Reliability and validity of individual and composite recall pain measures in patients with cancer

Optimizing Pain Intensity Assessment in Clinical Trials: How Many Ratings are Needed to Best Balance the Need for Validity and to Minimize Assessment Burden?

Pain intensity is the most commonly used outcome domain in pain clinical trials. To minimize the chances of type II error (ie, concluding that a treatment does not have beneficial effects, when in fact it does), the measure of pain intensity used should be sensitive to changes produced by effective pain treatments. Here we sought to identify the combination of pain intensity ratings that would balance the need for reliability and validity against the need to minimize assessment burden. We conducted secondary analyses using data from a completed 4-arm clinical trial of psychological pain treatments (N = 164 adults). Current, worst, least, and average pain intensity in the past 24 hours were assessed 4 times before and after treatment using 0 to 10 numerical rating scale-11. We created a variety of composite scores using these ratings and evaluated their reliability (Cronbach's alphas) and validity (ie, associations with a gold standard score created by averaging 16 ratings and sensitivity for detecting between-group differences in treatment efficacy). We found that for each measure, reliability increased as the number of ratings used to create the measures increased and that ratings from 3 or more days were needed to have adequately strong associations with the gold standard. Regarding sensitivity, the findings suggest that composite scores made up of ratings from 4 days are needed to maximize the chances of detecting treatment effects, especially with smaller sample sizes. In conclusion, using data from 3 or 4 days of assessment may be the best practice. PERSPECTIVE: Composite scores made up of at least 3 days of pain ratings appear to be needed to maximize reliability and validity while minimizing the assessment burden. TRIAL REGISTRATION: clinicaltrials.gov NCT01800604.

Underestimating or overestimating improvement in pain on a smartphone pain app: Role of disability, negative affect, and pain app engagement

Clinicians often ask people with chronic pain about their perceived benefit from interventions designed to improve their pain. The aim of this study is to identify factors that contribute to underestimating or overestimating perceived changes in daily pain intensity over a month of daily assessments. We examined data from individuals with chronic pain who provided at least 28 daily assessments using a pain app as secondary analyses. Participants provided baseline demographic information and completed questionnaires assessing pain, activity interference, mood, pain disability, and catastrophizing. Using the pain app, they entered daily ratings of pain (0=none; 10=worst pain possible) and impressions of perceived day-to-day change (0=better; 5=same; and 10=worse). Two hundred fifty-two (N=252) subjects with chronic pain met the inclusion criteria of completing at least 28 daily assessments. Those who underestimated their improvement tended to have higher pain intensity at baseline (p<0.001), reported greater activity interference and disability p<0.001) and were prone to greater catastrophizing and anxiety and depression (p<0.01). People who were more accurate in assessing their improvement engaged less with the app with fewer 2-way messages compared with those who either underestimated or overestimated their improvement and who had more 2-way messaging (p<0.05). This longitudinal study suggests that those who report greater levels of catastrophizing and anxiety and depression are more likely to underestimate any improvements of their pain over time but seem to engage more with a pain app. Future research will help in our understanding of what magnitude of perceived change in pain ratings is clinically meaningful. PERSPECTIVE: Those who report greater levels of pain, disability, anxiety, depression, and catastrophizing are most prone to underestimate improvements of their pain over time.

Multimodal hypersensitivity derived from quantitative sensory testing predicts pelvic pain outcome: an observational cohort study

ABSTRACT

Multimodal hypersensitivity (MMH)-greater sensitivity across multiple sensory modalities (eg, light, sound, temperature, pressure)-is associated with the development of chronic pain. However, previous MMH studies are restricted given their reliance on self-reported questionnaires, narrow use of multimodal sensory testing, or limited follow-up. We conducted multimodal sensory testing on an observational cohort of 200 reproductive-aged women, including those at elevated risk for chronic pelvic pain conditions and pain-free controls. Multimodal sensory testing included visual, auditory, and bodily pressure, pelvic pressure, thermal, and bladder pain testing. Self-reported pelvic pain was examined over 4 years. A principal component analysis of sensory testing measures resulted in 3 orthogonal factors that explained 43% of the variance: MMH, pressure pain stimulus response, and bladder hypersensitivity. The MMH and bladder hypersensitivity factors correlated with baseline self-reported menstrual pain, genitourinary symptoms, depression, anxiety, and health. Over time, MMH increasingly predicted pelvic pain and was the only component to predict outcome 4 years later, even when adjusted for baseline pelvic pain. Multimodal hypersensitivity was a better predictor of pelvic pain outcome than a questionnaire-based assessment of generalized sensory sensitivity. These results suggest that MMHs overarching neural mechanisms convey more substantial long-term risk for pelvic pain than variation in individual sensory modalities. Further research on the modifiability of MMH could inform future treatment developments in chronic pain.

