Showing papers in "Pain Medicine in 2010"

Causes and consequences of inadequate management of acute pain.

Abstract: Context. Intense acute pain afflicts millions of patients each year. Despite the recently increased focus on the importance of pain control, management of acute pain has remained suboptimal. Objective. The objective of this study was to identify through a review of recent literature the barriers to effective treatment of acute pain and the potential consequences of inadequate pain management. Design. A comprehensive literature review was conducted to identify articles relevant to the management of acute pain. Information regarding the underlying causes of inadequate pain management, as well as the sequelae associated with undermanaged pain was extracted and summarized. Results. Studies indicate that treatment of acute pain remains suboptimal due to attitudes and educational barriers on the part of both physicians and patients, as well as the intrinsic limitations of available therapies. Inadequate management of acute pain negatively impacts numerous aspects of patient health, and may increase the risk of developing chronic pain. Although opioids are the preferred treatment for most moderate to severe acute pain, their side effects can impede their use, and thus, their clinical effectiveness. Analgesic regimens with an improved efficacy/tolerability balance have the potential to improve acute pain management, and thus reduce the incidence of chronic pain. Studies examining the use of multiple analgesics with different mechanisms of action suggest that multimodal therapies may offer an improved efficacy/tolerability balance over single agent regimens. Conclusions. There exists a significant need for effective, well-tolerated analgesic therapies to limit the negative consequences of undermanaged acute pain. The use of multimodal therapy has demonstrated increasing promise and is supported by current practice guidelines.

The Patient–Provider Relationship in Chronic Pain Care: Providers' Perspectives

Abstract: Background. Pain is the most commonly reported symptom in primary care and is a leading cause of disability. Primary care providers (PCPs) face numerous challenges in caring for patients with chronic pain including communication and relational difficulties. Objective. The objective of the study was to elicit providers' perspectives on their experiences in caring for patients with chronic pain. Design. The design used was a qualitative study using open-ended, in-depth interviews. Participants. Twenty providers (10 men, 10 women) from five different clinics were interviewed at the Roudebush Veterans Affairs Medical Center. Results. Three broad themes emerged from the analysis: 1) providers emphasized the importance of the patient–provider relationship, asserting that productive relationships with patients are essential for good pain care; 2) providers detailed difficulties they encounter when caring for patients with chronic pain, including feeling pressured to treat with opioids, believability of patients' reports of pain, worries about secondary gain/diversion, and “abusive” or “difficult” patients; and 3) providers described the emotional toll they sometimes felt with chronic pain care, including feeling frustrated, ungratified, and guilty. Findings. Findings were interpreted within a model of patient-centered care. Conclusions. The clinical implications of these findings are two-fold. First, PCPs' needs cannot be ignored when considering pain care. PCPs need support, both instrumental and emotional, as they care for patients with chronic pain. Second, improving PCPs' patient-centered communication skills—including demonstrating empathy and encouraging shared decision-making—holds promise for alleviating some of the strain and burden reported by providers, ultimately leading to improved patient care.

The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain.

Abstract: Background. Transforaminal injection of steroids is used to treat lumbar radicular pain. Not known is whether the route of injection or the agent injected is significant. Study Design. A prospective, randomized study compared the outcomes of transforaminal injection of steroid and local anesthetic, local anesthetic alone, or normal saline, and intramuscular injection of steroid or normal saline. Patients and outcome evaluators were blinded as to agent administered. Methods. The primary outcome measure was the proportion of patients who achieved complete relief of pain, or at least 50% relief, at 1 month after treatment. Secondary outcome measures were function, disability, patient-specified functional outcomes, use of other health care, and duration of relief beyond 1 month. Results. A significantly greater proportion of patients treated with transforaminal injection of steroid (54%) achieved relief of pain than did patients treated with transforaminal injection of local anesthetic (7%) or transforaminal injection of saline (19%), intramuscular steroids (21%), or intramuscular saline (13%). Relief of pain was corroborated by significant improvements in function and disability, and reductions in use of other health care. Outcomes were equivalent for patients with acute or chronic radicular pain. Over time, the number of patients who maintained relief diminished. Only some maintained relief beyond 12 months. The proportions of patients doing so were not significantly different statistically between groups. Discussion. Transforaminal injection of steroids is effective only in a proportion of patients. Its superiority over other injections is obscured when group data are compared but emerges when categorical outcomes are calculated. Over time, the proportion of patients with maintained responses diminishes.

"They Don't Want Anything to Do with You": Patient Views of Primary Care Management of Chronic Pain

Abstract: Objective. Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care. Design. Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used struc- tured questions and were tape recorded, tran- scribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish.

The Brief Pain Inventory and its “Pain at its Worst in the last 24 Hours” Item: Clinical Trial Endpoint Considerations

Abstract: Context. In 2006, the United States Food and Drug Administration (FDA) released a draft Guidance for Industry on the use of patient-reported outcomes (PRO) Measures in Medical Product Development to Support Labeling Claims. This draft guidance outlines psychometric aspects that should be considered when designing a PRO measure, including conceptual framework, content validity, construct validity, reliability, and the ability to detect clinically meaningful score changes. When finalized, it may provide a blueprint for evaluations of PRO measures that can be considered by sponsors and investigators involved in PRO research and drug registration trials. Objective. In this review we examine the short form of the Brief Pain Inventory (BPI) and particularly the “pain at its worst in the last 24 hours” item in the context of the FDA draft guidance, to assess its utility in clinical trials that include pain as a PRO endpoint. Results and Conclusions. After a systematic evaluation of the psychometric aspects of the BPI, we conclude that the BPI and its “pain at its worst in the last 24 hours” item generically satisfy most key recommendations outlined in the draft guidance for assessing a pain-reduction treatment effect. Nonetheless, when the BPI is being considered for assessment of pain endpoints in a registration trial, sponsors and investigators should consult with the appropriate FDA division early during research design to discuss whether there is sufficient precedent to use the instrument in the population of interest or whether additional evaluations of measurement properties are advisable.

