International estimates place the prevalence of chronic pain at about 18% to 30% of adults in the community, most of whom report at least some pain-related interference with activities.7,23,48 Further, recent U.S data indicate that of the five most common disorders contributing to years lived with disability, positions 1, 3 and 4 are occupied by back pain, other musculoskeletal disorders, and neck pain, respectively.60 With such a high burden of functional disability, it is important for both clinical and research purposes that there be reliable and valid measures for the assessment of activity limitations caused by chronic pain.
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Thursday, August 30, 2018
Deployment-related Traumatic Brain Injury and Risk of New Episodes of Care for Back Pain in Veterans
The United States (US) Department of Veterans Affairs (VA) and the Department of Defense (DOD) define traumatic brain injury (TBI) as a structural injury and/or physiological disruption in brain function as the result of an external force, indicated by the onset or worsening of clinical signs immediately following the event.9 The diagnosis of TBI was made in more than 375,000 US military service members between 2000 and 2017.8 A systematic review found that chronic pain is common following TBI, and that prevalence of chronic pain differed by TBI severity (mild vs.
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Sudden onset abdominal pain
A 48 year old woman attended the emergency department with a sudden onset of severe abdominal pain, worsening over the few hours before presentation. She underwent a computed tomography scan for...
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Tuesday, August 28, 2018
Cortical Thickness Alterations in Chronic Pain Disorder: An Exploratory MRI Study
Objective Chronic pain disorder (CPD) has been associated with brain changes, especially in limbic circuits. However, in most patients with chronic pain, depression or anxiety is a common comorbidity. In this exploratory and naturalistic study, we investigated brain cortical thickness (CTh) differences between patients with CPD and healthy controls, with consideration of concurrent psychiatric symptoms. Methods Twenty-three patients with CPD and 23 age- and sex-matched healthy volunteers were included in this study. CTh was estimated using Freesurfer on high-resolution three-dimensional T1-weighted images acquired with a 3T scanner. Group differences were investigated using an analysis of covariance model that included age, sex, and Beck Depression Inventory I and Trait Anxiety Inventory scores as covariates. The relationship between CTh and Toronto Alexithymia Scale (TAS-20) scores was also investigated in patients. Data were corrected for multiplicity using the False Discovery Rate approach (q < .05). Results The comparison between groups using demographics and Beck Depression Inventory I scores as covariates showed thinner cortex in patients compared with controls, after correction for multiplicity in the left precentral (F(1,42) = 21.9, p < .05) and postcentral gyri (F(1,42) = 26.9, p < .05) and in the left inferior temporal sulcus (F(1,42) = 19.6, p < .05). Moreover, using the Trait Anxiety Inventory as covariate, a trend toward significance (p < .001 uncorrected) was seen for the left precentral gyrus (F(1,42) = 13.8), right middle frontal (F(1,42) = 14.3) and inferior parietal gyri (F(1,42) = 13.4), and right anterior temporal pole (F(1,42) = 15.9). Conclusions The results indicate that brain morphological differences between patients with chronic pain disorder and healthy controls are localized to regions that correspond to sensory as well as affective dimensions of pain processing.from Psychosomatic Medicine - Featured Articles - Current Issue Highlights https://ift.tt/2MYhA8d
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Efficiency of Neuromuscular Electrical Stimulation and Transcutaneous Nerve Stimulation on Hemiplegic Shoulder Pain: A Randomized Controlled Trial
Publication date: September 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 9
Author(s): Meimei Zhou, Fang Li, Weibo Lu, Junfa Wu, Song Pei
Abstract
Objective
To compare the efficacy of neuromuscular electrical stimulation (NMES) and transcutaneous nerve stimulation (TENS) on hemiplegic shoulder pain (HSP).
Design
This is a prospective randomized controlled trial.
Setting
A rehabilitation hospital.
Participants
Participants (N=90) were randomized into NMES (n=36), TENS (n=36), or control groups (n=18).
Interventions
NMES (15Hz, pulse width 200μs) was applied to supraspinatus and deltoids (medial and posterior parts), whereas TENS (100Hz, pulse width 100μs) was used on the same areas. The surface electrodes were placed near the motor points of the supraspinatus and medial or posterior bundle of deltoids. The 4-week treatment consisted of 20 sessions, each session composed of 1 hour of stimulation per day. Routine rehabilitation program without any stimulation was administered to the control and the NMES/TENS groups. Numerical rating scale (NRS), active/passive range of motion (AROM/PROM) of shoulder, upper extremity Fugl-Meyer Assessment (FMA), modified Ashworth scale (MAS), Barthel Index (BI), and stroke-specific quality of life scale (SSQOLS) were assessed in a blinded manner at baseline, 2, 4, and 8 weeks after treatment, respectively.
Main Outcome Measures
The primary endpoint was the improvement from baseline in NRS for HSP at 4 weeks.
Results
NRS scores in NMES, TENS, and control groups had decreased by 2.03, 1.44, and 0.61 points, respectively after 4 weeks of treatment, with statistically significant differences among the 3 groups (P<.001). The efficacy of the NMES group was significantly better than that of the TENS group (P=.043). Moreover, the efficacy of NMES and TENS groups was superior to that of the control group (P<.001, P=.044, respectively). The differences in the therapeutic efficacy on shoulder AROM/PROM, FMA, MAS, BI, and SSQOLS scores were not significant among the 3 groups.
Conclusions
TENS and NMES can effectively improve HSP, the efficacy of NMES being distinctly superior to that of TENS in maintaining long-term analgesia. However, NMES was not more efficacious than the TENS or control group in improving the shoulder joint mobility, upper limb function, spasticity, the ability of daily life activity, and stroke-specific quality of life in HSP patients.
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Physical Activity–Based Interventions Using Electronic Feedback May Be Ineffective in Reducing Pain and Disability in Patients With Chronic Musculoskeletal Pain: A Systematic Review With Meta-Analysis
Publication date: September 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 9
Author(s): Crystian B. Oliveira, Márcia R. Franco, Chris G. Maher, Paulo H. Ferreira, Priscila K. Morelhão, Tatiana M. Damato, Cynthia Gobbi, Rafael Z. Pinto
Abstract
Objective
To investigate the effectiveness of physical activity–based interventions using electronic feedback in reducing pain and disability compared to minimal or no interventions in patients with chronic musculoskeletal pain.
Data Sources
The following electronic databases were searched: EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Web of Science, Physiotherapy Evidence Database, and main clinical trial registers.
Study Selection
Randomized controlled trials investigating the effect of physical activity interventions using electronic feedback (eg, physical activity monitors) on pain and disability compared to minimal or no interventions in adults with chronic musculoskeletal pain were considered eligible.
Data Extraction
Pooled effects were calculated using the standardized mean difference (SMD), and the Grading of Recommendations Assessment, Development and Evaluation system was used to assess the overall quality of the evidence.
Data Synthesis
Four published randomized controlled trials and 4 registered unpublished randomized controlled trials were included. At short-term follow-up, pooled estimations showed no significant differences in pain (2 trials: n=116; SMD=−.50; 95% confidence interval, −1.91 to 0.91) and disability (2 trials: n=116; SMD=−.81; 95% confidence interval, −2.34 to 0.73) between physical activity–based interventions and minimal interventions. Similarly, nonsignificant results were found at intermediate-term follow-up. According to Grading of Recommendations Assessment, Development and Evaluation, the overall quality of the evidence was considered to be of low quality.
Conclusions
Our findings suggest that physical activity–based interventions using electronic feedback may be ineffective in reducing pain and disability compared to minimal interventions in patients with chronic musculoskeletal pain. Clinicians should be cautious when implementing this intervention in patients with chronic musculoskeletal pain.
