Efficacy of periosteal stimulation for chronic pain associated with advanced knee osteoarthritis: a randomized, controlled clinical trial

BACKGROUND

Because of morbidity associated with painful knee osteoarthritis (OA) and commonly prescribed analgesics, patients often pursue complementary and alternative modalities (eg, acupuncture). Clinical trials have demonstrated modest therapeutic efficacy of traditional Chinese acupuncture for knee OA pain, and patients with advanced disease have largely been excluded. We have previously demonstrated preliminary short-term tolerability and efficacy of periosteal stimulation therapy (PST) (ie, electrical stimulation of the periosteum facilitated by acupuncture needles) for older adults with advanced knee OA.

OBJECTIVE

This study evaluated the sustained efficacy of PST and boosters for treating chronic pain with advanced knee OA.

METHODS

One hundred ninety participants age >50 years with Kellgren-Lawrence grade 3 or 4 knee OA and chronic pain were randomized to (1) PST (once a week for 10 weeks) followed by PST boosters for 6 months (once every 2 weeks 2 times, then once a month), (2) control PST (ie, periosteal needles and brief electrical stimulation of control points) once a week for 10 weeks, or (3) PST for 10 weeks followed by control PST boosters for 6 months. Change in the Western Ontario and McMaster Universities Osteoarthritis Index pain score immediately after the 10-week intervention and at 6-month follow-up (9 months after baseline) was the primary outcome. OMERACT-OARSI (Outcome Measures in Rheumatology Clinical Trials-Osteoarthritis Research Society International) criteria also were evaluated. Secondary measures of outcome included (1) physical performance (Short Physical Performance Battery, gait speed, Timed Up and Go, and timed stair climb); (2) psychological factors (depressive symptoms measured with the Center for Epidemiologic Studies-Depression scale, coping measured with the catastrophizing subscale of the Coping Strategies Questionnaire, and self-efficacy measured with the Arthritis Self-Efficacy Scale); (3) health-related quality of life measured with the Medical Outcomes Study 36-Item Short-Form Health Survey; (4) rescue pain medication use tracked with diaries; and (5) health care utilization and interim physical activity were monitored via monthly telephone calls.

RESULTS

After adjustment for pain at baseline, the PST and control booster did not differ from controls at 10 weeks (difference, 1.3; 95% CI, -0.10 to 2.8; P = 0.0683) or 9 months (difference, 1.1; 95% CI, -0.32 to 2.6; P = 0.13). The PST and PST booster group had similar improvement compared with controls at 10 weeks (baseline adjusted difference, 1.1; 95% CI, -0.34 to 2.5; P = 0.1369) but significantly more improvement at 9 months (baseline adjusted difference, 1.5; 95% CI, 0.069 to 3.0; P = 0.0401). Baseline depressive symptoms, low self-efficacy, higher difficulty performing daily activities, and greater knee stiffness predicted a lower likelihood of response.

CONCLUSION

PST plus PST boosters in patients age >50 with advanced knee OA were well-tolerated and modestly reduced pain. ClinicalTrials.gov identifier: NCT00865046.

Pain as the fifth vital sign: exposing the vital need for pain education

The push to evaluate pain in patients as exemplified by the fifth vital sign has exposed serious deficits in practitioner education and training in pain assessment and management because patient report of pain level has become commonplace in clinical practice. The rapid increase in prescription opioid medications suggests that practitioners are trying to address their patients' pain by prescribing opioids. However, the increase in prescription opioids has also been associated with an increase in prescription opioid-related unintended deaths. In clinical practice, the fifth vital sign has proven to be more complex to assess, evaluate, and manage than originally anticipated. Expanding pain education and training is critical to remedying some of the issues the routine report of pain by patients has uncovered.

Fear avoidance beliefs predict disability in older adults with chronic low back pain

OBJECTIVES

To determine whether fear avoidance beliefs (FABs) in older adults with chronic low back pain (CLBP) are significantly associated with gait speed decline and/or self-report of greater disability.