Nonimmersive Virtual Reality Mirror Visual Feedback Therapy and Its Application for the Treatment of Complex Regional Pain Syndrome: An Open-Label Pilot Study

Abstract: Objective. Chronic pain conditions such as phantom limb pain and complex regional pain syn- drome are difficult to treat, and traditional pharma- cological treatment and invasive neural block are not always effective. Plasticity in the central nervous system occurs in these conditions and may be asso- ciated with pain. Mirror visual feedback therapy aims to restore normal cortical organization and is applied in the treatment of chronic pain conditions. However, not all patients benefit from this treatment. Virtual reality technology is increasingly attracting attention for medical application, including as an analgesic modality. An advanced mirror visual feed- back system with virtual reality technology may have increased analgesic efficacy and benefit a wider patient population. In this preliminary work, we developed a virtual reality mirror visual feedback system and applied it to the treatment of complex regional pain syndrome. Design. A small open-label case series. Five patients with complex regional pain syndrome received virtual reality mirror visual feedback therapy once a week for five to eight sessions on an outpatient basis. Patients were monitored for con- tinued medication use and pain intensity. Results. Four of the five patients showed >50% reduction in pain intensity. Two of these patients ended their visits to our pain clinic after five sessions. Conclusion. Our results indicate that virtual reality mirror visual feedback therapy is a promising alter- native treatment for complex regional pain syn- drome. Further studies are necessary before concluding that analgesia provided from virtual reality mirror visual feedback therapy is the result of reversing maladaptive changes in pain perception.

Patient‐Centered Perspective on Treatment Outcomes in Chronic Pain

Abstract: Objective. To define patient-determined success criteria for fibromyalgia and back pain treatment across four outcome domains: pain, fatigue, emotional distress, interference with daily activities. Design. Retrospective correlational clinical sample design. Setting. Tertiary care clinics at health science center. Patients. 248 fibromyalgia patients and 52 back pain patients. Interventions. N/A. Outcome Measures. Patient Centered Outcomes Questionnaire, measures of usual pain intensity and pain unpleasantness. Results. Overall, for treatment to be considered successful, fibromyalgia patients required pain levels of 3.30 (54% reduction), fatigue levels of 3.08 (60% reduction), distress levels of 2.49 (60% reduction), and interference levels of 2.67 (63% reduction). Comparatively, back pain patients required pain levels of 2.23 (58% reduction), fatigue levels of 2.29 (57% reduction), distress levels of 1.65 (67% reduction), and interference levels of 1.81 (68% reduction). Overall, both fibromyalgia and back pain patients did not expect to meet their criteria for success. Conclusions. Results highlight the importance of assessing the patient's view of successful outcome. Both fibromyalgia and back pain patients appear to have stringent criteria for success that existing treatments are often unlikely to meet. Comparison across groups indicated fibromyalgia patients have higher usual levels of pain, fatigue, distress, and interference. Interestingly, fibromyalgia patients also require greater changes across domains in order to consider treatment successful, despite rating higher levels of pain, fatigue, distress, and interference as successful. Recognizing patients' success criteria and treatment expectations encourages discussion and development of individualized treatment goals, and wider implementation of individualized treatment for chronic-pain populations is encouraged.

Opioids, pain, the brain, and hyperkatifeia: a framework for the rational use of opioids for pain.

Abstract: Objective Opioids have relieved more human suffering than any other medication, but their use is still fraught with significant concerns of misuse, abuse, and addiction. This theoretical article explores the hypothesis that opioid misuse in the context of pain management produces a hypersensitivity to emotional distress, termed hyperkatifeia.

Subcutaneous injection of botulinum toxin a is beneficial in postherpetic neuralgia.

Abstract: Objective. To assess the benefits of subcutaneous injection of botulinum toxin A (BTX-A) for the treatment of postherpetic neuralgia (PHN). Design. We investigated the therapeutic benefits of BTX-A in subjects with PHN in a randomized, double-blind, placebo-controlled study. Sixty subjects with PHN were randomly and evenly distributed into BTX-A, lidocaine, and placebo groups. Measures. After randomization, one of the following solutions was injected subcutaneously in the affected dermatome: 5 u/mL BTX-A, 0.5% lidocaine, or 0.9% saline (placebo). Visual analog scale (VAS) pain and sleeping time (hours) were evaluated at the time of pretreatment, day 1, day 7, and 3 months posttreatment. Opioid usage was calculated at day 7 and 3 months posttreatment. Results. Compared with pretreatment, VAS pain scores decreased at day 7 and 3 months posttreatment in all three groups ( P < 0.01). However, the VAS pain scores of the BTX-A group decreased more significantly compared with lidocaine and placebo groups at day 7 and 3 months posttreatment ( P < 0.01). Sleep time (hours) had improved at day 7 and at 3 months compared with pretreatment in all three groups, but the BTX-A group improved more significantly compared with lidocaine and placebo groups ( P < 0.01). The percent of subjects using opioids posttreatment in the BTX-A group was the lowest (21.1%) compared with the lidocaine (52.6%) and placebo (66.7%) groups ( P < 0.01). Conclusions. Subcutaneous administration of BTX-A significantly decreased pain in PHN and reduced opioid use compared with lidocaine and placebo at day 7 and 3 months post-treatment. It also increased subjects' sleep times.

