Pain Prevalence, Localization, and Intensity in Adults with and without COPD: Results from the Danish Health and Morbidity Survey (a Self-reported Survey)

Assessing Risk Factors and Comorbidities in the Treatment of Chronic Pain: A Narrative Review

PURPOSE OF REVIEW

Chronic pain affects a significant portion of the population globally, making it a leading cause of disability. Understanding the multifaceted nature of chronic pain, its various types, and the intricate relationship it shares with risk factors, comorbidities, and mental health issues like depression and anxiety is critical for comprehensive patient care. Factors such as socioeconomic status (SES), age, gender, and obesity collectively add layers of complexity to chronic pain experiences and pose management challenges.

RECENT FINDINGS

Low SES presents barriers to effective pain care, while gender differences and the prevalence of chronic pain in aging adults emphasize the need for tailored approaches. The association between chronic pain and physical comorbidities like cardiovascular disease, chronic obstructive pulmonary disease (COPD), and diabetes mellitus reveals shared risk factors and further highlights the importance of integrated treatment strategies. Chronic pain and mental health are intricately linked through biochemical mechanisms, profoundly affecting overall quality of life. This review explores pharmacologic treatment for chronic pain, particularly opioid analgesia, with attention to the risk of substance misuse and the ongoing opioid epidemic. We discuss the potential role of medical cannabis as an alternative treatment with a nuanced perspective on its impact on opioid use. Addressing the totality and complexity of pain states is crucial to individualizing chronic pain management. With different types of pain having different underlying mechanisms, considerations should be made when approaching their treatment. Moreover, the synergistic relationship that pain states can have with other comorbidities further complicates chronic pain conditions.

Beyond breathing: Systematic review of global chronic obstructive pulmonary disease guidelines for pain management

CONTEXT

Patients with chronic obstructive pulmonary disease (COPD) experience pain as both symptom and comorbidity. There has been no evaluation of the recommendations for pain management in updated clinical practice guidelines (CPGs).

OBJECTIVES

Update the evidence on pain management, determine alignment of pain management recommendations with best-practice, and advocate for optimal pain management in patients with COPD.

METHODS

PubMed, Guideline International Network, Guideline Portal, Agency for Healthcare Research and Quality, National Institute for Healthcare Excellence, Scottish International Guidelines Network, Institute of Medicine, grey literature, national websites, and bibliographies were searched. CPGs available online for stable COPD produced by organizations representing reputable knowledge of COPD management were included. CPGs unavailable online, not translatable into English, or not including techniques within the defined scope were excluded. Researchers performed frequency counts for the verbatim terms "pain," "physical activity," "exercise," "rehabilitation," "physical therap(ist)/(y), "physiotherap(ist)/(y)," recorded context, and collected recommendations for pain management/treatment when present.

RESULTS

Of 32 CPGs, 24 included "pain" verbatim. Of these, 13 included recommendations for pain treatment/management. Common recommendations included opioids, pharmacological management, further medical assessment, and surgical intervention. Two CPGs referred to palliative care, one CPG discussed treating cough, and one discussed massage, relaxation, and breathing.

CONCLUSIONS

Pain management recommendations vary and are not aligned with evidence. Pain should be addressed in patients with COPD, whether directly or indirectly related to the disease. Reduction of variability in pain management and the disease burden is necessary. Pain management should include referrals to providers who can maximize benefit of their services.

Co-prescribing of Central Nervous System-Active Medications for COPD Patients: Impact on Emergency Room Visits and Hospitalization

BACKGROUND

Anxiety and chronic pain are common comorbidities in patients with chronic obstructive pulmonary disease (COPD), which are frequently managed with benzodiazepines (BZDs) and opioids, respectively.

OBJECTIVE

The purpose of this study was to determine whether different combinations of opioids, BZD, and their substitutes-gabapentinoids (GABA) and selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs)-are associated with lower risk of acute respiratory events in COPD patients with co-occurring chronic pain and anxiety.