DESIGN

Cross-sectional analysis.

SETTING

An academic medical center (single site).

PARTICIPANTS

Two hundred English-speaking participants aged 65 years and older with CLBP every day or almost every day of moderate or greater intensity for ≥3 months.

MAIN OUTCOME MEASUREMENTS

The physical activity portion of the FAB questionnaire assessed FABs. Disability was measured with gait speed and the Roland Morris Questionnaire. Covariates measured included age, gender, body mass index, chronic disease (Cumulative Illness Rating Scale), depression (Geriatric Depression Scale), and pain (McGill Pain Questionnaire Short Form).

RESULTS

FABs were significantly associated with the Roland Morris Questionnaire (P < .0001) and gait speed (P = .002) after controlling for all covariates.

CONCLUSION

FABs related to physical activity in older adults with CLBP were significantly associated with both self-reported and performance-based disability after controlling for known confounders. Previous studies have reported similar associations between self-reported measures of disabling back pain and FABs. Ours is the first study to examine the relationship between FAB and gait speed, a powerful predictor of morbidity and mortality. Future work should examine whether targeting fear avoidance in addition to other psychosocial measures in older adults with CLBP improves gait speed and functional independence.

The role of chiropractic care in older adults

There are a rising number of older adults; in the US alone nearly 20% of the population will be 65 or older by 2030. Chiropractic is one of the most frequently utilized types of complementary and alternative care by older adults, used by an estimated 5% of older adults in the U.S. annually. Chiropractic care involves many different types of interventions, including preventive strategies. This commentary by experts in the field of geriatrics, discusses the evidence for the use of spinal manipulative therapy, acupuncture, nutritional counseling and fall prevention strategies as delivered by doctors of chiropractic. Given the utilization of chiropractic services by the older adult, it is imperative that providers be familiar with the evidence for and the prudent use of different management strategies for older adults.

Addressing both depression and pain in late life: the methodology of the ADAPT study

OBJECTIVE

To describe the methodology of the first NIH-funded clinical trial for seniors with comorbid depression and chronic low back pain.

METHODS

Randomized controlled effectiveness trial using stepped care methodology. Participants are ≥60 years old. Phase 1 (6 weeks) is open treatment with venlafaxine xr 150 mg/day and supportive management (SM). Response is 2 weeks of PHQ-9 ≤5 and at least 30% improvement in the average numeric rating scale for pain. Nonresponders progress to phase 2 (14 weeks) in which they are randomized to high-dose venlafaxine xr (up to 300 mg/day) with problem solving therapy for depression and pain (PST-DP) or high-dose venlafaxine xr and continued SM. Primary outcomes are the univariate pain and depression response and both observed and self-reported disability. Survival analytic techniques will be used, and the clinical effect size will be estimated with the number needed to treat. We hypothesize that self-efficacy for pain management will mediate response for subjects randomized to venlafaxine xr and PST-DP.

RESULTS

Not applicable.

CONCLUSIONS

The results of this trial will inform the care of these complex patients and further understanding of comorbid pain and depression in late life.

The relationship of pain and cognitive impairment with social vulnerability--an analysis of the Canadian Study of Health and Aging

OBJECTIVE

The objective of this study was to delineate the relationship between noncancer pain and cognitive impairment with social vulnerability.

DESIGN

The study was designed as a cross-sectional analysis of the Canadian Study of Health and Aging, 1996 wave.

SETTING

  Community-dwelling older adults in Canada.

SUBJECTS

3,776 study participants.

OUTCOME MEASURES

Pain was categorized as no or very mild pain vs moderate or severe pain. Cognitive impairment was dichotomized from the Modified Mini-Mental State Examination (0-100) to no (>77) or impairment (77 or <). Social vulnerability (outcome) was operationalized as the accumulation of 39 possible self-report variables related to social circumstance, scores range from 0 to 1, where higher scores indicate greater vulnerability. Additional covariates included demographics, depressed mood, comorbidity, and functional impairment. Bivariate and multivariate relationships between pain and cognitive impairment with social vulnerability were assessed using t-tests and linear regression, respectively.

