Size does matter, but it isn't everything: the challenge of modest treatment effects in chronic pain clinical trials

Twenty years ago, Andrew Moore and colleagues28 concluded on the basis of a series of simulations that “size is everything” if the samples of patients enrolled in randomized clinical trials (RCTs) are to provide credible estimates of the clinical efficacy of acute pain treatments. The results of 2 recent studies suggest that factors such as increasing placebo group response and changes in study methodologic characteristics may limit or reduce estimates of the effects of chronic pain treatments and thereby necessitate larger sample sizes for adequate statistical power to identify minimally clinically important effects.

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[Perspectives] A last cup of tea

When on Nov 1, 2006, Russian ex-secret agent Alexander Litvinenko was admitted with acute abdominal pain, diarrhoea, and vomiting to hospital in London, UK, doctors did not realise that they were facing a case of poisoning with polonium-210. As described by the doctors who treated Litvinenko in The Lancet, early symptoms of polonium-210 poisoning were indistinguishable from those of a wide range of chemical toxins. When polonium-210 was finally identified as the source of the poisoning, Litvinenko's condition was desperate and he died on Nov 23.

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Application of ICD‐11 among individuals with chronic pain: A post hoc analysis of the Stanford Self‐Management Program

Abstract

Background

Chronic primary pain (CPP) is one of seven diagnostic groups within the proposed classification of chronic pain in ICD‐11. Our aims were to apply the proposed ICD‐11 criteria in a large cohort of chronic pain patients participating in the Chronic Pain Self‐Management Program (CPSMP) and further investigate whether participants with CPP differed from participants with chronic secondary pain (CSP) regarding health, health expenditure, and the effect of participating in the CPSMP.

Methods

A secondary analysis of a randomized, controlled trial on the effect of the CPSMP. Four examiners categorized participants’ pain according to ICD‐11 using register‐based medical diagnoses and patients’ self‐reported symptoms. Afterwards, differences between CPP and CSP were examined.

Results

Out of 394 participants, 312 were successfully classified into CPP (n=164) or CSP (n=148) whereas 76 had a mixed pain condition. Participants with CPP were younger, more likely to be women, and had a longer pain duration compared to participants with CSP. Participants with CPP reported worse health‐related quality of life on the SF‐36 Mental Component Summary and subscales of vitality, social functioning, and bodily pain. Participants with CSP had more physical comorbidities and higher total health expenditure. None of the groups benefitted from the CPSMP.

Conclusions

We successfully applied the new classification of chronic pain in ICD‐11 on the basis of ICD‐10 medical diagnoses and symptom self‐report. Participants with CPP differed significantly from participants with CSP on baseline characteristics, self‐reported health measures, and total health expenditure. The CPSMP was not effective in any of the groups.

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Right posterior neck pain and swelling

This is a clinical photograph of cellulitis and an abscess over follicular dendritic cell sarcoma (fig 1).bmj;366/sep26_6/l5388/F1F1f1Fig 1The patient was a 51 year old man with two weeks of right...

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Effects of smoking on patients with chronic pain: a propensity-weighted analysis on the Collaborative Health Outcomes Information Registry

Tobacco smoking is associated with adverse health effects, and its relationship to pain is complex. The longitudinal effect of smoking on patients attending a tertiary pain management center is not well established. Using the Collaborative Health Outcomes Information Registry of patients attending the Stanford Pain Management Center from 2013 to 2017, we conducted a propensity-weighted analysis to determine independent effects of smoking on patients with chronic pain. We adjusted for covariates including age, sex, body mass index, depression and anxiety history, ethnicity, alcohol use, marital status, disability, and education. We compared smokers and nonsmokers on pain intensity, physical function, sleep, and psychological and mood variables using self-reported NIH PROMIS outcomes. We also conducted a linear mixed-model analysis to determine effect of smoking over time. A total of 12,368 patients completed the CHOIR questionnaire of which 8584 patients had complete data for propensity analysis. Smokers at time of pain consultation reported significantly worse pain intensities, pain interference, pain behaviors, physical functioning, fatigue, sleep-related impairment, sleep disturbance, anger, emotional support, depression, and anxiety symptoms than nonsmokers (all P < 0.001). In mixed-model analysis, smokers tended to have worse pain interference, fatigue, sleep-related impairment, anger, emotional support, and depression over time compared with nonsmokers. Patients with chronic pain who smoke have worse pain, functional, sleep, and psychological and mood outcomes compared with nonsmokers. Smoking also has prognostic importance for poor recovery and improvement over time. Further research is needed on tailored therapies to assist people with chronic pain who smoke and to determine an optimal strategy to facilitate smoking cessation.

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Transcriptional profile of spinal dynorphin-lineage interneurons in the developing mouse

Mounting evidence suggests that the spinal dorsal horn (SDH) contains multiple subpopulations of inhibitory interneurons that play distinct roles in somatosensory processing, as exemplified by the importance of spinal dynorphin-expressing neurons for the suppression of mechanical pain and chemical itch. Although it is clear that GABAergic transmission in the SDH undergoes significant alterations during early postnatal development, little is known about the maturation of discrete inhibitory “microcircuits” within the region. As a result, the goal of this study was to elucidate the gene expression profile of spinal dynorphin (pDyn)-lineage neurons throughout life. We isolated nuclear RNA specifically from pDyn-lineage SDH interneurons at postnatal days 7, 21, and 80 using the Isolation of Nuclei Tagged in Specific Cell Types (INTACT) technique, followed by RNA-seq analysis. Over 650 genes were ≥2-fold enriched in adult pDyn nuclei compared with non-pDyn spinal cord nuclei, including targets with known relevance to pain such as galanin (Gal), prepronociceptin (Pnoc), and nitric oxide synthase 1 (Nos1). In addition, the gene encoding a membrane-bound guanylate cyclase, Gucy2d, was identified as a novel and highly selective marker of the pDyn population within the SDH. Differential gene expression analysis comparing pDyn nuclei across the 3 ages revealed sets of genes that were significantly upregulated (such as Cartpt, encoding cocaine- and amphetamine-regulated transcript peptide) or downregulated (including Npbwr1, encoding the receptor for neuropeptides B/W) during postnatal development. Collectively, these results provide new insight into the potential molecular mechanisms underlying the known age-dependent changes in spinal nociceptive processing and pain sensitivity.

