Activation of the descending pain modulatory system using cuff pressure algometry: Back translation from man to rat

Abstract

Background

Diffuse noxious inhibitory controls (DNIC) as measured in rat and conditioned pain modulation (CPM), the supposed psychophysical paradigm of DNIC measured in humans, are unique manifestations of an endogenous descending modulatory pathway that is activated by application of a noxious conditioning stimulus. The predictive value of the human CPM processing is crucial when deliberating the translational worth of the two phenomena.

Methods

For CPM or DNIC measurement, test and conditioning stimuli were delivered using a computer‐controlled cuff algometry system or manual inflation of neonate blood pressure cuffs respectively. In humans (n=20), cuff pain intensity (for pain detection and pain tolerance thresholds) was measured using an electronic visual analogue scale. In isoflurane‐anaesthetised naïve rats, nociception was measured by recording deep dorsal horn wide dynamic range (WDR) neuronal firing rates (n=7) using in vivo electrophysiology.

Results

A painful cuff‐pressure conditioning stimulus on the leg increased pain detection and pain tolerance thresholds recorded by cuff stimulation on the contralateral leg in humans by 32±3% and 24±2% (mean±SEM) of baseline responses respectively (P<0.001). This finding was back‐translated by revealing that a comparable cuff‐pressure conditioning stimulus (40 kPa) on the hind paw inhibited the responses of WDR neurons to noxious contralateral cuff test stimulation to 42±9% of the baseline neuronal response (P=0.003).

Conclusions

These data substantiate that the noxious cuff pressure paradigm activates the descending pain modulatory system in rodent (DNIC) and man (CPM), respectively. Future back and forward translational studies using cuff pressure algometry may reveal novel mechanisms in varied chronic pain states.

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Multimodal Pain Management and Postoperative Outcomes in Lumbar Spine Fusion Surgery: A Population-based Cohort Study

Study Design. Retrospective population-based cohort analysis. Objective. Given the lack of large-scale data on the use and efficacy of multimodal analgesia in spine fusion surgery, we conducted a population-based analysis utilizing the nationwide claims-based Premier Healthcare database. Summary of Background Data. Multimodal analgesia, combining different pain signaling pathways to achieve additive and synergistic effects, is increasingly emerging as the standard of care. Methods. Cases of posterior lumbar fusion surgery were extracted (2006–2016). Opioid-only analgesia was compared to multimodal analgesia, that is, systemic opioid analgesia + either acetaminophen, steroids, gabapentinoids, ketamine, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, or neuraxial anesthesia (categorized into 1, 2, or >2 additional analgesic modes). Mixed-effects models measured associations between multimodal analgesia categories and outcomes, including opioid prescription dose, cost/length of hospitalization, and opioid-related complications. Odds ratios (ORs, or % change) and 95% confidence intervals (CIs) are reported. Results. Among 265,538 patients the incidence of multimodal analgesia was 61.1% (162,156); multimodal pain management—specifically when adding NSAIDs/COX-2 inhibitors to opioids—was associated with reduced opioid prescription (−13.3% CI −16.7 to −9.7%), cost (−2.9% CI −3.9 to −1.8%) and length of hospitalization (−7.3% CI −8.5 to −6.1%). Multimodal analgesia in general was associated with stepwise decreased odds for gastrointestinal complications (OR 0.95, 95% CI 0.88–1.04; OR 0.84, CI 0.75–0.95; OR 0.78, 95% CI 0.64–0.96), whereas odds were increased for postoperative delirium (OR 1.14, 95% CI 1.00–1.32; OR 1.33, 95% CI 1.11–1.59; OR 1.31, 95% CI 0.99–1.74), and counterintuitively- naloxone administration (OR 1.25, 95% CI 1.13–1.38; OR 1.56, 95% CI 1.37–1.77; OR 1.84, 95% CI 1.52–2.23) with increasing analgesic modes used: one, two, or more additional analgesic modes, respectively. Post-hoc analysis revealed that specifically gabapentinoid use increased odds of naloxone requirement by about 50%, regardless of concurrent opioid dose (P <� 0.001). Conclusion. Although multimodal analgesia was not consistently implemented in spine fusion surgery, particularly NSAIDs and COX-2 inhibitors demonstrated opioid sparing effects. Moreover, results suggest a synergistic interaction between gabapentinoids and opioids, the former potentiating opioid effects resulting in greater naloxone requirement. Level of Evidence: 3

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Risk Factors for Postsurgical Foot Complaints One Year Following Degenerative Lumbar Spinal Surgery

Mini Postsurgical foot complaints occurred frequently in 853 degenerative lumbar surgeries (prevalence, 20.6%; n = 176). Risk factor analysis showed that the incidence of postsurgical foot complaint was significantly higher in patients with preoperative foot symptoms (adjusted odds ratio, 5.532) and in those with preoperative sensory deficits on the leg (adjusted odds ratio, 1.904). Study Design. Retrospective. Objective. To investigate the prevalence and risk factors of postsurgical foot complaints (PFCs) following spinal surgery by using a modified pain drawing (PD) instrument. Summary of Background Data. Although many patients report nonspecific foot symptoms with various clinical presentation, there is not a well defined diagnostic criterion. PDs are essential for measuring spinal surgery outcomes. We created a modified patient-physician communication-based PD instrument to overcome the limitations of the previous system. Methods. We included 853 consecutive patients who underwent decompression with or without fusion. PFCs were defined as sensory foot symptoms, including ambiguous sensations that were not clearly due to spinal pathology. Patients who complained of postoperative foot symptoms at more than two consecutive visits were assigned to the PFC group. The remaining patients were assigned to the asymptomatic group. We collected medical records using our PD instrument and compared variables between the two groups. Results. In total, 176 (20.6%) of the 853 patients had PFCs. The duration of preoperative leg pain was significantly longer in the PFC group than in the asymptomatic group (2.8 vs. 2.2 years; P = 0.048). The proportions of preoperative foot symptoms (82.9% vs. 43.3%) and sensory deficits on the leg (48.6% vs. 27%) were significantly greater in the PFC group than in the asymptomatic group (P <� 0.001). Multivariable logistic regression analysis revealed two independent risk factors: the presence of preoperative foot symptoms (adjusted odds ratio, 5.532) and preoperative sensory deficits on the leg (adjusted odds ratio, 1.904). Conclusion. PFCs occurred frequently after degenerative lumbar spinal surgery (prevalence, 20.6%). Based on our data using PD instrument, it can help reduce the incidence of PFCs if patients are informed and educated that preoperatively existing foot symptom and sensory deficits on the leg are significant risk factors for PFC development. Level of Evidence: 4

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Pregabalin and gabapentin for pain

What you need to knowPregabalin and gabapentin can be effective as first line treatment for some people with neuropathic pain such as post-herpetic neuralgia and diabetic peripheral neuropathyThey...