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Systematic Review on the Effects of Serious Games and Wearable Technology Used in Rehabilitation of Patients With Traumatic Bone and Soft Tissue Injuries
Publication date: September 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 9
Author(s): Henriëtte A. Meijer, Maurits Graafland, J. Carel Goslings, Marlies P. Schijven
Abstract
Objective
To assess the effects on functional outcomes and treatment adherence of wearable technology and serious games (ie, interactive computer applications with specific purposes useful in the “real world”) currently used in physical rehabilitation of patients after traumatic bone and soft tissue injuries.
Data Sources
PubMed, EMBASE, Cochrane Library, and Current Index to Nursing and Allied Health Literature were searched without publication date restrictions for the terms wearable, serious game, videogame or mobile application, and rehabilitation, exercise therapy, and physiotherapy.
Study Selection
The search yielded 2704 eligible articles, which were screened by 2 independent reviewers. Studies comparing serious games to standard therapy were included.
Data Extraction
Methodology and results of the studies were critically appraised in conformity with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Data Synthesis
Twelve articles were included, all of which tested “off-the-shelf” games. No studies on “wearable-controlled” games or games specifically developed for rehabilitation could be included. Medical conditions included postoperative rehabilitation and acute traumatic injuries. All studies were of low to moderate quality. Only 2 studies found beneficial effects of serious games compared to conventional therapy. One of 3 studies reporting pain scores found beneficial effects of serious games compared to physiotherapy. One of 5 trials reporting treatment adherence found a statistically significant advantage in the game group compared to conventional physiotherapy. Because of heterogeneity in study design and outcome measures, pooling of data was not possible.
Conclusions
Serious games seem a safe alternative or addition to conventional physiotherapy after traumatic bone and soft tissue injuries. Future research should determine their validity and effectiveness in rehabilitation therapy, next to their cost-effectiveness and effect on treatment adherence.
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Psychometric Testing of a Rehabilitative Care Patient Experience Instrument
Publication date: September 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 9
Author(s): Josephine McMurray, Heather McNeil, Alicia Gordon, Jacobi Elliott, Paul Stolee
Abstract
Objective
To evaluate the internal consistency and test-retest reliability, construct validity, and feasibility of the WatLX, a measure of the experience of patients in rehabilitative care.
Design
Multisite, cross-sectional, and test-retest self-report study.
Setting
Outpatient rehabilitative care settings.
Participants
The WatLX was administered to English-speaking, cognitively intact outpatients (N=1174) over 18 years old who had completed a program of cardiac, musculoskeletal, neurologic, stroke, pulmonary, or speech language rehabilitative care, at 2 separate time points: (1) immediately following completion of their rehabilitation program, and (2) 2 weeks later (n=29). A subsequent feasibility study was conducted with 1013 patients from 19 clinics.
Interventions
Not applicable.
Main Outcome Measures
The WatLX measures 6 concepts, previously identified as key to outpatient rehabilitative care patients’ experience: (1) ecosystem issues, (2) client and informal caregiver engagement, (3) patient and health care provider relations, (4) pain and functional status, (5) group and individual identity, and (6) open-ended feedback.
Results
Reliability analyses were conducted on 2 versions of the WatLX. Using a 7-point versus a 5-point Likert scale resulted in higher internal consistency and reliability scores. Cronbach’s alpha coefficients were .863 and .957 for the 5- and 7-point scale, respectively, and the ICC scores were .827 and .880, respectively. The proof of concept study recruited 1013 patients with little interruption of workflow; results displayed strong internal consistency (Cronbach’s alpha coefficient =.906). There is evidence of ceiling effects.
Conclusions
The WatLX is a parsimonious question set that is feasible for administration in ambulatory rehabilitative care settings, and which shows promising psychometric properties.
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Assessment of Nociception and Pain in Participants in an Unresponsive or Minimally Conscious State After Acquired Brain Injury: The Relation Between the Coma Recovery Scale–Revised and the Nociception Coma Scale–Revised
Publication date: September 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 9
Author(s): Camille Chatelle, Solveig L. Hauger, Charlotte Martial, Frank Becker, Bernd Eifert, Dana Boering, Joseph T. Giacino, Steven Laureys, Marianne Løvstad, Petra Maurer-Karattup
Abstract
Objectives
To investigate the relation between consciousness and nociceptive responsiveness (ie, Nociception Coma Scale–Revised [NCS-R]), to examine the suitability of the NCS-R for assessing nociception in participants with disorders of consciousness (DOC), and to replicate previous findings on psychometric properties of the scale.
Design
Specialized DOC program.
Setting
Specialized DOC program and university hospitals.
Participants
Participants (N=85) diagnosed with DOC.
Interventions
Not applicable.
Main Outcome Measures
We prospectively assessed consciousness with the Coma Recovery Scale–Revised (CRS-R). Responses during baseline, non-noxious, and noxious stimulations were scored with the NCS-R and CRS-R oromotor and motor subscales.
Results
CRS-R total scores correlated with NCS-R total scores and subscores. CRS-R motor subscores correlated with NCS-R total scores and motor subscores, and CRS-R oromotor subscores correlated with NCS-R total scores as well as verbal and facial expression subscores. There was a difference between unresponsive wakefulness syndrome and minimally conscious state in the proportion of grimacing and/or crying participants during noxious conditions. We replicated previous findings on psychometric properties of the scale but found a different score as the best threshold for nociception.
Conclusions
We report a strong relation between the responsiveness to nociception and the level of consciousness. The NCS-R seems to be a valuable tool for assessing nociception in an efficient manner, but additional studies are needed to allow recommendations for clinical assessment of subjective pain experience.
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Effectiveness of the Pilates Method in the Treatment of Chronic Mechanical Neck Pain: A Randomized Controlled Trial
Publication date: September 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 9
Author(s): Luciana de Araujo Cazotti, Anamaria Jones, Diego Roger-Silva, Luiza Helena Coutinho Ribeiro, Jamil Natour
Abstract
Objective
To assess the effectiveness of the Pilates method on pain, function, quality of life, and consumption of pain medication in patients with mechanical neck pain.
Design
The design was a randomized controlled trial, with a blinded assessor and intention-to-treat analysis.
Setting
The study took place in the outpatient clinic of the rheumatology department, referral center.
Participants
Patients (N=64) with chronic mechanical neck pain were randomly allocated to 2 groups: the Pilates group (PG) and a control group (CG).
Interventions
The PG attended 2 sessions of Pilates per week, for 12 weeks. The protocol included Pilates exercises performed on a mat and on equipment and was adapted depending on the physical fitness of each participant; the repetitions varied from 6 to 12, respecting patient reports of fatigue and pain, using a single series for each exercise. The CG received only the standard pharmacological treatment. Both groups were instructed to use acetaminophen 750 mg if necessary. Patients were evaluated at baseline after 45, 90, and 180 days.
Main Outcome Measures
We used the Numerical Pain Scale for pain, the Neck Disability Index for function, and the SF-36 questionnaire for quality of life.
Results
The groups were homogeneous at baseline, the only exception being body mass index (BMI), with the PG showing higher BMI. Regarding the assessment between groups over time, statistical differences were identified for pain (P<.001), function (P<.001) and the SF-36 (functional capacity, P=.019; pain, P<.001; general health, P=.022; vitality, P<.001; mental health, P=.012) with the PG consistently achieving better results. Drug consumption was lower in PG patients (P=.037).
Conclusions
This trial demonstrated the effectiveness of the Pilates method for the treatment of chronic mechanical neck pain, resulting in improvement of pain, function, quality of life, and reduction of the use of analgesics.
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Response to Letter to the Editor regarding “Concerns for Potential Risk of Bias in Diagnostic Validity Study of Patellofemoral Pain”
Publication date: September 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 9
Author(s): Simon Décary, François Desmeules
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Osteopathic Manipulative Treatment Including Specific Diaphragm Techniques Improves Pain and Disability in Chronic Nonspecific Low Back Pain: A Randomized Trial
Publication date: September 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 9
Author(s): Mireia Martí-Salvador, Laura Hidalgo-Moreno, Julio Doménech-Fernández, Juan Francisco Lisón, Maria Dolores Arguisuelas
Abstract
Objective
To investigate the effects of an osteopathic manipulative treatment (OMT), which includes a diaphragm intervention compared to the same OMT with a sham diaphragm intervention in chronic nonspecific low back pain (NS-CLBP).
