Showing papers in "The Clinical Journal of Pain in 2012"
TL;DR: It is argued that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes.
Abstract: Objective: The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability. Methods: A narrative review. Results: There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals. Discussion: To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals.
732 citations
TL;DR: There is evidence that anxiety and catastrophizing play a role in the development of CPSP, and anxiety measures should be incorporated in future studies investigating the prediction and transition from acute to chronic postoperative pain.
Abstract: Objectives: Anxiety and pain catastrophizing predict acute postoperative pain. However, it is not well established whether they also predict chronic postsurgical pain (CPSP). The aim of this systematic review and meta-analysis was to investigate whether high levels of preoperative anxiety or pain catastrophizing are associated with an increased risk of CPSP.
Methods: Electronic search databases included PubMed and PsychINFO. Additional literature was obtained by reference tracking and expert consultation. Studies from 1958 until October 2010, investigating the association between preoperative anxiety or pain catastrophizing and CPSP in adult surgery patients, were assessed. The primary outcome was the presence of pain at least 3 months postoperatively.
Results: Twenty-nine studies were included; 14 instruments were used to assess anxiety or pain catastrophizing. Sixteen studies (55%) reported a statistically significant association between anxiety or pain catastrophizing and CPSP. The proportion of studies reporting a statistically significant association was 67% for studies of musculoskeletal surgery and 36% for other types of surgery. There was no association with study quality, but larger studies were more likely to report a statistically significant relationship. The overall pooled odds ratio, on the basis of 15 studies, ranged from 1.55 (95% confidence interval, 1.10-2.20) to 2.10 (95% confidence interval, 1.49-2.95). Pain catastrophizing might be of higher predictive utility compared with general anxiety or more specific pain-related anxiety.
Discussion: There is evidence that anxiety and catastrophizing play a role in the development of CPSP. We recommend that anxiety measures should be incorporated in future studies investigating the prediction and transition from acute to chronic postoperative pain.
431 citations
TL;DR: Intravenous perioperative lidocaine decreases the incidence and severity of PPSP after breast cancer surgery, and prevention of the induction of central hyperalgesia is a potential mechanism.
Abstract: Objectives:Breast cancer surgery is associated with a high incidence of persistent postsurgical pain (PPSP). The aim of this study was to evaluate the impact of intravenous (IV) lidocaine on acute and PPSP, analgesic requirements, and sensation abnormalities in patients undergoing surgery for breast
155 citations
TL;DR: Perceived injustice appears to be associated with problematic health and mental health recovery trajectories after the onset of a pain condition and future directions for research and treatment are addressed.
Abstract: Background: Emerging research suggests that perceptions of injustice after musculoskeletal injury can have a significant impact on a number of pain-related outcomes.
Aims: The purpose of this paper is to review evidence linking perceptions of injustice to adverse pain outcomes. For the purposes of this paper, perceived injustice is defined as an appraisal cognition comprising elements of the severity of loss consequent to injury ("Most people don't understand how severe my condition is"), blame ("I am suffering because of someone else's negligence"), a sense of unfairness ("It all seems so unfair"), and irreparability of loss ("My life will never be the same").
Results: Cross-sectional studies show that high scores on perceptions of injustice are correlated with pain catastrophizing, fear of movement, and depression. Prospective studies show that high scores on perceived injustice are a prognostic indicator of poor rehabilitation outcomes and prolonged work disability. Research shows that perceptions of injustice interfere not only with physical recovery after injury, but perceptions of injustice also impact negatively on recovery of the mental health problems that might arise subsequent to traumatic injury. Although research has yet to address the process by which perceptions of injustice impact on pain-related outcomes systematically; possible mechanisms include attentional disengagement difficulties, emotional distress, maladaptive coping, heightened displays of pain behavior, anger, and revenge motives.
Conclusions: Perceived injustice appears to be associated with problematic health and mental health recovery trajectories after the onset of a pain condition. Future directions for research and treatment are addressed.
155 citations
TL;DR: A day-hospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPSs that have failed to improve with outpatient treatment.