RESULTS

Of 5,703 respondents, 1,927 were missing a component of the social vulnerability index and of these nine were missing a pain response, leaving 3,767 (66.1%) of the original sample. A total of 2,435 (64.6%) reported no/mild pain and 3,435 (91.2%) were cognitively intact. The mean (standard deviation) social vulnerability index was 9.97 (3.62) with scores ranging from 1.12 to 26.85. Moderate or severe pain 0.44 (95% confidence interval [CI] 0.21, 0.66, P < 0.01) and cognitive impairment 0.49 (95% CI 0.13, 0.86, P < 0.01) were independently associated with social vulnerability, but the interaction term was not statistically significant, 0.40 (95% CI -0.32,1.14, P = 0.27).

CONCLUSION

Pain and cognitive impairment are independently associated with social vulnerability. Improvements in pain management might mitigate social vulnerability in a growing number of older adults with either or both conditions.

Persistent pain and frailty: a case for homeostenosis

OBJECTIVES

To compare the association between self-reported moderate to severe pain and frailty.

DESIGN

Cross-sectional analysis of the Canadian Study of Health and Aging Wave 2.

SETTING

Community.

PARTICIPANTS

Representative sample of persons aged 65 and older in Canada.

MEASUREMENTS

Pain (exposure) was categorized as no or very mild pain versus moderate or greater pain. Frailty (outcome) was operationalized as the accumulation of 33 possible self-reported health attitudes, illnesses, and functional abilities, subsequently divided into tertiles (not frail, prefrail, and frail). Multivariable logistic regression assessed for the association between pain and frailty.

RESULTS

Of participants who reported moderate or greater pain (35.5%, 1,765/4,968), 16.2% were not frail, 34.1% were prefrail, and 49.8% were frail. For persons with moderate or greater pain, the odds of being prefrail rather than not frail were higher by a factor of 2.52 (95% confidence interval (CI) = 2.13-2.99; P < .001). For persons with moderate or greater pain, the odds of being frail rather than not frail were higher by a factor of 5.52 (95% CI = 4.49-6.64 P < .001).

CONCLUSION

Moderate or higher pain was independently associated with frailty. Although causality cannot be ascertained in a cross-sectional analysis, interventions to improve pain management may help prevent or ameliorate frailty.

The design and methods of the aging successfully with pain study

Chronic low back pain (CLBP) is widespread among older adults (≥ 65 years) and is often treated inadequately. With a rapidly growing aging population, CLBP will increase and so will the demand for treatment. We believe that mind-body therapies can help to meet this demand. We present the methodology of a randomized, controlled clinical trial of 300 individuals with CLBP aged 65 years or older. The specific aims are, 1) to determine the effectiveness of a mindfulness meditation program in increasing function and reducing pain among older adults with CLBP, and 2) to evaluate the impact of mindfulness meditation on neuropsychological performance in older adults with CLBP. The intervention program is modeled on the Mindfulness-Based Stress Reduction Program (MBSR) and the control is adapted from the 10 Keys to Healthy Aging. We will measure self-reported and objectively measured physical function and include a variety of measures to assess pain intensity and pain interference and psychological function. Our primary hypothesis is that the MBSR program will be more effective than the 10 Keys program in increasing function and decreasing pain. The proposed study represents the first large, well-controlled, comprehensive examination of the effects of a mind-body program on older adults with chronic pain.

The association between noncancer pain, cognitive impairment, and functional disability: an analysis of the Canadian study of health and aging

BACKGROUND

Noncancer pain and cognitive impairment affect many older adults and each is associated with functional disability, but their combined impact has yet to be rigorously studied.

