Management of Chronic Pain in Long-Term Care: A Systematic Review and Meta-Analysis

Altered brain dynamics in chronic neck and shoulder pain revealed by hidden Markov model

Chronic neck and shoulder pain (CNSP) is the most common clinical symptom of cervical spondylosis, which not only greatly affects individuals' quality of life but also places a significant burden on social healthcare systems. Existing analgesic treatments are often associated with significant adverse effects and limited efficacy. Recently, non-invasive neuromodulation techniques have shown promise, but the central mechanisms underlying chronic pain remain poorly understood. Recent advances in resting-state functional magnetic resonance imaging (rs-fMRI) have highlighted altered brain connectivity in CNSP patients. However, traditional methods, such as the sliding window approach, have limitations in capturing rapid fluctuations and individual differences in brain activity. The Hidden Markov Model (HMM) assumes that the brain is in different hidden states at different time points, with each state corresponding to a distinct connectivity pattern. It identifies state changes adaptively, without relying on preset time windows. In this study, we applied HMM to rs-fMRI data from CNSP patients and healthy controls to explore brain activity dynamics and state transition patterns. We identified five distinct brain states, revealing significant differences in functional occupancy, lifetime, switching rate, and state transition probabilities between CNSP patients and controls. This offers a novel neuroimaging perspective for personalizing interventions based on the individualized dynamic characteristics of CNSP patients. However, further research is needed to determine whether the number and nature of the internal states identified in this study can be generalized to other CNSP patient cohorts.

Efficacy of Low-Dose Naltrexone in Treating Patients with Fibromyalgia: systematic Review and Meta-Analysis

Low-dose naltrexone (LDN) has demonstrated mixed efficacy in treating fibromyalgia. This systematic review and meta-analysis aimed to evaluate the efficacy of LDN for fibromyalgia. We systematically searched electronic databases and gray literature from inception to May 2024. Included studies were clinical trials in humans published in English, reporting mean changes in pain scores and fibromyalgia symptom severity, comparing baseline to endpoint and LDN to placebo. Of 575 identified articles, eight met the eligibility criteria. In the LDN group, the Standardized Mean Difference (SMD) for pain decreased by 1.03 (95% confidence interval (CI): -1.25, -0.80; I2 = 25%), and fibromyalgia symptom severity decreased by 1.02 (95% CI: -1.35, -0.69; I2 = 52%) post-LDN treatment compared to the baseline. However, no significant differences in mean change in pain (SMD -0.50, 95% CI: -1.19, 0.19; I2 = 91%) and fibromyalgia symptoms severity scores (SMD -0.67, 95% CI: -1.67, 0.34; I2 = 95%) were observed between the LDN and placebo groups. Although LDN marginally reduced pain and symptom severity from baseline, these effects were not superior to placebo. This suggests that LDN may not provide significant clinical benefit over placebo in fibromyalgia management, warranting further research.

Assessing the fidelity of the "photo-with-movement program" (PMP) for community-dwelling older adults with pain: A randomized controlled trial

PURPOSE

To measure intervention fidelity of the Photo-with-Movement Program (PMP) and to report the findings of the program.

METHODS

This study was a two-arm, pilot randomized controlled trial of the PMP. An intervention fidelity checklist and semi-structured interviews were utilize to evaluate the fidelity of the PMP. Twenty-four older adults and informal caregiver dyads enrolled in the study, with 12 dyads in the experimental group and another 12 in the control group. The PMP integrated visual stimulation, physical exercise, and digital-based activity to deliver a comprehensive, non-pharmacological pain relief syllabus to the participants in the experimental group. The control group received pain management pamphlets. The data collected were analyzed using SPSS to compare the outcomes between the experimental and control groups.

RESULTS

The PMP led to significant findings on reducing pain intensity and high scores on intervention fidelity. Participants showed great acceptance of this delivery format.

CONCLUSIONS

This study revealed the fidelity and effectiveness of a multimodal non-pharmacological intervention, suggesting that it could be used for pain management and caregiving.