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Injustice Appraisal but not Pain Catastrophizing Mediates the Relationship Between Perceived Ethnic Discrimination and Depression and Disability in Low Back Pain

The pain literature documents notable racial/ethnic disparities in chronic pain experience and care.1,25 Individuals identifying as Black/African American endorse more frequent and disabling pain across a number of conditions compared to other racial groups, most notably Whites.1,25 With respect to low back pain – the leading cause of pain and disability in the United States – research in the area of Worker's Compensation highlights racial disparities in evaluation, treatment, and litigation outcomes of work-related lower back injuries9,10,12,13 with Blacks showing long-term vulnerability to greater pain intensity, catastrophizing, emotional distress, financial stress9,11 and future disability.

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The decline of endogenous pain modulation with aging: A meta-analysis of temporal summation and conditioned pain modulation

The prevalence estimates of chronic pain among older adults in the United States are alarming, with estimates as high as 60% to 75% among community-dwelling older adults.43 Furthermore, epidemiological research shows that the prevalence of chronic pain increases with age up to the seventh decade of life and then plateaus.14 A growing body of evidence suggests one potential mechanism predisposing older adults to increased risk of chronic pain is an age-related decline in the capacity to endogenously modulate pain.

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Nociceptor Interleukin 33 Receptor/ST2 Signaling in Vibration-Induced Muscle Pain in the Rat

Occupational vibration exposure produces a condition characterized by musculoskeletal, neurological and vascular pathology, referred to as hand-arm vibration syndrome (HAVS).31 This condition affects up to 50% of workers who use handheld power tools such as jackhammers, pneumatic chipping and grinding mechanical tools.36 One of the most problematic symptoms of HAVS is persistent muscle pain, which can be extremely disabling and resistant to treatment.13,14,31 We have developed a preclinical model of HAVS in the rat that displays persistent mechanical hyperalgesia in the gastrocnemius muscle, mediated by pro-inflammatory cytokines, interleukin (IL) 6 and tumor necrosis alpha (TNFα).

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Changes in Trunk and Pelvis Motion among Persons with Unilateral Lower Limb Loss during the First Year of Ambulation

Publication date: Available online 19 September 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Caitlin E. Mahon, Courtney M. Butowicz, Christopher L. Dearth, Brad D. Hendershot

Abstract

Objective

To retrospectively investigate trunk-pelvis kinematic outcomes among persons with unilateral transtibial and transfemoral limb loss with time from initial independent ambulation with a prosthesis, while secondarily describing self-reported presence and intensity of low back pain. Over time, increasing trunk-pelvis range of motion and decreasing trunk-pelvis coordination with increasing presence and/or intensity of low back pain were hypothesized. Additionally, less trunk-pelvis range of motion and more trunk-pelvis coordination for persons with more distal limb loss was hypothesized.

Design

Inception cohort with up to five repeated evaluations, including both biomechanical and subjective outcomes, during a one-year period (0, 2, 4, 6, and 12-months) after initial ambulation with a prosthesis.

Setting

Biomechanics laboratory within Military Treatment Facility.

Participants

Twenty-two males with unilateral transtibial limb loss and ten males with unilateral transfemoral limb loss.

Interventions

Not applicable

Main Outcome Measures

Tri-planar trunk-pelvis range of motion, and intersegmental coordination (continuous relative phase), obtained at self-selected (∼1.30m/s) and controlled (∼1.20m/s) walking velocities. Self-reported presence and intensity of low back pain.

Results

An interaction effect between time and group existed for sagittal (p=.039) and transverse (p=.009) continuous relative phase at self-selected walking velocity, and transverse trunk range of motion (p=.013) and sagittal continuous relative phase (p=.005) at controlled walking velocity. Trunk range of motion generally decreased and trunk-pelvis coordination generally increased with increasing time after initial ambulation. Sagittal trunk and pelvis ROM were always less and frontal trunk-pelvis coordination always greater for persons with more distal limb loss. Low back pain increased for persons with transtibial limb loss and decreased for persons with transfemoral limb loss following the 4-month timepoint.

Conclusions

Temporal changes (or lack thereof) in features of trunk-pelvis motions within the first year of ambulation help elucidate relationships between (biomechanical) risk factors for low back pain after limb loss.

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Acute and chronic pain in children and adolescents with cerebral palsy: prevalence, interference and management

Publication date: Available online 12 September 2019

Source: Archives of Physical Medicine and Rehabilitation

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

Abstract

Objective

To determine the prevalence, impact and management of acute and chronic pain amongst youth aged 5-18 years with cerebral palsy, attending outpatient rehabilitation services.

Design

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

Setting

Outpatient rehabilitation.

Participants

280 participants with cerebral palsy aged 5-18 years and/or their parent/caregiver. 45.7% (n=128) self-report and 54.3% (n=152) proxy-report.

Interventions

Not applicable.

Main outcome measure

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

Results

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

Conclusions

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

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Frequency of primary neck pain in mild traumatic brain injury/concussion patients

Publication date: Available online 4 September 2019

Source: Archives of Physical Medicine and Rehabilitation

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

Abstract

Objectives

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

Design

Cohort study.

Setting

Level I trauma center ED.

Participants

95 patients presenting to the ED with symptoms of mTBI having been exposed to an event that could have caused a mTBI.

Interventions

Not applicable.

Main outcome measures

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

Results

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

Conclusions

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

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

Publication date: September 2019

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

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

Abstract

Objective

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

Data Sources

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

Study Selection

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

Data Extraction

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

Data Synthesis

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

Conclusion

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

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

Publication date: September 2019

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

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

Abstract

Objective

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

Data Sources

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

Study Selection

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

Data Extraction

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

Data Synthesis

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

Conclusions

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

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

Publication date: September 2019

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

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

Abstract

Objective

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

Design

Randomized controlled trial with placebo control.

Setting

Outpatient physical therapy clinics within a hospital network.

Participants

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

Interventions

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

Main Outcome Measures

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

Results

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

Conclusions

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

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

Publication date: September 2019

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

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

Abstract

Objective

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

Design

Double-blind randomized placebo-controlled clinical trial.

Setting

Tertiary care university hospital.

