Multi-site Pain Is Associated with Long-term Patient-Reported Outcomes in Older Adults with Persistent Back Pain

Association between multisite musculoskeletal pain and disability trajectories among community-dwelling older adults

BACKGROUND

Pain is linked to disability, but how multisite musculoskeletal pain leads to disability over time is not well elaborated.

OBJECTIVE

To examine the associations of multisite musculoskeletal pain with disability among a nationally representative cohort.

DESIGN

We used data from the National Health and Aging Trends Study (NHATS) 2015-22. Disability was assessed by basic activities of daily living (ADL) and instrumental activities of daily living (IADL).

PARTICIPANTS

A total of 5557 individuals with multisite musculoskeletal pain dwelling in the community were included in this study.

METHODS

Group-based trajectory models were applied to identify distinct profiles of disability in ADL and IADL. Design-based logistic regressions were used to examine associations among multisite musculoskeletal pain, disability, and dual trajectory group memberships, adjusted for sociodemographic, health status, behavioral, and mental characteristics.

RESULTS

Persons who experienced multisite musculoskeletal pain were at higher risk of disability in ADL and IADL. We identified five heterogeneous disability trajectories and named them based on baseline levels and rates of increase over time. Approximately, 52.42% of older adults with multisite musculoskeletal pain were in trajectories with ADL and IADL declines, and 33.60% experienced a rapid decline. Multisite musculoskeletal pain was associated with elevated relative risk for the adverse disability trajectories, which generally increases with multisite musculoskeletal pain frequency and number of sites.

CONCLUSIONS

Persons with multisite musculoskeletal pain had a higher risk of disability. It is essential to adopt effective pain management strategies to maintain the independent living ability of older adults and to realize active aging.

Data-driven identification of distinct pain drawing patterns and their association with clinical and psychological factors: a study of 21,123 patients with spinal pain

ABSTRACT

The variability in pain drawing styles and analysis methods has raised concerns about the reliability of pain drawings as a screening tool for nonpain symptoms. In this study, a data-driven approach to pain drawing analysis has been used to enhance the reliability. The aim was to identify distinct clusters of pain patterns by using latent class analysis (LCA) on 46 predefined anatomical areas of a freehand digital pain drawing. Clusters were described in the clinical domains of activity limitation, pain intensity, and psychological factors. A total of 21,123 individuals were included from 2 subgroups by primary pain complaint (low back pain (LBP) [n = 15,465]) or midback/neck pain (MBPNP) [n = 5658]). Five clusters were identified for the LBP subgroup: LBP and radiating pain (19.9%), radiating pain (25.8%), local LBP (24.8%), LBP and whole leg pain (18.7%), and widespread pain (10.8%). Four clusters were identified for the MBPNP subgroup: MBPNP bilateral posterior (19.9%), MBPNP unilateral posterior + anterior (23.6%), MBPNP unilateral posterior (45.4%), and widespread pain (11.1%). The clusters derived by LCA corresponded to common, specific, and recognizable clinical presentations. Statistically significant differences were found between these clusters in every self-reported health domain. Similarly, for both LBP and MBPNP, pain drawings involving more extensive pain areas were associated with higher activity limitation, more intense pain, and more psychological distress. This study presents a versatile data-driven approach for analyzing pain drawings to assist in managing spinal pain.

Pain, Balance-Confidence, Functional Mobility, and Reach Are Associated With Risk of Recurrent Falls Among Adults With Lower-Limb Amputation

Objective

The study evaluated whether pain intensity and extent, balance-confidence, functional mobility, and balance (eg, functional reach) are potential risk factors for recurrent falls among adults with a lower-limb amputation.

Design

Cross-sectional study.

Setting

Research laboratory.

Participants

Eighty-three adults with unilateral lower-limb amputation that occurred >1 year prior (26 transfemoral- and 57 transtibial-level amputation; 44.6% women; 51.8% traumatic cause of amputation; N=83).

Intervention

Not applicable.

Main Outcome Measures

Participants reported on the number of falls in the past year, as well as pain intensity in the low back, residual, and sound limbs. Balance-confidence (per the Activities-Specific Balance-Confidence Scale [ABC]), functional mobility (per the Prosthetic Limb Users Survey of Mobility ([PLUS-M]), and balance (per the Functional Reach and modified Four Square Step Tests) were obtained.

Results

After considering non-modifiable covariates, greater extent of pain, less balance-confidence, worse self-reported mobility, and reduced prosthetic-side reach were factors associated with recurrent fall risk. Adults reporting pain in the low back and both lower-limbs had 6.5 times the odds of reporting recurrent falls as compared with peers without pain. A 1-point increase in ABC score or PLUS-M T score, or 1-cm increase in prosthetic-side reaching distance, was associated with a 7.3%, 9.4%, and 7.1% decrease in odds of reporting recurrent falls in the past year, respectively.

