obstructions that might require readmission to hospital or surgical re-interventions. In an effort to assess the magnitude of this problem, the Surgical and Clinical Adhesion Research (SCAR) report1 published in 1999 used the Scottish National Health Service database to identify patients undergoing open abdominal or pelvic surgery between 1981 and 1986. After 10 years of follow-up, around one in three patients were readmitted for a reason potentially related to adhesions, with 5·7% admitted for causes directly related to adhesions.

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