Participants

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

Intervention

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

Main Outcome Measures

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

Results

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

Conclusion

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

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High frequency medical cannabis use is associated with worse pain among individuals with chronic pain

Cannabis use is becoming increasingly widespread as more states legalize cannabis for medical and recreational states purposes. There are an estimated >2.1 million people with medical cannabis licenses51 in the 33 states with legalized medical cannabis,50 and we recently showed that chronic pain accounts for 62% of patient qualifying conditions for medical cannabis licenses nationwide.6 Coupled with the common lack of physician knowledge on cannabis26 and reports of decreased opioid and other pain medication prescribing in states with legalized medical cannabis,11-13,70 this finding may indicate dissatisfaction with current pain medications – many of which have significant side effects and only work in a subset of the population.

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A Systematic Review on the Effects of Group Singing on Persistent Pain in People with Long‐term Health Conditions

Abstract

Background and Objectives

Singing can have a range of health benefits; this paper reviews evidence of the effects of group singing for chronic pain in people with long‐term health conditions.

Database and Data Treatment

We searched for published peer‐reviewed singing studies reporting pain measures (intensity, interference and depression) using major electronic databases (last search date 31/07/2018). After screening 123 full texts, 13 studies met the inclusion criteria: five RCTs, seven non‐RCTs and one qualitative study. Included studies were appraised using Downs and Black and CASP quality assessments.

Results

Included studies reported differences in the type of singing intervention, long‐term condition and pain measures. Due to the high heterogeneity, we conducted a narrative review. There is a positive trend of singing interventions reducing pain intensity, but more equivocal support for reductions in pain interference and depression. Additionally, qualitative data synthesis identified three key linked and complementary themes: physical, psychological and social benefits.

Conclusion

Group singing appears to have potential to reduce pain intensity, pain interference and depression; however, we conclude there is only partial support for singing on some pain outcomes based on the limited available evidence of varied quality. Given the positive findings of qualitative studies, this review recommends that practitioners are encouraged to continue this work. More studies of better quality are needed. Future studies should adopt more robust methodology and report their singing intervention in details. Group singing may be an effective and safe approach for reducing persistent pain and depression in people with long‐term health conditions.

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Changes in Trunk and Pelvis Motion among Persons with Unilateral Lower Limb Loss during the First Year of Ambulation

Publication date: Available online 19 September 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Caitlin E. Mahon, Courtney M. Butowicz, Christopher L. Dearth, Brad D. Hendershot

Abstract

Objective

To retrospectively investigate trunk-pelvis kinematic outcomes among persons with unilateral transtibial and transfemoral limb loss with time from initial independent ambulation with a prosthesis, while secondarily describing self-reported presence and intensity of low back pain. Over time, increasing trunk-pelvis range of motion and decreasing trunk-pelvis coordination with increasing presence and/or intensity of low back pain were hypothesized. Additionally, less trunk-pelvis range of motion and more trunk-pelvis coordination for persons with more distal limb loss was hypothesized.

Design

Inception cohort with up to five repeated evaluations, including both biomechanical and subjective outcomes, during a one-year period (0, 2, 4, 6, and 12-months) after initial ambulation with a prosthesis.

Setting

Biomechanics laboratory within Military Treatment Facility.

Participants

Twenty-two males with unilateral transtibial limb loss and ten males with unilateral transfemoral limb loss.

Interventions

Not applicable

Main Outcome Measures

Tri-planar trunk-pelvis range of motion, and intersegmental coordination (continuous relative phase), obtained at self-selected (∼1.30m/s) and controlled (∼1.20m/s) walking velocities. Self-reported presence and intensity of low back pain.

Results

An interaction effect between time and group existed for sagittal (p=.039) and transverse (p=.009) continuous relative phase at self-selected walking velocity, and transverse trunk range of motion (p=.013) and sagittal continuous relative phase (p=.005) at controlled walking velocity. Trunk range of motion generally decreased and trunk-pelvis coordination generally increased with increasing time after initial ambulation. Sagittal trunk and pelvis ROM were always less and frontal trunk-pelvis coordination always greater for persons with more distal limb loss. Low back pain increased for persons with transtibial limb loss and decreased for persons with transfemoral limb loss following the 4-month timepoint.

Conclusions

Temporal changes (or lack thereof) in features of trunk-pelvis motions within the first year of ambulation help elucidate relationships between (biomechanical) risk factors for low back pain after limb loss.

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Psychometric evaluation of the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool: factor structure, reliability, and validity

Psychological characteristics consistently predict clinical outcomes for musculoskeletal pain conditions.1,3,4,24,25,36,47,55 National pain management initiatives15,57 and clinical practice guidelines11,14,37,43 recommend clinicians routinely assess psychological characteristics for pain conditions. Multiple tools exist to aid clinicians in evaluating pain-related psychological characteristics. Unidimensional tools that measure discrete psychological characteristics (e.g. pain catastrophizing or depressive symptoms) are common.

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Changes in pain-related fear and pain when avoidance behaviour is no longer effective

When one is confronted with acute pain, trying to avoid subsequent exposure to the presumed nociceptive stimulus is an adaptive strategy potentially preventing (further) injury. The fear-avoidance model describes how chronic pain may develop after an acute pain episode. If an individual appraises the pain experience as threatening, defensive behaviours might spiral into a vicious and self-perpetuating cycle that promotes avoidance behavior, leading to disability, negative affect and pain.28,29 However, in chronic pain where there is often no objectifiable injury, avoidance becomes maladaptive, and disconnected from its initial function.

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Linking non-restorative sleep and activity interference through pain catastrophizing and pain severity: An intra-day process model among individuals with fibromyalgia

Fibromyalgia (FM) is a chronic widespread musculoskeletal pain condition that predominantly affects women and interferes with individuals’ daily functioning.58,80 Repeated activity interference can substantially limit one's successful adjustment to chronic pain through the development of negative self-schema and reduction of rewards that stem from engaging in meaningful and enjoyable activities.23,26 Hence, a central target of chronic pain management is helping individuals increase their engagement in and performance of important daily activities.

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Observational pain assessment in older persons with dementia in four countries: observer agreement of items and factor structure of the Pain Assessment in Impaired Cognition

Abstract

Background

Recognition of pain in people with dementia is challenging. Observational scales have been developed, but there is a need to harmonise and improve the assessment process. In EU initiative COST‐Action TD1005, 36 promising items were selected from existing scales to be tested further. We aimed to study the observer agreement of each item, and to analyse the factor structure of the complete set.