Effectiveness of Therapeutic Exercise and Patient Education on Cancer-Related Fatigue in Breast Cancer Survivors: A Randomised, Single-Blind, Controlled Trial with a 6-Month Follow-Up

This study aimed to determine the effectiveness of therapeutic exercise plus patient therapeutic education on perceived fatigue, functional capacity and pain in breast cancer survivors with cancer-related fatigue. A randomised, single-blind, clinical trial was conducted with a total of 80 breast cancer survivors who presented cancer-related fatigue. Women were randomised into a supervised therapeutic exercise group (STE-G) (n = 40) or an unsupervised exercise group (UE-G) (n = 40). Both interventions included patient therapeutic education and were delivered in three sessions per week over eight weeks. The main outcome was perceived fatigue as assessed by the Spanish version of the Functional Assessment of Chronic Illness Therapy-Fatigue subscale (FACIT-F). Other evaluated outcomes were pain measured on a visual analogue scale, and distance measured using the 6-Minute Walk Test. Data were collected at baseline, immediately post-intervention, and at three and six months after baseline. Significantly greater improvements across all variables were observed in the STE-G throughout the entire follow-up period with the exception of pain. Conclusions: A supervised therapeutic exercise program plus patient therapeutic education significantly reduce perceived fatigue and increase functional capacity in breast cancer survivors suffering from cancer-related fatigue compared to an unsupervised physical exercise program based on individual preferences with patient therapeutic education.

Impact of Cannabis Use on Least Pain Scores Among African American and White Patients with Cancer Pain: A Moderation Analysis

INTRODUCTION

Based on many published reports, African American patients with cancer experience higher pain severity scores and lower pain relief than White patients. This disparity results from undertreatment of pain and is compounded by low adherence to prescribed non-opioid and opioid analgesics among African American patients with cancer. While nearly one in four patients use cannabis to manage cancer-related symptoms, less is known about how cannabis use influences pain relief in this patient population.

METHODS

This study is based on preliminary data from an ongoing study of longitudinal outcomes of opioid therapy among African American and White patients with cancer. Linear mixed-effects models were utilized to assess the interaction of race and cannabis use on pain relief using "least pain" item scores from the Brief Pain Inventory (BPI) averaged across three time points. Models were adjusted for sociodemographic and clinical variables.

RESULTS

This analysis included 136 patients (49 African American, 87 White). Overall, 30.1% of the sample reported cannabis use for cancer pain. The mean "least pain" score on BPI was 3.3 (SD=2.42) on a scale of 0-10. African American patients had a mean "least pain" score 1.32±0.48 units higher (indicating lower pain relief) than White patients (p=0.006). Cannabis use did not have a significant main effect (p=0.28). However, cannabis use was a significant moderator of the relationship between race and "least pain" (p=0.03). In the absence of cannabis use, African Americans reported higher "least pain" scores compared to Whites (mean difference=1.631±0.5, p=0.001). However, this disparity was no longer observed in African American patients reporting cannabis use (mean "least pain" difference=0.587±0.59, p=0.32).

CONCLUSION

These findings point to the possible role of cannabis in cancer pain management and its potential to reduce racial disparities. These findings are preliminary and further research into the role of cannabis in cancer pain outcomes is needed.

Comparison of weekly and daily recall of pain as an endpoint in a randomized phase 3 trial of cabozantinib for metastatic castration-resistant prostate cancer

Introduction

Scant evidence reveals whether the use of weekly versus daily pain ratings leads to meaningful differences when measuring pain as a clinical trial outcome. We compared the ability of weekly ratings and descriptors of daily ratings to evaluate pain as an endpoint in a randomized phase 3 drug trial.