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Necrotising fasciitis

What you need to knowNecrotising fasciitis can present with non-specific signs that evolve rapidly over time, with life threatening consequencesDisproportionate pain is a serious sign that warrants...

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Musculoskeletal pain phenotyping: our end point should be clinical feasibility ‐A commentary to Meisingset et al.'s "Novel approach towards musculoskeletal phenotypes

Abstract

The study’s aim was to identify and validate phenotypes of patients with musculoskeletal (MSK) pain based on eleven common prognostic factors across the biopsychosocial domains. Using a sample of n=435 patients attending physiotherapy in primary care, latent class analysis identified five groups. The five groups mainly differed in terms of severity across the well‐established prognostic factors. Outcomes at 3 months reflected baseline scores; those with a more severe profile had worse clinical outcomes. Two of the five groups were separated on differing patterns of mental distress and fear avoidance.

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Peripheral input and phantom limb pain: a somatosensory event‐related potential study

Abstract

Background

Following amputation, nearly all amputees report non‐painful phantom phenomena and many of them suffer from chronic phantom limb pain (PLP) and residual limb pain (RLP). The etiology of PLP remains elusive and there is an ongoing debate on the role of peripheral and central mechanisms. Few studies have examined the entire somatosensory pathway from the truncated nerves to the cortex in amputees with PLP compared to those without PLP. The relationship between afferent input, somatosensory responses and the change in PLP remains unclear.

Methods

Transcutaneous electrical nerve stimulation was applied on the truncated median nerve, the skin of the residual limb and the contralateral homologous nerve in twenty‐two traumatic upper‐limb amputees (12 with and 10 without PLP). Using somatosensory event‐related potentials, the ascending volley was monitored from the brachial plexus, the spinal cord, the brainstem and the thalamus to the primary somatosensory cortex.

Results

Peripheral input could evoke PLP in amputees with chronic PLP (7/12), but not in amputees without a history of PLP (0/10). The amplitudes of the somatosensory components were comparable between amputees with and without PLP. In addition, evoked potentials from the periphery through the spinal, subcortical and cortical segments were not significantly associated with PLP.

Conclusions

Peripheral input can modulate PLP but seems insufficient to cause PLP. These findings suggest the multifactorial complexity of PLP and different mechanisms for PLP and RLP.

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Circulating miR-155-5p as a Novel Biomarker of Lumbar Degenerative Disc Disease

Mini Circulating microRNAs provide an insight into current disease states. Comparing patients with degenerative disc disease to healthy controls, patients with disc disease were found to have significantly downregulated levels of miR-155-5p. This marker was found to be an accurate diagnostic predictor for the presence of degeneration (P = 0.006). Study Design. Case-control study measuring differential gene expression of circulating microRNA (miRNA) in patients with degenerative disc disease (DDD). Objective. To identify miRNA dysregulation in serum samples of patients with DDD compared to healthy controls (HC). Summary of Background Data. Early DDD can be a difficult diagnosis to make clinically, with lack of positive and specific findings on physical exam or advanced imaging. miRNAs are a class of molecules that act as gene regulators and have been shown to be dysregulated in local degenerative disc tissue. However, to date no studies have identified dysregulation of serum miRNA in patients with DDD. Methods. Whole blood samples were obtained from 69 patients with DDD and 16 HC. Patient-reported outcomes were collected preoperatively and degree of DDD was classified using Pfirrmann grade on preoperative imaging. Differential gene expression analysis using a screening assay for several hundred miRNAs and further characterization for five specific miRNAs (miR-16-5p, miR-21-5p, miR-142-3p, miR-146a-5p, and miR-155-5p) was performed. In addition, a pro-inflammatory cytokine multiplex assay and bioinformatics analysis were done. Results. The initial screening assay showed 13 miRNA molecules that were significantly dysregulated in DDD patients, with miR-155-5p showing significant downregulation (p = 0.027) and direct interactions with the pro-inflammatory cytokine IL-1β, and the tumor suppressor genes p53 and BRAF. Analyzing the whole cohort, miR-155 showed an almost four-fold downregulation in DDD patients (−3.94-fold, P <� 0.001) and was the sole miRNA that accurately predicted the presence of disc degeneration (P = 0.006). Downregulation of miR-155 also correlated with increased leg pain (P = 0.018), DDD (P = 0.006), and higher Pfirrmann grade (P = 0.039). On cytokine analysis, TNF-α (0.025) and IL-6 (P <� 0.001) were significantly higher in DDD patients. Conclusion. Serum miR-155-5p is significantly downregulated in patients with DDD and may be a diagnostic marker for degenerative spinal disease. Level of Evidence: N/A

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Half of Unplanned Readmissions Following One or Two-Level Anterior Cervical Decompression and Fusion Are Unrelated to Surgical Site