Abstract: OBJECTIVES To examine clinical outcomes of an interdisciplinary day-hospital treatment program (comprised of physical, occupational, and cognitive-behavioral therapies with medical and nursing services) for pediatric complex regional pain syndrome (CRPS). METHODS The study is a longitudinal case series of consecutive patients treated in a day-hospital pediatric pain rehabilitation program. Participants were 56 children and adolescents with ages 8 to 18 years (median=14 y) with CRPS spectrum conditions who failed to progress sufficiently with a previous outpatient and/or inpatient treatments. Patients participated in daily physical therapy, occupational therapy, and psychological treatment and received nursing and medical care as necessary. The model places equal emphasis on physical and cognitive-behavioral approaches to pain management. Median duration of stay was 3 weeks. Outcome measures included assessments of physical, occupational, and psychological functioning at program admission, discharge, and at posttreatment follow-up at a median of 10 months after discharge. Scores at discharge and follow-up were compared with measures on admission by Wilcoxon tests, paired t tests, or analysis of variance as appropriate, with corrections for multiple comparisons. RESULTS Outcomes demonstrate clinically and statistically significant improvements from admission to discharge in pain intensity (P<0.001), functional disability (P<0.001), subjective report of limb function (P<0.001), timed running (P<0.001), occupational performance (P<0.001), medication use (P<0.01), use of assistive devices (P<0.001), and emotional functioning (anxiety, P<0.001; depression, P<0.01). Functional gains were maintained or further improved at follow-up. DISCUSSION A day-hospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPSs that have failed to improve with outpatient treatment.
151 citations
TL;DR: Use of this pilot intervention seems to have had positive effects on a number of pain-related outcomes, including disability, and future research will evaluate the effectiveness of the completed intervention, with particular attention to quality of life and disability.
Abstract: Objectives: Research has shown that cognitive and behavioral therapies can effectively improve quality of life in chronic pain patients. Unfortunately, many patients lack access to cognitive and behavioral therapy treatments. We developed a pilot version of an interactive online intervention to teach self-management skills for chronic lower back pain, a leading cause of disability and work absenteeism. The objective of this randomized, controlled trial was to evaluate its efficacy. Methods: Individuals with chronic lower back pain were recruited over the Internet, screened by phone, and randomly assigned to receive access to the intervention (Wellness Workbook; WW) either immediately (intervention group) or after a 3-week delay (wait-list control). Participants (n=141, 83% female, 23% minority) were asked to complete the WW over 3 weeks. Self-report measures of pain, disability, disabling attitudes and beliefs, self-efficacy for pain control, and mood regulation were completed at baseline, week 3, and week 6. Results: Controlling for baseline individual differences in the outcome measures, multivariate analysis of covariance revealed that, at week 3, the intervention group scored better than the waitlist control group on all outcomes, including pain severity ratings. At week 6, after both groups had been exposed to the WW, there were no differences between groups. Discussion: Use of this pilot intervention seems to have had positive effects on a number of pain-related outcomes, including disability. Future research will evaluate the effectiveness of the completed intervention, with particular attention to quality of life and disability.
144 citations
TL;DR: The findings provide an important picture of the increasing prevalence of musculoskeletal conditions in the female Veteran population and highlight the importance of the VA targeting treatment programs that focus on issues of particular importance to women with musculOSkeletal pain.
Abstract: BackgroundWe sought to describe sex differences in the prevalence of painful musculoskeletal conditions in men and women Veterans after deployment in Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) (OEF-OIF).MethodsThis is an observational study using Veterans Affairs (VA
129 citations
TL;DR: Serious consideration should be given to the development of short (<8 weeks) group and healthcare professional-delivered interventions but more research is required to establish the most effective and cost-effective course components.