Methods

Participants (n = 119) with metastatic castration-resistant prostate cancer were randomized to treatment arms and rated their pain on the average and at its worst during a baseline week and at weeks 3, 6, and 12 of study treatment. For each reporting period, participants rated their pain daily for 7 days. On day 7, participants rated their pain over the prior 7 days. We estimated mean differences and intraclass correlation coefficients of the weekly ratings and the mean and the maximum daily ratings. We compared the ability of the weekly ratings and the daily rating descriptors to detect change in pain and evaluated the agreement of the weekly rating and the mean daily rating of pain at its worst to detect treatment response.

Results

For both pain constructs, the weekly rating was consistently higher than the mean daily rating and lower than the maximum daily rating yet was moderately to highly correlated with both daily rating descriptors (intraclass correlation coefficient range = 0.55–0.94). The weekly rating and the daily rating descriptors consistently detected change in pain for the study sample and participant subgroups. Substantial agreement existed between the weekly rating and the mean daily rating of pain at its worst when used with trial protocol opioid criteria to detect treatment response (Cohen’s κ = 0.71).

Conclusion

Use of daily over weekly ratings delivered no added benefit in evaluating pain in this clinical trial. This study is the first to compare weekly and daily recall to measure pain as an endpoint in a randomized phase 3 drug trial, and the pattern of differences in ratings that we observed is consistent with other recent evaluations of weekly and daily symptom reporting.

Chronic neck pain and depression: the mediating role of sleep quality and exercise

Previous researches have found that chronic neck pain was closely related to depression. However, the relation between chronic neck pain, sleep quality, exercise and depression remains unclear. This study aims to evaluate the association between these factors, based on the assumption that sleep quality and exercise are potential mediators in the relationship between chronic neck pain and depression. This cross-sectional study enrolled 231 patients with chronic neck pain who were referred to outpatient clinics in department of neurology between July and December 2016. Data analysis was performed using a structural equation model to evaluate the mediating effects of sleep quality and exercise frequency on the relation between chronic neck pain intensity and depression. A positive correlation between neck pain intensity and depression was unveiled. In addition, sleep quality was identified as a significant positive mediator between neck pain intensity and depression, and exercise can help relieve depression. Poor sleep quality leads to an increase of the symptoms of depression for people with high neck pain intensity which can be effectively relieved via additional exercise.

Net Pain Relief After Palliative Radiation Therapy for Painful Bone Metastases: A Useful Measure to Reflect Response Duration? A Further Analysis of the Dutch Bone Metastasis Study

Purpose

Pain response rates are equivalent after single 8 Gy and fractionated palliative radiation therapy for bone metastases. Reirradiation remains more frequent after a single fraction, although this does not simply reflect pain recurrence. Given the possible role of stereotactic radiation therapy in providing durable pain control, measures of durability are required. Net pain relief (NPR), the proportion of remaining life spent with pain response, may provide this. This study assesses the use of NPR as an outcome measure after palliative radiation therapy for bone metastases.

Methods and Materials

This is a secondary analysis of data collected in the Dutch Bone Metastasis Study, a randomized trial comparing palliative radiation therapy delivered as 8 Gy in a single fraction and 24 Gy in 6 fractions. NPR was assessed by survival cohorts, treatment regimen, and primary diagnoses. The consequences of missing data upon the use of NPR in future studies were considered within sensitivity analyses.

Results

Patients whose pain improved after palliative radiation therapy experienced improvement for 56.6% of their remaining lives. Missing responses in questionnaires mean the range of uncertainty in NPR is 36.1% to 62.1%. When response beyond reirradiation was excluded, NPR after treatments of single-fraction 8 Gy and 24 Gy in 6 fractions was 49.0% and 56.5%, respectively (P = .004). Differential willingness to reirradiate may be influencing this outcome. When response beyond reirradiation was included, this difference was not seen (NPR of 55.4% vs 57.7%, respectively [P = .191]).

Conclusions

Patients who responded to conventional radiation therapy experienced improved pain control for approximately half of their remaining life. NPR may provide valuable information in assessing pain response durability. Missing data are, however, inevitable in this population. This must be minimized and the consequences recognized and reported. Additionally, reirradiation protocols and the frequency and duration of trial follow-up may have a significant impact upon this outcome, requiring careful consideration during trial design if NPR is to be used in future studies.

Pain Intensity Factors Changing Breakthrough Pain Prevalence in Patients with Advanced Cancer: A Secondary Analysis of a Cross-Sectional Observational International Study

INTRODUCTION

Different definitions of breakthrough pain (BTP) influence the observed BTP prevalence. This study examined BTP prevalence variability due to use of different cutoffs for controlled background pain, different assessment periods for background pain, and difference between worst and average pain intensity (PI).