Conclusions

Of the 83 adults, 36% reported recurrent falls in the past year. Presence of pain in the low back and both lower-limbs, less balance-confidence, worse PLUS-M score, and less prosthetic-side reaching distance were identified as modifiable factors associated with an increased odd of recurrent falls.

Comorbid pain and falls among Chinese older adults: the association, healthcare utilization and the role of subjective and objective physical functioning

BACKGROUND

Pain and falls are significant disabling health conditions which cause substantial economic burdens on older adults and their families. Physical functioning (both subjective and objective) might play a significant role in older adults' pain and falls. In this study we aimed to examine: (1) the relationship between pain and falls among Chinese older adults; (2) pain-fall status (i.e., comorbid pain-fall, pain-only, fall-only, and neither-pain-nor-fall) in relation to healthcare utilization; and (3) whether physical functioning measured either subjectively or objectively would contribute differently to the pain intensity and to the occurrence of falls.

METHODS

We used a nationally-representative sample of older adults from the 2011-2012 baseline survey of the China Health and Retirement Longitudinal Study (N = 4,461, aged 60-95 years). Logistic, linear, and negative binomial models adjusted for demographic variables were used in the analysis.

RESULTS

Overall, 36% of older adults reported pain, 20% had fall occurrences, and 11% had comorbid pain and falls. Pain intensity was significantly associated with falls. Individuals in groups of pain-only, fall-only, and comorbid pain-fall reported significantly higher healthcare utilization, that is, more frequent inpatient care and doctor visits than those in the neither-pain-nor-fall group. Subjective, not objective, physical functioning was associated with pain and falls.

CONCLUSION

Pain and falls are significantly associated with each other, and both can lead to increased healthcare utilization. Compared to objective physical functioning, subjective physical functioning is more likely to correlate with pain and falls, suggesting that self-reported physical status should be considered when designing pain-fall preventive strategies.

Impact of pain in other body regions on the foot-specific quality of life in patients with hallux valgus

OBJECTIVES

The purpose of this study was to clarify the prevalence of pain outside the foot, and to determine the associations of pain outside the foot with foot-specific quality of life (QOL) in patients with hallux valgus.

METHODS

Patients scheduled to undergo hallux valgus surgery were recruited. Patients answered whether they experienced disabling pain in 13 body regions other than the foot. Foot-specific QOLwas assessed using the Self-Administered Foot Evaluation questionnaire (SAFE-Q). Foot pain was quantified using the visual analogue scale (VAS). Patient characteristics, including age, sex, comorbidity, anxiety, and depression, were also surveyed. The association between pain elsewhere and the SAFE-Q and pain VAS scores were assessed using univariate and multivariate analyses.

RESULTS

Of 102 patients, 55 (54%) experienced pain other than the foot. All SAFE-Q subscale scores were lower, and pain VAS was higher in patients with pain elsewhere than in patients without. In the multivariate analysis, an increase in the number of pain regions was independently associated with a decrease in SAFE-Q scores and an increase in pain VAS.

CONCLUSION

More than half of the patients with hallux valgus experienced pain elsewhere. The presence of pain elsewhere was associated with poorer foot-specific QOL and severer foot pain.

Pain, obesity, and physical function in Mexican American older adults during 20 years of follow-up

INTRODUCTION

Pain remains largely undertreated in older adults irrespective of health care setting. Mexican American adults in the United States have a high age-adjusted prevalence of obesity. However, the association of pain and obesity with physical function is understudied in this population.

OBJECTIVE

To examine the association of co-occurring pain and obesity with physical function over 20 years of follow-up in a cohort of older Mexican Americans who scored ≥7 (moderate to high) in the Short Physical Performance Battery (SPPB) test and were nondisabled at baseline.

DESIGN

Longitudinal population-based study.

SETTING

Community-dwelling older adults from Southwestern United States.

PARTICIPANTS

Mexican American adults age 65 years and older.

INTERVENTIONS

Not Applicable.

MAIN OUTCOME MEASURES

Physical function was assessed with the SPPB test (standing balance, timed 8-ft walk, and five repeated timed chair stands). Participants at baseline were divided into four groups: no pain-no obesity (n = 869), obesity only (n = 282), pain only (n = 216), and pain-obesity (n = 159). Generalized Estimating Equation models were used to estimate the odds ratio (OR) and 95% confidence interval (CI) of lower performance in physical function over 20 years as a function of pain-obesity grouping.