Design
Parallel group randomized controlled trial.
Setting
Private and institutional health centers.
Participants
Participants (N=66) (18-60y) with a diagnosis of NS-CLBP lasting at least 3 months.
Interventions
Participants were randomized to receive either an OMT protocol including specific diaphragm techniques (n=33) or the same OMT protocol with a sham diaphragm intervention (n=33), conducted in 5 sessions provided during 4 weeks.
Main Outcome Measures
The primary outcomes were pain (evaluated with the Short-Form McGill Pain Questionnaire [SF-MPQ] and the visual analog scale [VAS]) and disability (assessed with the Roland–Morris Questionnaire [RMQ] and the Oswestry Disability Index [ODI]). Secondary outcomes were fear-avoidance beliefs, level of anxiety and depression, and pain catastrophization. All outcome measures were evaluated at baseline, at week 4, and at week 12.
Results
A statistically significant reduction was observed in the experimental group compared to the sham group in all variables assessed at week 4 and at week 12 (SF-MPQ [mean difference −6.2; 95% confidence interval, −8.6 to −3.8]; VAS [mean difference −2.7; 95% confidence interval, −3.6 to −1.8]; RMQ [mean difference −3.8; 95% confidence interval, −5.4 to −2.2]; ODI [mean difference −10.6; 95% confidence interval, −14.9 to 6.3]). Moreover, improvements in pain and disability were clinically relevant.
Conclusions
An OMT protocol that includes diaphragm techniques produces significant and clinically relevant improvements in pain and disability in patients with NS-CLBP compared to the same OMT protocol using sham diaphragm techniques.
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Cardiac scan nearly halves future risk of heart attack in patients with chest pain, finds study
Investigating patients with stable chest pain using coronary computed tomographic angiography (CTA) nearly halves their risk of death due to coronary heart disease or of non-fatal myocardial...
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NRS20: Combined Back and Leg Pain Score: A Simple and Effective Assessment of Adult Spinal Deformity
Study Design. Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. Objective. To evaluate back and leg pain as a combined score in ASD and compare their relative and cumulative correlations with health-related quality of life (HRQOL) and sagittal parameters. Summary of Background Data. Pain and disability are commonly reported in patients with ASD. This can affect their back, their legs or both. ASD-associated pain has been correlated with numerous HRQOL scores and radiological parameters. Methods. Preoperative pain intensity was assessed with a Numerical Rating Scale (NRS) for individual back and leg pain as well as a combined score, NRS20 (0–20, back plus leg pain). This yielded a range of static measures in all patients with ASD with differing burdens of disease. Linear regression analysis was performed to calculate the correlation between pain and HRQOL scores (Scoliosis Research Society 22, 36-Item Short Form Health Survey Physical Component Summary, 36-Item Short Form Health Survey Mental Component Summary, Core Outcome Measures Index, and Oswestry Disability Index), and radiological spinopelvic parameters (sagittal and coronal planes). Results. A total of 1309 patients were included in this study. A combined score (NRS20) was better correlated with HRQOL (P < 0.01 for all) and sagittal parameters (P < 0.01 for all) than individual back or leg pain scores. Evaluation of the relative contributions of back and leg pain demonstrate a higher correlation with HRQOL scores for back pain and a higher correlation with sagittal parameters for leg pain. The distribution of NRS20 pain scores demonstrated three clear patterns of pain: back pain only, moderate back pain with varying mild-moderate leg pain, and severe equivalent back and leg pain. Similar values were noted for nonoperative and operative patients. Conclusion. The distribution and intensity of pain and its correlations with clinical and radiological parameters provide insight into the pathogenesis of ASD. A combined score has a simple yet valuable contribution to the assessment of symptoms in ASD. Level of Evidence: 3from Spine - Featured Articles - Featured Articles https://ift.tt/2NnRWXi
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Exploration of the Inter-Relationships Between Obesity, Physical Inactivity, Inflammation, and Low Back Pain
Study Design. Retrospective analysis wherein 103 patients were considered, and 76 patients were included: 49 were classified as chronic non-specific low back pain (CNSLBP) (Study group) and 27 had identifiable cases of specific chronic low back pain (LBP) (Control group). Objective. Elucidate markers of systemic inflammation in patients with CNSLBP. Summary of Background Data. Mechanisms of LBP are poorly understood. Pro-inflammatory cytokines are increased in obesity and involved with pain modulation; we previously proposed a theoretical model of their mediating role in LBP. Methods. Demographic information was acquired via questionnaire, chart review, and blood test data. Univariate analysis identified factors associated with CNSLBP and markers of systemic inflammation. A receiver operating curve and Youden Index were used to select optimal cut-off points for elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Multivariable logistic regression analysis calculated the adjusted strength of relationship between factors that were proposed in our theoretical model for CNSLBP. Results. Unadjusted CRP was significantly correlated with ESR (R = 0.63, P < 0.0001) and body mass index (BMI) (R = 0.38, P = 0.0015). Physically inactive patients had significantly higher CRP (6.1 vs. 1.2, P = 0.0050). ESR was significantly correlated with number of comorbidities (R = 0.34, P = 0.0047), BMI (R = 0.38, P = 0.0014), and age (R = 0.36, P = 0.0026). Physically inactive patients (10.4 vs. 3.6, P = 0.0001) and females (11.2 vs. 6.4, P = 0.0422) had significantly higher ESR. Adjusted analyses indicated significant relationships between physical inactivity and markers of systemic inflammation (adjusted odds ratios for ESR and CRP: 15.9, P = 0.0380; 15.2, P = 0.0272, respectively), and between elevated CRP and CNSLBP (adjusted odds ratio: 8.0, P = 0.0126). Conclusion. Systemic inflammation may act as a mediator for physical inactivity and obesity in the pathogenesis of CNSLBP. Level of Evidence: 2from Spine - Featured Articles - Featured Articles https://ift.tt/2C5q2yn
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Does Duration of Pain at Baseline Influence Clinical Outcomes of Low Back Pain Patients Managed on an Evidence-based Pathway?