Abstract: Objectives: the objective of the study was to report the evidence for effectiveness of different self-management course characteristics and components for chronic musculoskeletal pain. Methods: we searched 9 relevant electronic databases for randomized, controlled trials (RCTs). Two reviewers selected studies against inclusion criteria and assessed their quality. We classified RCTs according to type of course delivery (group, individual, mixed or remote), tutor (healthcare professional, lay or mixed), setting (medical, community or occupational), duration (more or less than 8 weeks), and the number and type of components (psychological, lifestyle, pain education, mind body therapies, and physical activity). We extracted data on pain intensity, physical function, self-efficacy, global health, and depression and compared these outcomes for self-management and usual care or waiting list control. We used random effects standardized mean difference meta-analysis. We looked for patterns of clinically important and statistically significant beneficial effects for courses with different delivery characteristics and the presence or absence of components across outcomes over 3 follow-up intervals. Results: we included 46 RCTs (N=8539). Group-delivered courses that had healthcare professional input showed more beneficial effects. Longer courses did not necessarily give better outcomes. There was mixed evidence of effectiveness for components of courses, but data for courses with a psychological component showed slightly more consistent beneficial effects over each follow-up period. Discussion: serious consideration should be given to the development of short (<8 weeks) group and healthcare professional-delivered interventions but more research is required to establish the most effective and cost-effective course components
127 citations
TL;DR: The value of music intervention to the management of chronic pain and anxiety/depression appears to be useful in managing chronic pain as it enables a significant reduction in the consumption of medication.
Abstract: Objective:A music intervention method in the management of pain was recently developed while taking account of recommendations in the scientific literature. The objective of this study was to assess the usefulness of this music intervention to the management of patients with chronic pain.Methods:A c
118 citations
TL;DR: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research presents the IOM study committee’s findings and recommendations.
Abstract: Chronic pain a!ects at least 116 million American adults—more than the total a!ected by heart disease, cancer, and diabetes combined. Pain also costs the nation up to $635 billion each year in medical treatment and lost productivity. The 2010 Patient Protection and A!ordable Care Act required the Department of Health and Human Services (HHS) to enlist the Institute of Medicine (IOM) in examining pain as a public health problem. Acting through the National Institutes of Health (NIH), HHS asked the IOM to assess the state of the science regarding pain research, care, and education and to make recommendations to advance the field. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research presents the IOM study committee’s findings and recommendations.
113 citations
TL;DR: Lateral epicondylalgia patients presenting with severe pain and disability could be distinguished by hypersensitivity to thermal stimuli, notably bilateral cold hyperalgesia, which may help explain the poorer outcomes found in this subpopulation.
Abstract: Objectives:To evaluate if sensory, motor, and psychological factors are different in severe lateral epicondylalgia compared with less severe cases and control.Methods:A total of 164 patients with unilateral lateral epicondylalgia and 62 healthy control participants of comparable age and sex underwen
TL;DR: This finding suggests that the selection of exercise based on a precise assessment of the patients’ neuromuscular control and targeted exercise interventions based on this assessment are likely to be the most beneficial to patients with neck pain.
Abstract: Objectives: Altered activation of the deep cervical flexors (longus colli and longus capitis) has been found in individuals with neck pain disorders but the response to training has been variable. Therefore, this study investigated the relationship between change in deep cervical flexor muscle activity and symptoms in response to specific training.
TL;DR: These data may guide future research of psychological factors in ACLR populations so that levels predictive of risk for developing chronic pain and/or inability to return to pre-injury activity levels can be determined.
Abstract: Objective
Recent work suggests that psychological influence on pain intensity and knee function should be considered for patients following anterior cruciate ligament reconstruction (ACLR). The Tampa Scale for Kinesiophobia (TSK) and Pain Catastrophizing Scale (PCS) have been used to determine psychological influence in these patients. However, TSK and PCS factor structures have not been described for patients with ACLR. This study investigated 2 groups of patients post-ACLR to determine if the use of shortened questionnaires is warranted.
TL;DR: The clinical consequence of the shift in thinking is to stop trying to restore normal motor control in case of chronic nociception, and Activation of central nOCiceptive inhibitory mechanisms, by decreasing noc iceptive input, might address nocICEption-motor interactions.