METHODS

Cancer patients from the EPCRC-CSA study who reported flare-ups of pain past 24 h were potential BTP cases. BTP prevalence was calculated for different cutoffs for background PI on numeric rating scales (NRS 0-10) for the past week, past 48 and past 24 h period. Furthermore, BTP cases were categorized based on the difference between maximum and average PI past 24 h (range, 0 to > 2 points, NRS 0-10).

RESULTS

Of 696 respondents, 302 patients (43.4%) reported pain flares the past 24 h. The BTP prevalence when using a defined background PI ≤ 4 for the past week was 19.8%. This number varied for different defined cutoffs for background PI. Actual background PI and BTP prevalence also varied between the assessment periods "past week", "past 48 h", and "past 24 h" (PI 4.0, 3.6, and 3.4; BTP prevalence 19.8, 22.7, and 24.9% for background PI ≤ 4). For patients with background PI ≤ 4 past week, 105 had a difference between maximum and average PI ≥ one point and 48 had a difference > two points.

CONCLUSIONS

The reported BTP prevalence is dependent on the cutoff for background PI in the BTP definition, population background PI during the assessment period, and defined cutoff for the difference between worst and average PI.

FUNDING

NTNU, Norwegian University of Science and Technology.

A longitudinal analysis of pain experience and recall in fibromyalgia

AIM

To evaluate pain experiences and memories in fibromyalgia (FM) patients over time.

METHOD

Participants included 572 females who were members of a large health maintenance organization who had a diagnosis of FM syndrome (FMS) and met inclusion criteria for the study. Recruitment was for an intervention study that tested the effects of social support and education treatment arms, but there were no treatment effects. Reports of experiential pain (EP), historical peak pain (HPP), and historical valley pain (HVP) for FM were collected. Differences between HPP and EP and EP and HVP (bias) were calculated to determine whether HPP and HVP were distributed evenly around EP over time across participants. Models were performed to assess personal history and psychosocial factors that affect EP, HPP, HVP, and bias.

RESULTS

There was systematic tendency for HPP to be significantly larger than EP relative to EP vs HVP. EP and HPP decreased significantly over time, but not HVP. There were significant predictors of EP, HPP, HVP, and bias, including depression, self-efficacy, and sleep quality, among others.

CONCLUSION

The experiences and recollections of pain in FM appear to provide a unique means of understanding the maintenance of chronic pain-including factors that affect this process.

Core outcome measurement instruments for clinical trials in nonspecific low back pain

To standardize outcome reporting in clinical trials of patients with nonspecific low back pain, an international multidisciplinary panel recommended physical functioning, pain intensity, and health-related quality of life (HRQoL) as core outcome domains. Given the lack of a consensus on measurement instruments for these 3 domains in patients with low back pain, this study aimed to generate such consensus. The measurement properties of 17 patient-reported outcome measures for physical functioning, 3 for pain intensity, and 5 for HRQoL were appraised in 3 systematic reviews following the COSMIN methodology. Researchers, clinicians, and patients (n = 207) were invited in a 2-round Delphi survey to generate consensus (≥67% agreement among participants) on which instruments to endorse. Response rates were 44% and 41%, respectively. In round 1, consensus was achieved on the Oswestry Disability Index version 2.1a for physical functioning (78% agreement) and the Numeric Rating Scale (NRS) for pain intensity (75% agreement). No consensus was achieved on any HRQoL instrument, although the Short Form 12 (SF12) approached the consensus threshold (64% agreement). In round 2, a consensus was reached on an NRS version with a 1-week recall period (96% agreement). Various participants requested 1 free-to-use instrument per domain. Considering all issues together, recommendations on core instruments were formulated: Oswestry Disability Index version 2.1a or 24-item Roland-Morris Disability Questionnaire for physical functioning, NRS for pain intensity, and SF12 or 10-item PROMIS Global Health form for HRQoL. Further studies need to fill the evidence gaps on the measurement properties of these and other instruments.