METHODS

This retrospective cohort study used a nationally representative sample of Medicare beneficiaries with COPD, chronic pain, and anxiety. Patients were grouped based on drug combination (opioid + BZD/Z-hypnotics, opioid + GABA, opioid + SSRI/SNRI, BZD/Z-hypnotics + GABA, BZD/Z-hypnotics + SSRI/SNRI, GABA + SSRI/SNRI, or ≥3 drugs). The primary outcome was emergency room (ER) visit or hospitalization due to acute respiratory events assessed up to 180 days following initiation of drug combination. Overdose secondary to central nervous system (CNS)-related drugs was also assessed up to 180 days following initiation of drug combination.

RESULTS

The drug combination opioid + GABA was associated with decreased risk for ER visit (hazard ratio [HR] = 0.73; 95% CI = 0.61-0.87) and hospitalization (HR = 0.69; 95% CI = 0.55-0.85). Opioid + SSRI/SNRI also showed decreased risk for ER visit (HR = 0.84; 95% CI = 0.71-0.99). There was no significant difference in risk for CNS-related drug overdose among different drug combinations compared with opioid + BZD/Z-hypnotics.

CONCLUSION AND RELEVANCE

Opioids in combination with GABA and SSRI/SNRI demonstrate relatively lower risk for acute respiratory events among patients with COPD and comorbid chronic pain and anxiety. The findings emphasize the need for multimodal management in this vulnerable population.

Sleep Quality and Self-Reported Symptoms of Anxiety and Depression Are Associated with Physical Activity in Patients with Severe COPD

Sleep quantity, quality and symptoms of depression or anxiety potentially affect the level of daily physical activity (PAL) and plausibly counteracts benefits from pulmonary rehabilitation programs. Their collective impact on PAL is sparsely investigated, particularly in patients with severely progressed chronic obstructive pulmonary disease (COPD). Aim: To investigate if sleep quantity, quality and symptoms from self-reported hospital anxiety and depression scores (HADS) are associated with PAL. Methods: In this exploratory cross-sectional study data were analysed from 148 participants with COPD; GOLD grade II-IV; GOLD group B to D (52% female, mean 69.7 ± SD of 8.4 years, FEV1% predicted 33.6 ± 10.9, 6MWD 327 ± 122 m, CAT 20 ± 7 points), eligible for conventional outpatient hospital-based pulmonary rehabilitation. Participants had sleep and PAL measured 24 h per day for five consecutive days with an activPAL monitor. Adjusted negative binomial regression was applied to investigate the associations with PAL. Results: Participants walked median (25th, 75th percentile) of 2358 (1325.75; 3822.25) steps per day and 14% walked >5000 steps per day on average. Time in bed (TIB) were a median (25th, 75th percentile) of 8.3 (7.1; 9.7) hours and numbers of nocturnal sleeping bouts (NSB) were 1.5 (0.8; 3), Anxiety (HADS-A) and depression (HADS-D) scores were median (25th, 75th percentile) of 5 (3; 8) points and 3 (2; 6) points, respectively, whereof 29% (HADS-A) and 15% (HADS-D) reported scores ≥8 points indicating significant symptoms. The fully adjusted rate ratio (RR) for steps per day for TIB (hours) [RR 0.97 (95% CI: 0.92; 1.02)], NSB (numbers) [RR 1.02 (95% CI: 0.97; 1.07)] were not significantly associated with number of steps per day, while there was a significantly association with number of steps per day for HADS-A [RR 1.04 (95% CI: 1.01; 1.07)] and HADS-D [RR 0.95 (95% CI: 0.91; 0.99)]. Conclusion: This exploratory cross-sectional study found a statistically significant association between HADS-A and HADS-D with numbers of steps per day in patients with severe COPD.

Exploration of the feasibility to combine patients with chronic obstructive pulmonary disease and chronic heart failure in self-management groups with focus on exercise self-efficacy

OBJECTIVE

To compare the level of exercise self-efficacy, symptoms, functional capacity and health status and investigate the association between these variables in patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). Additionally, to investigate how diagnosis, symptoms and patient characteristics are associated with exercise self-efficacy in these patient groups.

DESIGN

Cross-sectional study.

SETTING

Primary care.

SUBJECTS

Patients (n = 150) with COPD (n = 60), CHF (n = 60) and a double diagnosis (n = 30).