Study Design. Longitudinal observational study. Objective. To investigate the association between the duration of pain at baseline and the clinical outcomes of patients with low back pain (LBP) enrolled on the North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). Summary of Background Data. The NERBPP is a clinical pathway based upon National Institute for Health and Care Excellence (NICE) guidelines (2009) for LBP of <1-year duration. Recent changes to NICE guidelines (2016) advocate the same management for all LBP patients regardless of pain duration. Methods. Patients with LBP referred onto the NERBPP by their General Practitioner between May 2015 and January 2017 were included. Data from 667 patients, who provided pre- and post data for pain (Numerical rating scale), function (Oswestry Disability Index), quality-of-life (EuroQol five-dimension, five-level questionnaire), anxiety (the Generalized Anxiety Disorder Screener), and depression (the Patient Health Questionnaire), were analyzed using a series of covariate-adjusted models. Patients were categorized into four groups based upon baseline pain duration: <3 months, ≥3 to <6 months, ≥6 months to <12 months, ≥12 months. Results. Each group showed improved outcomes greater than the minimal clinically important difference (MCID) for each measure as defined in NICE guidelines (2016). There was a trend toward better outcomes for those with shorter pain durations. The magnitude of the differences between the groups, in most instances, was below the MCID. For example, mean improvement in function for those with baseline pain duration <3 months was 20 points and 12 points for those of pain duration ≥12 months, both above the MCID of ≥10. Conclusion. Patients with different durations of LBP at baseline improved on the NERBPP, supporting the recent modification to NICE guidelines. However, those with shorter durations of pain may have superior outcomes in the short term, suggesting added benefit in getting patients onto the pathway in the early stages of LBP. Level of Evidence: 3from Spine - Featured Articles - Featured Articles https://ift.tt/2ohF5v4
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Wednesday, August 22, 2018
Selective deficiencies in descending inhibitory modulation in neuropathic rats: implications for enhancing noradrenergic tone
Pontine noradrenergic neurones form part of a descending inhibitory system that influences spinal nociceptive processing. Weak or absent descending inhibition is a common feature of chronic pain patients. We examined the extent to which the descending noradrenergic system is tonically active, how control of spinal neuronal excitability is integrated into thalamic relays within sensory-discriminative projection pathways, and how this inhibitory control is altered after nerve injury. In vivo electrophysiology was performed in anaesthetised spinal nerve–ligated (SNL) and sham-operated rats to record from wide dynamic range neurones in the ventral posterolateral thalamus (VPL). In sham rats, spinal block of α2-adrenoceptors with atipamezole resulted in enhanced stimulus-evoked and spontaneous firing in the VPL, and produced conditioned place avoidance. However, in SNL rats, these conditioned avoidance behaviours were absent. Furthermore, inhibitory control of evoked neuronal responses was lost, but spinal atipamezole markedly increased spontaneous firing. Augmenting spinal noradrenergic tone in neuropathic rats with reboxetine, a selective noradrenergic reuptake inhibitor, modestly reinstated inhibitory control of evoked responses in the VPL but had no effect on spontaneous firing. By contrast, clonidine, an α2 agonist, inhibited both evoked and spontaneous firing, and exhibited increased potency in SNL rats compared with sham controls. These data suggest descending noradrenergic inhibitory pathways are tonically active in sham rats. Moreover, in neuropathic states, descending inhibitory control is diminished, but not completely absent, and distinguishes between spontaneous and evoked neuronal activity. These observations may have implications for how analgesics targeting the noradrenergic system provide relief.from PAIN - Featured Articles - Current Issue Highlights https://ift.tt/2PxDfCA
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Monday, August 20, 2018
A toolkit for data transparency takes shape
A toolkit for data transparency takes shape
A toolkit for data transparency takes shape, Published online: 20 August 2018; doi:10.1038/d41586-018-05990-5
A simple software toolset can help to ease the pain of reproducing computational analyses.
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Saturday, August 18, 2018
Should the 6-minute walk test be stopped if oxyhemoglobin saturation falls below 80%?
Publication date: Available online 18 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Sumbla Afzal, Angela T. Burge, Annemarie L. Lee, Janet Bondarenko, Anne E. Holland
Objective
To examine the occurrence of adverse events in patients undergoing assessment for pulmonary rehabilitation when a 6-minute walk test (6MWT) continues despite desaturation below 80%.
Design
Retrospective audit following REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement.
Setting
Large teaching hospital.
Participants
All patients assessed for pulmonary rehabilitation (September 2005 to January 2016).
Interventions
The standardized tests were conducted by experienced cardiorespiratory physiotherapists. Oxyhemoglobin saturation was monitored continuously using a pulse oximeter (lowest value used for analysis). Medical records were reviewed, and adverse events defined as tachycardia, bradycardia, chest pain or other sign/symptom necessitating cessation.
Main outcome measure
6MWT.
Results
Data from 672 walk tests were included (55% men, mean age 69 (standard deviation 11) years) with mean distance 369 (124) meters. The main diagnoses were chronic obstructive pulmonary disease (70%), interstitial lung disease (14%) and bronchiectasis (8%). Sixty individuals (11%) recorded desaturation below 80% without adverse events. Two adverse events were recorded during tests without desaturation; in one instance, chest pain with no evidence of cardiorespiratory compromise and in another, the patient stopped due to concern regarding blood sugar levels (11.5 mmol/L when tested). Independent predictors of desaturation to less than 80% were resting oxyhemoglobin saturation < 95% (odds ratio 3.82, 95% confidence interval 2.06 to 7.08) and a diagnosis of interstitial lung disease or pulmonary arterial hypertension (OR 5.24, 2.59 to 10.58).
Conclusions
This study found that desaturation to less than 80% during a 6MWT was not associated with adverse events in a large cohort of patients referred to pulmonary rehabilitation and assessed by experienced physiotherapists, suggesting that test cessation due to desaturation in stable patients may be unwarranted.
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Return-to-work barriers among manual workers after hand injuries: one-year follow-up cohort study
Publication date: Available online 18 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Batia S. Marom, Navah Z. Ratzon, Rafael S. Carel, Moshe Sharabi
Abstract
Objective
To determine time of return to work (TRTW) in relation to multivariable predictors among male manual workers after hand injury (HI) over a 12-month follow-up.
Design
A cohort study with baseline medical information, functional evaluation, and three-, six-, nine-, and 12-month follow-up telephone interviews.
Setting
Seven physical rehabilitation community occupational therapy clinics.
Participants
178 subjects with acute HI aged 22 to 65. Two participants were lost to follow-up.
Intervention
Not applicable.
Main Outcome Measure
The dependent variable was TRTW. The independent variables originated from four domains: personal factors, environmental factors, body function and structure, and activity limitation and participation restriction. The proportion of RTW at each time point was calculated. Multiple Cox regressions established a predictive model for TRTW.
Results
At the end of the study, 75.3% participants returned to work. The median TRTW was 94 days. In the final model, only compensation factors and education contributed significantly to overall RTW, but when separate analyses were performed, decreased level of self-efficacy, higher workplace demands, level of pain, level of emotional response to trauma, reduced physical capability of the hand, and higher level of disability were significantly associated with delayed TRTW.
Conclusions
TRTW was determined by the physical capability of the hand, pain, and psychosocial factors, but it was also affected by legal factors. Subjects who did not RTW during the first nine months are at risk for long-term disability. Developing treatment programs for those who are at risk for not RTW, taking into consideration these factors, is recommended.
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Friday, August 17, 2018
A compound offers itch and pain relief without side effects
A compound offers itch and pain relief without side effects
A compound offers itch and pain relief without side effects, Published online: 17 August 2018; doi:10.1038/d41586-018-05957-6
Brain-cell experiments reveal the molecular roots of a potential drug’s unusual advantage.
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Thursday, August 16, 2018
Widespread Pressure Pain Hypersensitivity in Musculoskeletal and Nerve Trunk Areas as Sign of Altered Nociceptive Processing in Unilateral Plantar Heel Pain
Plantar heel pain is a foot condition commonly treated by healthcare providers16. Subjects with this condition report insidious sharp pain under the plantar surface of the heel, usually spreading from the medial border of the plantar fascia to its insertion at the medial tuberosity of the calcaneus1. The pain increases in the morning with the first step after getting out of bed, after prolonged periods of inactivity and/or at the beginning of a workout3. Due to the presence of degenerative changes and the absence of inflammation in the plantar fascia14, it has been proposed that the proper term for this pain condition is plantar fasciopathy22 or plantar heel pain15.
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Tuesday, August 14, 2018
Alternative to pethidine could halve rate of epidurals
Using remifentanil instead of pethidine to relieve pain during labour could halve the number of women needing an epidural, a randomised controlled trial has shown.1About a third of women receiving...
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Saturday, August 11, 2018
Cost-effectiveness and cost-utility of internet-delivered exposure therapy for fibromyalgia: results from a randomized controlled trial
Fibromyalgia (FM) is a disabling chronic pain disorder, with a prevalence ranging between 2 and 4% 25,53,57, often presenting with a range of other somatic and psychiatric symptoms such as fatigue, sleep disturbances, anxiety and depression. Furthermore, FM is a costly disorder for both healthcare providers and society. One study 7 showed that FM patients on average utilize four times as many physician visits, twice as many other outpatient visits, and four times more emergency room visits compared with other primary care patients.
