What is known and what is still unknown within chronic musculoskeletal pain? A systematic evidence and gap map

ABSTRACT

Evidence and gap maps (EGMs) can be used to identify gaps within specific research areas and help guide future research agendas and directions. Currently, there are no EGMs within the broad domain of chronic musculoskeletal (MSK) pain in adults. The aim of this study was to create a contemporary EGM of interventions and outcomes used for research investigating chronic MSK pain. This EGM was based on systematic reviews of interventions published in scientific journals within the past 20 years. Embase, PubMed, the Cochrane Library, and PsycINFO were used to retrieve studies for inclusion. The quality of the included reviews was assessed using AMSTAR-II. Interventions were categorised as either physical, psychological, pharmacological, education/advice, interdisciplinary, or others. Outcomes were categorised using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. Of 4299 systematic reviews, 457 were included. Of these, 50% were rated critically low quality, 25% low quality, 10% moderate quality, and 15% rated high quality. Physical interventions (eg, exercise therapy) and education were the most common interventions reported in 80% and 20% of the studies, respectively. Pain (97%) and physical functioning (87%) were the most reported outcomes in the systematic reviews. Few systematic reviews used interdisciplinary interventions (3%) and economic-related outcomes (2%). This contemporary EGM revealed a low proportion of high-quality evidence within chronic MSK pain. This EGM clearly outlines the lack of high-quality research and the need for increased focus on interventions encompassing the entire biopsychosocial perspective.

Participatory research: a Priority Setting Partnership for chronic musculoskeletal pain in Denmark

OBJECTIVES

Patient and stakeholder engagements in research have increasingly gained attention in healthcare and healthcare-related research. A common and rigorous approach to establish research priorities based on input from people and stakeholders is the James Lind Alliance Priority Setting Partnership (JLA-PSP). The aim of this study was to establish research priorities for chronic musculoskeletal (MSK) pain by engaging with people living with chronic MSK pain, relatives to people living with chronic MSK pain, healthcare professionals (HCP), and researchers working with chronic MSK pain.

METHODS

This JLA-PSP included a nation-wide survey in Denmark, an interim prioritisation, and an online consensus building workshop. The information gained from this was the basis for developing the final list of specific research priorities within chronic MSK pain.

RESULTS

In the initial survey, 1010 respondents (91% people living with chronic MSK pain/relatives, 9% HCPs/researchers) submitted 3121 potential questions. These were summarised into 19 main themes and 36 sub-themes. In the interim prioritisation exercise, 51% people living with pain/relatives and 49% HCPs/researchers reduced the list to 33 research questions prior to the final priority setting workshop. 23 participants attended the online workshop (12 people/relatives, 10 HCPs, and 1 researcher) who reached consensus for the most important research priorities after two rounds of discussion of each question.

CONCLUSIONS

This study identified several specific research questions generated by people living with chronic MSK pain, relatives, HCPs, and researchers. The stakeholders proposed prioritization of the healthcare system's ability to support patients, focus on developing coherent pathways between sectors and education for both patients and HCP. These research questions can form the basis for future studies, funders, and be used to align research with end-users' priorities.

Preliminary validity and test-retest reliability of two depression questionnaires compared with a diagnostic interview in 99 patients with chronic pain seeking specialist pain treatment