Mini In this study we analyze rates of readmission, and the timing and reasons for readmission after one to two level anterior cervical decompression and fusion. Among 18,833 patients who underwent anterior cervical decompression and fusion, 3% were readmitted to the hospital within 30 days. 39.5% of readmissions were for reasons related to surgical site. Study Design. Retrospective review of a national database. Objective. In this study we analyze rates of readmission, and the timing and reasons for readmission after one to two level anterior cervical decompression and fusion (ACDF). Summary of Background Data. The safety profile of ACDF has been previously described with readmission rates typically between 2% and 4%. However no studies have investigated the primary diagnoses driving readmission, and whether these diagnoses are related to the surgical site. Methods. Demographics, comorbidities, and procedural characteristics were collected for all patients undergoing one or two-level ACDF for degenerative indications identified by Current Procedural Terminology (CPT) coding in the National Surgical Quality Improvement Program (NSQIP) database. The incidence of 30-day complications and readmissions was calculated, and the reasons for readmission as well as the timing of readmission were reviewed. Multivariate logistic regression analyses were performed to identify risk factors associated with complications or readmissions within 30 days of surgery. Results. Eighteen thousand eight hundred thirty three patients underwent ACDF (15,464 single-level and 3369 two-level, mean age 53.7 yrs, standard deviation [SD]: 11.6; 50% male). Postoperative complication rate of was 4.3% in two-level fusions and 3.5% in single-level fusion (P = 0.027). Five hundred sixty nine unplanned readmissions were identified (3.0%), of which 39.5% were related to the surgical site and 49.7% were unrelated to the surgical site (10.5% unknown cause of readmission). The most frequent reason for 30-day readmission was pneumonia (9.3%, mean time to readmission of 11.3 d) followed by dysphagia (7.4%, 6.3 d), and acute postoperative pain (7.2%, 11.4 d). Conclusion. In this nationwide analysis of 18,833 ACDF cases, 3.0% of patients were readmitted within 30 days, of which at least 49.7% were for reasons unrelated to the surgical site. Level of Evidence: 3

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Intrathecal Dexmedetomidine and Postoperative Pain: A Systematic Review and Meta‐analysis of Randomised Controlled Trials

ABSTRACT

Background and Objective

A systematic review and meta‐analysis of randomised controlled trials was undertaken to evaluate the effect of intrathecal dexmedetomidine (DEX) on the duration of postoperative analgesia, postoperative pain scores and incidences of adverse effects.

Databases and Data Treatment: Database search was performed from inception until January 2019. All randomised controlled trials analysing acute postoperative pain characteristics after intrathecal DEX administration in adults undergoing spinal anaesthesia for elective surgery were included. The primary outcome was postoperative analgesic duration, defined as the time to first analgesic request. The secondary outcomes included pain scores at 6, 12, and 24 post‐operative hours and rates of hypotension, bradycardia, shivering and postoperative nausea and vomiting.

Results

Twenty‐four studies comprising a total of 1460 patients were included. Postoperative analgesic duration was prolonged with intrathecal DEX compared to placebo, with a pooled mean difference of 191.3 minutes (95% CI 168.8 to 213.8). Patients who received intrathecal DEX reported lower Visual Analogue Scale (VAS) scores at 24 postoperative hours compared with those patients receiving placebo, with a mean difference (95% CI) of ‐1.05 (‐1.89 to ‐0.20, p=0.02). There were no differences in the incidence of adverse effects, except for a lower rate of postoperative shivering in the intrathecal DEX group (pooled RR 0.58, 95% CI 0.34 to 0.98, p=0.04).

Conclusions

Compared to placebo, intrathecal DEX prolonged postoperative analgesic duration, reduced 24‐hour pain intensity and reduced the incidence of shivering without an increase in other adverse effects.

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Commentary on “Effectiveness of motor imagery and action observation training on musculoskeletal pain intensity: A systematic review and meta‐analysis” by Suso‐Martí et al.

European Journal of Pain, EarlyView.

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A Systematic Review of the Incidence, Prevalence, Costs, and Activity/Work Limitations of Amputation, Osteoarthritis, Rheumatoid Arthritis, Back Pain, Multiple Sclerosis, Spinal Cord Injury, Stroke, and Traumatic Brain Injury in the United States: A 2019 Update

Publication date: Available online 24 April 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Jessica Lo, Leighton Chan, Spencer Flynn

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Comparable conditioned pain modulation and augmented blood pressure responses to cold pressor test among resistance exercisers compared to healthy controls

Publication date: Available online 22 April 2020

Source: Biological Psychology

Author(s): Masataka Umeda, Akiko Okifuji

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Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services

No abstract available

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Impact of opioid dose escalation on pain intensity: a retrospective cohort study

Prescribers are often confronted with the decision to escalate opioid doses to achieve adequate analgesia. Understanding the impact of dose escalation on pain intensity is warranted. Using a retrospective cohort study design, Veterans with chronic pain and chronic opioid therapy were identified. Opioid dose escalators (>20% increase in average morphine milligram equivalent daily dose) were compared with dose maintainers (±20% change in average morphine milligram equivalent daily dose) assessed over 2 consecutive 6-month windows. Pain intensity was measured by the Numeric Rating Scale. The primary analyses used linear repeated-measures models among a 1:1 matched sample of escalators and maintainers matched on propensity score and within ±180 days of the index date. Sensitivity analyses were conducted using adjusted linear repeated-measures models with and without incorporating stabilized inverse probability of treatment weighting. There were 32,420 dose maintainers and 20,767 dose escalators identified with 19,358 (93%) matched pairs. Pain scores were persistently higher among dose escalators at each 90-day period after the index date (0-90 days after index date: dose escalators: 4.68, 95% confidence interval [CI]: 4.64-4.72 dose maintainers: 4.32, 95% CI: 4.28-4.36, P < 0.0001; 91-180 days after index date: dose escalators: 4.53, 95% CI: 4.49-4.57; dose maintainers: 4.25, 95% CI: 4.22-4.29, P < 0.0001) but were not different in the 90 days before the index date (dose escalators: 4.64, 95% CI: 4.61-4.68; dose maintainers: 4.59, 95% CI: 4.55-4.63, P = 0.0551). Sensitivity analyses provided similar results as the primary analyses. Opioid dose escalation among patients with chronic pain is not associated with improvements in Numeric Rating Scale pain scores.