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Risk of pain and gastrointestinal complaints at six months after elective abdominal surgery
The incidence of chronic postoperative abdominal pain (CPAP) after abdominal surgery is estimated at 11%. CPAP is associated with an increase of gastrointestinal symptoms and decreases overall quality of life 5, 10. Around 30% of patients after gastrointestinal surgery report having pain-related interference with mood, sleep and enjoyment of life and 12% visit the emergency department for pain related symptoms 36. Intra-abdominal adhesions are deemed as the cause of CPAP in 60% of patients. In these patients no anatomic or functional abnormalities are found apart from adhesions 32.
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Friday, August 10, 2018
Spinal 5-HT1AR contributes to the analgesia of acupoint catgut embedding by inhibiting phosphorylation of the NMDA receptor GluN1 subunit in CFA-induced inflammatory pain in rats
Acupuncture, which can be performed in several different ways, has been widely used for managing many diseases, including chronic inflammatory pain, especially in drug-refractory patients 3, 4, 55. Several large studies have also provided evidence that acupuncture is a relatively safe treatment 34, 47, 50.
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Effectiveness of Oral Pain Medication and Corticosteroid Injections for Carpal Tunnel Syndrome: A Systematic Review
Publication date: August 2018
Source: Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 8
Author(s): Bionka M. Huisstede, Manon S. Randsdorp, Janneke van den Brink, Thierry P.C. Franke, Bart W. Koes, Peter Hoogvliet
Abstract
Objective
To present an evidence-based overview of the effectiveness of oral pain medication and corticosteroid injections to treat carpal tunnel syndrome (CTS).
Data Sources
The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs).
Study Selection
Two reviewers independently applied the inclusion criteria to select potential studies.
Data Extraction
Two reviewers independently extracted the data on pain (visual analog scale), function or recovery, and assessed the methodologic quality.
Data Synthesis
A best-evidence synthesis was performed to summarize the results of the included studies. Four reviews and 9 RCTs were included. For oral pain medication, strong and moderate evidence was found for the effectiveness of oral steroids versus placebo in the short term. Moderate evidence was found in favor of oral steroids versus splinting in the short term. No evidence was found for the effectiveness of oral steroids in the long term. For corticosteroid injections, strong evidence was found in favor of a corticosteroid injection versus a placebo injection and moderate evidence was found in favor of corticosteroid injection versus oral steroids in the short term. Also, in the short term, moderate evidence was found in favor of a local versus a systematic corticosteroid injection. Higher doses of corticosteroid injections seem to be more effective in the midterm; however, the benefits of corticosteroid injections were not maintained in the long term.
Conclusions
The reviewed evidence supports that oral steroids and corticosteroid injections benefit patient with CTS particularly in the short term. Although a higher dose of steroid injections seems to be more effective in the midterm, the benefits of oral pain medication and corticosteroid injections were not maintained in the long term.
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Tidemark Avulsions are a Predominant Form of Endplate Irregularity
Study Design. Descriptive histologic and magnetic resonance imaging study of human cadaveric spines. Objective. To identify and characterize common endplate pathologies to form a histologic foundation for an etiology-based classification system. Summary of Background Data. Irregularities at the spinal disc-vertebra interface are associated with back pain and intervertebral disc herniation injuries. However, there is currently a lack of consensus regarding terminology for classification. This limits the potential for advancing understanding of back pain mechanisms, and prohibits meaningful comparisons for identifying priorities for prevention and treatment. Prior classification systems largely rely on observations from clinical imaging, which may miss subtle pathologic features. Methods. Fifteen cadaveric spines with moderate to severe disc degeneration were obtained and scanned with MRI in the sagittal plane using two-dimensional T1-weighted and T2-weighted fast spin-echo sequences. Eighty-nine lumbar and lower thoracic bone-disc-bone motion segments were extracted, fixed, sectioned, and stained for histologic evaluation. Focal endplate irregularities were identified and categorized based on features that inferred causation. The presence, type, and anatomic location were recorded. A classification system with three major categories of focal endplate irregularities was created. Results. Disc-vertebra avulsion and vertebral rim degeneration were more common than subchondral nodes: 50% of irregularities were classified as rim degeneration (75/150), 35% were classified as avulsions (52/150), and 15% were classified as nodes (23/150). Ninety percent of avulsions were subclassified as “tidemark avulsions,” a highly prevalent form of endplate irregularity in which the outer annulus separates from the vertebra at the tidemark. These tidemark avulsions have not been previously described, yet are visible on T2-weighted MRI as high-intensity regions. Conclusion. This study provides histologic basis for a system to classify focal endplate irregularities. Included is a previously unidentified but prevalent finding of tidemark avulsions, which are visible with both histology and magnetic resonance imaging. These observations will help clinicians better organize patients into meaningful groups to facilitate diagnosis, treatment, and clinical research. Level of Evidence: 3from Spine - Featured Articles - Featured Articles https://ift.tt/2Mbxk7v
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The Relationship Between Improvements in Myelopathy and Sagittal Realignment in Cervical Deformity Surgery Outcomes
Study Design. Retrospective review. Objective. Determine whether alignment or myelopathy improvement drives patient outcomes after cervical deformity (CD) corrective surgery. Summary of Background Data. CD correction involves radiographic malalignment correction and procedures to improve motor function and pain. It is unknown whether alignment or myelopathy improvement drives patient outcomes. Methods. Inclusion: Patients with CD with baseline/1-year radiographic and outcome scores. Cervical alignment improvement was defined by improvement in Ames CD modifiers. modified Japanese Orthopaedic Association (mJOA) improvement was defined as mild [15–17], moderate [12–14], severe [<12]. Patient groups included those who only improved in alignment, those who only improved in mJOA, those who improved in both, and those who did not improve. Changes in quality-of-life scores (neck disability index [NDI], EuroQuol-5 dimensions [EQ-5D], mJOA) were evaluated between groups. Results. A total of 70 patients (62 yr, 51% F) were included. Overall preoperative mJOA score was 13.04 ± 2.35. At baseline, 21 (30%) patients had mild myelopathy, 33 (47%) moderate, and 16 (23%) severe. Out of 70 patients 30 (44%) improved in mJOA and 13 (18.6%) met 1-year mJOA minimal clinically important difference. Distribution of improvement groups: 16/70 (23%) alignment-only improvement, 13 (19%) myelopathy-only improvement, 18 (26%) alignment and myelopathy improvement, and 23 (33%) no improvement. EQ-5D improved in 11 of 16 (69%) alignment-only patients, 11 of 18 (61%) myelopathy/alignment improvement, 13 of 13 (100%) myelopathy-only, and 10 of 23 (44%) no myelopathy/alignment improvement. There were no differences in decompression, baseline alignment, mJOA, EQ-5D, or NDI between groups. Patients who improved only in myelopathy showed significant differences in baseline-1Y EQ-5D (baseline: 0.74, 1 yr:0.83, P < 0.001). One-year C2-S1 sagittal vertical axis (SVA; mJOA r = −0.424, P = 0.002; EQ-5D r = −0.261, P = 0.050; NDI r = 0.321, P = 0.015) and C7-S1 SVA (mJOA r = −0.494, P < 0.001; EQ-5D r = −0.284, P = 0.031; NDI r = 0.334, P = 0.010) were correlated with improvement in health-related qualities of life. Conclusion. After CD-corrective surgery, improvements in myelopathy symptoms and functional score were associated with superior 1-year patient-reported outcomes. Although there were no relationships between cervical-specific sagittal parameters and patient outcomes, global parameters of C2-S1 SVA and C7-S1 SVA showed significant correlations with overall 1-year mJOA, EQ-5D, and NDI. These results highlight myelopathy improvement as a key driver of patient-reported outcomes, and confirm the importance of sagittal alignment in patients with CD. Level of Evidence: 3from Spine - Featured Articles - Featured Articles https://ift.tt/2MbxdsB
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Diagnostic Benefits of Axial-Loaded Magnetic Resonance Imaging Over Recumbent Magnetic Resonance Imaging in Obese Lower Back Pain Patients
