AIM OF REPORT. This report reviews the evidence about the effectiveness of treatments for chronic pain. While treatment of chronic pain is usually seen as an integrated service, this report concentrates on the individual interventions that constitute the service. HOW THE RESEARCH WAS CONDUCTED. Searches of databases and journals identified over 15,000 randomised studies with pain as an outcome, and many more which were not randomised. Over 150 systematic reviews relevant to chronic pain treatment were identified and their quality assessed using a simple scoring system. Systematic reviews conducted for this report were based mainly on randomised trials. The number needed to treat (NNT) was chosen as the output for the report. NNTs of 2-4 indicate effective treatments. Because NNT is treatment-specific it overcomes problems associated with highly variable placebo or control event rates in pain trials. Such variability is predominantly due to the limited numbers of patients in the clinical trials. Dichotomous outcome measures are important in synthesising information from many studies, and in deriving NNTs. Methods have been developed which allow mean information on pain relief and intensity to be converted reliably into the simple dichotomous outcome of at least 50% pain relief. RESEARCH FINDINGS. PHYSICAL INTERVENTIONS. Transcutaneous electrical nerve stimulation (TENS) has been shown not to be effective in postoperative and labour pain. In chronic pain, there is evidence that TENS effectiveness increases slowly, and that large doses need to be used. There is lack of evidence for the effectiveness of TENS in chronic pain. There is a lack of evidence for the effectiveness of relaxation. Intravenous systemic regional blockade with guanethidine has been shown to be without effect. Epidural corticosteroids are effective in the short term for back pain and sciatica. Injections of corticosteroids in or around shoulder joints for shoulder pain have been shown not to be effective. There is a lack of evidence supporting spinal cord stimulators. Case series are of poor quality and do not provide evidence of effectiveness, although at least 50% pain relief at 5 years is reported in over 50% of patients. PHARMACOLOGICAL INTERVENTIONS. Minor analgesics are important in chronic pain. NNTs were calculated for analgesics given orally for moderate or severe acute postoperative pain. The NNTs found ranged from 17 (poor) for codeine, 60 mg, to 2.5 (good) for ibuprofen, 400 mg. Anticonvulsant and antidepressant drugs are prescribed for neuropathic pains like diabetic neuropathy. NNTs are of the order of 2.5, showing them to be effective treatments. However, there are too few studies with too few patients to determine which is the best drug. Minor adverse events are common, and major adverse events occur in about 1 in 20 patients. There are no studies comparing antidepressants and anticonvulsants directly. Systemic local anaesthetic-type drugs have been shown to be effective in nerve injury pain but there is little or no evidence to support their use in migraine or cancer-related pain. Topical NSAIDs (for example, gels, creams) are effective in rheumatological conditions with an overall NNT of 3. There are too few studies to determine which is the best agent. Topical NSAIDs have few adverse events; most importantly they are without the major gastrointestinal adverse events found with oral NSAIDs, which might make them an important choice for some patients with peripheral arthritis. (ABSTRACT TRUNCATED)

Systematic review of outpatient services for chronic pain control.

Although published treatment outcome studies for chronic pain have provided favorable support for the efficacy of many pain clinics and the use of specific modalities such as biofeedback and relaxation, there are several factors that mitigate against euphoria. Two related factors that influence interpretation of these reported outcomes are discussed, namely, noncompliance with therapeutic recommendations during treatment and subsequent to treatment termination, and relapse. Conceptual and methodological problems for establishing the prevalence of noncompliance and relapse are reviewed. Several factors that contribute to noncompliance (individual differences, nature of disease or injury, characteristics of the prescribed treatment regimen, health-care provider-patient relationship, and contextual) are discussed. The literature reveals that noncompliance with treatment regimens is quite prevalent across diverse treatment modalities and pain syndromes. The incidence of relapse following initially successful treatment of persistent pain also appears to be high, ranging from 30% to 60%. Studies on arthritis and heterogeneous pain clinic populations suggest that noncompliance and relapse are related; however, this association is less well established for headache patients. Strategies for assessing compliance (i.e., self-report, behavioral, biochemical, and clinical outcome) and the perspectives' of patients and health-care providers on the application of self-care recommendations are discussed. Strategic planning and adherence enhancement tactics to facilitate maintenance of post-treatment gains are described.

