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Sean M, Coulombe-Lévêque A, Nadeau W, Charest AC, Martel M, Léonard G, Tétreault P. Counting your chickens before they hatch: improvements in an untreated chronic pain population, beyond regression to the mean and the placebo effect. Pain Rep 2024; 9:e1157. [PMID: 38689593 PMCID: PMC11057814 DOI: 10.1097/pr9.0000000000001157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/22/2024] [Accepted: 02/20/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction Isolating the effect of an intervention from the natural course and fluctuations of a condition is a challenge in any clinical trial, particularly in the field of pain. Regression to the mean (RTM) may explain some of these observed fluctuations. Objectives In this paper, we describe and quantify the natural trajectory of questionnaire scores over time, based on initial scores. Methods Twenty-seven untreated chronic low back pain patients and 25 healthy controls took part in this observational study, wherein they were asked to complete an array of questionnaires commonly used in pain studies during each of 3 visits (V1, V2, V3) at the 2-month interval. Scores at V1 were classified into 3 subgroups (extremely high, normal, and extremely low), based on z-scores. The average delta (∆ = V2 - V1) was calculated for each subgroup, for each questionnaire, to describe the evolution of scores over time based on initial scores. This analysis was repeated with the data for V2 and V3. Results Our results show that high initial scores were widely followed by more average scores, while low initial scores tended to be followed by similar (low) scores. Conclusion These trajectories cannot be attributable to RTM alone because of their asymmetry, nor to the placebo effect as they occurred in the absence of any intervention. However, they could be the result of an Effect of Care, wherein participants had meaningful improvements simply from taking part in a study. The improvement observed in patients with high initial scores should be carefully taken into account when interpreting results from clinical trials.
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Affiliation(s)
- Monica Sean
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Department of Anesthesiology, Sherbrooke, QC, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Alexia Coulombe-Lévêque
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- School of Rehabilitation, Sherbrooke, QC, Canada
- Research Centre on Aging, Sherbrooke, QC, Canada
| | - William Nadeau
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Anne-Catherine Charest
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Marylie Martel
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Guillaume Léonard
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- School of Rehabilitation, Sherbrooke, QC, Canada
- Research Centre on Aging, Sherbrooke, QC, Canada
| | - Pascal Tétreault
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Department of Anesthesiology, Sherbrooke, QC, Canada
- Centre de Recherche du CHUS, Sherbrooke, QC, Canada
- Department of Nuclear Medicine and Radiobiology, Sherbrooke, QC, Canada
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Sturmberg JP, Marcum JA. From cause and effect to causes and effects. J Eval Clin Pract 2024; 30:296-308. [PMID: 36779244 DOI: 10.1111/jep.13814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/14/2023]
Abstract
It is now-at least loosely-acknowledged that most health and clinical outcomes are influenced by different interacting causes. Surprisingly, medical research studies are nearly universally designed to study-usually in a binary way-the effect of a single cause. Recent experiences during the coronavirus disease 2019 pandemic brought to the forefront that most of our challenges in medicine and healthcare deal with systemic, that is, interdependent and interconnected problems. Understanding these problems defy simplistic dichotomous research methodologies. These insights demand a shift in our thinking from 'cause and effect' to 'causes and effects' since this transcends the classical way of Cartesian reductionist thinking. We require a shift to a 'causes and effects' frame so we can choose the research methodology that reflects the relationships between variables of interest-one-to-one, one-to-many, many-to-one or many-to-many. One-to-one (or cause and effect) relationships are amenable to the traditional randomized control trial design, while all others require systemic designs to understand 'causes and effects'. Researchers urgently need to re-evaluate their science models and embrace research designs that allow an exploration of the clinically obvious multiple 'causes and effects' on health and disease. Clinical examples highlight the application of various systemic research methodologies and demonstrate how 'causes and effects' explain the heterogeneity of clinical outcomes. This shift in scientific thinking will allow us to find the necessary personalized or precise clinical interventions that address the underlying reasons for the variability of clinical outcomes and will contribute to greater health equity.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Holgate, New South Wales, Australia
- Foundation President, International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont, USA
| | - James A Marcum
- Department of Philosophy, Baylor University, Waco, Texas, USA
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Shamabadi A, Karimi H, Arabzadeh Bahri R, Motavaselian M, Akhondzadeh S. Emerging drugs for the treatment of irritability associated with autism spectrum disorder. Expert Opin Emerg Drugs 2024; 29:45-56. [PMID: 38296815 DOI: 10.1080/14728214.2024.2313650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/30/2024] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Autism spectrum disorder (ASD) is an early-onset disorder with a prevalence of 1% among children and reported disability-adjusted life years of 4.31 million. Irritability is a challenging behavior associated with ASD, for which medication development has lagged. More specifically, pharmacotherapy effectiveness may be limited against high adverse effects (considering side effect profiles and patient medication sensitivity); thus, the possible benefits of pharmacological interventions must be balanced against potential adverse events in each patient. AREAS COVERED After reviewing the neuropathophysiology of ASD-associated irritability, the benefits and tolerability of emerging medications in its treatment based on randomized controlled trials were detailed in light of mechanisms and targets of action. EXPERT OPINION Succeeding risperidone and aripiprazole, monotherapy with memantine may be beneficial. In addition, N-acetylcysteine, galantamine, sulforaphane, celecoxib, palmitoylethanolamide, pentoxifylline, simvastatin, minocycline, amantadine, pregnenolone, prednisolone, riluzole, propentofylline, pioglitazone, and topiramate, all adjunct to risperidone, and clonidine and methylphenidate outperformed placebo. These effects were through glutamatergic, γ-aminobutyric acidergic, inflammatory, oxidative, cholinergic, dopaminergic, and serotonergic systems. All medications were reported to be safe and tolerable. Considering sample size, follow-up, and effect size, further studies are necessary. Along with drug development, repositioning and combining existing drugs supported by the mechanism of action is recommended.