Methods

190 older persons with dementia were recruited in four different countries (Italy, Serbia, Spain and The Netherlands) from different types of healthcare facilities. Patients represented a convenience sample, with no pre‐selection on presence of (suspected) pain. The Pain Assessment in Impaired Cognition (PAIC, research version) item pool includes facial expressions of pain (15 items), body movements (10 items), and vocalisations (11 items). Participants were observed by health professionals in two situations, at rest and during movement. Intrarater and interrater reliability was analysed by percentage agreement. The factor structure was examined with principal component analysis with orthogonal rotation.

Results

Health professionals performed observations in 40 to 57 patients in each country. Intrarater and interrater agreement was generally high (≥70%). However, for some facial expression items, agreement was sometimes below 70%. Factor analyses showed a 6‐component solution, which were named as follows: Vocal pain expression, Face anatomical descriptors, Protective body movements, Vocal defence, Tension, and Lack of affect.

Conclusions

Observation of PAIC items can be done reliably in healthcare settings. Observer agreement is quite promising already without extensive training.

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Incidence of shoulder pain in 40‐year‐olds and over and associated factors: a systematic review

Abstract

Background

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

Databases And Data Treatment

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

Results

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

Conclusion

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

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Acute and chronic pain in children and adolescents with cerebral palsy: prevalence, interference and management

Publication date: Available online 12 September 2019

Source: Archives of Physical Medicine and Rehabilitation

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

Abstract

Objective

To determine the prevalence, impact and management of acute and chronic pain amongst youth aged 5-18 years with cerebral palsy, attending outpatient rehabilitation services.

Design

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

Setting

Outpatient rehabilitation.

Participants

280 participants with cerebral palsy aged 5-18 years and/or their parent/caregiver. 45.7% (n=128) self-report and 54.3% (n=152) proxy-report.

Interventions

Not applicable.

Main outcome measure

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

Results

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

Conclusions

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

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Acute and chronic pain in children and adolescents with cerebral palsy: prevalence, interference and management

Publication date: Available online 12 September 2019

Source: Archives of Physical Medicine and Rehabilitation

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

Abstract

Objective

To determine the prevalence, impact and management of acute and chronic pain amongst youth aged 5-18 years with cerebral palsy, attending outpatient rehabilitation services.

Design

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

Setting

Outpatient rehabilitation.

Participants

280 participants with cerebral palsy aged 5-18 years and/or their parent/caregiver. 45.7% (n=128) self-report and 54.3% (n=152) proxy-report.

Interventions

Not applicable.

Main outcome measure

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

Results

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

Conclusions

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

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Acute and chronic pain in children and adolescents with cerebral palsy: prevalence, interference and management

Publication date: Available online 12 September 2019

Source: Archives of Physical Medicine and Rehabilitation

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

Abstract

Objective

To determine the prevalence, impact and management of acute and chronic pain amongst youth aged 5-18 years with cerebral palsy, attending outpatient rehabilitation services.

Design

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

Setting

Outpatient rehabilitation.

Participants

280 participants with cerebral palsy aged 5-18 years and/or their parent/caregiver. 45.7% (n=128) self-report and 54.3% (n=152) proxy-report.

Interventions

Not applicable.

Main outcome measure

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

Results

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

Conclusions

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

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[Perspectives] The pain and glory of ageing

Cinematic reflection on ageing is often about the extremes of life, such as in Pixar's Up, The Company of Strangers by Cynthia Scott, and Michael Haneke's Amour. But the transition from middle age to early old age is also a key time for reflection, recalibration, and refocus of the meaning of life and reconciliation of suffering, mistakes, and successes.

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Spinal DN-9, a peptidic multifunctional opioid/neuropeptide FF agonist produced potent nontolerance forming analgesia with limited side effects

Pain is one of the leading characteristics of injuries and nearly all diseases. Chronic pain presents a major health burden, and millions of individuals are suffering from various pains worldwide.1,8,14 According to the Medical Expenditure Panel Survey (MEPS) in 2008, in the United States, approximately 100 million adults were affected by chronic pain and the economic cost of pain was estimated to be between $560 and $635 billion annually.13 A large number of analgesics, including non-opioid analgesics (e.g., COX-2 inhibitors and other nonselective NSAIDs, acetaminophen, ketamine, and ketorolac) and opioid analgesics (e.g., morphine, fentanyl, etorphine, sufentanil, and hydromorphone), have been approved.

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Profiling Modifiable Psychosocial Factors among Children with Chronic Pain: A Person-Centered Methodology

Pediatric chronic pain is associated with risk of impact across social, emotional, and behavioral domains at child and family levels.30,52,67 Extant literature highlights psychosocial factors that can foster resilience and others that underlie vulnerability for poor pain coping and disability. Resilience factors, such as pain acceptance and psychosocial adjustment, have been found to promote the use of adaptive pain coping strategies within this population.14 Greater child and parent pain catastrophizing, clinically significant internalizing symptoms (e.g., anxiety, depression), and maladaptive parent responses (e.g., over attending to pain complaints) are associated with greater pain, disability, and poorer response to treatment for children with chronic pain.

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Evaluating the effects of acupuncture using a dental pain model in healthy subjects – a randomized, cross-over trial

Acupuncture might help to reduce opioid use49 for pain management because it has been shown to have clinical effects on several prevalent chronic pain conditions75,76 including osteoarthritis of the knee,78 chronic back pain,10 tension-type headache52 and migraine,45 with effect sizes comparable to other common pharmacological opioid alternatives.7 In addition, acupuncture has shown to be relatively safe,48,79 and it is used by patients.17 It has also been shown to be cost-effective within accepted thresholds.

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Pain acceptance in people with chronic pain and spinal cord injury: Daily fluctuation and impacts on physical and psychosocial functioning

Approximately 65% of individuals with spinal cord injury (SCI) experience chronic pain; of these, nearly one-third rate their pain as severe, with adverse effects on physical and psychosocial function and well-being.1,4-10 Psychosocial treatments have demonstrated efficacy as stand-alone interventions and useful extensions and compliments to standard medical pain management in SCI.2,13,56

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Predictors of Functional Outcome in Musculoskeletal Healthcare: An Umbrella Review

Abstract

Background

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

Objectives

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

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

Results

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

Conclusions

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

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Treading the tightrope of opioid restrictions

Nature, Published online: 11 September 2019; doi:10.1038/d41586-019-02687-1

US efforts to control opioid prescriptions are having unintended effects on people with chronic pain.