Topical NSAID Therapy for Musculoskeletal Pain

Abstract: Objective. Systematic reviews previously reported in the literature document that topical nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in relieving pain in acute and chronic painful musculoskeletal disorders including osteoarthritis, tendonitis, and muscle strains. Because several topical NSAIDs are available, with important differences among the formulations, there is a need to address and summarize the evidence of their effectiveness and safety. Design. We searched Medline and Cochrane CENTRAL databases for clinical trials and systematic reviews of topical NSAIDs in musculoskeletal pain, using the following keywords: “NSAID,”“nonsteroidal,”“anti-inflammatory,”“topical,”“cream,”“gel,”“solution,”“lotion,”“patch,” plaster,”“musculoskeletal,”“tendonitis,”“strain,”“sprain,”“trauma,” and word roots “pain” and “arthritis.” Conclusions. Topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects, based on NSAID molecule and the formulation chosen. Some topical NSAID formulations have been shown to be more effective than placebo in multiple studies, or to have comparable efficacy and a better safety profile than oral NSAIDs for single joint osteoarthritis and acute muscle injuries. In acute and chronic low back pain, widespread musculoskeletal pain, and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDs.

A Hypothesis for the Cause of Complex Regional Pain Syndrome-Type I (Reflex Sympathetic Dystrophy): Pain Due to Deep-Tissue Microvascular Pathology

Abstract: †§¶ Departments of *Anesthesia, † Neurology & Neurosurgery, and ‡ Psychology, § Faculty of Dentistry, Abstract Complex regional pain syndrome-type I (CRPS-I; reflex sympathetic dystrophy) is a chronic pain con- dition that usually follows a deep-tissue injury such as fracture or sprain. The cause of the pain is unknown. We have developed an animal model (chronicpost-ischemiapain)thatcreatesCRPS-I-like symptomatology. The model is produced by occlud- ing the blood flow to one hind paw for 3 hours under general anesthesia. Following reperfusion, the treated hind paw exhibits an initial phase of hyper- emia and edema. This is followed by mechano- hyperalgesia, mechano-allodynia, and cold- allodynia that lasted for at least 1 month. Light microscopic analyses and electron microscopic analyses of the nerves at the site of the tourniquet show that the majority of these animals have no sign of injury to myelinated or unmyelinated axons. However, electron microscopy shows that the ischemia-reperfusion injury produces a microvascu- larinjury,slow-flow/no-reflow,inthecapillariesofthe hind paw muscle and digital nerves. We propose that the slow-flow/no-reflow phenomenon initiates and maintains deep-tissue ischemia and inflammation, leading to the activation of muscle nociceptors, and the ectopic activation of sensory afferent axons due to endoneurial ischemia and inflammation. These data, and a large body of clinical evidence, suggest that in at least a subset of CRPS-I patients, the fundamental cause of the abnormal pain sensa- tions is ischemia and inflammation due to microvas- cular pathology in deep tissues, leading to a combination of inflammatory and neuropathic pain processes. Moreover, we suggest a unifying idea that relates the pathogenesis of CRPS-I to that of CRPS-II. Lastly, our hypothesis suggests that the role of the sympathetic nervous system in CRPS-I is a factor that is not fundamentally causative, but may have an important contributory role in early-stage disease.

Opioid analgesics for pain control: wisconsin physicians' knowledge, beliefs, attitudes, and prescribing practices.

Abstract: Objective. Opioid analgesics are the drugs of choice for the treatment of moderate to severe acute and cancer pain. Although their role in the management of chronic pain not related to cancer is controversial, there is increasing evidence for their benefit in certain patient populations. Design. A 32-item survey to assess Wisconsin physicians' knowledge, beliefs, and attitudes toward opioid analgesic use was mailed to 600 randomly selected licensed physicians, resulting in a 36% response rate. Results. Half of the respondents considered diversion a moderate or severe problem in Wisconsin. A majority considered addiction to be a combination of physiological and behavioral characteristics, rather than defining it solely as a behavioral syndrome. Most physicians felt it lawful and acceptable medical practice to prescribe opioids for chronic cancer pain, but only half held this view if the pain was not related to cancer. Fewer physicians considered such prescribing as lawful and generally accepted medical practice if the patient had a history of substance abuse. About two-thirds of physicians were not concerned about being investigated for their opioid prescribing practices, but some admitted that fear of investigation led them to lower the dose prescribed, limit the number of refills, or prescribe a Schedule III or IV rather than a Schedule II opioid. Conclusion. Wisconsin physicians who responded to this survey held many misconceptions about the prescribing of opioids. Such views, coupled with a lack of knowledge about laws and regulations governing the prescribing of controlled substances, may result in inadequate prescribing of opioids with resultant inadequate management of pain.

NGX‐4010, a High‐Concentration Capsaicin Patch, for the Treatment of Postherpetic Neuralgia: A Randomized, Double‐Blind, Controlled Study with an Open‐Label Extension

Abstract: Objectives. To assess the efficacy, tolerability, and safety of NGX-4010, a high-concentration capsaicin dermal patch (capsaicin 640 μg/cm2, 8%) in patients with postherpetic neuralgia (PHN). Methods. Patients were randomized to receive NGX-4010 or control patch in a 4-week, double-blind study. This was followed by an open-label extension phase (up to 48 weeks total) where patients could receive up to three additional treatments no sooner than 12 weeks after initial treatment. The primary efficacy variable was mean change from baseline in mean morning and evening numerical pain rating scale (NPRS) scores. Results. During days 8–28 after the double-blind treatment, NGX-4010 patients had a mean change in NPRS scores from baseline of −32.7% compared with −4.4% for control patients (P = 0.003). Mean NPRS scores decreased from baseline during week 1 in both treatment groups, remained relatively stable through week 12 in NXG-4010 patients, but returned to near baseline during weeks 2–4 in controls. Mean change in NPRS scores from baseline during weeks 2–12 was −33.8% for NGX-4010 and +4.9% for control recipients. A similar decrease in NPRS scores from baseline was maintained with subsequent NGX-4010 treatments, regardless of the number of treatments received. Transient increases in application site pain were adequately managed with analgesics. No increases in application site reactions or adverse events were observed with repeated treatments. No patients discontinued the study due to an adverse event. Conclusion. NGX-4010 is a promising topical treatment for PHN patients, which appears to be tolerable, generally safe, and effective.