TummyTrials: A Feasibility Study of Using Self-Experimentation to Detect Individualized Food Triggers

Diagnostic self-tracking, the recording of personal information to diagnose or manage a health condition, is a common practice, especially for people with chronic conditions. Unfortunately, many who attempt diagnostic self-tracking have trouble accomplishing their goals. People often lack knowledge and skills needed to design and conduct scientifically rigorous experiments, and current tools provide little support. To address these shortcomings and explore opportunities for diagnostic self-tracking, we designed, developed, and evaluated a mobile app that applies a self-experimentation framework to support patients suffering from irritable bowel syndrome (IBS) in identifying their personal food triggers. TummyTrials aids a person in designing, executing, and analyzing self-experiments to evaluate whether a specific food triggers their symptoms. We examined the feasibility of this approach in a field study with 15 IBS patients, finding that participants could use the tool to reliably undergo a self-experiment. However, we also discovered an underlying tension between scientific validity and the lived experience of self-experimentation. We discuss challenges of applying clinical research methods in everyday life, motivating a need for the design of self-experimentation systems to balance rigor with the uncertainties of everyday life.

Construct validity and reliability of a real-time multidimensional smartphone app to assess pain in children and adolescents with cancer

We evaluated the construct validity (including responsiveness), reliability, and feasibility of the Pain Squad multidimensional smartphone-based pain assessment application (app) in children and adolescents with cancer, using 2 descriptive studies with repeated measures. Participants (8-18 years) undergoing cancer treatment were drawn from 4 pediatric cancer centers. In study 1, 92 participants self-reported their level of pain twice daily for 2 weeks using the Pain Squad app to assess app construct validity and reliability. In study 2, 14 participants recorded their level of pain twice a day for 1 week before and 2 weeks after cancer-related surgery to determine app responsiveness. Participants in both studies completed multiple measures to determine the construct validity and feasibility of the Pain Squad app. Correlations between average weekly pain ratings on the Pain Squad app and recalled least, average, and worst weekly pain were moderate to high (0.43-0.68). Correlations with health-related quality of life and pain coping (measured with PedsQL Inventory 4.0, PedsQL Cancer Module, and Pain Coping Questionnaire) were -0.46 to 0.29. The app showed excellent internal consistency (α = 0.96). Pain ratings changed because of surgery with large effect sizes between baseline and the first week postsurgery (>0.85) and small effect sizes between baseline and the second week postsurgery (0.13-0.32). These findings provide evidence of the construct validity, reliability, and feasibility of the Pain Squad app in children and adolescents with cancer. Use of real-time data capture approaches should be considered in future studies of childhood cancer pain. A video accompanying this abstract is available online as Supplemental Digital Content at http://links.lww.com/PAIN/A169.

Agreement Between Patient-reported and Cardiology-adjudicated Medical History in Patients With Possible Ischemic Chest Pain: An Observational Study

OBJECTIVE

Obtaining an accurate medical history is essential in the assessment of patients, particularly in emergency department (ED) patients with acute chest pain, as there can be a time imperative for diagnosis and commencement of treatment. We aimed to evaluate reliability of patient-reported compared with physician-adjudicated medical history by assessing patient's recall and communication of personal events and its influence on the accuracy of the medical history.

METHODS

A total of 776 patients presenting at ED with suspected cardiac chest pain were recruited. Data collection included self-reported patient history, electrocardiogram testing, and troponin I measurements. Independent assessment of risk factors and medical history was adjudicated by cardiologists. Diagnosis of acute coronary syndrome (ACS) at 30 days after presentation was assessed. Cohen's kappa measured patient-cardiologist agreement. Cardiologist adjudicated events were taken as true to assess accuracy.

RESULTS

A total of 83 participants (10.7%) were diagnosed with ACS at 30 days after presentation. "Previous coronary artery bypass grafting" showed highest agreement (K = 1.00) between patient-reported and cardiologist-adjudicated events. Lowest agreement between patient-reported and cardiologist-adjudicated events was found for "prior ventricular dysrhythmia" (K = 0.33). Accuracy of reported "prior congestive heart failure" differed significantly between patients with and without diagnosed ACS at 30 days (92.8% and 97.5%, respectively).

CONCLUSIONS

Accuracy of patient's recall and communication of medical history and risk factors was substantial but not perfect in the assessment of patients with ACS in the ED context. Our study reinforces the importance in the utilization of medical records and collateral information to address possible discrepancies in the medical history and improve patient care.