METHODS

This is a cross-sectional analysis of the Canadian Study of Health and Aging. Pain was collapsed from a 5-point to a dichotomous scale (no and very mild vs moderate and greater). Cognitive status was dichotomized from the Modified Mini-Mental State Examination (0-100) to no (>77) or mild-moderate (77-50) impairment. Five Instrumental Activities of Daily Living (IADL) and seven Activities of Daily Living (ADL) were self-rated as "accomplished without any help" (0), "with some help" (1), or "completely unable to do oneself" (2) and then summed to create a composite score of 0-10 and 0-14, respectively. Multivariate linear regression analysis was conducted to determine the associations between self-reported functional status with moderate or greater pain, cognitive impairment, and the interaction of the two.

RESULTS

A total of 5,143 (90.2%) participants were eligible, 1,813 (35.6%) reported pain at a moderate intensity or greater and 727 (14.3%) were cognitively impaired. The median IADL and ADL summary scores increased among the pain and cognition categories in the following order: no pain and cognitively intact (0.63 SD 1.24, 0.23 SD 0.80), pain and cognitively intact (1.18 SD 1.69, 0.57 SD 1.27), no pain and cognitively impaired (1.64 SD 2.22, 0.75 SD 1.57), and pain and cognitively impaired (2.27 SD 2.47, 1.35 SD 2.09), respectively. Multivariate linear regression found IADL summary scores were associated with pain, coefficient .17 (95% confidence interval [CI] 0.07-0.26), p < .01; cognitive impairment, coefficient .67 (95% CI 0.51-0.83), p < .01; and an interaction effect of pain with cognitive impairment, coefficient .24 (95% CI 0.01-0.49), p = .05. ADL summary scores were associated with pain coefficient .10 (95% CI 0.04-0.17), p < .01 and cognitive impairment, coefficient .29 (95% CI 0.19-0.39), p < .01, but had a nonsignificant interaction term, coefficient .12 (95% CI -0.03 to 0.29), p = .12.

CONCLUSIONS

Noncancer pain and cognitive impairment are independently associated with IADL and ADL impairment and IADL impairment is even greater when both conditions are present.

Differences in brain structure and function in older adults with self-reported disabling and nondisabling chronic low back pain

OBJECTIVE

The primary aim of this pilot study was to identify structural and functional brain differences in older adults with self-reported disabling chronic low back pain (CLBP) compared with those who reported nondisabling CLBP.

DESIGN

Cross-sectional.

PARTICIPANTS

Sixteen cognitively intact older adults, eight with disabling CLBP and eight with nondisabling CLBP. Exclusions were psychiatric or neurological disorders, substance abuse, opioid use, or diabetes mellitus.

METHODS

Participants underwent: structural and functional brain MRI; neuropsychological assessment using the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Tests A and B; and physical performance assessment using the Short Physical Performance Battery.

RESULTS

In the disabled group, there was significantly lower white matter (WM) integrity (P < 0.05) of the splenium of the corpus callosum. This group also demonstrated activation of the right medial prefrontal cortex at rest whereas the nondisabled demonstrated activation of the left lateral prefrontal cortex. Combined groups analysis revealed a strong positive correlation (r(s) = 0.80, P < 0.0002) between WM integrity of the left centrum semiovale with gait-speed. Secondary analysis revealed a strong negative correlation between total months of CLBP and WM integrity of the SCC (r(s) = -0.59, P < 0.02).

CONCLUSIONS

Brain structure and function is different in older adults with disabling CLBP compared with those with nondisabling CLBP. Deficits in brain morphology combining groups are associated with pain duration and poor physical function. Our findings suggest brain structure and function may play a key role in chronic pain related disability and may be important treatment targets.

Duloxetine and care management treatment of older adults with comorbid major depressive disorder and chronic low back pain: results of an open-label pilot study

OBJECTIVE

In older adults, major depressive disorder (MDD) and chronic low back pain (CLBP) are common and mutually exacerbating. We predicted that duloxetine pharmacotherapy and Depression and Pain Care Management (DPCM) would result in (1) significant improvement in MDD and CLBP and (2) significant improvements in health-related quality of life, anxiety, disability, self-efficacy, and sleep quality.