RESULTS

Participants with pain only (OR = 1.61, 95% CI = 1.34-1.95) and with co-occurring pain and obesity (OR = 2.32, 95% CI = 1.83-2.95) had significantly greater odds of physical function impairment over those with no pain-no obesity or obesity only, after controlling for all covariates.

CONCLUSION

Older Mexican American adults were at high risk for physical function impairment over time if they had pain or co-occurring pain and obesity. Early assessment and proper pain management as well as maintaining a healthy weight may reduce declines in physical function in older Mexican American adults.

The Effect of a Non-Pharmacological Multicomponent Pain Management Program on Pain Intensity and Quality of Life in Community-Dwelling Elderly Men With Chronic Musculoskeletal Pain

BACKGROUND AND AIM

Improving the level of care for the elderly with musculoskeletal pain requires pharmacological and non-pharmacological pain control methods. This study aimed to investigate the effect of a non-pharmacological pain management intervention on pain intensity and quality of life in community-dwelling older men with musculoskeletal pain who were referred to comprehensive healthcare centers in the city of Ilam, Iran.

MATERIALS AND METHODS

A quasi-experimental study with pre and post-test design was performed on 65 older men with chronic musculoskeletal pain. The samples were selected regarding inclusion criteria as available and randomly assigned to either the control (usual care) or the experimental group (educational intervention plus physical exercises). Baseline characteristics of participants, the Visual Analogue Scale, and the CASP-19 Quality of Life were used to collect data. Data were analyzed by SPSS software using the ANCOVA, independent and paired t-test, and chi-square test at the statistically significant level of 5 %.

RESULTS

According to the findings, there was a significant difference between the experimental and control groups in terms of quality of life (p < .05) and pain intensity (p < .05) after the intervention. No relevant differences were found between groups regarding demographic characteristics at baseline.

CONCLUSIONS

A six-week physical activity and education program for community-dwelling older men with chronic musculoskeletal pain could improve quality of life and decrease pain intensity after a one-month follow-up compared with usual care. Therefore, it seems necessary to consider pain management programs in the elderly care program and familiarize health care professionals with these pain control methods.

Yoga Versus Education for Veterans with Chronic Low Back Pain: a Randomized Controlled Trial

BACKGROUND

Yoga is effective for chronic low back pain (cLBP) in civilians but understudied among Veterans.

OBJECTIVE

Determine whether yoga is more effective than an educational book for improving disability and pain among Veterans with cLBP.

DESIGN, SETTING, AND PARTICIPANTS

Veterans diagnosed with cLBP at a VA medical center enrolled in a randomized controlled trial from March to December of 2015.

INTERVENTIONS

Twelve weekly hatha yoga classes or education using The Back Pain Helpbook.

MEASURES

Co-primary outcomes were changes from baseline at 12 weeks in back-related disability on the modified Roland Morris Disability Questionnaire and pain on the Defense & Veterans Pain Rating Scale. Secondary outcomes were global improvement, patient satisfaction, pain medication use, and post-traumatic stress symptoms. An intention-to-treat approach was used in primary analyses.

RESULTS

One hundred twenty Veterans (mean age, 55.5 [SD = 16.9]; 11 [9%] women; mean number of chronic conditions, 5.5) were randomized to yoga (n = 62) and education (n = 58). At 12 weeks, reductions in back-related disability in yoga (mean difference [MD] = - 3.50, 95% CI: - 5.03, - 1.97) were not significantly different than education (MD = - 2.55, 95% CI: - 4.10, - 0.99; between-group difference: - 0.95 [95% CI: - 3.14, 1.23], p = 0.39). For pain, there was no significant difference between yoga (MD = - 1.01, 95% CI: - 1.67, - 0.35) and education (MD = - 0.81, 95% CI: - 1.36, - 0.27; between-group difference: - 0.20, 95% CI: - 1.06, 0.66, p = 0.65). More yoga than education participants reported being very much or extremely improved (39% vs 19%, OR = 3.71, 95% CI: 1.37, 10.02, p = 0.01) and very satisfied with treatment (60% vs 31%, OR = 4.28, 95% CI: 1.70, 10.77, p = 0.002). No differences in pain medication use or post-traumatic stress symptoms were observed at 12 weeks. No serious adverse events were reported in either group.

CONCLUSION

Twelve weekly yoga classes were not more effective than an education intervention for improving pain or disability outcomes among mostly older male Veterans with cLBP and multiple comorbid health conditions.

GOV IDENTIFIER

NCT02224183.

"Like Peanut Butter and Jelly": A Qualitative Study of Chiropractic Care and Home Exercise Among Older Adults With Spinal Disability

OBJECTIVE

A mixed-methods, randomized controlled trial comparing short- and long-term chiropractic care and exercise therapy for spinal disability in older adults found no between-group differences in the primary outcome. However, those who received long-term management reported greater improvement in neck pain, self-efficacy, function, and balance. This nested qualitative study explored participants' perceptions of the benefits and drawbacks of chiropractic care and exercise for spine-related outcomes, with an emphasis on understanding what makes treatment for spine-related problems worthwhile.