Study Design. Single center before-after case series study. Objective. To determine when and in which kind of lower back pathologies, axial-loaded magnetic resonance imaging (MRI) provides additional benefit over recumbent MRI. Summary and Background Data. Systems simulating physiological axial loading of the spine in patients examined in the supine position have recently been introduced in clinical practice. However, indications for examinations with axial loading have yet to be clearly specified. Methods. Ninety patients (46 men, 44 women, aged 20–90 yr) with lower back pain underwent lumbar spine MRI with and without axial loading. MRI was performed in a supine position on a 1.5 T system using a compression device. A high-resolution 3D T2-weighted sequence was used for image acquisition. Clinical characteristics of patients were established using questionnaire surveys and demographic data. MR images were assessed for the appearance of changes after axial loading. After determining which patients showed significant changes, logistic regression analysis was performed with 15 independent variables (clinical, demographic, and imaging-related). Results. After axial loading, 48.9% of patients showed additional changes. Multivariate analysis revealed that only obesity was a statistically significant predictor of the occurrence of changes (P < 0.05). After axial loading, 11 potentially clinically relevant changes appeared in seven patients, the most common being absolute spinal stenosis (n = 7). Conclusion. Axial loading may increase the diagnostic value of lumbar spine MRI in patients with obesity and/or those with suspected spinal canal stenosis. Level of Evidence: 4from Spine - Featured Articles - Featured Articles https://ift.tt/2KGMpJ6
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Back Pain and Co-occurring Conditions: Findings From a Nationally Representative Sample
Study Design. Cross-sectional population-level health survey. Objective. To describe the frequency of co-occurring conditions with back pain; to identify risk factors for back pain controlling for co-occurring conditions; and to examine the association between back pain and individual co-occurring conditions. Summary of Background Data. Back pain shares risk factors with a range of other conditions. Most studies have considered risk factors for back pain without taking into account the potential influence of co-occurring conditions. Methods. Analysis of the 2013 Canadian Community Health Survey (n = 61,854, age ≥15 yr). Back pain status and co-occurring conditions were determined from questions about long-term health conditions diagnosed by a health profession. Multivariable log-Poisson regression analysis was used to assess the adjusted association of back pain with demographic and lifestyle characteristics and co-occurring conditions. Results. The population prevalence of reported back pain was 19.3%. Most (71%) reported at least one co-occurring condition. Most frequently reported were arthritis (35%), high blood pressure (26%), migraine (18%), and mood disorders (14%). Following the addition of co-occurring condition count to the regression model, being female and being overweight/obese were no longer significantly associated with back pain, and the associations with ages 45 to 54 years and older, low-income, smoking, and being physical inactive were significantly attenuated. The highest prevalence ratio, 3.32 (95% confidence interval: 3.06–3.59), was for 3+ co-occurring conditions. In multivariable regression all but a few individual chronic conditions remained significant associated with back pain. Conclusion. Established risk factors for back pain may be largely a reflection of shared risk factors with co-occurring conditions. The high frequency of co-occurring conditions likely reflects diverse mechanisms related to heterogeneity of back pain. The extent of association of co-occurring conditions with back pain has implications for clinical management and need for further research to characterize subgroups. Level of Evidence: 2from Spine - Featured Articles - Featured Articles https://ift.tt/2Mm4D81
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Health-related Quality of Life of Adolescents With Severe Untreated Congenital Kyphosis and Kyphoscoliosis in a Developing Country
Study Design. A cross-sectional study Objective. The aim of this study was to study the health-related quality of life (HRQOL) of adolescents with severe untreated congenital kyphosis (CK) and congenital kyphoscoliosis (CKS) in a developing country. Summary of Background Data. Surgical intervention is generally indicated early in patients with progressive CK or CKS to prevent the progression of deformity and to improve the quality of life of the patients. HRQOL of adolescents with untreated CK and CKS in developing countries has never been investigated. Methods. Arabic version of the Scoliosis Research Society 22 revision (SRS-22r) questionnaire used to study HRQOL of adolescents with severe untreated CK or CKS in a dev eloping country. Results. A total of 134 adolescent (mean age 17.1 years) completed SRS-22r questionnaire: 38 patients with CK from 80° to 110° (group 1), 24 patients with CK > 110° (group 2), 27 patients with CKS (group 3), and 45 healthy controls (group 4). Group 1 had significant lower scores than group 4 in all SRS 22r domains (P < 0.001). Scores of all domains except pain showed significant (P < 0.001) decrease with increase of the severity of CK. Group 3 had significant lower scores than group 2 in all SRS-22r domains except mental health. Satisfaction domain had significant lower scores than all other SRS-22r domains for group 1, 2, and 3. All patients of groups 2 and 3 gave the minimum answers for satisfaction domain questions. A total of 69%, 84% and 94% of group 1, 2, and 3, respectively, gave the minimum answer when asked whether their back condition affects their personal relationships. Female patients of group 1, 2, and 3 had significant lower scores for self-image domain. Conclusion. HRQOL is severely affected in adolescents with untreated severe CK and CKS in a developing country. Level of Evidence: 3from Spine - Featured Articles - Featured Articles https://ift.tt/2MwPaP7
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Influence of the Initial Sagittal Lumbar Alignment on Clinical and Radiological Outcomes of Single-Level Lumbar Total Disc Replacements at a Minimum 2-Year Follow-up
Study Design. Retrospective cohort study Objective. To analyze the clinical and radiographic outcomes of patients undergoing a one-level lumbar total disc replacement (TDR), according to the initial sagittal alignment of the spine. Summary of Background Data. No authors have highlighted correlation between the initial spinopelvic parameters and the postoperative outcome after a one-level TDR. Methods. Seventy-eight patients were included: 14 TDR at L4-L5 and 64 TDR at L5-S1 level. Clinical assessment was performed on leg pain and axial back pain Visual Analog Scale (VAS), Oswestry Disability Index, and Short Form-36 Health Survey. Radiographic assessment included full spine standing anteroposterior and lateral films. Data were compared according to the initial lumbar sagittal alignment described by Roussouly. Results. Forty-five female patients and 33 male patients with a mean age of 41.7 years (95% confidence interval [40.3–43.1]) were included. The mean follow-up was 46.4 months (95% [40.6–51.6]). Two patients were considered as Roussouly type 1 (2.6%), 36 patients as type 2 (46.2%), 33 patients as type 3 (42.3%), and 7 patients as type 4 (9%). Preoperatively, there were no clinical differences depending on Roussouly's type of back. Pelvic incidence (P < 0.001), sacral slope (P < 0.001), lumbar lordosis (P < 0.001), and spinosacral angle (P < 0.001) were different between the Roussouly's types of back. Postoperative clinical outcome improved (P < 0.001) but did not vary according to the Roussouly types except for leg pain VAS (P = 0.03). Post hoc tests did not reveal difference between the Roussouly's types and leg pain VAS. Postoperative radiographic outcomes did not change excepted for the lumbar lordosis (P < 0.001), thoracic kyphosis (P = 0.007), and spinosacral angle (P = 0.02). The Roussouly type had no effect on the postoperative course of radiographic parameters. Conclusion. Equivalent clinical and radiographic outcomes have been highlighted independently of the increasing of the sacral slope for patients with one-level lumbar TDR. Level of Evidence: 3from Spine - Featured Articles - Featured Articles https://ift.tt/2OV3tP4
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Thursday, August 9, 2018
Measurement properties of Visual Analogue Scale, Numeric Rating Scale and Pain Severity subscale of the Brief Pain Inventory in patients with low back pain: a systematic review
Low back pain (LBP) is the most disabling health condition worldwide 33. Measuring the impact of LBP on patients’ lives is fundamental to monitor clinical management and to study the (cost-) effectiveness of treatments 4. Patients with LBP have indicated that the most important domains to be measured are: physical functional activities, pain reduction, quality of life, enjoyment of life, emotional well-being, and fatigue 9, 43, 103. A core outcome set initiative (involving patients) aimed at standardizing measurement for LBP identified four core outcome domains for clinical trials: physical functioning, pain intensity, health-related quality of life, and number of deaths 9.