DESIGN AND INTERVENTION

Twelve week open-label study using duloxetine up to 120 mg/day + DPCM.

SETTING

Outpatient late-life depression research clinic.

PATIENTS

Thirty community-dwelling adults >60 years old.

OUTCOME MEASURES

Montgomery Asberg Depression Rating Scale (MADRS) and McGill Pain Questionnaire-Short Form (MPQ-SF).

RESULTS

46.7% (n = 14) of the sample had a depression remission. All subjects who met criteria for the depression remission also had a pain response. 93.3% (n = 28) had a significant pain response. Of the subjects who met criteria for a low back pain response, 50% (n = 14) also met criteria for the depression remission. The mean time to depression remission was 7.6 (SE = 0.6) weeks. The mean time to pain response was 2.8 (SE = 0.5) weeks. There were significant improvements in mental health-related quality of life, anxiety, sleep quality, somatic complaints, and both self-efficacy for pain management and for coping with symptoms. Physical health-related quality of life, back pain-related disability, and self-efficacy for physical functioning did not improve.

CONCLUSIONS

Serotonin and norepinephrine reuptake inhibitors like duloxetine delivered with DPCM may be a good choice to treat these linked conditions in older adults. Treatments that target low self-efficacy for physical function and improving disability may further increase response rates.

A mind-body program for older adults with chronic low back pain: results of a pilot study

OBJECTIVES

Determine the impact of an 8-week mindfulness meditation program on disability, psychological function, and pain severity in community-dwelling older adults with chronic low back pain, and to test the education control program for feasibility.

DESIGN

Randomized controlled trial. Participants. Forty community-dwelling older adults with moderate low back pain or greater for at least the previous 3 months. Intervention. Participants were randomized to an 8-week meditation program or an 8-week education control program.

OUTCOME MEASURES

Disability, psychological function, and pain severity were assessed. The same measures were obtained for both groups at baseline, at the end of the program, and 4 months after program completion.

RESULTS

Sixteen participants (80%) completed the meditation program and 19 (95%) completed the education program. Both the meditation and control group improved on measures of disability, pain, and psychological function, both at program completion and 4-month follow-up. The differences between the two groups did not reach statistical significance. The meditation group practiced mindfulness meditation a mean of 5 days/week (range 1-7) and mean of 31 minutes/session (range 22-48). At 4 months follow-up 14/16 (88%) participants continued to meditate.

CONCLUSION

Both the intervention group and the education control group improved on outcome measures suggesting both programs had a beneficial effect. Participants continued to meditate on 4-month follow-up. The control program was feasible but not inert. Piloting the control program in mind-body research can inform the design of larger clinical trials.

Impact of chronic musculoskeletal pathology on older adults: a study of differences between knee OA and low back pain

OBJECTIVES

The study aimed to compare the psychological and physical characteristics of older adults with knee osteoarthritis (OA) vs those of adults with chronic low back pain (CLBP) and to identify psychological and physical predictors of function as measured by gait speed.

DESIGN

Secondary data analysis.

METHOD AND PATIENTS

Eighty-eight older adults with advanced knee OA and 200 with CLBP who had participated in separate randomized controlled trials were selected for this study.

MEASURES

Inclusion criteria for both trials included age > or =65 and pain of at least moderate intensity that occurred daily or almost every day for at least the previous 3 months. Psychological constructs (catastrophizing, fear avoidance, self-efficacy, depression, affective distress) and physical measures (comorbid medical conditions, pain duration, pain severity, pain related interference, self-rated health) were obtained.

RESULTS

Subjects with CLBP had slower gait (0.88 m/s vs 0.96 m/s, P = 0.002) and more comorbid conditions than subjects with knee pain (mean 3.36 vs 1.97, P < 0.001). All the psychological measures were significantly worse in the CLBP group except the Multidimensional Pain Inventory-Affective Distress score. Self-efficacy, pain severity, and medical comorbidity burden were associated with slower gait regardless of the location of the pain.