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Mechanistic pain profiling in young adolescents with patellofemoral pain before and after treatment: a prospective cohort study

Patellofemoral pain (PFP) is a common complaint among young sports active adolescents. This study evaluated the longitudinal changes in pronociceptive and antinociceptive mechanisms in young adolescents with PFP, their impact on prognosis, and responsiveness to treatment. Adolescents (N = 151, aged 10-14 years) diagnosed with PFP were compared with age-matched controls (N = 50) and subsequently tracked while participating in an intervention focussed on activity modification. They underwent quantitative sensory testing at baseline (preintervention), 4 weeks (during initial treatment), and 12 weeks (after treatment). Pressure pain thresholds (PPTs) were recorded on the knee, shin, and elbow. Temporal summation of pain (TSP) was assessed by the increase in pain intensity during 10 repeated cuff pressure pain stimulations on the leg. Conditioned pain modulation (CPM) was defined as change in cuff pain thresholds on one leg, during painful cuff conditioning on the contralateral leg. At baseline, adolescents with PFP had decreased PPTs at the knee, shin, and elbow (P < 0.001) as well as more facilitated TSP (P < 0.05) compared with controls. For CPM at baseline, controls displayed an increase in cuff pain thresholds during conditioning (P < 0.05), while those with PFP did not. More facilitated baseline TSP was associated with less improvements in pain intensity during the intervention (P < 0.01). Pressure pain thresholds increased at both follow-ups (P < 0.001), and the increased PPTs were associated with decreases in pain intensity (r = 0.316; P < 0.001). Overall, TSP remained facilitated at follow-ups, and there was no change in CPM. This is the first study to demonstrate a pronociceptive mechanism as a prognostic factor in young adolescents with PFP.

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Mindfulness meditation is related to sensory‐affective uncoupling of pain in trained novice and expert practitioners

Abstract

Background

Mindfulness meditation can alleviate acute and chronic pain. It has been proposed that mindfulness meditation reduces pain by uncoupling sensory and affective pain dimensions. However, studies to date have reported mixed results, possibly due to a diversity of styles of and expertise in mindfulness meditation. Furthermore, the interrelations between mindfulness meditation and pain catastrophizing during acute pain remain little known.

Methods

This cross‐sectional study investigated the effect of a style of mindfulness meditation called Open Monitoring on sensory and affective pain experience by comparing novice (2‐day formal training; average ~20h practice) to expert practitioners (>10.000h practice). We implemented a paradigm that was designed to amplify the cognitive‐affective aspects of pain experience by the manipulation of pain anticipation and uncertainty of stimulus length (8s or 16s thermal pain stimuli). We collected pain intensity and unpleasantness ratings and assessed trait pain catastrophizing with the Pain Catastrophizing Scale (PCS).

Results

Across groups, mindfulness meditation reduced unpleasantness but not intensity ratings compared to attentional distraction. Experts reported a lower score on PCS, reduced amplification of unpleasantness by long painful stimuli, and larger sensory‐affective uncoupling than novices particularly during long painful stimuli. In experts, meditation‐induced uncoupling spilled over the control condition. Across groups and task conditions, a higher score on PCS predicted lower sensory‐affective uncoupling during long painful stimuli and higher ratings of pain intensity during short painful stimuli.

Conclusion

These findings suggest that mindfulness meditation specifically down‐regulates pain affect as opposed to pain intensity, and that pain catastrophizing undermines sensory‐affective uncoupling of pain.

Significance

In this study, we found that a style of mindfulness meditation referred to as Open Monitoring reduced unpleasantness but not intensity ratings compared to attentional distraction in trained novice (state effect) and expert meditators (state and trait effects). We also observed that trait pain catastrophizing scores predicted this sensory‐affective uncoupling. These findings advance our understanding of the cognitive mechanisms underlying mindfulness meditation and can inform treatment strategies for chronic pain.

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

Publication date: May 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 5

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

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Effect of Low Back Pain Chronicity on Patient Outcomes Treated in Outpatient Physical Therapy: A Retrospective Observational Study

Publication date: May 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 5

Author(s): Zachary Walston, Cherilyn McLester, John McLester

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Pressure Pain Threshold in Subjects With Piriformis Syndrome: Test-Retest, Intrarater, and Interrater Reliability, and Minimal Detectible Changes

Publication date: May 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 5

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

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Chronic Pain Self-Management Support With Pain Science Education and Exercise (COMMENCE) for People With Chronic Pain and Multiple Comorbidities: A Randomized Controlled Trial

Publication date: May 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 5

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

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Gut pain sensors help to combat infection

Nature, Published online: 20 April 2020; doi:10.1038/d41586-020-01105-1

The mammalian gut must defend against a variety of infectious agents. Neurons, cells not usually thought of as first-responders during infection, are now found to aid the gut’s barrier function and stop bacteria from spreading elsewhere.

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Response to Comment by Bhatia

Abstract

We thank Dr Bhatia for their commentary (Bhatia, 2020) on our review Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta‐analysis (Abdel Shaheed et al., 2020).

Dr Bhatia raised the point that if steroids have a role in the treatment of sciatica what route would be most effective and should studies be done to compare the epidural route (especially transforaminal approach) against oral and other parenteral routes? We agree it will not be easy to answer these questions.

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A multi‐center international study of Acupuncture for lateral elbow pain ‐ Results of a randomized controlled trial

Abstract

Background

Lateral elbow pain (LEP) due to tendinosis is one of the most common musculoskeletal pains of the upper limbs, yet there is no satisfactory treatment. This study was an international, prospective, multi‐center, randomized, controlled, clinical trial to evaluate the efficacy of acupuncture compared to sham laser in the treatment of LEP.

Methods

The study used a parallel and stratified design (1:1 allocation using a computer‐generated sequence) and was participant‐, outcome assessor‐ and statistician blinded. Subjects from 18 to 80 years with unilateral chronic LEP (minimum three months) were recruited at four centers in Australia, China, Hong Kong and Italy. The treatment group received manual acupuncture at acupoints LI 10 and LI 11 on the affected side whereas the control group received sham‐laser acupuncture at the same acupoints. The primary endpoint was the disabilities of the arm, shoulder, and hand (DASH) questionnaire score at the three‐week post‐treatment follow‐up visit. Three VAS scales (pain at rest, pain on motion and pain during exertion were secondary outcomes. Ninety‐six subjects were allocated to either the treatment group (n = 47) or control group (n = 49) and were all included in the analysis.