Association Between Organizational Context and Resident Pain in Assisted Living: A Repeated Cross-Sectional Study

OBJECTIVES

Resident pain has been a common quality challenge in congregate care for older adults, and organizational context may explain variations in resident pain beyond resident-level factors. Most studies have focused on nursing homes (NHs), largely neglecting assisted living (AL). AL residents are at similar risk for pain as NH resident, but with AL providing fewer services and staffing resources. Our objective was to examine whether organizational context in AL was associated with resident pain during the first two waves of the COVID-19 pandemic.

METHODS

This repeated cross-sectional study linked AL home surveys, collected in COVID-19 waves 1 (March-June 2020) and 2 (October 2020-February 2021) from a key contact, to administrative Resident Assessment Instrument-Home Care (RAI-HC) records in these homes. Surveys assessed preparedness for COVID-19 outbreaks, availability of a registered nurse or nurse practitioner, direct care staff shortages, decreased staff morale, COVID-19 outbreaks, confinement of residents to their rooms, supporting video calls with physicians, facilitating caregiver involvement. The dependent variable (moderate daily pain or pain of a severe intensity) and resident covariates came from the RAI-HC. Using general estimating equations, adjusted for repeated resident assessments and covariates, we assessed whether AL organizational context was associated with resident pain during the pandemic.

RESULTS

We included 985 residents in 41 facilities (wave 1), and 1134 residents in 42 facilities (wave 2). Pain prevalence [95% confidence interval] decreased non-significantly from 20.6% [18.6%-23.2%] (March-June 2019) to 19.1% [16.9%-21.6%] (October 2020-February 2021). Better preparedness (odds ratio = 1.383 [1.025-1.866]), confinement of residents to their rooms (OR = 1.616 [1.212-2.155]), availability of a nurse practitioner (OR = 0.761 [0.591-0.981]), and staff shortages (OR = 0.684 [0.527-0.888]) were associated with resident pain.

CONCLUSIONS

AL organizational context factors were associated with resident pain. Policy and management interventions can and must address such factors, providing potentially powerful levers for improving AL resident quality of care.

Trends in Korean intervention studies on complementary and alternative therapies in rehabilitation nursing

In nursing, complementary and alternative therapies (CATs) can be provided alongside, or as alternatives, to conventional medical treatments to maximize therapeutic effects, accelerate rehabilitation, and enhance patient satisfaction. Fostering the correct knowledge and attitudes toward CATs is crucial not only for theoretical development but also for practical application. To gain a comprehensive understanding of recent domestic research trends, this study conducted an integrative review to analyze different types of CAT-related intervention studies in rehabilitation nursing in South Korea. A literature search of relevant databases suggested 14 papers. The review revealed that most studies focused on older adult patients, with manipulative and body-based therapies being the most common CAT interventions, followed by energy therapies, mind-body therapies, and others. The efficacy analysis of the CATs used in the selected studies indicated that their effects varied depending on participant characteristics and outcome measures, even when the same CAT was employed. To advance the field of rehabilitation nursing, effective CATs that are proven to be safe for older adult patients need to be developed and actively utilized. Additionally, specialized nurse training programs and clinical and community-based applications for rehabilitation patients requiring interventions need to be developed.

Pain, mindfulness, and placebo: a systematic review

Introduction

Pain is a complex phenomenon influenced by psychosocial variables, including the placebo effect. The effectiveness of mindfulness-based interventions (MBIs) for pain has been demonstrated in experimental studies and systematic reviews, but the mechanisms of action are only starting to be established. Whether the expectations of individuals experiencing pain can be manipulated during MBIs remains to be systematically evaluated, and what role placebo effects might play remains to be explored.

Methods

To evaluate the literature analyzing placebo effects in MBIs for pain, we performed a systematic review based on searches conducted in PubMed, Web of Science, and SCOPUS databases. Our search revealed a total of 272 studies, of which only 19 studies were included (10 acute pain and nine chronic pain), considering the inclusion and exclusion criteria related to expectations and placebo effects.

Results

From the 19 included studies, six measured placebo effects only in relation to the pharmacological intervention used in the study and not to an MBI.

Discussion

The results of the few studies that focused on the placebo effects of the MBIs indicate that placebo and expectations play a role in the MBIs' effects on pain. Although expectations and placebo effects are frequently discussed in the context of mindfulness and pain research, these results show that these factors are still not routinely considered in experimental designs. However, the results of the few studies included in this systematic review highlight a clear role for placebo and expectancy effects in the overall effects of MBIs for both acute and chronic pain, suggesting that routine measurement and further consideration in future studies are warranted. Additional research in this fascinating and challenging field is necessary to fully understand the connection between MBIs, placebo/expectations, and their effects on pain relief.