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Affiliation(s)
- Ahmad Shamabadi
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hanie Karimi
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Razman Arabzadeh Bahri
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Song WJ, Lee HY. Measuring Cough Severity: Time to Replace VAS With Patient Global Impression Scale? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3713-3714. [PMID: 38065639 DOI: 10.1016/j.jaip.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Hwa Young Lee
- Division of Allergy, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Taylor KA, Burke C, George SZ, Danyluk S, Kingsbury CA, Kapos FP, Seebeck K, Lewis CE, Ford E, Plez C, Kosinski A, Filippo R, Brown M, Goode AP. Characterizing Acute Low Back Pain in a Community-Based Cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.02.23296149. [PMID: 37873225 PMCID: PMC10592986 DOI: 10.1101/2023.10.02.23296149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Acute low back pain (LBP) is a common experience, however, the associated pain severity, pain frequency, and characteristics of individuals with acute LBP in community settings have yet to be well understood. The purpose of this manuscript is to categorize and compare acute LBP groups for differences in the following characteristics: 1) sociodemographic, 2) general and physical health, and 3) psychological. This cross-sectional study used baseline data from 131 community-based participants with acute LBP (<4 weeks duration before screening and > 30 pain-free days before acute LBP onset). Two LBP categorization definitions were used based on LBP frequency combined with either: 1) pain interference frequency (impact-based) or 2) pain intensity (intensity-based). Descriptive associations were calculated as prevalence ratios for categorical variables and Hedges' g for continuous variables. Our analyses identified several large associations for impact-based and intensity-based categories for pain interference with activity and with enjoyment in life, global mental health, STarT Back Screening Tool risk category, general health, and Fear Avoidance Beliefs Questionnaire-Physical Activity subscale. Larger associations were found with social constructs (racially and ethnically minoritized, performance of social roles, and isolation) when using the intensity-based versus impact-based categorization. This study adds to the literature by providing standard ways to characterize community-based individuals experiencing acute LBP. The robust differences observed between these categorization approaches suggest they may be used to improve the early identification of factors potentially contributing to the development of chronic LBP.
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Langford DJ, Baron R, Edwards RR, Gewandter JS, Gilron I, Griffin R, Kamerman PR, Katz NP, McDermott MP, Rice AS, Turk DC, Vollert J, Dworkin RH. What should be the entry pain intensity criteria for chronic pain clinical trials? An IMMPACT update. Pain 2023; 164:1927-1930. [PMID: 37288944 PMCID: PMC10523853 DOI: 10.1097/j.pain.0000000000002930] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/06/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Dale. J. Langford
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, USA
- Department of Anesthesiology & Perioperative Medicine, University of Rochester, Rochester, NY, USA
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Ralf Baron
- Department of Neurology, University of Kiel, Kiel, Germany
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer S. Gewandter
- Department of Anesthesiology & Perioperative Medicine, University of Rochester, Rochester, NY, USA
| | - Ian Gilron
- Department of Anesthesiology & Perioperative Medicine, Queen’s University, Kingston, ON, USA
| | - Robert Griffin
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Peter R. Kamerman
- School of Psychology, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Michael P. McDermott
- Department of Anesthesiology & Perioperative Medicine, University of Rochester, Rochester, NY, USA
| | - Andrew S.C. Rice
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Dennis C. Turk
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Jan Vollert
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Robert H. Dworkin
- Department of Anesthesiology & Perioperative Medicine, University of Rochester, Rochester, NY, USA
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Cherup NP, Robayo LE, Vastano R, Fleming L, Levin BE, Widerström-Noga E. Neuropsychological Function in Traumatic Brain Injury and the Influence of Chronic Pain. Percept Mot Skills 2023; 130:1495-1523. [PMID: 37219529 DOI: 10.1177/00315125231174082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Cognitive dysfunction, pain, and psychological morbidity all present unique challenges to those living with traumatic brain injury (TBI). In this study we examined (a) the impact of pain across domains of attention, memory, and executive function, and (b) the relationships between pain and depression, anxiety, and post-traumatic stress disorder (PTSD) in persons with chronic TBI. Our sample included 86 participants with a TBI and chronic pain (n = 26), patients with TBI and no chronic pain (n = 23), and a pain-free control group without TBI (n = 37). Participants visited the laboratory and completed a comprehensive battery of neuropsychological tests as part of a structured interview. Multivariate analysis of covariance using education as a covariate, failed to detect a significant group difference for neuropsychological composite scores of attention, memory, and executive function (p = .165). A follow-up analysis using multiple one-way analysis of variance (ANOVA) was conducted for individual measures of executive function. Post-hoc testing indicated that those in both TBI groups preformed significantly worse on measures of semantic fluency when compared to controls (p < 0.001, ηρ2 = .16). Additionally, multiple ANOVAs indicated that those with TBI and pain scored significantly worse across all psychological assessments (p < .001). We also found significant associations between measures of pain and most psychological symptoms. A follow-up stepwise linear regression among those in the TBI pain group indicated that post concussive complaints, pain severity, and neuropathic pain symptoms differentially contributed to symptoms of depression, anxiety, and PTSD. These findings suggest deficits in verbal fluency among those living with chronic TBI, with results also reinforcing the multidimensional nature of pain and its psychological significance in this population.
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Affiliation(s)
- Nicholas P Cherup
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
| | - Linda E Robayo
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
| | - Roberta Vastano
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
| | - Loriann Fleming
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
| | - Bonnie E Levin
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eva Widerström-Noga
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, USA
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL, USA
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