Abstract: OBJECTIVES: Research has provided us with an increased understanding of nociception-motor interaction. Nociception-motor interaction is most often processed without conscious thoughts. Hence, in many cases neither patients nor clinicians are aware of the interaction. It is aimed at reviewing the scientific literature on nociception-motor interaction, with emphasis on clinical implications. METHODS: Narrative review. RESULTS: Chronic nociceptive stimuli result in cortical relay of the motor output in humans, and a reduced activity of the painful muscle. Nociception-induced motor inhibition might prevent effective motor retraining. In addition, the sympathetic nervous system responds to chronic nociception with enhanced sympathetic activation. Not only motor and sympathetic output pathways are affected by nociceptive input, afferent pathways (proprioception, somatosensory processing) are influenced by tonic muscle nociception as well. DISCUSSION: The clinical consequence of the shift in thinking is to stop trying to restore normal motor control in case of chronic nociception. Activation of central nociceptive inhibitory mechanisms, by decreasing nociceptive input, might address nociception-motor interactions. Language: en
TL;DR: The finding that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD.
Abstract: Whiplash-associated disorders (WAD) are common and involve both physical and psychological impairments. Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes. Trauma-focused cognitive-behavioral therapy (TF-CBT) has shown moderate effectiveness in chronic pain samples. However, to date, there have been no clinical trials within WAD. Thus, this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder (PTSD). Twenty-six participants were randomly assigned to either TF-CBT or a waitlist control, and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview, self-report questionnaires, and measures of physiological arousal and sensory pain thresholds. Clinically significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at postassessment, with further gains noted at the follow-up. The treatment of PTSD was also associated with clinically significant improvements in neck disability, physical, emotional, and social functioning and physiological reactivity to trauma cues, whereas limited changes were found in sensory pain thresholds. This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD. The finding that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD. Clinical implications of the findings and future research directions are discussed.
TL;DR: Patients with chronic nonspecific low back pain reported less increase in pain and faster resolution of pain when moving in an environment that enabled them to visualize their back.
Abstract: Objectives:The aim of this study was to determine whether visualization of the back influenced parameters of movement-related pain in people with chronic nonspecific low back pain.Methods:We used a randomized cross-over experiment in which 25 participants performed repeated lumbar spine movements un
TL;DR: Nocebo effects substantially accounted for AEs in drug trials of FMS and DPN and Standards to assess and report AEs should be defined by regulatory agencies and strategies to minimize nocebos effects should be developed.
Abstract: Objective The objectives of the study were to determine the impact of nocebo effects on adverse events (AEs) in drug trials in fibromyalgia syndrome (FMS) and painful diabetic peripheral neuropathy (DPN). Methods MEDLINE, CENTRAL, SCOPUS, and the databases of the U.S. National Institutes of Health and the Pharmaceutical Research and Manufacturers of America were searched until December 31, 2010. Randomized controlled trials with a parallel design of any drug therapy compared with pharmacological placebo in patients with FMS and DPN were included. Pooled estimates of nocebo effects (number of patients with at least 1 AE and dropping out due AEs) were calculated for placebo and true drug groups by a random effects model. Results Fifty-eight FMS (62 DPN) trials included a total of 5065 (5095) patients in placebo groups. The quality of reporting the assessment strategy of AEs was poor in most trials. The pooled estimate of the event rate drop out rate due to AEs in placebo groups was 9.6 [95% confidence control (CI): 8.6-10.7] in placebo and 16.3 (95% CI: 14.1-31.2) in true drug groups of FMS trials and was 5.8 (95% CI: 5.1-6.6) in placebo and 13.2 (95% CI: 10.7-16.2) in true drug groups of DPN trials. Nocebo effects accounted for 72.0% (44.9) of the drop outs in true drug groups in FMS (DPN). Discussion Nocebo effects substantially accounted for AEs in drug trials of FMS and DPN. Standards to assess and report AEs should be defined by regulatory agencies. Strategies to minimize nocebo effects in both clinical trials and clinical practice should be developed.