Feasibility and Usability Pilot Study of a Novel Irritable Bowel Syndrome Food and Gastrointestinal Symptom Journal Smartphone App

OBJECTIVES:

Seventy percent of patients with irritable bowel syndrome (IBS) identify certain foods as triggers for their symptom flare-ups. To help identify potential trigger foods, practitioners often rely on patient food and gastrointestinal (GI) symptom journaling. The aim of the study was to evaluate the feasibility and usability of a novel food and symptom journal app, specifically designed for patients with IBS. Secondary aims were to explore the effect of using the app on GI symptoms and to describe associations between diet and GI symptoms suggested by individual patient data.

METHODS:

The feasibility and usability of the novel app was studied in 11 IBS patients (8 women), aged 21–65 years. Participants were asked to log GI symptoms (abdominal pain, bloating, diarrhea, constipation) using a 100-point color-graded sliding scale (green=none, red=severe) four times a day and to log every meal/snack they ate (at least three times a day) over a 2-week period. The app's feasibility as a data collection tool was evaluated by daily completion, compliance, data hoarding, and fatigability rates. Usability was evaluated with the System Usability Scale (SUS). To explore potential impact of using the app on bowel distress, we compared before and after intervention IBS-Symptom Severity Scale (IBS-SSS) scores. Meal entries were analyzed for nutrients using the Nutrition Data System for Research. Regression analyses were conducted for each participant journal to explore relationships between meal nutrients and subsequent GI symptoms.

RESULTS:

Daily average completion rates of the minimum requested entries for meal and GI symptoms were 112±47% and 78±44%, respectively. Average 24-h compliance rates were 90±19% and 94±12%, respectively. The SUS score was above average (mean 83, range 65–97.5; n=10). Most participants did not have a clinically significant decrease in IBS-SSS. At least one strong association (P≤0.05) between GI symptoms and a meal nutrient was found in 73% of participants. The mean number of associations was 2 (range 0–7; n=11). Patterns of associations differed between individual participants.

CONCLUSIONS:

Our app appeared to be a feasible and usable tool for IBS patients. Our findings are in line with anecdotes that most IBS patients have food triggers and that these vary by individual. Future studies can explore whether individualized dietary changes guided by an app can result in IBS symptom improvement.

The Number of Ratings Needed for Valid Pain Assessment in Clinical Trials: Replication and Extension

OBJECTIVES

To provide additional empirical findings regarding the number of pain ratings needed to obtain valid measures for assessing outcomes in pain clinical trials.

DESIGN

Secondary analyses of data from a clinical study examining the effects of psychological treatments on pain. Eleven adults with multiple sclerosis and chronic pain reported on four domains of pain intensity (current pain and 24-hour recalled worst, least, and average pain) on four occasions before and after receiving 16 sessions of psychological pain treatments. We evaluated the reliability and validity of four single ratings and 16 different composite scores.

RESULTS

Many of the single pain ratings were inadequately reliable while almost all of the composite scores, including the scores created from two ratings, evidenced adequate to excellent reliability. There was a noticeable increase in validity (ability to detect treatment effects) as the number of ratings used increased from one to two. However, there was little change in the validity as the number of items used to create composite scores increased from 2 to 3 or more. The findings also indicated that the scores assessing recalled worst pain were more valid than the scores assessing any of the other pain intensity domains.

CONCLUSIONS

Composite pain intensity scores created from two individual ratings of recalled pain appear to be adequately valid for detecting treatment effects. Moreover, the findings indicate that the selection of the pain intensity domain to use as a primary outcome variable may play a more important role than increasing reliability by obtaining more assessments; specifically, ratings of recalled worst pain may be more valid for detecting treatment effects than ratings of average pain.

Effectiveness of app-based relaxation for patients with chronic low back pain (Relaxback) and chronic neck pain (Relaxneck): study protocol for two randomized pragmatic trials

BACKGROUND

Chronic low back pain (LBP) and neck pain (NP) are highly prevalent conditions resulting in high economic costs. Treatment guidelines recommend relaxation techniques, such as progressive muscle relaxation, as adjuvant therapies. Self-care interventions could have the potential to reduce costs in the health care system, but their effectiveness, especially in a usual care setting, is unclear. The aim of these two pragmatic randomized studies is to evaluate whether an additional app-delivered relaxation is more effective in the reduction of chronic LBP or NP than usual care alone.