Objectives Depression symptomatology is highly prevalent in patients with chronic pain, but accurate identification of major depression may be challenged due to time constraints and diagnostic interviews are therefore not routinely performed in clinical practice. Assessment of depression may be facilitated through the use of full-length depression screening questionnaires with acceptable construct validity and test-retest reliability. However, as previously indicated screening questionnaires may overestimate depression in patients with chronic pain, possibly due to overlapping symptoms. However, the failure to screen for depression may raise a concern for missing relevant cases with depression. The objectives of this study were to (1) quantify the validity of the 9-items Patient-Health Questionnaire (PHQ9) and the Major Depression Inventory (MDI) compared with a diagnostic interview in patients with chronic pain seeking specialist pain treatment, and (2) assess the relative test-retest reliability of PHQ9 and MDI over two weeks. Methods Responses to the PHQ9 and MDI were compared with a Present-State-Examination (PSE) interview in 99 patients with chronic pain referred to interdisciplinary pain treatment. PHQ9 and MDI were completed twice over two weeks. Construct validity were assessed with the area under the curve (AUC) analysis, and performance characteristics derived from 2 × 2 contingency tables in which scores on the screening questionnaires were dichotomized and compared with the classification of clinical depression based on the diagnostic interview. Relative test-retest reliability was assessed with intraclass correlation coefficients (ICC). Results Based on the PSE interview, the prevalence of depression was 22.2%, and according to the PHQ9 and MDI questionnaires the prevalence was 26.3 and 34.3%, respectively. Compared with the diagnostic PSE, the PHQ9 and MDI questionnaires had areas under the curve of 0.83 and 0.88, respectively. Both questionnaires had high negative predictive values (PHQ9: cut-off of 11; MDI: cut-off of 26), but low positive predictive values for all possible scores. ICC values were excellent. Conclusions The PHQ9 and MDI questionnaires reliably identified chronic pain patients unlikely to have clinical depression, but showed limited validity identifying patients with clinical depression. These preliminary results may have clinical implications in depression screening in patients with chronic pain seeking specialist pain treatment. Clinicians in a specialty care pain clinic can use these screening questionnaires to identify patients without depression, but caution should be used when positive cases are identified by PHQ9 or MDI due to the risk of false positives.

A Cognitive Functional Therapy+ Pathway Versus an Interdisciplinary Pain Management Pathway for Patients With Severe Chronic Low Back Pain (CONFeTTI Trial): Protocol for a Pragmatic Randomized Controlled Trial

OBJECTIVE

Chronic low back pain (cLBP) is the leading cause of disability. Interdisciplinary pain management is recommended for patients with severe/high-impact cLBP. Such programs are expensive, not easily accessible, and have limited effect; therefore, new cost-effective strategies are warranted. Cognitive functional therapy (CFT) has shown promising results but has not been compared with an interdisciplinary pain management approach. The primary aim of this randomized controlled trial is to investigate if a pathway starting with CFT including psychologist support (CFT+) with the option of additional usual care (if needed) is superior in improving disability and more cost-effective at 12 months compared with an interdisciplinary pain management pathway (usual care).

METHODS

This pragmatic, 2-arm, parallel-group randomized controlled trial will randomly allocate patients (n = 176) aged 18 to 75 years referred to an interdisciplinary pain center due to severe cLBP to 1 of 2 groups (1:1 ratio). Participants randomized to CFT+ will participate in a 3-month functional rehabilitation pathway with the option of additional usual care (if needed), and participants randomized to the interdisciplinary pain management pathway will participate in an individualized program of longer duration designed to best suit the individual's situation, needs, and resources. The primary outcome is the proportion of participants with an 8-point improvement in the Oswestry Disability Index score at 12 months. Exploratory outcomes are change in Oswestry Disability Index scores over time and an economic analysis of quality-adjusted life years using the 3-level version of the EuroQol EQ-5D.

IMPACT

The study evaluates the cost-effectiveness of CFT+ with the option of additional usual care (if needed) for individuals with severe cLBP. Findings can potentially improve future care pathways and reduce cost for the health care system.

PainData: A clinical pain registry in Denmark

Aims

Chronic pain is a significant clinical problem with few effective therapies. Objectives of this clinical registry are (1) to assist clinical decision-making, and (2) facilitate quality assurance and research projects to improve understanding and optimize treatment of patients with chronic pain.

Methods

PainData is an electronic software system developed for online data capture and clinical reporting, currently implemented in public pain clinics in Odense, Silkeborg, Aalborg, Næstved, Køge and Holbæk. The system captures patient-specific information across several bio-psychosocial domains of pain before the first consultation at the pain clinic as well as immediately after treatment, and 12 months after treatment. The registry also includes information from clinicians (e.g. pain diagnosis, and standardized pain sensitivity testing). PainData is registered as a clinical and research database with the Danish Data Protection Agency (16/39398, 14/44319).