NMDA receptor antagonists for the treatment of neuropathic pain

Abstract: Objective. The N-methyl-D-Aspartate (NMDA) receptor has been proposed as a primary target for the treatment of neuropathic pain. The aim of the present study was to perform a meta-analysis evaluating the effects of (individual) NMDA receptor antagonists on neuropathic pain, and the response (sensitivity) of individual neuropathic pain disorders to NMDA receptor antagonist therapy. Design. PubMed (including MEDLINE), EMBASE and CENTRAL were searched up to October 26, 2009 for randomized placebo controlled trials (RCTs) on neuropathic pain. The methodological quality of the included trials was independently assessed by two authors using the Delphi list. Fixed or random effects model were used to calculate the summary effect size using Hedges' g. Setting. NA. Patients. The patients used for the study were neuropathic pain patients. Interventions. The interventions used were NMDA receptor antagonists. Outcome measurements. The outcome of measurements was the reduction of spontaneous pain. Results. Twenty-eight studies were included, meeting the inclusion criteria. Summary effect sizes were calculated for subgroups of studies evaluating ketamine IV in complex regional pain syndrome (CRPS), oral memantine in postherptic neuralgia and, respectively, ketamine IV, and oral memantine in postamputation pain. Treatment with ketamine significantly reduced pain in postamputation pain (pooled summary effect size: −1.18 [confidence interval (CI) 95% −1.98, −0.37], P = 0.004). No significant effect on pain reduction could be established for ketamine IV in CRPS (−0.65 [CI 95% −1.47, 0.16], P = 0.11) oral memantine in postherptic neuralgia (0.03 [CI 95% −0.51, 0.56], P = 0.92) and for oral memantine in postamputation pain (0.38 [CI 95% −0.21, 0.98], P = 0.21). Conclusions. Based on this systematic review, no conclusions can yet be made about the efficacy of NMDA receptor antagonists on neuropathic pain. Additional RCTs in homogenous groups of pain patients are needed to explore the therapeutic potential of NMDA receptor antagonists in neuropathic pain.

Sex differences in pain and pain-related disability among primary care patients with chronic musculoskeletal pain

Abstract: Background. Although previous research suggests women report more severe pain than men, evidence for sex-related differences in pain-related disability is conflicting. Also, the impact of psychological factors on sex differences in disability is uncertain. Objective. The purpose of this study is to assess sex differences in pain-related disability and evaluate whether they are accounted for by psychological factors. Methods. Analysis of baseline data from the Stepped Care for Affective disorders and Musculoskeletal Pain study. Participants included 241 male and 249 female primary care patients with moderately severe persistent pain of the back, hip, or knee. Multivariable log-linear models were used to determine the association between sex and pain-related disability and whether sex differences persisted after adjustment for psychiatric comorbidity and potential psychological mediators. Results. Compared with men, women reported worse pain intensity, greater pain-related interference with function, and more disability days due to pain. They also had worse depression, anxiety, and self-efficacy. Sex differences in pain interference with function and pain disability days remained significant in multivariable models. Depression, poor self-efficacy, and fear of reinjury were independently associated with disability in both men and women. Conclusions. Women report greater pain-related disability than do men, even after controlling for depression, anxiety, and other psychological factors. Pain management strategies that target functional disability may be particularly important in the treatment of women with pain.

Intraforaminal location of the great anterior radiculomedullary artery (artery of Adamkiewicz): a retrospective review.

Abstract: Purpose. The purpose of this study was to better characterize the intraforaminal location of the great anterior radiculomedullary artery (artery of Adamkiewicz [AKA]) within the neural foramen that would allow safer targeting of thoracic and lumbar transforaminal epidural steroid injections. Material and Methods. A retrospective review of conventional thoracic and lumbar spinal angiograms performed at the Mayo Clinic from 1998–2008 was conducted. Two hundred forty-eight patients were identified and their spinal angiograms reviewed. The cephalo-caudal location of the AKA within the foramen at the mid-pedicular plane was documented along with the side and level of the AKA. Results. From the 248 patients, 113 radiculomedullary arteries could be clearly evaluated within a neural foramen. The AKA was located in the superior one-half of the foramen in 97% (110). Eighty-eight percent (100) were located in the upper third; 9% (10) were located in the middle third; and 2% (2) were located in the lower third. The AKA was never seen in the inferior one-fifth of the foramen. Eighty-eight percent (100) of the radiculomedullary arteries were located on the left while 17% (20) were located on the right. The radiculomedullary arteries were identified from T2-L3. 92% (110) were located between T8 and L1. 28% (34) were located at T10, the highest incidence. Conclusions. The AKA was overwhelmingly located in the superior aspect of the neural foramen. Contrary to traditional teaching, the safest needle placement for an epidural steroid injection, particularly at L3 and above, may not be in the superior aspect of the foramen, but rather in an inferior and slightly posterior position within the foramen and relative to the nerve.