Neglected topics in the treatment of chronic pain patients — relapse, noncompliance, and adherence enhancement

Thisarticleprovidesabestevidence-informedreviewofthecurrentscientificun- derstandingofmyofascialtriggerpointswithregardtotheiretiology,�pathophysiology,�and� clinicalimplications.�Evidence-informedmanualtherapyintegratesthebestavailablescien- tificevidencewithindividualclinicians'�judgments,�expertise,�andclinicaldecision-making.� Afterabriefhistoricalreview,�theclinicalaspectsofmyofascialtriggerpoints,�theinterrater� reliabilityforidentifyingmyofascialtriggerpoints,� andseveralcharacteristicfeaturesare� discussed,� includingthetautband,� localtwitchresponse,� andreferredpainpatterns.� The� etiologyofmyofascialtriggerpointsisdiscussedwithadetailedandcomprehensivereviewof� themostcommonmechanisms,�includinglow-levelmusclecontractions,�unevenintramus- cularpressuredistribution,� directtrauma,� unaccustomedeccentriccontractions,� eccentric� contractionsinunconditionedmuscle,�andmaximalorsub-maximalconcentriccontractions.� Manycurrentscientificstudiesareincludedandprovidesupportforconsideringmyofascial� triggerpointsintheclinicaldecision-makingprocess.�Thearticleconcludeswithasummary� offrequentlyencounteredprecipitatingandperpetuatingmechanical,�nutritional,�metabolic,� andpsychologicalfactorsrelevantforphysicaltherapypractice.�Currentscientificevidence� stronglysupportsthatawarenessandworkingknowledgeofmuscledysfunctionandinpar- ticularmyofascialtriggerpointsshouldbeincorporatedintomanualphysicaltherapypractice� consistentwiththeguidelinesforclinicalpracticedevelopedbytheInternationalFederation� ofOrthopaedicManipulativeTherapists.�Whiletherearestillmanyunansweredquestionsin� explainingtheetiologyofmyofascialtriggerpoints,�thisarticleprovidesmanualtherapists� withanup-to-dateevidence-informedreviewofthecurrentscientificknowledge.

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Myofascial Trigger Points: An Evidence-Informed Review

Opioid use in the treatment of chronic pain: Assessment of addiction

The child with burns suffers severe pain at the time of the burn and during subsequent treatment and rehabilitation. Pain has adverse physiological and emotional effects, and research suggests that pain management is an important factor in better outcomes. There is increasing understanding of the private experience of pain, and how children benefit from honest preparation for procedures. Developmentally appropriate and culturally sensitive pain assessment, pain relief, and reevaluation have improved, becoming essential in treatment. Pharmacological treatment is primary, strengthened by new concepts from neurobiology, clinical science, and the introduction of more effective drugs with fewer adverse side effects and less toxicity. Empirical evaluation of various hypnotic, cognitive, behavioral, and sensory treatment methods is advancing. Multidisciplinary assessment helps to integrate psychological and pharmacological pain-relieving interventions to reduce emotional and mental stress, and family stress as well. Optimal care encourages burn teams to integrate pain guidelines into protocols and critical pathways for improved care.

http://file.lacounty.gov/SDSInter/dhs/205455_22_tpbc.pdf

Treatment of Pain in Acutely Burned Children

In the past ten years developments in social psychology, neurochemistry, learning theory, and psychophysiology have expanded the concept of chronic pain into a biopsychosocial model, in which pain is viewed as a form of abnormal illness behavior influenced by a wide range of biological, social, and psychological factors. Using the literature on chronic pain, the authors discuss the evolution of the chronic pain concept into the multidisciplinary multimodal approach used by pain clinics today, and the factors identified in the literature that influence a patient's perception of pain. Finally, based on their experiences in setting up a pain clinic and on the literature on leading pain management programs, they discuss in detail the evaluation, treatment, and management strategies of a comprehensive chronic pain management program.

David S. Dahl

Papers

Chronic Pain Management