METHODS

Of 171 individual interviews conducted after completing study treatment, 50 participants (25 per treatment group) were randomly selected for this analysis. Qualitative descriptive analysis included dual coding of verbatim transcripts by 2 investigators (MM and SAS), which was further distilled into a consensus-derived codebook of themes and organized using NVIVO software.

RESULTS

Participants described trial interventions as complementary to one another for spine-related disability. Chiropractic care was viewed as improving spinal pain and controlling symptoms, while exercise therapy was noted for its long-term impact on self-efficacy and self-management. These older adults considered changes in pain, global sense of improvement, and improved biomechanical function as making treatment worthwhile.

CONCLUSION

Older adults valued nonpharmacologic treatment options that aided them in controlling spine-related symptoms, while empowering them to maintain clinical benefit gained after a course of chiropractic spinal manipulation and exercise. The complementary nature of provider-delivered and active care modalities may be an important consideration when developing care plans. This study underscores the importance of understanding participants' values and experiences when interpreting study results and applying them to practice.

The association between pain and central nervous system depressing medication among hospitalised Norwegian older adults

OBJECTIVES

Central nervous system depressant medications (CNSD) including benzodiazepines, z-hypnotics and opioids are regularly prescribed for the older patient. These medications are linked to dependence and associated with severe side effects in some older patients. Consensus recommendations for this group suggest limiting their use. We have recently described a high proportion of long-term CNSD use and dependence among older in-hospital patients. In this study, we aim to investigate factors associated with pain intensity and presentation of pain among older adults with long-term use of CNSDs compared to non-users.

METHODS

Two hundred and forty six elderly hospitalised patients were recruited consecutively in a cross-sectional study. Data was collected from patients and electronic health records (EHR). Independent variables were sex, age, education, emotional symptoms (hospital anxiety and depression scale [HADS]), cognitive function (Mini-mental State Examination test [MMSE]), comorbidity (cumulative illness rating score - geriatrics [CIRS-G]), loneliness (the six-item De Jong Gierveld Loneliness Scale) and prolonged (≥4 weeks) use of any CNSDs or prolonged use of opioids (≥4 weeks). All variables, including pain intensity, were collected at one time point consistent with the cross-sectional study design. Statistical analyses included descriptive statistics and linear regression models using the above mentioned variables and pain intensity (visual analogue scale for pain intensity [VAS] pain 0-100) as outcome. Additional information regarding pain presentation was extracted from the patients' EHR.

RESULTS

Mean pain intensity VAS (SD) was 35.2 (30.4) and 18.1 (24.2) respectively, for patients with vs. without prolonged use of CNSDs. In the multivariable linear regression analysis, prolonged use of CNSDs and opioids were positively associated with pain intensity (VAS) (regression coefficient (95% CI) 20.7 (11.0; 30.3), p<0.001, and 19.8 (5.7; 33.8), p=0.006, respectively), while sex, age, education, MMSE, HADS, CIRS-G and loneliness scores were not. Pain related to back (23.2%) and lower extremities (23.2%) were most common pain sites, and those with one or more pain sites reported overall higher pain intensity compared to those with no reported pain sites (p<0.006).

CONCLUSIONS

Prolonged use of CNSD medications as well as prolonged use of opioids are both positively associated with pain intensity. The results may have implications for treatment and long-term pain management for older patients.

Prevalence and factors associated with comorbid depressive symptoms among people with low back pain in China: A cross-sectional study

BACKGROUND

Low back pain is a common medical condition among the general population that is associated with many adverse health effects when comorbid with depressive symptoms. However, little is known about depressive symptoms in the population with low back pain in China. Our study evaluated the prevalence of depressive symptoms and analyzed the factors associated with this condition in the Chinese population with low back pain.

METHODS

We conducted a cross-sectional analysis of data from the 2018 China Health and Retirement Longitudinal Study. We collected low back pain information for each participant and identified depressive symptoms using the brief version of the Center for Epidemiologic Studies Depression Scale. A wide range of sociodemographic and health-related characteristics of the subjects were extracted. We measured the prevalence of depressive symptoms comorbid with low back pain and analyzed the associated factors by multiple logistic regression.