Results

At the follow‐up visit, we found significant differences in DASH score between the two groups (P = 0.015). The median change to baseline for the treatment group was ‐11.7 (interval: ‐50.83 to 23.33), and for the control group ‐7.50 (interval: ‐36.67 to 29.10). The estimated effect size was 0.47, indicating a medium effect. Significant differences were also found for secondary outcome measures for VAS pain. There were no severe adverse events. Our findings suggest that acupuncture has a moderate efficacy in the treatment of LEP.

Conclusions

Acupuncture was shown to be efficacious in improving the function of the arm associated with lateral elbow tendinosis. Both the DASH score and the VAS pain on two occasions (at rest and during motion) showed a significant change over time indicating acupuncture as a potential treatment for LEP due to tendinosis.

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[Clinical Picture] Treating hypoparathyroidism with recombinant human parathyroid hormone (1–34): long-term safety concerns

A 27-year-old woman came to our hospital with increasing diffuse pain around the joints of her shoulders, elbows, wrists, hips, knees, and ankles. She was well known to us because of her long history of problems due to autoimmune polyendocrine syndrome type 1—with a mutation in the autoimmune regulator (AIRE) gene.

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Issue Information

European Journal of Pain, Volume 24, Issue 5, Page 873-874, May 2020.

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Effectiveness of motor imagery and action observation training on musculoskeletal pain intensity: A systematic review and meta‐analysis

Abstract

Background and Objective

Movement representation techniques such as motor imagery (MI) and action observation (AO) could play an important role in the field of rehabilitation of patients with musculoskeletal pain; however, the effects of these tools on clinical pain remain unclear. Our objective is therefore to develop a systematic review and meta‐analysis of the effects of MI and AO regarding the pain intensity on patients with musculoskeletal pain.

Databases and Data Treatment

MEDLINE, EMBASE, CINAHL and Google Scholar were searched. Last search was run on July 2019. Meta‐analysis was conducted to determine the effectiveness on pain intensity in patients with post‐surgical pain or chronic pain, and GRADE was used to rate the quality, certainty and applicability of the evidence.

Results

A total of 10 studies were included. AO or MI were compared versus usual rehabilitation care. The meta‐analysis showed statistically significant differences in MI and AO interventions in patients with pain after surgery in six studies, with a large clinical effect (n = 124; SMD = −0.84; 95% CI: −1.47 to −0.21). In patients with chronic pain, results showed statistically significant differences in MI and AO interventions in three studies, with a large clinical effect (n = 83; SMD = −2.14; 95% CI: −3.81 to −0.47). Risk of bias, imprecision and inconsistency decreased the GRADE level of evidence.

Conclusions

There was very low‐quality evidence regarding the effects of movement representation techniques intervention (AO and MI) on pain intensity in patients with post‐surgical pain. In addition, there was very low‐quality evidence regarding the effects of MI and AO interventions on chronic pain.

Significance

Movement representation techniques in combination with usual care are capable of producing a decrease in pain intensity compared with conventional treatment, in both post‐surgical and chronic pain. However, the very low‐quality evidence found regarding these techniques showed that more research is needed for their application in a clinical context.

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Commentary on “Effectiveness of motor imagery and action observation training on musculoskeletal pain intensity: A systematic review and meta‐analysis” by Suso‐Marti et al

Abstract

This journal recently published a paper by Suso‐Marti et al., entitled “Effectiveness of motor imagery and action observation training on musculoskeletal pain intensity: A systematic review and meta‐analysis” (2020). Motor imagery training and action observation training are rehabilitation approaches that involve imagining oneself executing a particular action, and watching actions that are performed by others, respectively. Both are thought to activate similar neural substrates that are responsible for the actual execution of an action (Eaves et al., 2016). Motor imagery and action observation have been used to enhance motor skill performance in several groups – including athletes and musicians who require highly accurate and precise movement for professional performances, and a similar approach has been employed during rehabilitation with variable outcomes in people after stroke, spinal cord injury and persistent pain.

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Heterogeneous presentation of caspr2 antibody associated peripheral neuropathy – a case series

Abstract

Painful peripheral neuropathies are common. The most prevalent causes of peripheral neuropathies are diabetes, toxins like alcohol or chemotherapeutics, or autoimmune diseases (Visser et al., 2015). However, routine tests do not usually uncover the underlying cause of a significant proportion of peripheral neuropathies. This is in particular true for small fiber neuropathies.

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Percutaneous Transforaminal Endoscopic Discectomy Versus Microendoscopic Discectomy for Lumbar Disc Herniation: Two-Year Results of a Randomized Controlled Trial

Study Design. A prospective randomized controlled study. Objective. To clarify whether percutaneous transforaminal endoscopic discectomy (PTED) has better clinical outcomes and less surgical trauma compared with microendoscopic discectomy (MED). Summary of Background Data. Two kinds of minimally invasive spine surgeries, PTED and MED, are now widely used for the treatment of lumbar disc herniation (LDH). It is still a controversial issue to choose the proper surgical approach. Methods. In this single-center, open-label, randomized controlled trial, patients were included if they had persistent signs and symptoms of radiculopathy with corresponding imaging-confirmed LDH, and were randomly allocated to PTED or MED group. The primary outcome was the score of Oswestry Disability Index (ODI) and the secondary outcomes included the score of Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain and physical function scales, European Quality of Life-5 Dimensions, and Visual Analogue Scales for back pain and leg pain. Results. A total of 250 participants were randomly assigned to two treatment groups, 241 of that received the specific surgical procedure. Two hundred twenty-two patients (92.1%) have completed the 2-year follow-up. Both the primary and secondary outcomes did not differ significantly between the two treatment groups at each prespecified follow-up time (P > 0.05). For PTED, the postoperative improvement of ODI score in the median herniation subgroup was less compared with paramedian subgroup. For MED, less improvement of ODI score was found in far-lateral herniation subgroup compared with paramedian subgroup. Total complication rate over the course of 2 year was 13.44% in PTED group and 15.57% in MED group (P = 0.639). Ten cases (8.40%) in PTED group and five cases (4.10%) in MED group suffered from residue/recurrence of herniation, for which reoperation was required. Conclusion. Over the 2-year follow-up period, PTED did not show superior clinical outcomes and did not appear to be safer procedure for patients with LDH compared with MED. PTED had inferior results for median disc herniation, whereas MED did not appear to be the best option for far-lateral disc herniation. Level of Evidence: 2