TL;DR: This study characterized Quebec physiotherapists’ knowledge, attitudes, and beliefs about LBP and their intolerance of uncertainty (IU) to determine whether and how these characteristics predict judgments of assessment and treatment recommendations.
Abstract: Background Low back pain (LBP) remains a common health problem that is characterized by ambiguity and can progress to chronic disability. In recent years researchers have started to focus on understanding whether and how the attitudes and beliefs of the health care providers influence the management and the outcome of LBP. Objectives The purpose of this study was to characterize Quebec physiotherapists' (PTs') knowledge, attitudes, and beliefs about LBP and their intolerance of uncertainty (IU) to determine whether and how these characteristics predict judgments of assessment and treatment recommendations. Methods A total of 108 PTs from Quebec, Canada completed the Pain Attitudes and Beliefs Scale for Physiotherapists, the Fear of Pain Questionnaire, and the Intolerance of Uncertainty Scale. Participants also read 2 vignettes that described patients with LBP and reported their assessment and treatment recommendations. Results Only 13 PTs (12%) were able to identify clinical practice guidelines for LBP. In addition, PTs did not generally agree with recommendations to return to work or activity. A biomedical orientation was a significant predictor of clinical judgments of spinal pathology and was associated with an increased sense of IU. In contrast, a behavioral approach better predicted treatment recommendations for return-to-work or activity. Finally, the association between IU and treatment decisions was mediated by treatment orientation. Discussion Health care practitioners play a significant role in the management of LBP. Research on the process of knowledge translation, clinical decision making, and dealing with uncertainty to avoid aggravating LBP disability is clearly warranted.
TL;DR: The prevalence of prescribed opioids in HIV patients was highest for certain subgroups, including women, and those with a comorbidity and substance abuse history, whereas its use increased in the general population.
Abstract: Objectives
To examine changes in use of prescription opioids for the management of chronic non-cancer pain in HIV-infected patients and to identify patient characteristics associated with long-term use.
TL;DR: The culturally adapted version of the painDETECT questionnaire presents good psychometric properties and shows to be a valid patient-reported outcome for measuring the presence of a neuropathic component in patients with chronic pain.
Abstract: Objective: The aim of this study was to culturally adapt into Spanish and validate the painDETECT questionnaire, a brief selfadministered instrument designed to screen the presence of a neuropathic pain component in usual clinical practice. Methods: The original English painDETECT questionnaire was culturally adapted into Spanish (Spain) by 2 independent translators under supervision of an expert panel. The LANNS, and a pain visual analog scale were administered along with the painDETECT questionnaire to a sample of 252 patients with neuropathic, nociceptive, or mixed pain for at least 3 months. Patients were classified by experienced specialists under normal conditions of clinical practice. A retest measure after 24 to 48 hours was also carried out. Reliability, construct validity, convergent validity, criterion, and discriminant validity were assessed. Results: An e! ective sample of 221 patients with chronic pain was recruited, 32% diagnosed of neuropathic origin, 32% of nociceptive, and remaining 36% presented mixed pain. The average age was 57.8 years (SD=14.2) and 59% were women. Cronbach alpha attained a value of 0.86, and the intraclass correlation coe" cient with the retest was 0.93. The factor structure was coherent with the one informed for the original instrument. Pearson correlation with the LANSS scale was 0.88. Area under the receiver operating characteristic curve was 0.88 when comparing neuropathic and nociceptive groups. Using the suggested cuto! value for pain presence of 19 points or higher, the following discriminant values are obtained: sensitivity=75%, specificity=84%, Youden Index=0.595, positive predictive value=92%, and negative predictive value=60%. The absence cuto! value of 12 points or bellow raised the following values: sensitivity=93%, specificity= 68%, Youden Index=0.61, positive predictive value=87%, and negative predictive value=80%. When mixed pain patients are included in the group with a neuropathic component, discriminant values are slightly reduced, as expected. Conclusions: The culturally adapted version of the painDETECT presents good psychometric properties and shows to be a valid patient-reported outcome for measuring the presence of a neuropathic component in patients with chronic pain.