MAIN OUTCOME MEASURES

Swedish SCI Exercise Self-Efficacy score, modified Medical Research Council Dyspnea score (mMRC), fatigue score, pain severity score, Hospital Anxiety and Depression Scale, functional capacity measured as six-minute walking distance and health status measured by a Visual Analogue Scale.

RESULTS

Levels of exercise self-efficacy, health status and symptoms were alike for patients with COPD and patients with CHF. Functional capacity was similar after correction for age. Associations with exercise self-efficacy were found for slight dyspnea (mMRC = 1) (R -4.45; 95% CI -8.41- -0.50), moderate dyspnea (mMRC = 2) (-6.60;-10.68- -2.52), severe dyspnea (mMRC ≥ 3) (-9.94; -15.07- -4.80), fatigue (-0.87;-1.41- -0.32), moderate pain (-3.87;-7.52- -0.21) and severe pain (-5.32;-10.13- -0.52), symptoms of depression (-0.98;-1.42- -0.55) and anxiety (-0.65;-0,10- -0.32), after adjustment for diagnosis, sex and age.

CONCLUSION AND IMPLICATIONS

Patients with COPD or CHF have similar levels of exercise self-efficacy, symptoms, functional capacity and health status. More severe symptoms are associated with lower levels of exercise self-efficacy regardless of diagnosis, sex and age. When forming self-management groups with a focus on exercise self-efficacy, it seems more relevant to consider level of symptoms than the specific diagnosis of COPD or CHF.Key pointsExercise training is an important part of self-management in patients with COPD and chronic heart failure (CHF). High exercise self-efficacy is required for optimal exercise training.Patients with COPD and CHF have similar symptoms and similar levels of exercise self-efficacy, functional capacity and health status.Not the diagnosis, but symptoms of dyspnea, fatigue, pain, depression and anxiety are important factors influencing exercise self-efficacy and need to be addressed.When forming self-management groups with a focus on exercise self-efficacy, it seems more relevant to consider the level of symptoms than the specific diagnosis of COPD or CHF.

Impairment of scapular control in individuals with chronic obstructive pulmonary disease (COPD): Systematic review and meta-analysis

BACKGROUND

Upper quadrant geometrical changes in individuals with chronic obstructive pulmonary disease (COPD) appear to have negative influences on geometrical arrangements of the thorax and scapula.

OBJECTIVE

The purpose of this systematic review was to assess the impairment of scapular control in individuals with COPD as compared with healthy controls.

METHODS

We systematically searched seven electronic databases from inception to June 2021 and updated the searches again in December 2021. Eligible studies included the participants with COPD and compared scapular control outcomes (scapular/shoulder kinematic or related muscle activity) with a control group. Two researchers independently searched for, screened, extracted data from, and evaluated the quality of all articles.

RESULTS

Seven studies met the inclusion criteria and only five studies with 190 subjects were included in the meta-analyses. Subgroup analyses showed that the control group exhibited more scapular anterior tilt (SMD: 0.46; 95% CI: 0.01 to 0.90) and shoulder flexion (SMD: -1.02; 95% CI: -1.79 to -0.26) as compared with the COPD group. Conversely, the COPD group exhibited more scapular elevation (SMD: -1.03; 95% CI: -1.69 to -0.37), internal rotation (SMD: -1.65; 95% CI: -3.19 to -0.10), and protraction (SMD: -0.75; 95% CI: -1.18 to -0.32) compared with the control group. All other outcomes revealed non-significant findings.

CONCLUSION

This review demonstrated scapular control impairments, such as scapular elevation, internal rotation, protraction, and anterior tilt in a static position in patients with COPD. To validate these findings, high-quality randomized control trials with large sample sizes and reliable outcome measures should be conducted.

The relationship between vertebral deformities and thoracic arthropathy with back pain in Chronic Obstructive Pulmonary Disease

OBJECTIVES

The aim of the study was to investigate the relationship between back pain and thoracic vertebral deformities and arthropathy in patients with COPD who underwent thorax CT scans to screen for lung nodules and cancer.