RESULTS

A total of 5,779 respondents aged 45 and over with low back pain formed the sample, 41.8% of whom reported depressive symptoms. Multiple logistic regression analysis indicated greater vulnerability to depressive symptoms among females (OR = 1.41, 95% CI, 1.16-1.73), relatively younger persons (60-74 years: OR = 0.72, 95% CI, 0.63-0.83; ≥ 75 years: OR = 0.62, 95% CI, 0.49-0.79, reference: 45-59 years), those from the central and western regions (central: OR = 1.39, 95% CI, 1.18-1.64; western: OR = 1.56, 95% CI, 1.33-1.83), participants with extremely short sleep duration (OR = 2.74, 95% CI, 2.33-3.23), those with poor self-perceived health status (OR = 2.91, 95% CI, 2.34-3.63,), multisite pain (OR = 1.54, 95% CI, 1.20-1.98) and disability in activities of daily living (Basic: OR = 1.70, 95% CI, 1.47-1.98; Instrumental: OR = 1.95, 95% CI, 1.70-2.24).

CONCLUSION

Depressive symptoms were highly prevalent in the Chinese population ≥ 45 years with low back pain. More attention should be paid to the individuals at high-risk confirmed by this study to facilitate early identification and intervention against depressive symptoms.

Characteristics of older adults with back pain associated with choice of first primary care provider: a cross-sectional analysis from the BACE-N cohort study

OBJECTIVES

To describe characteristics of older adults with back pain in primary care, and to assess associations between patient characteristics and type of first primary care provider (general practitioner (GP), physiotherapist (PT) or chiropractor).

DESIGN

Cross-sectional analysis from the Back Complaints in the Elders-Norway cohort study.

SETTING

Norwegian GP, PT and chiropractic primary care centres.

PARTICIPANTS

Patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain were invited to participate. Between April 2015 and February 2020, we included 452 patients: 127 first visited a GP, 130 first visited a PT and 195 first visited a chiropractor.

PRIMARY AND SECONDARY OUTCOME MEASURES

For the first objective, the outcome measure was descriptive statistics of patient characteristics, covering the following domains: sociodemographic, general health, current and previous back pain, psychological and clinical factors. For the second objective, first primary care provider was the outcome measure. Associations between patient characteristics and visiting a GP or PT compared with a chiropractor were assessed with multiple multinomial regression analyses.

RESULTS

Median (IQR) age was 66 (59-72) years. Levels of back-related disability was moderate to severe, with a median (IQR) Roland-Morris Disability Questionnaire (range 0-24) score of 9 (5-13). Recurring episodes were common, 301 (67%) patients had monthly or yearly recurrences. Patients with worse back-related disability, longer duration of symptoms, lower expectations for full recovery and worse physical performance measured with the Back Performance Scale had higher odds of visiting a GP or PT compared with a chiropractor (p<0.05).

CONCLUSION

Older back pain patients in primary care had moderate to severe levels of back-related disability, and most had recurring episodes. Our results suggest that older adult's choice of first primary care provider was associated with important patient characteristics, which highlights the need for caution with generalisations of study results across primary care populations.

TRIAL REGISTRATION NUMBER

NCT04261309.

Prevalence, Incidence, and Factors Associated With Non-Specific Chronic Low Back Pain in Community-Dwelling Older Adults Aged 60 Years and Older: A Systematic Review and Meta-Analysis

Chronic low back pain (CLBP) is common among older adults. This systematic review aimed to summarize: (1) the prevalence and incidence of CLBP in older adults, and (2) demographic, psychological, and clinical factors positively/negatively associated with prevalence/incidence of CLBP among older adults. Four databases were searched to identify relevant publications. Ten studies (31,080 older adults) were included after being screened by 5 independent reviewers using predetermined criteria. The methodological quality of these studies was evaluated by standardized tools. The quality of evidence for all factors were appraised by modified GRADE for cohort studies. Twenty-eight and 1 factors were associated with a higher prevalence and a lower 5-year cumulative incidence of CLBP, respectively. No prognostic factor was identified. There was very limited to limited evidence that females, obesity, anxiety, depression, mental disorders, self-expectation of recovery, self-perceived health status, lifestyle (smoking, daily fluoride consumption), previous falls or lower body injury, retirement/disability due to ill health, family history of body pain, comorbidity (knee osteoarthritis, or chronic obstructive pulmonary disease with/without hypertension), weak abdominal muscles, leg pain, leg pain intensity, widespread pain, pain interference on functioning, use of pain medication, occupational exposure (driving for >20 years, or jobs involving bending/twisting for >10 years), disc space narrowing and severe facet osteoarthritis were significantly related to a higher prevalence of CLBP in older adults. However, very limited evidence suggested that intermediate level of leisure-time physical activity was associated with a lower prevalence of CLBP in older adults. Given the aging population and limited information regarding risk factors for CLBP in older adults, future high-quality prospective studies should identify relevant risk factors to help develop proper preventive and treatment strategies. PERSPECTIVE: Despite the high prevalence of non-specific chronic low back pain among older adults, there is only very limited to limited evidence regarding factors associated with a higher prevalence of chronic low back pain in this population. Given the aging population, high-quality prospective studies are warranted to address this gap.