TL;DR: Evidence for the effectiveness of premedication with laxatives for prevention of opioid-induced constipation is shown, however, premedications with dopamine D2 blockers was not sufficient to prevent nausea or vomiting.
Abstract: Objectives:The aim of this study was to evaluate the effectiveness of prophylactic treatment with laxatives and antiemetics on the incidence of gastrointestinal adverse reactions such as constipation, nausea and vomiting in cancer patients who received oral opioid analgesics for the first time.Metho
TL;DR: The results provide much needed psychometric information regarding newly developed pain assessments measures for seniors with dementia and support the utility of comprehensive coverage of the AGS-recommended pain assessment domains.
Abstract: Objectives Pain assessment in patients with dementia and severe limitations in ability to communicate can be challenging. The American Geriatrics Society (AGS) encourages the incorporation of 6 behavioral domains (ie, facial expressions, verbalizations/vocalizations, body movements, changes in interpersonal interactions, changes in activity patterns/routines and mental status changes) when conducting pain assessments among seniors with dementia. We investigated 6 observational pain assessment measures (differing with respect to the extent that they cover the AGS-recommended domains) under 2 different pain conditions (ie, influenza vaccination and movement-exacerbated pain) in a sample of long-term care residents with cognitive impairments. Given that a criticism of pain assessment scales is that many of the pain behaviors assessed are highly overlapping with symptoms of delirium, we also investigated the impact of the elimination of delirium-related items. Results Consistent with expectations, all measures were able to differentiate between pain and baseline conditions. Reliability and validity varied across measures. Most measures continued to differentiate between pain and baseline states after items that overlap with delirium were eliminated. Discussion Our results provide much needed psychometric information regarding newly developed pain assessments measures for seniors with dementia. The measures differed with respect to ability to differentiate pain-related from non-pain-related states. Moreover, our findings support the utility of comprehensive coverage of the AGS-recommended pain assessment domains.
TL;DR: Both Botox and Lidocaine/Depomedrol injections resulted in immediate improvement of RLP (not PLP) and pain tolerance, which lasted for 6 months in amputees who failed in conventional treatments.
Abstract: ObjectiveBotulinum toxin type A (Botox) injection has been used to manage pain. However, it remains to be proved whether Botox injection is effective to relieve residual limb pain (RLP) and phantom limb pain (PLP).DesignRandomized, double-blinded pilot study.SettingMedical College and an outpatient
TL;DR: The commonly held concept that “chronic pain patients on stable opioids are safe to drive” cannot be generalized to all such patients in everyday practice, but may be applicable only to a subset who meet certain criteria.
Abstract: Introduction: The effect of opioids on driving performance has been much debated. Driving is a complex task requiring integration of psychomotor, cognitive, motor and decision-making skills, visualspatial abilities, divided attention, and behavioral and emotional control. The objective of this systematic review was to assess the quality of studies and to revisit the concept that patients on stable opioids are safe to drive as it applies to everyday practice. Methods: We searched MEDLINE, EMBASE, PSYCinfo, CENTRAL, TRANSPORT, CINAHL, reference lists of retrieved articles and narrative reviews, for studies on chronic cancer and noncancer pain patients on opioids, tested by driving, driving simulator, or cognitive/ psychomotor tests. Methodological quality was assessed with Methodological Index for Nonrandomized Studies, cognitive/psychomotor tests were appraised regarding their sensitivity and validation, and whether confounding variables potentially affecting the study conclusions were recorded. The results were analyzed both quantitatively and qualitatively. Results: We included 35 studies (2044 patients, 1994 controls), 9% of the studies were of poor, 54% of fair, and 37% of high quality; 3 quarters of the studies used high sensitivity cognitive tests. Amount and dose of opioids varied largely in many studies. Mean number of possible but unreported confounders was 2.2 (range, 0 to 4), relating to failure of the studies to mention coprescriptions with psychotropic effects, pain severity, sleep disorder or daytime somnolence, and/or significant depressive or anxiety-related problems. Interpretation: The commonly held concept that “chronic pain patients on stable opioids are safe to drive” cannot be generalized to all such patients in everyday practice, but may be applicable only to a subset who meet certain criteria.