Cancer Pain: Part 1: Pathophysiology; Oncological, Pharmacological, and Psychological Treatments: A Perspective from the British Pain Society Endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners

Abstract: Objective. This discussion document about the management of cancer pain is written from the pain specialists' perspective in order to provoke thought and interest in a multimodal approach to the manage- ment of cancer pain, not just towards the end of life, but pain at diagnosis, as a consequence of cancer therapies, and in cancer survivors. It relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain. Methods. This document has been produced by a consensus group of relevant health care profession- als in the United Kingdom and patients' representa- tives making reference to the current body of evidence relating to cancer pain. In the first of two parts, pathophysiology, oncological, pharmacologi- cal, and psychological treatment are considered. Conclusions. It is recognized that the World Health Organization (WHO) analgesic ladder, while provid- ing relief of cancer pain towards the end of life for many sufferers worldwide, may have limitations in

painACTION-Back Pain: A Self-Management Website for People with Chronic Back Pain

Abstract: Objective. To determine whether an interactive self-management Website for people with chronic back pain would significantly improve emotional management, coping, self-efficacy to manage pain, pain levels, and physical functioning compared with standard text-based materials. Design. The study utilized a pretest–posttest randomized controlled design comparing Website (painACTION-Back Pain) and control (text-based material) conditions at baseline and at 1-, 3, and 6-month follow-ups. Participants. Two hundred and nine people with chronic back pain were recruited through dissemination of study information online and at a pain treatment clinic. The 6-month follow-up rates for the Website and control groups were 73% and 84%, respectively. Measurements. Measures were based on the recommendations of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials and included measures of pain intensity, physical functioning, emotional functioning, coping, self-efficacy, fear-avoidance, perceived improvement with treatment, self-efficacy, and catastrophizing. Results. Compared with controls, painACTION-Back Pain participants reported significantly: 1) lower stress; 2) increased coping self-statements; and 3) greater use of social support. Comparisons between groups suggested clinically significant differences in current pain intensity, depression, anxiety, stress, and global ratings of improvement. Among participants recruited online, those using the Website reported significantly: 1) lower “worst” pain; 2) lower “average” pain; and 3) increased coping self-statements, compared with controls. Participants recruited through the pain clinic evidenced no such differences. Conclusions. An online self-management program for people with chronic back pain can lead to improvements in stress, coping, and social support, and produce clinically significant differences in pain, depression, anxiety, and global rates of improvement.

The utility of the short version of the Depression Anxiety Stress Scales (DASS-21) in elderly patients with persistent pain: does age make a difference?

Abstract: Objective. This study examined the assessment of the negative emotional constructs of depression, anxiety and stress with the short version (21 items) of the Depression Anxiety Stress Scales (DASS-21) in elderly patients (age > 60 years) with persistent pain. Design. A convenience sample of 2,045 patients attending a tertiary referral pain centre were categorized by age and included a group aged 60 years and under (n = 1,245) for assessment of age differences. Elderly patients (n = 800) were divided into 3 groups: 61–70 years (n = 366), 71–80 years (n = 308) and 81 years and over (n = 126). Patients completed the DASS-21 as part of an initial clinical assessment process. Results. The failure rate for scale completion increased across age groups and was significantly higher in the oldest group compared to the youngest group. All scales demonstrated reasonable convergent and divergent validity. Confirmatory factor analysis confirmed a three-factor structure and is consistent with previous studies. Age differences in depression, anxiety and stress scores were also assessed. Interestingly, patients aged 60 years and under had significantly higher Depression and Stress scores compared to all other age groups. This group also had significantly higher Anxiety scores compared to patients aged 61–70 years. Conclusions. Overall, the DASS-21 is a reliable and valid measure of depression, anxiety and stress in elderly patients with persistent pain. There are some age differences in the normative values for the reporting of mood symptoms and these need to be taken into account when assessing pain-related mood disturbance in older populations.