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Operating without opioids

Nature, Published online: 11 September 2019; doi:10.1038/d41586-019-02685-3

The opioid crisis is driving a rethink of pain relief in surgery.

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The painful truth about pain

Nature, Published online: 11 September 2019; doi:10.1038/d41586-019-02688-0

A harrowing medical experience gave Travis N. Rieder more insight than he would have wished for into how people end up hooked on opioids.

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Analgesia without opioids

Nature, Published online: 11 September 2019; doi:10.1038/d41586-019-02683-5

Fresh strategies and targets for chronic pain could deliver much needed replacements for opioid-based painkillers.

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Sex Differences in Rat Intervertebral Disc Structure and Function Following Annular Puncture Injury

Study Design. A rat puncture injury intervertebral disc (IVD) degeneration model with structural, biomechanical, and histological analyses. Objective. To determine if males and females have distinct responses in the IVD after injury. Summary of Background Data. Low back pain (LBP) and spinal impairments are more common in women than men. However, sex differences in IVD response to injury have been underexplored, particularly in animal models where sex differences can be measured without gender confounds. Methods. Forty-eight male and female Sprague Dawley rats underwent sham, single annular puncture with tumor necrosis factor α (TNFα) injection (1×), or triple annular puncture with TNFα injection (3×) surgery. Six weeks after surgery, lumbar IVDs were assessed by radiologic IVD height, spinal motion segment biomechanical testing, histological degeneration grading, second harmonic generation (SHG) imaging, and immunofluorescence for fibronectin and α-smooth muscle actin. Results. Annular puncture injuries significantly increased degenerative grade and IVD height loss for males and females, but females had increased degeneration grade particularly in the annulus fibrosus (AF). Despite IVD height loss, biomechanical properties were largely unaffected by injury at 6 weeks. However, biomechanical measures sensitive to outer AF differed by sex after 3× injury—male IVDs had greater torsional stiffness, torque range, and viscoelastic creep responses. SHG intensity of outer AF was reduced after injury only in female IVDs, suggesting sex differences in collagen remodeling. Both males and females exhibited decreased cellularity and increased fibronectin expression at injury sites. Conclusion. IVD injury results in distinct degeneration and functional healing responses between males and females. The subtle sex differences identified in this animal model suggest differences in response to IVD injury that might explain some of the variance observed in human LBP, and demonstrate the need to better understand differences in male and female IVD degeneration patterns and pain pathogenesis. Level of Evidence: N/A

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Preoperative Chronic Opioid Therapy Negatively Impacts Long-term Outcomes Following Cervical Fusion Surgery

Study Design. Retrospective, observational. Objective. The aim of this study was to define the impact of preoperative chronic opioid therapy (COT) on outcomes following cervical spine fusions. Summary of Background Data. Opioid therapy is a commonly practiced method to control acute postoperative pain. However, concerns exist relating to use of prescription opioids, including inherent risk of abuse, tolerance, and inferior outcomes following major surgery. Methods. A commercial dataset was queried from 2007 to 2015 for patients undergoing primary cervical spine arthrodesis [ICD-9 codes 81.01-81.03]. Primary outcome measures were 1-year and 2-year reoperation rates, emergency department (ED) visits, adverse events, and prolonged postoperative opioid use. Secondary outcomes included short-term outcomes including 90-day complications (cardiac, renal, neurologic, infectious, etc.). COT was defined as a history of opioid prescription filling within 3 months before surgery and was the primary exposure variable of interest. Generalized linear models investigated the association of preoperative COT on primary/secondary endpoints following risk-adjustment. Results. Overall, 20,730 patients (51.3% female; 85.9% >50 years) underwent primary cervical spine arthrodesis. Of these, 10,539 (n = 50.8%) met criteria for COT. Postoperatively, 75.3% and 29.8% remained on opioids at 3 months and 1 year. Multivariable models identified an association between COT and an increased risk of 90-day ED visit [odds ratio (OR): 1.25; P < 0.001] and wound complications (OR: 1.24; P = 0.036). At 1 year, COT was strongly associated with reoperations (OR: 1.17; P = 0.043), ED visits (OR: 1.31; P < 0.001), and adverse events including wound complications (OR: 1.32; P < 0.001), infections (OR: 1.34; P = 0.042), constipation (OR: 1.11; P = 0.032), neurological complications (OR: 1.44; P = 0.01), acute renal failure (OR: 1.24; P = 0.004), and venous thromboembolism (OR: 1.20; P = 0.008). At 2 years, COT remained a significant risk factor for additional long-term negative outcomes such as reoperations, including adjacent segment disc disease (OR: 1.21; P = 0.005), ED visits (OR: 1.32; P < 0.001), and other adverse events. Preoperative COT was associated with prolonged postoperative narcotic use at 3 months (OR: 1.30; P < 0.001), 1 year (OR: 5.17; P < 0.001), and at 2 years (OR: 5.75; P < 0.001) after cervical arthrodesis. Conclusion. Preoperative COT is a modifiable risk factor that is strongly associated with prolonged postoperative opioid use. In addition, COT was associated with inferior short-term and long-term outcomes after cervical spine fusion. Level of Evidence: 3

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Non-mobile Adjacent Level Cervical Spondylolisthesis Does Not Always Require Fusion in Patients Undergoing ACDF