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Exploring the relationships between altered body perception, limb position sense, and limb movement sense in complex regional pain syndrome
Perceiving the size, shape, position and movement of our limbs is essential to help us interact adequately with our environment. An extensive literature shows that chronic pain conditions are often accompanied by various distortions in body perception, which can include changes in perception of the size, shape and temperature of the painful limb11,17,18,22,36. In addition, alterations of the sense of limb position (assessed with the limb in a static posture) have also been observed1,11,33. For example, individuals with Complex Regional Pain Syndrome (CRPS) were shown to overestimate the angular position of their painful wrist on active and passive movements but passive movement elicited the greatest disparity1.
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The Pain Course: 12 and 24 month outcomes from a randomised controlled trial of an internet-delivered pain management program provided with different levels of clinician support
Internet-delivered pain management programs have considerable potential for increasing access to evidence-based pain management [16, 25, 31]. Internet-delivered pain management programs are often based on the same principles and teach the same self-management skills as face-to-face programs. However, these programs employ carefully designed online modules to teach pain management information and support patients to develop their self-management skills [36]. These programs can be offered in clinician guided formats, where patients are provided weekly support throughout the program via telephone or email, or in more self-guided formats with little or no clinician contact.
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Wednesday, August 8, 2018
Ethical, Palliative, and Policy Considerations in Disorders of Consciousness
Publication date: Available online 8 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Joseph J. Fins, James L. Bernat
Abstract
This essay complements the scientific and practice scope of the American Academy of Neurology Guideline on Disorders of Consciousness by providing a discussion of the ethical, palliative, and policy aspects of the management of this group of patients. We endorse the renaming of “permanent” vegetative state to “chronic” vegetative state given the increased frequency of reports of late improvements but suggest that further refinement of this class of patients is necessary to distinguish late recoveries from patients who were misdiagnosed or in cognitive-motor dissociation. Additional nosologic clarity and prognostic refinement is necessary to preclude overestimation of low probability events. We argue that the new descriptor “unaware wakefulness syndrome” is no clearer than “vegetative state” in expressing the mismatch between apparent behavioral unawareness when patients have covert consciousness or cognitive motor dissociation. We advocate routine universal pain precautions as an important element of neuropalliative care for these patients given the risk of covert consciousness. In medical decision-making, we endorse the use of advance directives and the importance of clear and understandable communication with surrogates. We show the value of incorporating a learning health care system so as to promote therapeutic innovation. We support the Guideline’s high standard for rehabilitation for these patients but note that those systems of care are neither widely available nor affordable. Finally, we applaud the Guideline authors for this outstanding exemplar of engaged scholarship in the service of a frequently neglected group of brain-injured patients.
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Practice Guideline Update Recommendations Summary: Disorders of Consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research
Publication date: Available online 8 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Joseph T. Giacino, Douglas I. Katz, Nicholas D. Schiff, John Whyte, Eric J. Ashman, Stephen Ashwal, Richard Barbano, Flora M. Hammond, Steven Laureys, Geoffrey S.F. Ling, Risa Nakase-Richardson, Ronald T. Seel, Stuart Yablon, Thomas S.D. Getchius, Gary S. Gronseth, Melissa J. Armstrong
Abstract
Objective
To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC).
Methods
Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended.
Recommendations
Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/ unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale–Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100–200 mg bid) for adults with traumatic VS/UWS or MCS (4–16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.
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Ethical, Palliative, and Policy Considerations in Disorders of Consciousness
Publication date: Available online 8 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Joseph J. Fins, James L. Bernat
Abstract
This essay complements the scientific and practice scope of the American Academy of Neurology Guideline on Disorders of Consciousness by providing a discussion of the ethical, palliative, and policy aspects of the management of this group of patients. We endorse the renaming of “permanent” vegetative state to “chronic” vegetative state given the increased frequency of reports of late improvements but suggest that further refinement of this class of patients is necessary to distinguish late recoveries from patients who were misdiagnosed or in cognitive-motor dissociation. Additional nosologic clarity and prognostic refinement is necessary to preclude overestimation of low probability events. We argue that the new descriptor “unaware wakefulness syndrome” is no clearer than “vegetative state” in expressing the mismatch between apparent behavioral unawareness when patients have covert consciousness or cognitive motor dissociation. We advocate routine universal pain precautions as an important element of neuropalliative care for these patients given the risk of covert consciousness. In medical decision-making, we endorse the use of advance directives and the importance of clear and understandable communication with surrogates. We show the value of incorporating a learning health care system so as to promote therapeutic innovation. We support the Guideline’s high standard for rehabilitation for these patients but note that those systems of care are neither widely available nor affordable. Finally, we applaud the Guideline authors for this outstanding exemplar of engaged scholarship in the service of a frequently neglected group of brain-injured patients.
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Practice Guideline Update Recommendations Summary: Disorders of Consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research
Publication date: Available online 8 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Joseph T. Giacino, Douglas I. Katz, Nicholas D. Schiff, John Whyte, Eric J. Ashman, Stephen Ashwal, Richard Barbano, Flora M. Hammond, Steven Laureys, Geoffrey S.F. Ling, Risa Nakase-Richardson, Ronald T. Seel, Stuart Yablon, Thomas S.D. Getchius, Gary S. Gronseth, Melissa J. Armstrong
Abstract
Objective
To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC).
Methods
Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended.
Recommendations
Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/ unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale–Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100–200 mg bid) for adults with traumatic VS/UWS or MCS (4–16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.
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Associations between adolescent chronic pain and prescription opioid misuse in adulthood
Prescription opioid misuse is defined as the consumption of opioids in manner or dose other than prescribed, consuming others’ prescriptions, or consuming opioids for feelings that are elicited (i.e. to get high)31. Prescription opioid misuse is a serious public health epidemic in the United States. In 2013, almost 10 million Americans (4.9% of the adult population) reported prescription opioid misuse 15. Prescription opioid misuse was found to be most prevalent among young adults 18-26 years of age, of whom 7.1% reported opioid misuse over the past 12 months in 2016 in the United States 4.
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Do people with chronic musculoskeletal pain have impaired motor imagery? A meta-analytical systematic review of the left/right judgement task
The brain contains representations of the body that are required for normal functioning, including goal directed movements and behavior20. This concept of a body schema17 includes integrated sensory inputs and ideas about ones body1. Both executed and imagined movements are subserved by this online representation of the body45. One way of investigating the integrity of the body schema is by the use of implicit motor imagery. The left/right judgement task (LRJT) is an implicit motor imagery task that involves viewing images of a body-part and determining whether each image belongs to, or is rotating towards, the left or right side of the body36.
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Tuesday, August 7, 2018
Prevalence and profile of High Impact Chronic Pain in the United States
Chronic pain is a major global health issue9 with immense social and economic impacts,4,8 yet has proven difficult to operationalize.25 Chronic pain is often defined by pain duration,1,13,23,25,26 where pain persisting 3-6 months or more since onset can yield prevalence estimates for chronic pain ranging from 19% to 43%, or up to 116 million Americans.10,12,15,19,26 While conceptually appealing, this hotly debated7 approach does not consider the multi-dimensional nature of chronic pain, namely the presence of activity limitations and participation restrictions,5,17,30-36 classifications recognized by the World Health Organization.
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The mice with human tumours: Growing pains for a popular cancer model
The mice with human tumours: Growing pains for a popular cancer model
The mice with human tumours: Growing pains for a popular cancer model, Published online: 07 August 2018; doi:10.1038/d41586-018-05890-8
Researchers had high hopes for patient-derived xenografts. Now they are contending with limitations in the clinic and the lab.