METHODS/DESIGN

Each pragmatic randomized two-armed study aims to include a total of 220 patients aged 18 to 65 years with chronic (>12 weeks) LBP or NP and an average pain intensity of ≥ 4 on a numeric rating scale (NRS) in the 7 days before recruitment. The participants will be randomized into an intervention and a usual care group. The intervention group will be instructed to practice one of these 3 relaxation techniques on at least 5 days/week for 15 minutes/day over a period of 6 months starting on the day of randomization: autogenic training, mindfulness meditation, or guided imagery. Instructions and exercises will be provided using a smartphone app, baseline information will be collected using paper and pencil. Follow-up information (daily, weekly, and after 3 and 6 months) will be collected using electronic diaries and questionnaires included in the app. The primary outcome measure will be the mean LBP or NP intensity during the first 3 months of intervention based on daily pain intensity measurements on a NRS (0 = no pain, 10 = worst possible pain). The secondary outcome parameters will include the mean pain intensity during the first 6 months after randomization based on daily measurements, the mean pain intensity measured weekly as the average pain intensity of the previous 7 days over 3 and 6 months, pain acceptance, 'LBP- and NP-related' stress, sick leave days, pain medication intake, adherence, suspected adverse reaction, and serious adverse events.

DISCUSSION

The designed studies reflect a usual self-care setting and will provide evidence on a pragmatic self-care intervention that is easy to combine with care provided by medical professionals.

TRIAL REGISTRATION

ClinicalTrials.gov identifier Relaxback NCT02019498, Relaxneck NCT02019134 registered on 18 December 2013.

Do patients undergoing physical testing report pain intensity reliably?

OBJECTIVE

To determine the reliability of patient reports of pain intensity during the application of physical tests.

METHODS

A single examiner required participants to use the numeric pain rating scale (NPRS) to report the intensity of pain provoked during physical testing of the hip. Standardized versions of 14 physical tests were used on 18 people with hip pain. Tests were repeated at 1 hour and 2-7 days later. Within- and between-session reliability of reports of pain intensity was calculated using intraclass correlation coefficients (ICCs) and Lin's concordance correlation coefficients (CCCs). Standard errors of measurement (SEMs) were calculated.

RESULTS

ICC/CCC values for within-session reports of pain intensity ranged from 0.34 (95% confidence interval [95% CI] -0.08, 0.66) to 0.88 (95% CI 0.73, 0.95). Patients demonstrated "substantial" or "almost perfect" reliability in reporting pain intensity with 9 of 14 tests and "moderate" reliability with 3 tests. Two tests were unreliable (ICC 0.35 and 0.34). ICC/CCC values for between-session reports of pain intensity ranged from -0.05 (95% CI -0.42, 0.34) to 0.84 (95% CI 0.44, 0.95). Patients demonstrated substantial or almost perfect reliability in reporting pain intensity with 11 of 14 tests. Two tests were unreliable (ICC 0.26 and -0.05). The average SEM value of 0.9 points on the NPRS was the same for both within- and between-session testing (range 0.6-1.6).

CONCLUSION

Patient reports of the intensity of pain provoked by physical tests are sufficiently reliable to be clinically useful. However, the SEM of 0.9 points should be considered when precise calculations of changes in pain intensity are important.

Pain intensity as prognostic factor in cancer pain management

AIM

The aim of this study was to prospectively assess the prognostic value of initial pain intensity and its duration in advanced cancer patients.

METHODS

A prospective study was conducted in a sample of patients with cancer requiring pain control. Patients underwent standard analgesic strategies used in our palliative care units. Pain intensity was measured at admission (T0) and after successful dose titration or opioid/route switching within a week (Ts). Patients were also asked about their pain intensity reported 15 days before admission (T-15). Doses of opioids and duration of opioid use were recorded. Patients were also assessed for the presence of incident pain, neuropathic pain, alcoholism, delirium, and symptom intensity, including items representing psychological distress. One week after or at time of stabilization (Ts), the opioid response was clinically graded as follows: (1) good pain control; (2) adequate pain control requiring more aggressive opioid escalation; (3) adequate pain control associated with the occurrence of adverse effects; (4) incapacity to achieve pain control within a week. Opioid escalation indexes and days for dose finding were also recorded.

RESULTS

Pain intensity at T0 and at T-15, opioid doses, duration of opioid therapy, and age were associated with more complex analgesic therapies, which were effective in almost all patients within a week.

CONCLUSION

High levels of pain intensity, often due to previous undertreatment, are predictive of more complex analgesic treatment. Opioid tolerance, as well as younger age, may also play a role.