Presence of widespread pain predicts comorbidities and treatment response in temporomandibular disorders patients

OBJECTIVES

Investigate the presence of widespread pain in a well-defined TMD group and analyze its interrelationship with various comorbidities. Also, longitudinally seek the difference in treatment response according to the presence of widespread pain.

SUBJECTS AND METHODS

The observational study involved 45 female TMD patients in their 20s. Patients were grouped into localized and widespread pain groups based on the widespread pain index (WPI ≥ 4). Clinical characteristics and levels of comorbidities were analyzed through physical examination and validated questionnaires. Differences between the groups and the power of pre-treatment WPI in predicting pre-treatment comorbidities and post-treatment pain level improvement were statistically analyzed.

RESULTS

Patients with widespread pain showed higher somatization and anxiety levels. SF-36 scores were significantly lower and more patients complained of gastrointestinal symptoms. Conventional treatment significantly reduced pain intensity in both groups but less in the widespread pain group. WPI showed significant chances to predict patients showing improvement in pain levels with treatment with a cutoff value of 4. WPI was also effective in differentiating patients that showed a higher level of somatization.

CONCLUSION

Widespread pain index could be effectively applied in differentiating those with a higher level of psychological distress and predicting TMD treatment response with further investigations into its reliability.

Development of a generalizable natural language processing pipeline to extract physician-reported pain from clinical reports: Generated using publicly-available datasets and tested on institutional clinical reports for cancer patients with bone metastases

OBJECTIVE

The majority of cancer patients suffer from severe pain at the advanced stage of their illness. In most cases, cancer pain is underestimated by clinical staff and is not properly managed until it reaches a critical stage. Therefore, detecting and addressing cancer pain early can potentially improve the quality of life of cancer patients. The objective of this research project was to develop a generalizable Natural Language Processing (NLP) pipeline to find and classify physician-reported pain in the radiation oncology consultation notes of cancer patients with bone metastases.

MATERIALS AND METHODS

The texts of 1249 publicly-available hospital discharge notes in the i2b2 database were used as a training and validation set. The MetaMap and NegEx algorithms were implemented for medical terms extraction. Sets of NLP rules were developed to score pain terms in each note. By averaging pain scores, each note was assigned to one of the three verbally-declared pain (VDP) labels, including no pain, pain, and no mention of pain. Without further training, the generalizability of our pipeline in scoring individual pain terms was tested independently using 30 hospital discharge notes from the MIMIC-III database and 30 consultation notes of cancer patients with bone metastasis from our institution's radiation oncology electronic health record. Finally, 150 notes from our institution were used to assess the pipeline's performance at assigning VDP.

RESULTS

Our NLP pipeline successfully detected and quantified pain in the i2b2 summary notes with 93% overall precision and 92% overall recall. Testing on the MIMIC-III database achieved precision and recall of 91% and 86% respectively. The pipeline successfully detected pain with 89% precision and 82% recall on our institutional radiation oncology corpus. Finally, our pipeline assigned a VDP to each note in our institutional corpus with 84% and 82% precision and recall, respectively.

CONCLUSION

Our NLP pipeline enables the detection and classification of physician-reported pain in our radiation oncology corpus. This portable and ready-to-use pipeline can be used to automatically extract and classify physician-reported pain from clinical notes where the pain is not otherwise documented through structured data entry.

Developing clinical prediction models for nonrecovery in older patients seeking care for back pain: the back complaints in the elders prospective cohort study

ABSTRACT

Back pain is a leading cause of disability worldwide and is common in older adults. No clinical prediction models for poor long-term outcomes have been developed in older patients with back pain. This study aimed to develop and internally validate 3 clinical prediction models for nonrecovery in this population. A prospective cohort study in general practice was conducted (Back Complaints in the Elders, Netherlands), including 675 patients >55 years with a new episode of care for back pain. Three definitions of nonrecovery were used combining 6-month and 12-month follow-up data: (1) persistent back pain, (2) persistent disability, and (3) perceived nonrecovery. Sample size calculation resulted in a maximum of 14 candidate predictors that were selected from back pain prognostic literature and clinical experience. Multivariable logistic regression was used to develop the models (backward selection procedure). Models' performance was evaluated with explained variance (Nagelkerke's R2), calibration (Hosmer-Lemeshow test), and discrimination (area under the curve [AUC]) measures. The models were internally validated in 250 bootstrapped samples to correct for overoptimism. All 3 models displayed good overall performance during development and internal validation (ie, R2 > 30%; AUC > 0.77). The model predicting persistent disability performed best, showing good calibration, discrimination (AUC 0.86, 95% confidence interval 0.83-0.89; optimism-adjusted AUC 0.85), and explained variance (R2 49%, optimism-adjusted R2 46%). Common predictors in all models were: age, chronic duration, disability, a recent back pain episode, and patients' recovery expectations. Spinal morning stiffness and pain during spinal rotation were included in 2 of 3 models. These models should be externally validated before being used in a clinical primary care setting.