Study Design. Retrospective review of a prospectively maintained database. Objective. Compare outcomes following anterior cervical decompression and fusion (ACDF) between patients with no adjacent level spondylolisthesis (NAS) and adjacent level spondylolisthesis (AS). Summary of Background Data. There are no prior studies evaluating the effect of preoperative adjacent-level cervical spondylolisthesis on outcomes following anterior cervical discectomy and fusion (ACDF). Methods. A retrospective review of consecutive patients who underwent ACDF for degenerative cervical disease was performed. Adjacent level spondylolisthesis was defined on radiographs as anterior displacement (> 1 mm) of the vertebra in relation to an adjacent “to be fused” level. Patients were categorized as either AS or NAS. Preoperative and 1-year postoperative outcomes including Short Form-12 Physical and Mental Component Scores, Neck Disability Index, Visual Analog Score for arm and neck pain, and rate of revision surgery were compared between the two groups. Radiographic changes were also analyzed for patients with AS. Results. A total of 264 patients met the inclusion criteria. There were 53 patients (20.1%) with AS and 211 patients (79.9%) with NAS. Both groups improved significantly from baseline with respect to all patient outcomes and there were no significant differences between the two groups. After accounting for confounding variables, the presence of an AS was not a predictor of any postoperative outcome. Revision rates did not differ between the two groups. Conclusion. Patients with an AS had similar postoperative clinical outcomes compared with NAS. Furthermore, the presence of an AS was not a predictor of poorer clinical outcomes. This is the first study to investigate the effect of AS in patients undergoing ACDF and suggests that an adjacent-level spondylolisthesis does not need to be included in a fusion construct if it is not part of the primary symptom generating pathology. Level of Evidence: 3

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Geography of Lumbar Paravertebral Muscle Fatty Infiltration: The Influence of Demographics, Low Back Pain, and Disability

Study Design. Cross-sectional. Objective. We quantified fatty infiltration (FI) geography of the lumbar spine to identify whether demographics, temporal low back pain (LBP), and disability influence FI patterns. Summary of Background Data. Lumbar paravertebral muscle FI has been associated with age, sex, LBP, and disability; yet, FI accumulation patterns are inadequately described to optimize interventions. Methods. This cross-sectional study employed lumbar axial T1-weighted magnetic resonance imaging in 107 Southern-Chinese adults (54 females, 53 males). Single-slices at the vertebral inferior end-plate per lumbar level were measured for quartiled-FI, and analyzed against demographics, LBP, and disability (Oswestry Disability Index). Results. Mean FI% was higher in females, on the right, increased per level caudally, and from medial to lateral in men (P < 0.05). FI linearly increased with age for both sexes (P < 0.01) and was notably higher at L 4&5 than L1, 2&3 for cases aged 40 to 65 years. BMI and FI were unrelated in females and inversely in males (P < 0.001). Females with LBPweek and males with LBPyear had 1.7% (each) less average FI (P < 0.05) than those without pain at that time-point. Men locating their LBP in the back had less FI than those without pain (P < 0.001). Disability was unrelated to FI for both sexes (P > 0.05). Conclusion. Lumbar paravertebral muscle FI predominates in the lower lumbar spine, notably for those aged 40 to 65, and depends more on sagittal than transverse distribution. Higher FI in females and differences of mean FI between sexes for BMI, LBP, and disabling Oswestry Disability Index suggest sex-differential accumulation patterns. Our study contradicts pain models rationalizing lumbar muscle FI and may reflect a normative sex-dependent feature of the natural history of lumbar paravertebral muscles. Level of Evidence: 2

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Cross-cultural Adaptation and Validation of the Hausa Version of the Oswestry Disability Index 2.1a for Patients With Low Back Pain

Study Design. Validation of a translated, culturally adapted questionnaire. Objective. To translate the Oswestry Disability Index (ODI) version 2.1a into Hausa Language and to validate its use in a cohort of patients with low back pain (LBP). Summary of Background Data. The ODI is one of the most commonly used condition-specific questionnaires for assessing functional disability in patients with LBP, yet, no formal cross-culturally adapted and validated Hausa version exists. Methods. The Hausa version of the ODI 2.1a (ODI-H) was developed according to established guidelines. Validation was performed among 200 patients with LBP recruited from both rural and urban Nigeria. Reliability was assessed using internal consistency (Cronbach α), test–retest reliability by computing intraclass correlation coefficient, standard error of measurement, and minimal detectable change. Convergent validity was assessed by correlating the ODI-H with Visual Analogue Scale for pain, Fear-Avoidance Beliefs Questionnaire, and finger-floor distance test. Divergent validity was assessed by correlating the ODI-H with age, educational level, and occupational status. Exploratory factor analysis (EFA) and confirmatory factor analysis were also performed. Confirmatory factor analysis was performed with three models: 1) one-factor theory-driven model, 2) two-factor theory-driven model (dynamic and static factors), and 3) a model based on our EFA. Results. The ODI-H had high internal consistency (Cronbach α = 0.87) and excellent test–retest reliability (intraclass correlation coefficient  = 0.937) with standard error of measurement and minimal detectable change being 3.69 and 10.2 respectively. The construct validity (convergent and divergent validity) is supported as all (6:6, 100%) the a priori hypotheses were confirmed. The EFA yielded a two-factor model explaining 54.3% of the total variance but demonstrated poor fit. The one-factor and two-factor theory-driven model had acceptable fit but the one-factor theory-driven model was better. Conclusion. The ODI-H version 2.1a was transculturally equivalent, reliable, and valid tool for assessing functional disability among Hausa-speaking patients with LBP. The use of this tool can be recommended for future clinical and research purposes. Level of Evidence: 3

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The Association Between Patient Reported Outcomes of Spinal Surgery and Societal Costs: A Register Based Study

Study Design. Retrospective register-based study using Swedish registers and data prospectively collected in quality register Swespine. Objective. Analyze the association of societal costs and spine surgery outcome in low back pain (LBP) patients based on patient reported outcome measures (PROMs). Summary of Background Data. Studies show that LBP has a substantial impact on societal cost. There are indications that the burden diverges over different patient groups, but little is known about cost patterns in relation to PROMs of LBP surgery. Methods. We utilized a database with data from six registers. All lumbar spine surgery patients registered in Swespine 2000 to 2012 were identified. Swespine collects PROMs Global Assessment of pain improvement (GA), Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and EuroQol five-dimension scale (EQ-5D). A literature search was conducted to identify threshold changes in ODI, VAS, and EQ-5D representing a significant improvement or deterioration as defined by the minimal clinically important difference (MCID). We categorized patients into groups by their GA response at 2-year follow-up and estimated mean changes in ODI, VAS, and EQ-5D for each group. These changes were compared with the MCID thresholds to determine a GA-anchored classification of surgical outcomes. Costs consisted of out/inpatient care, sick leave, early retirement, and pharmaceuticals. Results. In total, 12,350 patients were included. GA 1–2 (“pain has disappeared”/“pain is much improved”) were labeled successful surgery outcomes (67%), GA 3 (“pain somewhat improved”), undetermined (16%), and GA 4–5 (“no change in pain”/“pain has worsened”) unsuccessful (17%). Costs of the unsuccessful and undetermined were higher than of the successful during the entire study period, with differences increasing markedly post-surgery. For the successful, a downward cost trend was observed; costs almost returned to the level observed 3 years pre-surgery. No such trend was observed in the other groups. Conclusion. Identifying patients with higher probability of responding to surgery could lead to improved health and substantial societal cost savings. Level of Evidence: 3

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Intrusive imagery associated with pain

Warren describes the use of example imagery to help patients describe their pain experience, which should substantially improve doctor-patient communication.1 Padfield and colleagues explored the...