The First National Pain Medicine Summit—Final Summary Report

Abstract: Pain is ubiquitous. At some point in time it affects everyone. For many millions pain becomes chronic, a scourge that impacts every facet of life—work, hobbies, family relations, social fabric, finances, happiness, mood, and even the very essence of identity. According to the National Institutes of Health (NIH), pain is one of our most important national public health problems, a silent epidemic. In 1998, NIH reported that the annual amount spent on health care, compensation, and litigation related to pain had reached one hundred billion dollars ($100,000,000,000). Considering that health care costs have doubled since then, it is not unreasonable to assume that the costs related to pain care have doubled as well. Millions of patients suffer needlessly with acute pain, with cancer pain, and with chronic pain. The ineffective management of pain results in an escalating cascade of health care issues. Acute pain that is not treated adequately and promptly results in persistent pain that eventually causes irreversible changes in the nervous system. This translates into progressive bio-psycho-social epiphenomena resulting in further pain and disability. It creates a vicious cycle transforming a functional human being into an invalid who becomes a burden to family, to society, and to oneself. In the face of adequate medical science, adequate technical skills, and adequate resources the reality of delayed and inadequate pain care is paradoxical. This dilemma deserves close scrutiny and effective remediation. The American Medical Association (AMA), long dedicated to the need to improve pain care in this country, has been faced with this reality. It was from this vision that the idea of holding a Pain Medicine Summit was conceived. Resolution 321 (A-08) set in motion a process that would bring together a diverse group of stakeholders for the purpose of discussing the present and future status of pain care; a process that culminated in a broad-based coalition of physicians and organizations dedicated to improving pain care, the first National Pain Medicine Summit. The process began with the adoption of Resolution 321 (A-08) at an AMA Annual House of Delegates meeting in June 2008. Resolution 321 (A-08) states, in part, that “. . . the AMA encourages relevant specialties to collaborate in studying: 1) the scope and practice and body of knowledge encompassed by the field of Pain Medicine; 2) the adequacy of undergraduate, graduate, and post graduate education in the principles and practices of the field of Pain Medicine, considering the current and anticipated medical need for the delivery of quality pain care; and 3) appropriate training and credentialing criteria for this multi-disciplinary field of medical practice.” The next step was delegating the responsibility for implementing Resolution 321 (A-08) to the Pain and Palliative Medicine Specialty Section Council (PPMSSC). The PPMSSC, under the direction of its chairman, Philipp M. Lippe, MD, FACS, assumed responsibility in November 2008 for identifying a process that would achieve the goals established by Resolution 321 (A-08). The PPMSSC in turn established an Advisory Committee, charged with strategic planning, and an Implementation Committee, charged with tactical operations. The two groups began work immediately. The process included three distinct phases centered on a Pain Medicine Summit. Phase One involved a modified Delphi process identifying the five most pressing and relevant themes in pain care. Phase Two consisted of the Pain Medicine Summit itself, including a gathering of representatives from across the pain care spectrum to address the previously identified five most pressing themes. Phase Three was the preparation of this report, which describes the conclusions drawn and recommendations developed by the attendees at the Pain Medicine Summit. Based on a recommendation from the Advisory Committee, the PPMSSC decided to retain the services of a consulting firm to help the PPMSSC implement the Pain Medicine Summit process. In August 2009, PPMSSC selected Grey Matters, a New York-based advisory firm. The PPMSSC also appointed a Steering Committee to assist Grey Matters and to coordinate all activities. The Committee consisted of Charles Brock, MD; Ronald Crossno, MD; Jose David, MD; Michel Dubois, MD; Albert Ray, MD; and Philipp M. Lippe, MD, FACS (chair). The consulting firm, Grey Matters, proposed a multi-phasic process in order to facilitate the implementation of the Pain Medicine Summit and to ensure a coordinated, efficient, and productive outcome. This process consisting of three phases—pre-summit, summit, and post-summit—is described in detail in the following section. All aspects of the project were closely coordinated and supervised by the Steering Committee, which included the selection of the team leaders of the five Workgroups, based on specific criteria. The Pain Medicine Summit, adhering to the dictates of Resolution 321 (A-08), explored the body of knowledge and the scope of practice of Pain Medicine; the education and training in medical school, graduate, and postgraduate programs; and the credentialing and certification processes in the field of Pain Medicine. It addressed the barriers hampering delivery of high quality pain care. It recognized the need for clarification and consensus in many areas. Several points of consensus emerged: • The continuum of medical education in the field of Pain Medicine is inadequate and fragmented. It needs to be fortified in scope, content, and duration. • Credentialing and certification processes in Pain Medicine are variable, diverse, and deficient in many instances. • Deficiencies in these areas lead to suboptimal and fragmented pain care having a negative impact on direct patient care and public health. • Effective and prompt remediation is desirable and essential to achieving the goal of high quality pain care. • Barriers exist inhibiting or retarding progress toward the common good. There are several viable avenues to achieving our stated goal, “excellence in the delivery of high quality, cost-effective pain care to the patients we serve,” including the development of Pain Medicine as a distinct specialty with ACGME accredited residency programs and ABMS certification. The Pain Medicine Summit concluded with a number of recommendations, including the following: • That the pain community remains engaged in addressing the issues raised and in mitigating the barriers. • That the recommendations be referred to the AMA and the PPMSSC for support and implementation. • That another national Pain Medicine Summit with enhanced participation be convened. • That consideration be given to convening an International Pain Summit in conjunction with the IASP World Congress in Montreal. • That the final report of the Pain Medicine Summit be widely disseminated.

Intractable End‐of‐Life Suffering and the Ethics of Palliative Sedation

Abstract: Palliative sedation (sedation to unconsciousness) as an option of last resort for intractable end-of-life distress has been the subject of ongoing discussion and debate as well as policy formulation. A particularly contentious issue has been whether some dying patients experience a form of intractable suffering not marked by physical symptoms that can reasonably be characterized as "existential" in nature and therefore not an acceptable indication for palliative sedation. Such is the position recently taken by the American Medical Association. In this essay we argue that such a stance reflects a fundamental misunderstanding of the nature of human suffering, particularly at the end of life, and may deprive some dying patients of an effective means of relieving their intractable terminal distress.

Predictors of Complementary and Alternative Medicine Use in Chronic Pain Patients

Abstract: Objective. We used Andersen's behavioral model of healthcare utilization to assess the relationship between sociodemographic, physical and psycho- social factors, and Complementary and Alternative Medicine (CAM) use among chronic pain patients. Three practitioner-based alternative therapies were considered: acupuncture, biofeedback/relaxation training, and manipulation services. Design. A retrospective analysis of self-reported clinical data with 5,750 black and white adults pre- senting for initial assessment between 1994 and 2000 at the University of Michigan Multidisciplinary Pain Center was performed. Results. CAM therapies were used in high frequen- cies, with 34.7% users. Specifically 8.3% used acu- puncture, 13.0% used biofeedback/relaxation, and 24.9% used manipulation techniques. Race and age were predisposing factors associated with CAM use. Blacks used less biofeedback/relaxation and manipulation services than whites. Aging was related to more acupuncture, but less biofeedback/ relaxation use. Women marginally used more biofeedback/relaxation services than men, and edu- cation was positively associated with all three CAM use. Perceived pain control was a consistent enabling factor positively correlated with the use of all three CAM services. Among need factors, pain characteristics and physical health were positively associated with at least one of the modalities. Depressive symptoms were not related to CAM ser- vices use. Conclusion. This study identifies variable patterns of CAM usage based on sociodemographic and health factors in chronic pain patients. Overall, who uses CAM depends on the modality; however, edu- cation, pain severity, and pain duration are persis- tent correlates of CAM usage regardless of the therapy considered. We found that mental health, as measured by depressive symptoms, had no notice- able impact on CAM usage among chronic pain patients. The clinical, policy, and research implica- tions of CAM use are discussed.