Chronic pain in older adults with disabilities is associated with fall-related injuries: a prospective cohort study

PURPOSE

Previous studies have shown an association between chronic pain and the occurrence of falls in community-dwelling older adults; however, the association between chronic pain and fall-related injuries in older adults with disabilities is unclear. This study aimed to determine the association between chronic pain and fall-related injuries in older adults with disabilities.

METHODS

This 24-month prospective cohort study included older adults aged 65 years or older using Japanese long-term care insurance services. Chronic pain, defined as "pain that has persisted for more than three months to date," was assessed using a face-to-face questionnaire. Fall-related injuries, defined as "injuries requiring hospitalization or outpatient treatment due to a fall," were assessed using a fall calendar. Data were analyzed using a Cox proportional hazards model, with fall-related injury as the dependent variable, chronic pain as the independent variable, and confounders as covariates.

RESULTS

Among 133 included participants, 15 experienced fall-related injuries. After adjusting for age and sex as covariates, chronic pain was significantly associated with fall-related injuries (hazard ratio: 5.487, 95% confidence interval: 1.211-24.853, p = 0.027).

CONCLUSIONS

Chronic pain was associated with fall-related injuries in older adults with disabilities. In this population, a greater focus should be placed on treating chronic pain to reduce the occurrence of falls.

Addressing Pain Using a Mediterranean Ketogenic Nutrition Program in Older Adults with Mild Cognitive Impairment

Chronic pain has negative physical and cognitive consequences in older adults and may lead to a poorer quality of life. Mediterranean ketogenic nutrition (MKN) is a promising nonpharmacological intervention for pain management, but long-term adherence is challenging due to the carbohydrate restrictive diet regimen. The main objective of this study was to evaluate the effects of the pilot MKN Adherence (MKNA) Program on pain in older adults with mild cognitive impairment and to assess whether improvements in self-reported pain were associated with adherence to MKN. Older adults (N = 58) aged 60-85 with possible mild cognitive impairment were randomized to a 6-week MKNA arm or an MKN Education (MKNE) program arm. Both arms received the same nutrition education and group format; however, the MKNA arm received additional motivational interviewing and cognitive behavioral skills to enhance adherence. Changes in self-reported pain (Brief Pain Inventory, Roland Morris, Patient's Global Impression of Change) and adherence to MKN (ketone levels, self-reported adherence) were assessed at baseline, 6-weeks, and 3-months post intervention. Both arms showed clinically significant reductions in pain. Greater adherence to MKN across the 6-week intervention was associated with higher ratings of pain-related changes on the Patient's Global Impression of Change scale. Based on these findings, adherence to MKN may promote improvements in self-reported pain in older adults with mild cognitive impairment and findings support the need for future full-scale randomized clinical trials evaluating MKN programs on pain. Trial Registration: Clinicaltrials.gov ID: NCT04817176.

The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study)

BACKGROUND

This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations.

METHODS

Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators.

RESULTS

Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators.

CONCLUSIONS

This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Improvement in Nurses' Knowledge of Subcutaneous Catheter Use for Pain Management

BACKGROUND

Nurses often have insufficient knowledge of subcutaneous catheter use for pain management. This quality improvement project evaluated implementation of an evidence-based subcutaneous catheter nursing policy with education to improve pain management for hospitalized patients.

METHOD

A convenience sample of nurses (N = 515) completed a posttest after online training on effective subcutaneous pain management. Patient pain ratings were assessed to evaluate whether they changed after nurses' training.

RESULTS

Posttest scores showed the online learning module effectively contributed to nurses' knowledge of subcutaneous catheter pain management. A statistically significant reduction occurred in patient pain ratings (p < .001) postintervention. The number of patients experiencing moderate or severe pain decreased by 58%, for a significant reduction in pain.

CONCLUSION

An online learning module was successful in educating nurses on pain medication administration through an indwelling subcutaneous catheter. [J Contin Educ Nurs. 2024;55(1):13-20.].