CONCLUSIONS

Older adults with chronic pain may have distinct psychological and physical profiles that differentially impact gait speed. These findings suggest that not all pain conditions are the same in their psychological and physical characteristics and may need to be taken into consideration when developing treatment plans.

Older people's experiences of patient-centered treatment for chronic pain: a qualitative study

INTRODUCTION

Older adults with chronic pain who seek treatment often are in a health care environment that emphasizes patient-directed care, a change from the patriarchal model of care to which many older adults are accustomed.

OBJECTIVE

To explore the experiences of older adults seeking treatment for chronic pain, with respect to patient-directed care and the patient-provider relationship.

DESIGN

In-depth interviews with 15 Caucasian older adults with chronic pain who had been evaluated at a university-based pain clinic. All interviews were audiotaped and the transcripts were analyzed using a grounded theory based approach.

RESULTS

Older adults with chronic pain vary in their willingness to be involved in their treatment decisions. Many frequently participate in decisions about their pain treatment by asking for or refusing specific treatments, demanding quality care, or operating outside of the patient-provider relationship to manage pain on their own. However, others prefer to let their provider make the decisions. In either case, having a mutually respectful patient-provider relationship is important to this population. Specifically, participants described the importance of "being heard" and "being understood" by providers.

CONCLUSIONS

As some providers switch from a patriarchal model of care toward a model of care that emphasizes patient activation and patient-centeredness, the development and cultivation of valued patient-provider relationships may change. While it is important to encourage patient involvement in treatment decisions, high-quality, patient-centered care for older adults with chronic pain should include efforts to strengthen the patient-provider relationship by attending to differences in patients' willingness to engage in patient-directed care and emphasizing shared decision-making.

Pain interference impacts response to treatment for anxiety disorders

BACKGROUND

Anxiety disorders and pain are commonly comorbid, though little is known about the effect of pain on the course and treatment of anxiety.

METHODS

This is a secondary analysis of a randomized controlled trial for anxiety treatment in primary care. Participants with panic disorder (PD) and/or generalized anxiety disorder (GAD) (N=191; 81% female, mean age 44) were randomized to either their primary-care physician's usual care or a 12-month course of telephone-based collaborative care. Anxiety severity, pain interference, health-related quality of life, health services use, and employment status were assessed at baseline, and at 2-, 4-, 8-, and 12-month follow-up. We defined response to anxiety treatment as a 40% or greater improvement from baseline on anxiety severity scales at 12-month follow-up.

RESULTS

The 39% who reported high pain interference at baseline had more severe anxiety (mean SIGH-A score: 21.8 versus 18.0, P<.001), greater limitations in activities of daily living, and more work days missed in the previous month (5.8 versus 4.0 days, P=.01) than those with low pain interference. At 12-month follow-up, high pain interference was associated with a lower likelihood of responding to anxiety treatment (OR=.28; 95% CI=.12-.63) and higher health services use (26.1% with >/=1 hospitalization versus 12.0%, P<.001).

CONCLUSIONS

Pain that interferes with daily activities is prevalent among primary care patients with PD/GAD and associated with more severe anxiety, worse daily functioning, higher health services use, and a lower likelihood of responding to treatment for PD/GAD.

Efficacy of percutaneous electrical nerve stimulation and therapeutic exercise for older adults with chronic low back pain: a randomized controlled trial