A functional polymorphism in the ATP-Binding Cassette B1 transporter predicts pharmacologic response to combination of nortriptyline and morphine in neuropathic pain patients

Many genetic markers have been associated with variations in treatment response to analgesics, but none have been assessed in the context of combination therapies. In this study, the treatment effects of nortriptyline and morphine were tested for an association with genetic markers relevant to pain pathways. Treatment effects were determined for single and combination therapies. A total of 24 functional single nucleotide polymorphisms were tested within the gene loci of mu-opioid receptor (OPRM1) gene locus, ATP-Binding Cassette B1 Transporter (ABCB1), Cytochrome P450 gene family (CYP2C19 and CYP2D6), catecholamine inactivator Catechol-O-Methyl Transferase (COMT), and serotonin receptor 2A (HTR2A). Genotyping was performed in a population of neuropathic pain patients who previously participated in a clinical trial. For monotherapy, neither nortriptyline nor morphine responses were associated with single nucleotide polymorphisms. However, for nortriptyline + morphine combination therapy, the single nucleotide polymorphism rs1045642 within the drug efflux pump ABCB1 transporter significantly predicted analgesic response. The presence of the C allele accounted for 51% of pain variance in this subgroup in response to combination treatment. The T-allele homozygotes demonstrated only 20% improvement in pain scores, whereas the C-allele homozygotes 88%. There was no significant contribution of rs1045642 to the medication side effects under all treatment conditions. The UK Biobank data set was then used to validate this genetic association. Here, patients receiving similar combination therapy (opioid + tricyclic antidepressant) carrying the C allele of rs1045642 displayed 33% fewer body pain sites than patients without that allele, suggesting better pain control. In all, our results show a robust effect of the rs1045642 polymorphism in response to chronic pain treatment with a nortriptyline + morphine combination.

Metabolomic analysis coupled with extreme phenotype sampling identified that lysophosphatidylcholines are associated with multisite musculoskeletal pain

ABSTRACT

Musculoskeletal pain often occurs simultaneously at multiple anatomical sites. The aim of the study was to identify metabolic biomarkers for multisite musculoskeletal pain (MSMP) by metabolomics with an extreme phenotype sampling strategy. The study participants (n = 610) were derived from the Newfoundland Osteoarthritis Study. Musculoskeletal pain was assessed using a self-reported pain questionnaire where painful sites were circled on a manikin by participants and the total number of painful sites were calculated. Targeted metabolomic profiling on fasting plasma samples was performed using the Biocrates AbsoluteIDQ p180 kit. Plasma cytokine concentrations including tumor necrosis factor-α, interleukin-6, interleukin-1β, and macrophage migration inhibitory factor were assessed by enzyme-linked immunosorbent assay. Data on blood cholesterol profiles were retrieved from participants' medical records. Demographic, anthropological, and clinical information was self-reported. The number of reported painful sites ranged between 0 and 21. Two hundred and five participants were included in the analysis comprising 83 who had ≥7 painful sites and 122 who had ≤1 painful site. Women and younger people were more likely to have MSMP (P ≤ 0.02). Multisite musculoskeletal pain was associated with a higher risk of having incontinence, worse functional status and longer period of pain, and higher levels of low-density lipoprotein and non-high-density lipoprotein cholesterol (all P ≤ 0.03). Among the 186 metabolites measured, 2 lysophosphatidylcholines, 1 with 26 carbons with no double bond and 1 with 28 carbons with 1 double bond, were significantly and positively associated with MSMP after adjusting for multiple testing with the Bonferroni method (P ≤ 0.0001) and could be considered as novel metabolic markers for MSMP.

Distribution and prevalence of musculoskeletal pain co-occurring with persistent low back pain: a systematic review

BACKGROUND

Co-occurring musculoskeletal pain is common among people with persistent low back pain (LBP) and associated with more negative consequences than LBP alone. The distribution and prevalence of musculoskeletal pain co-occurring with persistent LBP has not been systematically described, which hence was the aim of this review.