Spinal Cord Stimulation for Chronic Visceral Abdominal Pain

Abstract: Background. Spinal cord stimulation (SCS) may reduce pain scores and improve function in patients with chronic visceral abdominal pain. We thus present our large clinical experience in SCS for visceral abdominal pain. Methods. We trialed spinal cord stimulation in 35 patients, each of whom was shown by retrograde differential epidural block to have either visceral pain (n = 32) or mixed visceral and central pain (n = 3). SCS trials lasted 4 to 14 days (median 9 days). SCS lead tips were mostly positioned at T5 (n = 11) or T6 (n = 10). Results. Thirty patients (86%) reported at least 50% pain relief upon completion of the trial. Among these, pretrial visual analog scale (VAS) pain scores averaged 8.2 ± 1.6 (SD) and opioid use averaged 110 ± 119 mg morphine sulfate equivalents. During the trial, VAS pain scores decreased to 3.1 ± 1.6 cm (P < 0.001, Mann–Whitney Rank Sum Test) and opioid use decreased to 70 ± 68 mg morphine equivalent a day (P = 0.212). Five patients failed the trial, one was lost to follow-up, and 19 were followed for the whole year. Seven patients were either followed for less than a year (n = 3) or the SCS system was removed due to infection or lead migration (n = 4). One patient despite the successful trial felt no improvements at 6 months after the implant and requested an explant of the SCS device. Among the 28 patients who received permanent implant, 19 were followed at least a year. Their VAS pain scores remained low (3.8 ± 1.9 cm; P < 0.001) at 1 year, as did opioid use (38 ± 48 mg morphine equivalents; P = 0.089). Conclusions. Spinal cord stimulation may be a useful therapeutic option for patients with severe visceral pain.

Evaluation of the Acceptability and Usability of a Decision Support System to Encourage Safe and Effective Use of Opioid Therapy for Chronic, Noncancer Pain by Primary Care Providers.

Abstract: Objective. To develop and evaluate a clinical decision support system (CDSS) named Assessment and Treatment in Healthcare: Evidenced-Based Automation (ATHENA)-Opioid Therapy, which encourages safe and effective use of opioid therapy for chronic, noncancer pain. Design. CDSS development and iterative evaluation using the analysis, design, development, implementation, and evaluation process including simulation-based and in-clinic assessments of usability for providers followed by targeted system revisions. Results. Volunteers provided detailed feedback to guide improvements in the graphical user interface, and content and design changes to increase clinical usefulness, understandability, clinical workflow fit, and ease of completing guideline recommended practices. Revisions based on feedback increased CDSS usability ratings over time. Practice concerns outside the scope of the CDSS were also identified. Conclusions. Usability testing optimized the CDSS to better address barriers such as lack of provider education, confusion in dosing calculations and titration schedules, access to relevant patient information, provider discontinuity, documentation, and access to validated assessment tools. It also highlighted barriers to good clinical practice that are difficult to address with CDSS technology in its current conceptualization. For example, clinicians indicated that constraints on time and competing priorities in primary care, discomfort in patient-provider communications, and lack of evidence to guide opioid prescribing decisions impeded their ability to provide effective, guideline-adherent pain management. Iterative testing was essential for designing a highly usable and acceptable CDSS; however, identified barriers may limit the impact of the ATHENA-Opioid Therapy system and other CDSS on clinical practices and outcomes unless CDSS are paired with parallel initiatives to address these issues.

Comparison of the Effectiveness of Lumbar Transforaminal Epidural Injection with Particulate and Nonparticulate Corticosteroids in Lumbar Radiating Pain

Abstract: Objective. Lumbar transforaminal epidural steroid injections are procedures often utilized in the treatment of low back pain associated with radicular pain. Particulate steroids have been known to play a role in embolism. It is, unknown whether nonparticulate steroids are as effective as particulate steroids. To investigate the effect of an epidural steroid injection on back pain, we conducted a randomized, controlled trial comparing nonparticulate steroid with particulate steroid to treat lumbar disc herniation. Design. One hundred-six patients were randomized to receive lumbar transforaminal epidural steroid injections (N = 53) with either dexamethasone 7.5 mg, or with triamcinolone acetate 40 mg (N = 53). Measurement were taken before treatment and one month after treatment using a visual analog scale, short McGill pain questionnaire, and revised Oswertry Back Disability Index. Results. There was a statistically significant difference in the visual analog score between those treated with dexamethasone and those given triamcinolone. The two groups did not differ significantly on the McGill Pain Questionnaire, or the Oswestry Disability Index before and after treatment. Conclusion. In this study, dexamethasone and triamcinolone treatments were shown to have different effects on low back pain with sciatica, with triamcinolone being more effective than dexamethsone in lumbar radiculopathy.

Plasticity of complex regional pain syndrome (CRPS) in children.