MATERIALS AND METHODS

The data of patients who underwent thoracic CT and pulmonary function tests (PFTs) between July 2019 and February 2020 were retrospectively reviewed. The patients were divided into two groups: the COPD (n = 64) and control groups (n = 101), according to the PFT results. The CT images were evaluated for vertebral deformities, osteoporosis and thoracic vertebral joint arthropathy, and the Spinal Deformity Index (SDI) was calculated.

RESULTS

Back pain was detected in 43.7% of the COPD patients and 20.9% of the controls. The patients with COPD had significantly higher rates of costotransverse, intervertebral, facet joint arthropathy, and osteoporosis than did the control group (P < .001). The OR analyses showed that the presence of a vertebral deformity (OR 4.42, 95% CI 2.26 - 8.63, P < .001), of facet joint arthropathy (OR 3.6, 95% CI 2.83-4.58, P < .001), and of costotransverse arthropathy (OR 2.20, 95% CI 1.47-2.77, P < .001) were associated with the presence of back pain. Although a strong positive correlation was found between the SDI and pain score, a moderate negative correlation was found between the FEV1% values and pain score.

CONCLUSIONS

Back pain was present in patients with COPD and was related to vertebral deformities and facet and costotransverse joint arthropathy. Additional studies are required to clarify the relationships of back pain with musculoskeletal system diseases, including cervical and lumbar spine arthropathy and vertebral deformities.

Are Fatigue and Pain Overlooked in Subjects with Stable Chronic Obstructive Pulmonary Disease?

Although there have been many published reports on fatigue and pain in patients with chronic obstructive pulmonary disease (COPD), it is considered that these symptoms are seldom, if ever, asked about during consultations in Japanese clinical practice. To bridge this gap between the literature and daily clinical experience, the authors attempted to gain a better understanding of fatigue and pain in Japanese subjects with COPD. The Brief Fatigue Inventory (BFI) to analyse and quantify the degree of fatigue, the revised Short–Form McGill Pain Questionnaire 2 (SF-MPQ-2) for measuring pain and the Kihon Checklist to judge whether a participant is frail and elderly were administered to 89 subjects with stable COPD. The median BFI and SF-MPQ-2 Total scores were 1.00 [IQR: 0.11–2.78] and 0.00 [IQR: 0.00–0.27], respectively. They were all skewed toward the milder end of the respective scales. A floor effect was noted in around a quarter on the BFI and over half on the SF-MPQ-2. The BFI scores were significantly different between groups regarding frailty determined by the Kihon Checklist but not between groups classified by the severity of airflow limitation. Compared to the literature, neither fatigue nor pain are considered to be frequent, important problems in a real-world Japanese clinical setting, especially among subjects with mild to moderate COPD. In addition, our results might suggest that fatigue is more closely related to frailty than COPD.

Association Between Sleep Quality and Pain Intensity in Mild Patients with COPD: A Community Study

Purpose

Poor sleep quality and pain were common and had been proved as an important influenced factor of quality of life for patients with COPD. The association of sleep quality with pain has been observed in other population but remains unclear in mild patients with COPD from a community setting.

Methods

A cross-sectional study was conducted to include eligible mild patients with COPD in Pudong New District of Shanghai. A structured questionnaire was used to collect general and clinical information for the patients. The Chinese version of Pittsburgh Sleep Quality Index (PSQI) and the short form of McGill Pain Questionnaire (SF-MPQ) was used to assess sleep quality and intensity of pain. Logistic regression was performed to test the association between sleeping quality and pain intensity.

Results

Two hundred and sixty-four patients with COPD, with an average age of 64 years (SD 5.78 years), were enrolled, and of 52% were women. Seventy-one (26.9%) participants reported at least one exacerbation during the past year. About 28.2% of the patients were classified as having poor sleep quality. Sleep quality was significantly associated with PRI score (adjusted odds ratio (ORad)=2.16, 95% CI: 1.16–4.00) and PPI rank (ORad=1.90, 95% CI: 1.08–3.34). People with daytime disturbance were more likely to have pain (ORad =2.03, 95% CI: 1.18–3.50).

Conclusion

Poor sleep quality was common in mild patients with COPD in community and was associated with higher pain intensity. Pain may involve an impairment of sleep quality.