TL;DR: Electronic von Frey was more reliable and rapid than VFM in exploring mechanical pain thresholds in undamaged areas in volunteers and patients and further studies are required to confirm whether these results can be extrapolated to areas affected by surgery.
Abstract: OBJECTIVES: Von Frey monofilaments (VFM) and Electronic von Frey are used as quantitative sensory testing to explore mechanical hyperalgesia. The aim of the study was to determine VFM and Electronic von Frey reproducibility and the time required for testing undamaged areas in volunteers and surgical in-hospital patients.
METHODS: Prospective study in 2 groups of individuals without neurological disorders and not receiving treatments that alter sensorial response. Group 1 was formed by 30 healthy volunteers and group 2 by 28 patients after knee arthroplasty who received unilateral femoral block as postoperative analgesia. Testing was performed by 2 trained investigators in the forearm and abdominal wall and repeated 24 hours later. Pain threshold was determined as the VMF or the pressure rate applied with the Electronic von Frey referred to as unpleasant. The time used in each test was measured. Intraobserver and interobserver reproducibility were analyzed by means of Kappa and Lin coefficients.
RESULTS: Intraobserver and interobserver reproducibility for VFM was only fair or moderate in both groups (Kappa 0.8). No differences were found between the 2 tested areas. Time used was 6.03 and 3.16 minutes for VFM and Electronic von Frey, respectively.
DISCUSSION: Exploration of mechanical allodynia in postoperative patients requires rapid and reliable quantitative sensory testing. Electronic von Frey was more reliable and rapid than VFM in exploring mechanical pain thresholds in undamaged areas in volunteers and patients. Further studies are required to confirm whether these results can be extrapolated to areas affected by surgery.
TL;DR: The results support the use of the biopsychosocial model of pain for understanding pain and its impact in individuals with MMD or FSHD and may inform the design and implementation of psychosocial pain treatments for people with muscular dystrophy and chronic pain.
Abstract: Objectives
The primary aim of this study was to test hypothesized associations between changes in psychological variables (i.e., pain beliefs, catastrophizing and coping strategies) and changes in pain intensity and related adjustment (i.e., pain interference and psychological functioning) in individuals with Myotonic Muscular Dystrophy (MMD) and Facioscapulohumeral Muscular Dystrophy (FSHD).
TL;DR: Findings showed that a main RCT is feasible and that 56 participants per group would need to be recruited, using multiple recruitment approaches, and that AA was safe and demonstrated additional benefits when combined with exercise for people with CLBP.
Abstract: OBJECTIVES: To evaluate the feasibility of a randomized-controlled trial (RCT) investigating the effects of adding auricular acupuncture (AA) to exercise for participants with chronic low-back pain (CLBP).METHODS: Participants with CLBP were recruited from primary care and a university population and were randomly allocated (n=51) to 1 of 2 groups: (1) "Exercise Alone (E)"-12-week program consisting of 6 weeks of supervised exercise followed by 6 weeks unsupervised exercise (n=27); or (2) "Exercise and AA (EAA)"-12-week exercise program and AA (n=24). Outcome measures were recorded at baseline, week 8, week 13, and 6 months. The primary outcome measure was the Oswestry Disability Questionnaire.RESULTS: Participants in the EAA group demonstrated a greater mean improvement of 10.7% points (95% confidence interval, -15.3,-5.7) (effect size=1.20) in the Oswestry Disability Questionnaire at 6 months compared with 6.7% points (95% confidence interval, -11.4,-1.9) in the E group (effect size=0.58). There was also a trend towards a greater mean improvement in quality of life, LBP intensity and bothersomeness, and fear-avoidance beliefs in the EAA group. The dropout rate for this trial was lower than anticipated (15% at 6 mo), adherence with exercise was similar (72% E; 65% EAA). Adverse effects for AA ranged from 1% to 14% of participants.DISCUSSION: Findings of this study showed that a main RCT is feasible and that 56 participants per group would need to be recruited, using multiple recruitment approaches. AA was safe and demonstrated additional benefits when combined with exercise for people with CLBP, which requires confirmation in a fully powered RCT.