Chronic low back pain (CLBP) in older adults may be disabling and therapeutically challenging, largely because of the inefficacy and/or morbidity associated with traditional pain treatment. We conducted a randomized controlled trial in 200 men and women > or = age 65 with CLBP to evaluate the efficacy of percutaneous electrical nerve stimulation (PENS) with and without general conditioning and aerobic exercise (GCAE), for reducing pain and improving physical function. Participants were randomized to receive (1) PENS, (2) control-PENS (brief electrical stimulation to control for treatment expectancy), (3) PENS+GCAE, or (4) control-PENS+GCAE, twice a week for 6 weeks. All four groups experienced significantly reduced pain (range -2.3 to -4.1 on the McGill Pain Questionnaire short form), improved self-reported disability (range -2.1 to -3.0 on Roland scale) and improved gait velocity (0.04-0.07 m/s), sustained at 6 months. The GCAE groups experienced significantly fewer fear avoidance beliefs immediately post-intervention and at 6 months than non-GCAE groups. There were no significant side effects. Since brief electrical stimulation (i.e., control-PENS) facilitated comparably reduced pain and improved function at 6 months as compared with PENS, the exact dose of electrical stimulation required for analgesia cannot be determined. GCAE was more effective than PENS alone in reducing fear avoidance beliefs, but not in reducing pain or in improving physical function.

Validity of pain behaviors in persons with mild to moderate cognitive impairment

OBJECTIVES

To evaluate the validity of traditional pain behaviors (guarding, bracing, rubbing, grimacing, and sighing) in persons with and without cognitive impairment and chronic low back pain (CLBP).

DESIGN

Prospective observational study.

SETTING

Outpatient clinics.

PARTICIPANTS

Thirty-seven cognitively intact and 40 cognitively impaired participants with and without CLBP.

MEASUREMENTS

Frequency of traditional pain behaviors.

RESULTS

Forty-six of the participants were pain free, and 31 had CLBP. The internal consistency reliability coefficient of the five pain behaviors was 0.32, suggesting that a unidimensional scale did not exist. Multivariate analysis of variance analysis according to the independent variables pain status (pain free vs CLBP) and cognitive status (intact vs impaired) with the dependent variable frequency of pain behaviors found significant differences according to pain status (F[5,61]=3.06, P=.02) and cognitive status (F[5,61]=5.41, P<.001) but without evidence of an interaction (F[5,61]=1.14, P=.35). Participants with CLBP exhibited significantly higher levels of grimacing (P<.001) and guarding (P=.02) than pain-free participants. Intact subjects exhibited fewer guarding (P=.02) and rubbing behaviors (P<.001) but a higher number of bracing behaviors (P=.03) than cognitively impaired participants.

CONCLUSION

These results support the utility of facial grimacing in assessing pain in patients with mild to moderate cognitive impairment and call into question the validity of guarding and rubbing in assessing pain in persons with mild to moderate cognitive impairment.

Persistent pain biases item response on the Geriatric Depression Scale (GDS): preliminary evidence for validity of the GDS-PAIN

OBJECTIVE

Differential item functioning (DIF) assesses the consistency of items on a metric across clinical samples in relation to the attribute being measured. We hypothesized that in older adults with persistent pain, items of the Geriatric Depression Scale (GDS) would evidence DIF based on presence or intensity of pain.

DESIGN

Unidimensionality was determined by factor and item analyses. DIF was tested using Rasch Modeling. We then evaluated the psychometric properties of a revised GDS (GDS-PAIN), comprised of items that did not evidence DIF. PATIENT AND SETTINGS: A total of 677 community dwelling older adults (age 65-91) participating in observational or treatment studies of low back or knee pain who endorsed at least moderate pain for at least 3 months. A total of 201 pain-free controls were included in the analysis.

RESULTS

Ten of the 30 items displayed significant DIF. These items were: 1) dropping activities and interests; 2) bothered by persistent thoughts; 3) often get fidgety and restless; 4) prefer to stay home; 5) do not feel full of energy; 6) do not enjoy getting up in the morning; 7) mind is not as clear as it was, 8) feel life is empty; 9) feel more problems with memory; and 10) do not find life very exciting. The modified GDS-PAIN scale did not adversely affect the psychometric properties of the scale.

CONCLUSIONS

The performance of the GDS is affected by pain. When unstable items are removed, the revised GDS (GDS-PAIN) appears to be psychometrically stable and maintains both internal consistency and similar correlation values with a measure of pain as the original scale.