Abstract: Complex regional pain syndrome I (CRPS I) is defined by the International Association for the Study of Pain (IASP) criteria to include pain that is disproportionate to the inciting event, sensory disturbances such as allodynia/ hyperalgesia, autonomic dysfunction, and motor dysfunction that usually occurs after trauma that is frequently trivial and generally expressed in an extremity. These symptoms are well described in the adult population, but there are relatively few data or reports of its prevalence in the pediatric population. Recent studies have demonstrated that unlike the adult population, about 90% of the cases reported are females in a range of 8 to 16 years, the youngest being 3 years old. There tends to be delay in recognizing the diagnosis, which may be as long as 4 months. In contrast to adults, the response to treatment, particularly exercise therapy with behavioral management will achieve almost 97% remission. While the pathophysiology is poorly understood, many features, particularly the neurologic abnormalities, suggest both peripheral and central nervous system involvement. Peripheral small fiber neuropathy as an etiology and inflammation involving small nerve fibers (neurogenic inflammatory pain) has been suggested. A tissue inflammatory etiology has been investigated over the past 25 years. However, these inflammatory aspects differ from those seen in other conditions involving tissue inflammation. The suggestion that CRPS in children is a different clinical entity than that seen in the adult, is probably incorrect, as recent evidence would suggest that the pathophysiology is most likely identical involving endocrine, behavioral, developmental, and environmental factors that distinguish clinical presentation in children from the adult. Behavioral management is a mandatory accompaniment of any program of exercise therapy and the sometimes extreme sensory disturbances and parental enmeshment do distinguish the clinical presentation from that in the adult. Interventional procedures may be required in the face of extreme allodynia preventing exercise therapy, and in occasional cases interruption of the sympathetic nerves may reverse this symptom in a few children. Occasionally, continuous analgesia techniques such as that which can be delivered by tunneled epidural catheter or an externalized neurostimulator (spinal cord stimulation) for short periods of time are effective.

Predictors of pain outcomes in patients with chronic musculoskeletal pain co-morbid with depression: results from a randomized controlled trial

Abstract: Objective. The combination of chronic musculoskeletal pain and depression is associated with worse clinical outcomes than either condition alone. In this study, we report the predictors of pain intensity and activity interference in primary care patients with co-morbid pain and depression. Methods. This is a secondary data analysis of the 250 persons who participated in a randomized clinical trial designed to test the effectiveness of 12 weeks of optimized antidepressant therapy for both depression and pain. Using multivariate linear regression analysis, we assessed the predictive value of baseline self-efficacy, fear of movement, pain beliefs, and demographic and clinical factors on 3-month Graded Chronic Pain Scale pain intensity and activity interference outcomes. Results. In the full model, significant sociodemographic predictors of less activity interference included being non-white (β−5.8, P = 0.04) and being employed (β−13.3, P < 0.0001). The latter was also predictive of less pain intensity (β−5.6, P = 0.01). As expected, the optimized antidepressant treatment arm was associated with improved outcomes (pain intensity: β−3.7, P = 0.0005 and activity interference: β−6.4, P = 0.01). Whereas stronger perceived pain control (β 3.6, P = 0.01) was associated with greater activity interference, higher degree of fear of movement (or fear avoidance) predicted greater pain intensity (β 0.46, P = 0.04) and activity interference (β 0.57, P = 0.05). Neither the location (low back vs hip/knee) nor duration of pain were predictive of pain intensity or interference outcomes. Conclusion. The findings are consistent with a bio-psychosocial model, implicating the need to consider the impact of sociodemographic variables and pain-related beliefs and cognition on pain-related outcomes for patients with co-morbid musculoskeletal pain and depression.

Cancer pain: part 2: physical, interventional and complimentary therapies; management in the community; acute, treatment-related and complex cancer pain: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners.

Abstract: Objective: This discussion document about the management of cancer pain is written from the pain specialists' perspective in order to provoke thought and interest in a multimodal approach to the management of cancer pain, not just towards the end of life, but pain at diagnosis, as a consequence of cancer therapies, and in cancer survivors. It relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain. Methods: This document has been produced by a consensus group of relevant healthcare professionals in the United Kingdom and patients' representatives making reference to the current body of evidence relating to cancer pain. In the second of two parts, physical, invasive and complementary cancer pain therapies; treatment in the community; acute, treatment-related and complex cancer pain are considered. Conclusions: It is recognized that the World Health Organization (WHO) analgesic ladder, whilst providing relief of cancer pain towards the end of life for many sufferers world-wide, may have limitations in the context of longer survival and increasing disease complexity. To complement this, it is suggested that a more comprehensive model of managing cancer pain is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, tailored to the needs of an individual, with the aim to optimize pain relief with minimization of adverse effects. Wiley Periodicals, Inc.

Low-level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study.

Abstract: Objective. The objective of the study was to inves- tigate clinical effects of low-level laser therapy (LLLT) in patients with acute neck pain with radiculopathy.

Cytokine Polymorphism in Patients with Migraine: Some Suggestive Clues of Migraine and Inflammation

Abstract: Objective. There are contrasting results obtained in migraineurs concerning the levels and the role of both pro-inflammatory and anti-inflammatory cytok- ines. In this study, the association of the occurrence and clinical characteristics of migraine with the polymorphisms of tumor necrosis factor a (TNF-a) -308 G/A (rs1800629), interleukin-1a (IL-1a) +4845 G/T (rs17561), IL-1 b+ 3953 C/T (rs1143634) and interleukin-1 receptor antagonist variable number tandem repeat (IL-1RA VNTR) genes were studied. We also investigated the genetic linkage between these genes. Design, Setting, Patients. Sixty-seven patients with migraine without aura (MwoA) and 96 unrelated, age- and sex-matched migraine-free, healthy control subjects from the same geographic area were investigated. Results. We observed significant differences in the genotypic distribution of the TNF- a- 308 G/A and IL-1 b+ 3953 C/T polymorphism for migraineurs com- pared with controls (P = 0.004). Frequency of the TNF- a- 308 GG genotype was higher in the control group than MwoA group (82.1% vs 55.2%). Differ- ences in the distribution of the allele frequencies were also observed, being the TNF- a- 308 G allele overrepresented in control group and TNF- a- 308 A allele in MwoA group. In addition, there was a significant increase of the IL-1 b+ 3953 T allele in MwoA cases compared with controls (P = 0.004). Conclusions. In conclusion, the present results indicate the possible contribution of TNF-a and IL-1b gene polymorphisms to migraine headache generation in MwoA patients.