TL;DR: It is demonstrated that individuals with CTS present with a selective impairment in left/ right judgment that is restricted to the affected quadrant, which indicates that left/right judgment is impaired in much less severe pain states than previously demonstrated.
Abstract: Impaired left/right judgment of the affected body part is regarded as a disruption of the body's representation in cortical and subcortical somatosensory and motor areas and has previously been demonstrated in patients with severe neuropathic pain states. It remains unknown whether persistent but less severe pain states are sufficient to induce a similar impairment. Twenty-seven patients with unilateral carpal tunnel syndrome (CTS) and 27 healthy matched subjects performed 4 visual left/right judgment tasks. Series of pictures of hands, feet, and necks from 4 different views were presented at 6 rotation angles. Participants had to decide as accurately and quickly as possible whether a right or left body part was presented (for hands and feet) or whether the pictured neck was rotated toward the right or left. To control for a generalized impairment in mental rotation, a recognition task for Shepard-Metzler figures was included. Recognition time for all tasks was comparable between participants with CTS and healthy participants (P>0.47). However, participants with CTS were ∼10% less accurate in recognizing their affected hand (P=0.008). Recognition accuracy was also reduced for necks (P=0.019) but not for feet or Shepard-Metzler figures (P>0.69). This study demonstrates that individuals with CTS present with a selective impairment in left/right judgment that is restricted to the affected quadrant. This indicates that left/right judgment is impaired in much less severe pain states than previously demonstrated. The findings are in line with previous reports, which suggested the presence of central mechanisms in patients with CTS.
TL;DR: Comparisons of descending pain inhibition, pain sensitivity, and ANS reactivity to pain in FM, IBS, and healthy controls suggest that patients with IBS and FM may present common, but graded, pain processing and autonomic dysfunctions.
Abstract: OBJECTIVES Past studies confirm that patients with fibromyalgia (FM) and irritable bowel syndrome (IBS) show similar pain processing dysfunctions, such as reduced pain inhibition and aberrant autonomic nervous system (ANS) responses. However, patients with FM and IBS have rarely been investigated in the same study. The aim of the present study, therefore, was to compare descending pain inhibition, pain sensitivity, and ANS reactivity to pain in FM, IBS, and healthy controls (HC). METHODS Female patients with FM (n=10), IBS (n=13), and HCs (n=10) were exposed to multiple cold water (12°C) immersions to study pain sensitivity and descending pain inhibition. Heart rate variability was also assessed during immersions. RESULTS Pain intensity scores were highest in FM, intermediate in IBS, and smallest in HCs. In contrast, pain inhibition was absent in FM, intermediate in IBS, and strongest in HCs. Importantly, controlling for differences in pain inhibition abolished group differences in pain sensitivity. Heart rate variability analyses confirmed that, in response to mild levels of pain, patients with FM showed greater sympathetic activity whereas HCs showed greater parasympathetic activity. Patients with IBS showed intermediate ANS responses. DISCUSSION Our results confirm the presence of graded levels of somatic hyperalgesia across patients with IBS and FM. A similar pattern of result was observed for pain inhibitory dysfunctions. These pain processing changes were accompanied by abnormal autonomic responses, which maintained patients (principally patients with FM) in a state of sympathetic hyperactivity. Results suggest that patients with IBS and FM may present common, but graded, pain processing and autonomic dysfunctions.
TL;DR: It is indicated that not all risk assessment tools are equal in their ability to accurately predict future aberrant drug-related behavior and it may be that written risk Assessment tools that use more subtle items are better suited to certain patient populations.
Abstract: ObjectivesRisk assessment and stratification has become an important aspect of the prescribing of opioids to patients with chronic pain. There is little empirical data available on the sensitivity and specificity of commonly used risk assessment tools. This paper describes 2 studies that compare the