METHODS

Literature searches were performed in MEDLINE, Embase, CINAHL and Scopus. We considered observational studies from clinical settings or based on cohorts of the general or working populations involving adults 18 years or older with persistent LBP (≥4 wks) and co-occurring musculoskeletal pain for eligibility. Study selection, data extraction and risk of bias assessment were carried out by independent reviewers. Results are presented according to study population, distribution and location(s) of co-occurring pain.

RESULTS

Nineteen studies out of 5744 unique records met the inclusion criteria. Studies were from high-income countries in Europe, USA and Japan. A total of 34,492 people with persistent LBP were included in our evidence synthesis. Methods for assessing and categorizing co-occurring pain varied considerably between studies, but based on the available data from observational studies, we identified three main categories of co-occurring pain - these were axial pain (18 to 58%), extremity pain (6 to 50%), and multi-site musculoskeletal pain (10 to 89%). Persistent LBP with co-occurring pain was reported more often by females than males, and co-occurring pain was reported more often in patients with more disability.

CONCLUSIONS

People with persistent LBP often report co-occurring neck pain, extremity pain or multi-site pain. Assessment of co-occurring pain alongside persistent LBP vary considerable between studies and there is a need for harmonisation of measurement methods to advance our understanding of how pain in different body regions occur alongside persistent LBP.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017068807 .

Innovations in Geroscience to enhance mobility in older adults

Aging is the primary risk factor for functional decline; thus, understanding and preventing disability among older adults has emerged as an important public health challenge of the 21st century. The science of gerontology - or geroscience - has the practical purpose of "adding life to the years." The overall goal of geroscience is to increase healthspan, which refers to extending the portion of the lifespan in which the individual experiences enjoyment, satisfaction, and wellness. An important facet of this goal is preserving mobility, defined as the ability to move independently. Despite this clear purpose, this has proven to be a challenging endeavor as mobility and function in later life are influenced by a complex interaction of factors across multiple domains. Moreover, findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, as well as the environment in which a person lives, can have a dramatic effect on an older person's mobility and function. For these reasons, behavioral interventions that incorporate complex walking tasks and other activities of daily living appear to be especially helpful for improving mobility function. Other pharmaceutical interventions, such as oxytocin, and complementary and alternative interventions, such as massage therapy, may enhance physical function both through direct effects on biological mechanisms related to mobility, as well as indirectly through modulation of cognitive and socioemotional processes. Thus, the purpose of the present review is to describe evolving interventional approaches to enhance mobility and maintain healthspan in the growing population of older adults in the United States and countries throughout the world. Such interventions are likely to be greatly assisted by technological advances and the widespread adoption of virtual communications during and after the COVID-19 era.

Musculoskeletal Pain in Older Adults: A Clinical Review

Persistent pain in older adults is a widely prevalent and disabling condition that is the manifestation of multiple contributing physical, mental, social, and age-related factors. To effectively treat pain, the clinician must assess and address contributing factors using a comprehensive approach that includes pharmacologic and nonpharmacologic therapies within the context of a strong therapeutic relationship among the patient, caregivers, and a multidisciplinary team. This article reviews the current understanding of persistent pain in older adults and suggests a general approach to its assessment and management, followed by specific considerations for musculoskeletal pain conditions commonly seen in older adults.

Framework for improving outcome prediction for acute to chronic low back pain transitions

Clinical practice guidelines and the Federal Pain Research Strategy (United States) have recently highlighted research priorities to lessen the public health impact of low back pain (LBP). It may be necessary to improve existing predictive approaches to meet these research priorities for the transition from acute to chronic LBP. In this article, we first present a mapping review of previous studies investigating this transition and, from the characterization of the mapping review, present a predictive framework that accounts for limitations in the identified studies. Potential advantages of implementing this predictive framework are further considered. These advantages include (1) leveraging routinely collected health care data to improve prediction of the development of chronic LBP and (2) facilitating use of advanced analytical approaches that may improve prediction accuracy. Furthermore, successful implementation of this predictive framework in the electronic health record would allow for widespread testing of accuracy resulting in validated clinical decision aids for predicting chronic LBP development.

A Biopsychosocial Model of Chronic Pain for Older Adults

Population

Comprehensive evaluation of chronic pain in older adults is multifaceted.

Objective and Methods

Research on chronic pain in older adults needs to be guided by sound conceptual models. The purpose of this paper is to describe an adaptation of the Biopsychosocial Model (BPS) of Chronic Pain for older adults. The extant literature was reviewed, and selected research findings that provide the empiric foundation for this adaptation of the BPS model of chronic pain are summarized. The paper concludes with a discussion of specific recommendations for how this adapted model can be used to guide future research.

Conclusions

This adaptation of the BPS model of chronic pain for older adults provides a comprehensive framework to guide future research in this vulnerable population.