Efficacy of periosteal stimulation therapy for the treatment of osteoarthritis-associated chronic knee pain: an initial controlled clinical trial

OBJECTIVES

To examine the efficacy of periosteal stimulation therapy (PST, osteopuncture) for the treatment of chronic pain associated with advanced knee osteoarthritis.

DESIGN

Randomized, controlled clinical trial.

SETTING

Outpatient pain clinic.

PARTICIPANTS

Eighty-eight community-dwelling older adults with moderate knee pain or greater for 3 months or longer and Kellgren-Lawrence (K-L) grade 2 through 4 radiographic severity (80% had K-L 4).

INTERVENTION

Participants were randomized to receive PST or control PST once a week for 6 weeks.

MEASUREMENTS

Pain severity and self-reported function (Western Ontario and McMasters University Osteoarthritis Index (WOMAC)) and physical performance (Short Physical Performance Battery (SPPB)) were assessed at baseline, after the last PST session (post), and 3 months later (follow-up). Pain severity was also assessed monthly using the multidimensional pain inventory short form.

RESULTS

Pain was reduced significantly more in the PST group than in the control PST group at post (P=.003; mean WOMAC pain subscale baseline 9.4 vs 6.4) and 1 month later (P<.001), but by 2 months, pain levels had regressed to pre-intervention levels. The group-by-time interaction for the WOMAC function scale was significant at post (P=.04) but not at follow-up (P=.63). No significant group differences were found for the SPPB. Neither analgesic use nor global improvement differed between groups. There were four treatment dropouts.

CONCLUSION

PST affords short-term modest pain reduction for older adults with advanced knee OA. Future research should test the effectiveness of booster treatments in sustaining analgesic benefits and of combining PST with therapeutic exercise in ameliorating disability risk.

Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study

The objectives of this pilot study were to assess the feasibility of recruitment and adherence to an eight-session mindfulness meditation program for community-dwelling older adults with chronic low back pain (CLBP) and to develop initial estimates of treatment effects. It was designed as a randomized, controlled clinical trial. Participants were 37 community-dwelling older adults aged 65 years and older with CLBP of moderate intensity occurring daily or almost every day. Participants were randomized to an 8-week mindfulness-based meditation program or to a wait-list control group. Baseline, 8-week and 3-month follow-up measures of pain, physical function, and quality of life were assessed. Eighty-nine older adults were screened and 37 found to be eligible and randomized within a 6-month period. The mean age of the sample was 74.9 years, 21/37 (57%) of participants were female and 33/37 (89%) were white. At the end of the intervention 30/37 (81%) participants completed 8-week assessments. Average class attendance of the intervention arm was 6.7 out of 8. They meditated an average of 4.3 days a week and the average minutes per day was 31.6. Compared to the control group, the intervention group displayed significant improvement in the Chronic Pain Acceptance Questionnaire Total Score and Activities Engagement subscale (P=.008, P=.004) and SF-36 Physical Function (P=.03). An 8-week mindfulness-based meditation program is feasible for older adults with CLBP. The program may lead to improvement in pain acceptance and physical function.

Office management of chronic pain in the elderly

Chronic pain plagues older adults more than any other age group; thus, practitioners must be able to approach this problem with confidence and skill. This article reviews the assessment and treatment of the most common chronic nonmalignant pain conditions that affect older adults--myofascial pain, generalized osteoarthritis, chronic low back pain (CLBP), fibromyalgia syndrome, and peripheral neuropathy. Specific topics include essential components of the physical examination; how and when to use basic and advanced imaging in older adults with CLBP; a stepped care approach to treating older adults with generalized osteoarthritis and CLBP, including noninvasive and invasive management techniques; how to diagnose and treat myofascial pain; strategies to identify the older adult with fibromyalgia syndrome and avoid unnecessary "diagnostic" testing; pharmacological treatment for the older adult with peripheral neuropathy; identification and treatment of other factors such as dementia and depression that may significantly influence response to pain treatment; and when to refer the patient to a pain specialist. While common, chronic pain is not a normal part of aging, and it should be treated with an emphasis on improved physical function and quality of life.