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Monday, August 6, 2018
Increase in lactate without change in nutritive blood flow or glucose at active trigger points following massage: A randomized clinical trial
Publication date: Available online 6 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Albert F. Moraska, Robert C. Hickner, Rachael Rzasa-Lynn, Jay P. Shah, Jonathan R. Hebert, Wendy M. Kohrt
Abstract
Objective
To investigate changes in nutritive blood flow as well as interstitial glucose and lactate within an active myofascial trigger point (MTrP) following massage.
Design
Randomized, placebo-controlled trial.
Setting
Subjects were recruited from the general population; procedures were conducted at a research center affiliated with a university hospital.
Participants
Twenty-five adults (18-49 years old) with episodic or chronic tension-type headache and an active MTrP in the upper trapezius muscle.
Interventions
Subjects were randomized to receive a single trigger point release (TRP) massage or sham ultrasound (US) treatment at an active MTrP in the upper trapezius muscle. Microdialysis was used to continuously sample interstitial fluid from the MTrP before, during, and for 60 min following intervention.
Main Outcome Measures
The primary outcome measure was nutritive blood flow within the MTrP as measured by microdialysis ethanol clearance; secondary measures included dialysate glucose, dialysate lactate, and subject discomfort with the procedures. Pressure-pain threshold (PPT) was determined to assess treatment effectiveness.
Results
There was no treatment effect of TPR massage on nutritive blood flow (p=0.663) or dialysate glucose (p=0.766). The interaction for lactate was significant indicating that dialysate lactate increased for TPR massage versus sham US (p=0.04); maximum lactate increase over baseline was observed at 60 minutes after TPR massage (p=0.007, 0.128 μM, 95% CI 0.045-0.212). Pain evoked by probe placement into an active MTrP was low. An interaction effect on PPT was significant (p= 0.005).
Conclusion
TPR massage of an active MTrP affected anaerobic metabolism as represented by an increase in dialysate lactate without change in nutritive blood flow or dialysate glucose. The lack of a treatment effect on blood flow is discussed.
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The Effects of Movement-to-Music (M2M) and Adapted Yoga on Physical and Psychosocial Outcomes in People with Multiple Sclerosis
Publication date: Available online 6 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Hui-Ju Young, Tapan S. Mehta, Cassandra Herman, Fuchenchu Wang, James H. Rimmer
Abstract
Objective
To investigate the effects of two 12-week exercise training interventions, movement-to-music (M2M) and adapted yoga (AY), on physical and psychosocial outcomes in people with multiple sclerosis (MS).
Design
Three-arm randomized controlled proof-of-concept trial.
Setting
A community-based fitness facility.
Participants
Participants (N=81) with MS (Patient Determined Disease Steps [PDDS] self-reported disease status scores: 0-6) between ages of 18 and 65 years were randomized to: M2M (n=27), AY (n=26), or waitlist control (n=28).
Interventions
Both M2M and AY completed three 60-minute exercise sessions per week for 12 weeks. Waitlist controls received biweekly newsletters via mail that contained educational information on living with MS.
Main Outcome Measures
Primary measures were Timed Up and Go (TUG, seconds), Six-minute Walk Test (6MWT, meters), and Five Times Sit-to-Stand Test (FTSST, seconds). Secondary measures were self-reported outcomes assessed using PROMIS Fatigue and Pain Interference Short Form 8a. Participants were evaluated at baseline and post-intervention. Primary analyses were performed using an intent-to-treat mixed model ANCOVA.
Results
Comparisons across all three groups revealed significant group differences in TUG and 6MWT. Post hoc analyses indicated significant improvements in TUG (LSM difference [95% CI]=-1.9s [-3.3, -0.5], p=0.01, d=0.7) and 6MWT (41.0m [2.2, 80.0], p=0.04, d=0.6; controlled for PDDS) in M2M compared to controls, while no significant differences were observed when compared AY to controls. No significant group differences were found on FTSST, fatigue and pain interference.
Conclusion
Movement-to-music may be a useful and enjoyable exercise form for people with MS in improving mobility and walking endurance and merits long-term study in larger study populations.
from ScienceDirect Publication: Archives of Physical Medicine and Rehabilitation https://ift.tt/2nftkV9
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Friday, August 3, 2018
Predictability and probability modulate the neural responses to other’s pain: An event-related potential investigation
Publication date: Available online 3 August 2018
Source: Biological Psychology
Author(s): Chong Liao, Haiyan Wu, Qing Guan, Yuejia Luo, Fang Cui
Abstract
Two ERP experiments were designed to explore the effect of predictability (Exp1) and probability (Exp2) on the perception of others’ pain, respectively. In Exp1, we compared the ERP responses to painful and non-painful pictures when they were fully predictable and fully unpredictable. Results revealed that when the valence of the pictures (painful or non-painful) was fully predictable, the amplitudes of N2 and P3 components triggered by the painful pictures were significantly more positive than the amplitudes of N2 and P3 components triggered by the non-painful ones. When the valence of the pictures was fully unpredictable, the amplitudes of N2 and P3 triggered by the painful and the non-painful pictures were comparable. Besides, the P3 amplitude was positively correlated with the scores of empathy trait (i.e., personal distress). In Exp2, the probability of the presentation of a painful picture was manipulated as low (30%), medium (60%) and high (90%). Results showed that with the increase in the probability of a painful picture’s presentation, the amplitude of N2 elicited decreased. No significant effect was observed on P3. These findings indicated that the early perceptual processing stage reflected in N2 was more likely to be a threat-detection stage, while the later stage reflected in P3 may actually be the stage in which participant empathized other’s pain. Moreover, the more expected pain of others induced stronger empathic responses reflected in the P3. To the best of our knowledge, this study offers the very first psychophysical evidence of the predictability and probability’s effect on pain empathy.
from ScienceDirect Publication: Biological Psychology https://ift.tt/2OGyLZX
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Wednesday, August 1, 2018
Comparative Effectiveness of Injection Therapies in Rotator Cuff Tendinopathy: A Systematic Review, Pairwise and Network Meta-analysis of Randomized Controlled Trials
Publication date: Available online 2 August 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Meng-Ting Lin, Ching-Fang Chiang, Chueh-Hung Wu, Yi-Ting Huang, Yu-Kang Tu, Tyng-Guey Wang
Objective
To compare the effectiveness of diverse injections in patients with rotator cuff tendinopathy using pairwise and network meta-analysis.
Data Sources
PubMed, EMBASE, Scopus and Cochrane Library were searched for studies published up to September 31, 2017.
Study Selection
We included all published or unpublished randomized controlled trials (RCTs) comparing diverse injections including corticosteroid, nonsteroidal anti-inflammatory drugs, hyaluronic acid, botulinum toxin, platelet-rich plasma (PRP), and prolotherapy in patients with rotator cuff tendinopathy. Among the 1495 records screened, 18 studies were included in the meta-analysis.
Data Extraction
The quality of RCTs was assessed with Cochrane Risk of Bias Tool by two independent raters. The primary outcome was pain reduction, and the secondary outcome was functional improvement.
Data Synthesis
Standardized mean difference (SMD) was utilized for pairwise and network meta-analysis. In pairwise meta-analysis, corticosteroid was more effective only in the short-term in both pain reduction and functional improvement. Network meta-analysis indicated that prolotherapy significantly reduced pain compared with placebo in the long-term [over 24 weeks, SMD: 2.63, 95% confidence interval (CI): 1.88–3.38]; meanwhile PRP significantly improved shoulder function compared with placebo in the long-term (over 24 weeks, SMD: 0.44, 95% CI: 0.05–0.84).
Conclusions
For patients with rotator cuff tendinopathy, corticosteroid plays a role in the short-term (3-6 weeks) but not in long-term (over 24 weeks) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long-term (over 24 weeks). On account of heterogeneity, interpreting these results with caution is warranted.
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Hip pain in young adults: consider primary bone sarcoma
Dick and colleagues cover in detail the management of hip pain in the young adult.1 The important differential of primary bone sarcoma, however, is glossed over with a very brief mention in box 1....
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from Latest headlines from BMJ https://ift.tt/2n3sUBu
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