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Technical and clinical performance of the thermo‐test device “Q‐Sense” to assess small fibre function: A head‐to‐head comparison with the “Thermal Sensory Analyzer” TSA in diabetic patients and healthy volunteers

Abstract

Background

Thermo‐test devices are rarely used outside specialized pain centres because of high acquisition costs. Recently, a new, portable device (“Q‐Sense”) was introduced, which is less expensive but has reduced cooling capacity (20°C). We assessed the reliability/validity of the “Q‐Sense” by comparing it with the Thermal Sensory Analyzer (TSA).

Methods

Using a phantom‐skin model, the physical characteristics of both devices were compared. The clinical performance was assessed in a multicentre study by performing Quantitative Sensory Testing (QST) in 121 healthy volunteers and 83 diabetic patients (Eudra‐Med‐No. CIV‐12‐05‐006501).

Results

Both device types showed ~40% slower temperature ramps for heating/cooling than nominal data. Cold/warm detection thresholds (CDT, WDT) and heat pain thresholds (HPT) of healthy subjects did not differ between device types. Cold pain thresholds (CPT) were biased for Q‐Sense by a floor effect (p < .001). According to intraclass correlation coefficients (ICC), agreement between TSA and Q‐Sense was good/excellent for CDT (ICC = 0.894) and WDT (ICC = 0.898), moderate for HPT (ICC = 0.525) and poor for CPT (ICC = 0.305). In diabetic patients, the sensitivity of Q‐Sense to detect cold hypoesthesia was reduced in males >60 years. Moderate correlations between thermal detection thresholds and morphological data from skin biopsies (n = 51) were similar for both devices.

Conclusions

Physical characteristics of both thermo‐test devices are similarly limited by the poor temperature conduction of the skin. The Q‐Sense is useful for thermal detection thresholds but of limited use for pain thresholds. For full clinical use, the lower cut‐off temperature should be set to ≤18°C.

Significance

High purchase costs prevent a widespread use of thermo‐test devices for diagnosing small fibre neuropathy. The air‐cooled “Q‐Sense” could be a lower cost alternative, but its technical/clinical performance needs to be assessed because of its restricted cut‐off for cooling (20°C). This study provides critical information on the physical characteristics and the clinical validity/reliability of the Q‐Sense compared to the “Thermal Sensory Analyzer” (TSA). We recommend lowering the cut‐off value of the Q‐Sense to ≤18°C for its full clinical use.

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Botulinum toxin type A for painful temporomandibular disorders: systematic review and meta-analysis

Painful temporomandibular disorders are chronic conditions that can have a negative impact on the quality of life and well-being of affected individuals. It is frequently associated with dysfunction of the masticatory muscles due to specific or non-specific temporomandibular disorders. Potential risk factors for painful temporomandibular disorders include trauma, dental malocclusion, excessive masticatory system loading, hypermobility, parafunctional habits and anatomical, psychosocial and/or systemic disorders.

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A neuronal circuit for activating descending modulation of neuropathic pain

Nature Neuroscience, Published online: 09 September 2019; doi:10.1038/s41593-019-0481-5

Huang and colleagues functionally map a brain circuit connecting the amygdala and the spinal cord that is altered after nerve injury and contributes to chronic pain.

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

Abstract

Background

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

Method

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

Results

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

Conclusions

Oral etoricoxib in a rat OA model (1) attenuates the development of OA, (2) concomitantly reduces nociception, and (3) modulates chondrocyte metabolism, possibly by inhibiting NGF expression and increasing TGF‐β expression.

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

Abstract

Background

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

Methods

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

Results

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

Conclusions

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

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“Some exercise is good, more is better,” say medical chiefs in new guidance

New mothers should undertake a moderate amount of exercise to help them regain strength, ease back pain, and reduce the risk of gestational diabetes, the UK’s four chief medical officers have...

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The Pain Assessment in Impaired Cognition scale (PAIC15): a multidisciplinary and international approach to develop and test a meta‐tool for pain assessment in impaired cognition, especially dementia

Abstract

Background

Over the last decades, a considerable number of observational scales have been developed to assess pain in persons with dementia. The time seems ripe now to build on the knowledge and expertise implemented in these scales to form an improved, “best‐of” meta‐tool. The EU‐COST initiative “Pain in impaired cognition, especially dementia” aimed to do this by selecting items out of existing observational scales and critically re‐assessing their suitability to detect pain in dementia. This paper reports on the final phase of this collaborative task.

Methods

Items from existing observational pain scales were tested for “frequency of occurrence (item difficulty)”, “reliability”, and “validity”. This psychometric testing was carried out in eight countries, in different healthcare settings, and included clinical as well as experimental pain conditions.

Results

Across all studies, 587 persons with dementia, 27 individuals with intellectual disability, 12 Huntington's disease patients, and 59 cognitively healthy controls were observed during rest and movement situations or while receiving experimental pressure pain, respectively. The psychometric outcomes for each item across the different studies were evaluated within an international and multidisciplinary team of experts and led a final selection of 15 items (5x facial expressions, 5x body movements, 5x vocalizations).

Conclusions

The final list of 15 observational items have demonstrated psychometric quality and clinical usefulness both in their former scales and in the present international evaluation; accordingly, they qualified twice to form a new internationally agreed‐on meta‐tool for Pain Assessment in Impaired Cognition, the PAIC‐15 scale.