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Self-Experienced Trunk Appearance in Individuals With and Without Idiopathic Scoliosis

Study Design. Cross-sectional. Objective. The aim of this study was to describe the self-experienced trunk appearance in individuals with and without idiopathic scoliosis. Summary of Background Data. Idiopathic scoliosis is the most common spinal deformity. A large scoliotic deformity increases the risk of back pain and pulmonary dysfunction. The deformity has also a psychological impact. Methods. The pictorial part of the spinal appearance questionnaire (pSAQ) was administered to 1416 individuals with idiopathic scoliosis (386 untreated, 529 brace treated, 501 surgically treated) and 272 individuals without scoliosis from the general population. Comparisons were made between individuals with and without scoliosis, between treatment groups and sex in the scoliosis group. Results. Mean (95% confidence interval) age of the individuals with scoliosis was 36.2 (35.5–36.9) years and for the individuals without scoliosis 40.2 (37.9–42.4). pSAQ total was 12.3 (12.1–12.5) for individuals with scoliosis and 7.4 (7.3–7.6) for individuals without scoliosis (P <� 0.001, adjusted for age and sex). pSAQ total was 11.5 (11.1–11.9) for untreated, 13.0 (12.6–13.3) for brace treated, and 12.3 (11.9–12.6) for surgically treated individuals (P <� 0.001, adjusted for sex and curve size). The pSAQ total between males and females with idiopathic scoliosis did not differ (P = 0.22 adjusted for age and curve size). Conclusion. This study shows that individuals with idiopathic scoliosis have more concern about their body appearance than individuals without scoliosis. Untreated individuals are not as bothered of their spinal appearance as treated individuals. Males and females with scoliosis do not differ significantly in the perception of their spinal appearance. Level of Evidence: 3

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Chronic Spinal Pain and Financial Worries in the US Adult Population

Study Design. Epidemiological study based on cross-sectional data of a representative sample. Objective. To determine whether financial worries are associated with chronic spinal pain in the US adult population. Summary of Background Data. This study used data from the US 2015 National Health Interview Survey. The sample size was 33,672 and the study population is defined as aged 18 to 85 years. Methods. To account for the complex sampling design, the Taylor linearized variance estimation method was used. Spinal pain was defined in two ways: chronic low back pain and neck pain, chronic low back pain and/or neck pain. Eight types of financial worries were assessed: paying monthly bills, maintaining standard of living, credit card payments, paying rent/mortgage/housing costs, medical costs for healthcare, money for retirement, medical costs of illness/accident, and paying for children's college. Results. Different types of financial worries were significantly associated with chronic spinal pain, controlling for demographic characteristics and socioeconomic status. These worries included paying monthly bills (odds ratio [OR] 2.5), maintaining standard of living (OR 2.5), credit card payments (OR 2.2), paying rent/mortgage/housing costs (OR 2.2), medical costs for healthcare (OR 2.2), money for retirement, (OR 2.3), medical costs of illness/accident (OR 2.2), and paying for children's college (OR 1.4). Conclusion. This study shows that financial worries were significantly associated with chronic spinal pain. Financial worries may be important to be taken into consideration by clinicians managing patients with spinal pain. More future research is needed to explore the association between financial worries and spinal pain. Level of Evidence: 3

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Importance of Early Improvement in the Treatment of Low Back Pain With Physical Therapy

Study Design. . A retrospective observational study. Objective. Assess the time course of functional outcome improvements during a physical therapy (PT) episode of care for patients with low back pain. In addition, assess the impact of patient variables, such as symptom duration, on the time course of functional outcome improvements. Summary of Background Data. Early improvement in patient-reported symptoms and functional limitations may play an important role in the eventual success of an intervention. Early improvements in pain are associated with greater improvement in disability and depression in patients with low back pain. Methods. A total 11,945 patients were included. Intake functional status (FS), FS change at discharge, predicted FS change at discharge, FS change at first progress report (FS1), duration of symptoms before treatment, and duration of PT episode of care were assessed. Pearson correlation analysis was used to assess correlation between collected variables and FS change. Results. The mean FS change was 16.995 units, mean FS1 was 12.024 units, total duration was 63.591 days, and duration at FS1 was 28.969 days, indicating 70.72% of FS change occurred in the first 45.45% of the episode of care. Similar results occurred in all symptom duration categories, ranging from “0 to 7 days" to “greater than 6 months" duration. Correlation analysis demonstrated that FS1 had the greatest correlation to FS. A strong correlation (r > 0.7) was demonstrated in all symptom duration categories ranging from 0.741 to 0.805. Conclusion. The results of this study yield further support for the importance of rapid functional improvements during a PT episode of care. In addition, patients demonstrated roughly two-thirds of their improvement in the first 40% of visits regardless of their symptom duration. This study may help clinicians identify a need to modify a plan of care if insufficient early improvement is observed. Level of Evidence: 3

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Cross-cultural Adaptation, Reliability, Validity, and Responsiveness of the Simplified-Chinese Version of Neck Disability Index

Study Design. Cross-cultural adaptation and psychometric evaluation. Objective. The aim of this study was to translate the Neck Disability Index (NDI) into the simplified-Chinese language and to evaluate the reliability, validity, and responsiveness of the new questionnaire. Summary of Background Data. Neck pain is a major health problem resulting in major disability. NDI is the most frequently used scale for self-rating of disability due to neck pain. At present, there is no simplified-Chinese version of the NDI. The aims of this study were to culturally adapt and translate the NDI into the simplified-Chinese language (NDI-SC) and to evaluate its psychometric properties in patients with neck pain. Methods. The NDI was translated into simplified-Chinese version based on established guidelines. A total of 70 patients participated in this study. Patients were asked to complete a set of questionnaires comprising of their demographic information, the NDI-SC, and a visual analog scale (VAS) of pain. Fifty-six patients returned after 1 to 2 weeks to complete the same set of questionnaires and the global rating of change (GROC) scale. Then, the NDI-SC was evaluated for content validity, construct validity, internal consistency, test-retest reliability, and responsiveness. Results. The NDI-SC demonstrated excellent internal consistency (Cronbach α = 0.92) and good test-retest reliability (ICC2,1 = 0.85). Content validity was confirmed as no floor or ceiling effects were detected for the NDI-SC total score. Construct validity was established with factor analysis revealing two-factor subscales explaining 66% of the variance. The NDI-SC showed a strong correlation with VAS (Rp = 0.61, P <� 0.001) and a moderate correlation with GROC (Rs = 0.46, P <� 0.001). The correlation between NDI-SC change scores and VAS change scores was also moderate (Rp = 0.59, P <� 0.001). Conclusion. The results showed that the NDI-SC is a reliable, valid, and responsive instrument to measure functional limitations in patients with neck pain. Level of Evidence: 3