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

Abstract

Objectives

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

Methods

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

Results

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

Discussion

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

Significance

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

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Change in Fatigue in Acceptance and Commitment Therapy‐Based Treatment for Chronic Pain and Its Association with Enhanced Psychological Flexibility

Abstract

Fatigue is commonly reported by people with chronic pain. The purpose of the current study was to examine Acceptance and Commitment Therapy (ACT), based on the Psychological Flexibility (PF) model, for fatigue in chronic pain. This study included 354 adults attending an interdisciplinary ACT‐oriented treatment for chronic pain. T‐tests and analyses of clinically meaningful change were used to investigate participant improvements in fatigue interference after the treatment. Pearson's correlations and hierarchical regressions were conducted to investigate associations between improvement in fatigue interference and improvements in PF processes. Finally, mixed effects models were used to explore associations between baseline fatigue interference and changes in treatment outcome measures. Participants improved in fatigue interference (d=.37), pain, some PF processes, and daily functioning (d=.18‐1.08). 39.7% of participants demonstrated clinically meaningfully improvements in fatigue interference. Changes in fatigue interference was associated with changes in pain, PF processes and daily functioning, |r|= .20‐.46. Change in fatigue interference was associated with change in pain acceptance independent of change in pain, β=‐.36, p<.001. However, baseline fatigue interference did not predict any treatment outcome. Overall, people with fatigue appeared to benefit from the ACT‐oriented interdisciplinary treatment for chronic pain, and relatively higher levels of fatigue did not appear to impede this benefit. ACT‐based treatments may benefit people with chronic pain and fatigue. Future studies including experimental designs, and studies investigating other PF processes, are needed to better understand the utility of ACT for co‐morbid fatigue and pain.

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Calcium channel α2δ1 subunit mediates secondary orofacial hyperalgesia through PKC-TRPA1/gap junction signaling

Chronic pain is a common clinical syndrome that has significant negative effects on quality of life and leads to enormous social and economic problems, and among chronic pain conditions orofacial pain can be the most severe and debilitating.41,50 Such pain can derive from orofacial inflammation and tissue and nerve injuries and is characterized by primary mechanical hyperalgesia (hypersensitivity at the site of injury) and secondary mechanical hyperalgesia (extra-territorial hypersensitivity outside the injured zone).

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Effects of oxytocin on placebo and nocebo effects in a pain conditioning paradigm: a randomized controlled trial.

Accumulating findings demonstrate the pain reducing effects of placebo analgesia21 and pain enhancing effects of nocebo hyperalgesia.31 Literature suggests that the placebo and nocebo effects are triggered by expectations which in turn can be induced by communication (verbal suggestions) or by classical conditioning.3,5,11 Positive expectations induced by verbal suggestions have been shown to induce robust reductions in pain in experimental and clinical settings,21 while expectations of negative treatment outcomes were associated with higher pain ratings.

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Pain, physical and psychosocial functioning in adolescents at-risk for developing chronic pain: A longitudinal case-control study

The burden experienced by adults with chronic pain extends to their children, who are at increased risk for developing chronic pain compared to children of parents without pain.32 Research with clinical, community, and epidemiological samples consistently shows increased risk of chronic pain and disability among offspring of adults who have chronic pain,11,28,53,59 and a large (n>5000) family linkage study demonstrated that maternal and paternal chronic pain increased the odds of chronic pain in adolescents.

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Therapy Habituation at 12 Months: Spinal Cord Stimulation Versus Dorsal Root Ganglion Stimulation for Complex Regional Pain Syndrome Type I and II

Complex regional pain syndrome (CRPS) type I and CRPS type II diminish quality of life and can lead to significant disability.15 Both conditions have varied and complex clinical features, with chronic debilitating pain being the primary symptom, usually involving the lower or upper extremities.16,24 The conditions are differentiated by the absence (CRPS-I) or presence (CRPS-II) of demonstrable nerve damage as an underlying etiology.

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Frequency of primary neck pain in mild traumatic brain injury/concussion patients

Publication date: Available online 4 September 2019

Source: Archives of Physical Medicine and Rehabilitation

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

Abstract

Objectives

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

Design

Cohort study.

Setting

Level I trauma center ED.

Participants

95 patients presenting to the ED with symptoms of mTBI having been exposed to an event that could have caused a mTBI.

Interventions

Not applicable.

Main outcome measures

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

Results

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

Conclusions

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

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AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery

Acute pain after breast surgery decreases the quality of life of cancer survivors. Previous studies using a variety of definitions and methods report prevalence rates between 10% to 80%, which suggests the need for a comprehensive framework that can be used to guide assessment of acute pain and pain-related outcomes after breast surgery. A multidisciplinary task force with clinical and research expertise performed a focused review and synthesis and applied the five dimensional framework of the AAAPT (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)- American Academy of Pain Medicine (AAPM)-American Pain Society (APS) Pain Taxonomy) to acute pain after breast surgery.

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Mechanisms of below-level pain following spinal cord injury (SCI)

Traumatic/contusive spinal injury produces all or most of the following disruptions of spinal cord integrity: tearing of the meninges with leakage of cerebral spinal fluid (CSF); disruption of the blood–spinal cord barrier; vertebral scarring with eventual tethering/compression of the cord; inflammation; vascular disruption with hemorrhage, edema and ischemia; free-radical injury with neuronal excitotoxicity, at-level neuronal hyperactivity, apoptosis and eventual cellular loss; mitochondrial dysfunction; electrolytic changes; accumulation or loss of transmitters; up- and down-regulation of transmitter receptors; damage to and/or constriction of dorsal and ventral roots; demyelination of propriospinal and long-track axons; interruption of long ascending and descending pathways to an indeterminant extent, with anterograde and retrograde degeneration; gliosis and scarring with impaired regeneration of axons; and spontaneous activity rostral and caudal to the injury in proportion to the extent and duration of neuronal deafferentation.

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Preferred self-administered questionnaires to assess depression, anxiety and somatization in people with musculoskeletal pain – A modified Delphi study

Low back pain and neck pain are the leading causes of disability.14 Major depressive and anxiety disorders are the third and ninth leading causes of disability.14 Moreover, spinal pain, depression and anxiety often coexist: 15-45% of people with persistent pain also experience some form of depression and/or anxiety.3,25,26 When these comorbidities exist, healthcare costs are considerable higher.28

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