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Determination of the Prevalence From Clinical Diagnosis of Sacroiliac Joint Dysfunction in Patients With Lumbar Disc Hernia and an Evaluation of the Effect of This Combination on Pain and Quality of Life

Study Design. A prospective cross-sectional study. Objective. To evaluate the prevalence of sacroiliac joint dysfunction in patients with lumbar disc hernia and examine the variations in clinical parameters cause by this combination. Summary of Background Data. Although one of the many agents leading to lumbar pain is sacroiliac dysfunction, little progress has still been made to evaluate mechanical pain from sacroiliac joint dysfunction within the context of differential diagnosis of lumbar pain. Methods. Two hundred thirty-four patients already diagnosed with lumbar disc hernia were included in the study. During the evaluation, sacroiliac joint dysfunction was investigated using specific tests, pain levels with a Visual Analog Scale, and the presence of neuropathic pain using Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale. Other clinical assessments were performed using the Beck Depression Inventory, Health Assessment Questionnaire, and Tampa Kinesiophobia Scale. Results. 63.2% of patients were female and 36.8% were male. Mean age was 46.72 ± 11.14 years. The level of sacroiliac joint dysfunction was 33.3% in the research population. In terms of sex distribution, the proportion of women was higher in the group with sacroiliac joint dysfunction (P <� 0.05). No significant difference was observed in pain intensity assessed using a Visual Pain Scale between the groups (P > 0.05), but the level of neuropathic pain was significantly higher in the group with dysfunction (P <� 0.05). In the group with sacroiliac joint dysfunction, the presence of depression was significantly higher (P = 0.009), functional capacity was worse (P <� 0.001), and the presence of kinesophobia was higher (P = 0.02). Conclusion. Our study results will be useful in attracting the attention of clinicians away from the intervertebral disc to the sacroiliac joint in order to avoid unnecessary and aggressive treatments. Level of Evidence: 2

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Translation, Cross-cultural Adaptation, and Psychometric Properties of the Hausa Versions of the Numerical Pain Rating Scale and Global Rating of Change Scale in a Low-literate Population With Chronic Low Back Pain

Study Design. Translation, cross-cultural adaptation, and psychometric testing. Objective. To translate, cross-culturally adapt, and validate the Numerical Pain Rating Scale (NPRS) and the Global Rating of Change Scale (GRCS) into Hausa language. Summary of Background Data. The NPRS and GRCS are commonly used patient-reported outcome measures in a variety of pain-related conditions including low back pain. To date, neither the NPRS nor GROC are available in Hausa language. Methods. The Hausa versions of the NPRS (NPRS-H) and GRCS (GRCS-H) were developed using recommended guidelines. The final versions were then administered to 120 patients with chronic low back pain to access their psychometric properties. Reliability assessment included calculations of intraclass correlation coefficient (ICC) and minimal detectable change among the stable group. Construct validity and concurrent validity were assessed using the Spearman rank correlation coefficient. Internal responsiveness was assessed using mean change scores, standardized effect size, and standard response mean. Receiver operating characteristic curves were plotted to determine the external responsiveness of the NPRS-H using the area under the curve, and minimal important change for small, medium, and large improvements. Outcome measures consisted of the Visual Analogue Scale for pain and Oswestry Disability Index. Results. The NPRS-H and GRCS-H were successfully developed. High test–retest reliability was demonstrated for both the NPRS-H (ICC = 0.95) and GRCS-H (ICC = 0.94) with minimal detectable change points of 1.0 and 1.2 respectively. The scales showed moderate to strong correlation with the Visual Analogue Scale for pain and Oswestry Disability Index. The mean change of the NPRS-H scores correlated moderately with the GRCS-H. Both scales demonstrated good internal responsiveness. External responsiveness of the NPRS-H was demonstrated at three levels with area under the curve  = 0.875 to 0.972, and minimal important change  = 2.5 to 3.5. Conclusions. The NPRS and GRCS were successfully adapted into Hausa language with acceptable reliability, validity, and responsiveness. These measures are appropriate for clinical and research use among Hausa-speaking patients. Level of Evidence: 2

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Mechanical Aspects of Intervertebral Disc Injury and Implications on Biomechanics

Study Design. This article comprises a review of the literature. Objective. The purpose of this study was to elucidate the different types of structural failures exhibited in intervertebral discs (IVDs), summarize their potential causes with respect to mechanical loading conditions and the consequences on cell homeostasis and biomechanics. Summary of Background Data. Many studies have been performed to gain insight into how discogenic back pain progresses in humans both in vitro and in vivo as well as in animal disc models. However, there is a major need to summarize the common factors which initiate the structural failures observed in IVDs and the typical biomechanical changes. This work could help in developing mechanisms aiming to restore the biochemical and biomechanical balance of IVDs. Methods. The different types of structural failures encountered in IVDs were reviewed from published literature. The types of mechanical loading causing these injuries and their physiological and biomechanical consequences were then summarized and linked to ongoing research in this area. Results. The most prominent structural failures associated with IVDs are annulus tears, disc prolapse, endplate damage, disc narrowing, radial bulging, and osteophyte formation in the vertebrae. IVDs were found to be vulnerable to compression, flexion, axial rotation, and complex loading mechanisms through single impact, cyclical, and continuous loading. However, chronic loadings had a more damaging impact on the spine. Significant consequences include imbalance of metabolic enzymes and growth factors, alteration in stress profiles of IVDs and a decrease in mechanical stiffness resulting in impaired biomechanics of the spine. Conclusion. The mode of loading has an important impact on the severity and nature of failures seen in IVDs and the resulting consequences to biomechanics. However, further research is necessary to better understand to the mechanisms that link injury to degeneration and regeneration of IVD tissues. Level of Evidence: 3

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How Does Body Mass Index Influence Outcomes in Patients After Lumbar Fusion?

Study Design. Retrospective study. Objective. The purpose of the present study is to determine how body mass index (BMI) affects patient-reported outcome measurements (PROMs) after lumbar fusions. Summary of Background Data. Although greater preoperative BMI is known to increase the rates of adverse events after surgery, there is a paucity of literature assessing the influence of BMI on PROMs after lumbar fusion. Methods. Patients undergoing lumbar fusion surgery between 1 and 3 levels were retrospectively identified. PROMs analyzed were the Short Form-12 Physical Component Score, Mental Component Score, Oswestry Disability Index (ODI), and Visual Analog Scale Back and Leg pain scores. Patients were divided into groups based on preoperative BMI: class 1, BMI <25.0; class 2, BMI 25.0 to 29.9; class 3, BMI 30.0 to 34.9; and class 4, BMI ≥35.0. Absolute PROM scores, the recovery ratio, and the percentage of patients achieving minimum clinically important difference between groups were compared. Results. A total of 54 (14.8%) patients in class 1, 140 (38.2%) in class 2, 109 (29.8%) in class 3, and 63 (17.2%) in class 4 were included. All patients improved after surgery across all outcome measures (P <� 0.001) except for class 4 patients, who did not improve in terms of Short Form-12 Mental Component Score scores after surgery (P = 0.276). Preoperative Short Form-12 Physical Component Score (P = 0.002) and Oswestry Disability Index (P <� 0.0001) scores were significantly different between BMI groups—with class 4 having worse disability than class 1 and 2. BMI was not a significant predictor for any outcome domain. Overall 30- and 90-day readmission rates were similar between groups, with a higher revision rate in the class 4 group (P = 0.036), due to a higher incidence of postoperative surgical site infections (P = 0.014). Conclusion. All patients undergoing short-segment lumbar fusion for degenerative disease improved to a similar degree with respect to PROMs. Those in the highest class of obesity (BMI ≥35.0) were, however, at a greater risk for postoperative surgical site infection. Level of Evidence: 3

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[Editorial] Palliative care and the COVID-19 pandemic

Palliative care services are under-resourced at the best of times. The 2017 Lancet Commission on Palliative Care and Pain Relief described the widespread lack of access to inexpensive and effective interventions as a travesty of justice. And these are not the best of times. As health systems become strained under COVID-19, providing safe and effective palliative care, including end-of-life care, becomes especially vital and especially difficult.

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Treatment preferences in fibromyalgia patients: A cross‐sectional web‐based survey

Abstract

Background

Therapeutic approaches to fibromyalgia (FM) are shifting towards a combined multi‐treatment approach to tackle the variety of symptoms experienced in FM. Importantly, little is known about FM patients’ attitude towards the available treatments.

Methods

A cross‐sectional web survey obtained responses from 464 individuals who satisfied diagnostic criteria for FM. Respondents were asked to report which treatments they adopted in their past, present, and intend to adopt in the future. They also rated their level of wellbeing, depression, anxiety and pain catastrophizing.

Results

Data revealed a predominantly combined multi‐treatment approach in a sample characterised by middle aged, caucasian women. Respondents reported pervasive use of pharmacological therapy but had also adopted non‐pharmacological treatment in the past. Future intentions clustered on alternative treatment or no treatment. Regression analyses revealed that pharmacological treatment in the past was predictive of both pharmacological and non‐pharmacological treatment in the present. However, use of non‐pharmacological treatment in the past was uniquely predictive of its re‐use in the present and future. This pattern was also accounted for by individual differences in pain magnification and wellbeing in the past.

Conclusions

Treatment preferences of FM individuals reveal an ambivalent combination of heavy reliance on pharmacological treatment with lower but consistent reliance on non‐pharmacological treatment for those individuals who used it in the past and present. This finding may inform longitudinal research into the relationship between pharmacological and non‐pharmacological treatment preference in FM patients, which could in turn inform guidelines for individualised therapeutic plans for clinicians.

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Neuropathic pain after thoracotomy: tracking signs and symptoms before and at monthly intervals following surgery

Abstract

Background

Because the development of neuropathic symptoms contributes to pain severity and chronification after surgery, their early prediction is important to allow targeted treatment.

Objectives

We longitudinally investigated trajectories of signs and symptoms in patients undergoing thoracotomy and assessed whether and at which time they were related to the development of neuropathic pain symptoms six months after surgery.

Methods

Presurgical and six, monthly postsurgical assessments included questionnaires for mental and physical well‐being (e.g. depression/anxiety, pain catastrophizing, sleep quality, neuropathic pain symptoms), and quantitative sensory testing (QST).

Results

QST trajectories indicated nerve impairment of the surgery site with predominant loss of function. Signs of recovery towards the end of the assessment period were observed for some tests. Unsupervised cluster analysis with NPSI scores six months after surgery as clustering variable identified one group with no/low levels of neuropathic symptoms and one with moderate levels. The two groups differed w.r.t. several signs and symptoms already at early time points. Notably, neuropathic pain anywhere in the body differed already preoperatively and sleep impairment differentiated the two groups at all time points. Regression analysis revealed three factors that seemed particularly suited to predicted six months NPSI scores, namely preoperative neuropathic pain symptoms, with contributions from sleep impairment one month after surgery and the presence of dynamic mechanical allodynia three months after surgery.

Conclusions

Clinical routine should focus on the individual’s physiological state, including pre‐existing neuropathic pain and sleep quality to identify patients early who might be at risk to develop chronic post‐surgical neuropathic pain.

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I feel I am missing a piece of the puzzle

For years I had experienced complex, unexplained symptoms. Symptoms such as frequent episodes of dizziness and vertigo, and trembling and pain that was concentrated in the legs. I had many tests, but...

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