Results

Since February 1st 2015 more than 3000 patients have completed questionnaires in PainData. The current completion rate at baseline is >80% and at follow-up is close to 50%. Pain-related data (e.g. pain-distribution, psychological distress and use of analgesics) from the registry will be presented on the poster.

Conclusions

The clinical pain registry contains data from a large cohort of consecutively referred chronic pain patients attending public pain clinics for multidisciplinary assessment and treatment. It contains detailed baseline and outcome data on a broad range of bio-psychosocial factors. The database has significant clinical relevance as it will contribute to an increased understanding of chronic pain conditions as well as contribute to substantial knowledge on how various psychological factors influence the experience of pain and disability in patients with chronic pain. In addition, early prediction of treatment efficacy and future stratification of patients with chronic pain has the potential to optimize treatment outcome. This will be of great interest to both the individual patient and to society.

[Low dose naltrexone for treatment of pain]

Recent years have seen an increasing interest in the use of low dose naltrexone (LDN) for off-label treatment of pain in diseases as fibromyalgia, multiple sclerosis and morbus Crohn. The evidence is poor, with only few randomized double-blind placebo-controlled studies. The studies currently available are reviewed in this paper. LDN could be a potentially useful drug in the future for the treatment of pain in fibromyalgia, but more studies are needed to verify that it is superior to placebo, and currently it cannot be recommended as first-line therapy.

Opioid prescriptions before and after high-energy trauma

OBJECTIVE

To describe the legal use of opioids in adult patients before and after high-energy trauma.

DESIGN

The study was a retrospective database study.

SETTING

Clinical care outside hospitals.

PATIENTS

All patients who suffered high-energy trauma and were brought to Odense University Hospital (OUH), Denmark, in 2007 and 2008 were retrieved from the trauma database. These patients were linked with data on opioid use from the regional prescription database. In all, 938 patients were included.

MAIN OUTCOME MEASURE

Redemption of opioid prescription during the 6 months prior to a multitrauma or redemption of two or more prescriptions for opioids 6 months or later after a multitrauma.

RESULTS

Of the 938 patients brought to OUH with severe trauma within the study period, 61 patients died (7 percent) and six of these had redeemed prescriptions for opioids within 6 months prior to the trauma (10 percent) compared to 65 patients of the 877 survivors (7 percent) (odds ratio 1.4, nonsignificant). In all, 62 patients (7 percent) redeemed opioid prescriptions later than 6 months after their trauma and in a multivariable analysis, severe injury itself and severe injuries of the lower extremities were associated with redemption of opioid prescription after the trauma.

CONCLUSIONS

The authors did not find any correlation between death by trauma and redemption of opioid prescriptions within the 6 months before the trauma. More severe traumas and especially severe traumas to the lower extremities were associated with redemption of opioid prescriptions after multitrauma.

Exercise and conditioned pain modulation have different effects on cuff pressure pain tolerance in humans

Background/aims

Exercise and experimental pain is known to cause an acute decrease of the pain sensitivity. Assessment of pain inhibitory mechanisms is often done by paradigms of exercise and experimental pain in both healthy subjects and pain patients. It is currently unknown whether pain and different types of exercise has similar effects on pain sensitivity. The aim of the present study was to investigate the effects of experimental pain and different types of exercise on deep tissue pain tolerance in healthy subjects.

Methods

On two separate days fifty-four healthy subjects (23 females, 33.8 ± 15.0 years) were assigned in random order to cold pressor tests (ice water at 1–2°C; 120 s duration) for the dominant hand and foot, bicycling exercises (100 W and 200 W; 20 min duration), and isometric contraction exercises (30% and 60% of maximal voluntary contraction, MVC; 180 s duration) of the dominant quadriceps and biceps brachii muscles. Before, immediately after, and 10 min after cold pressor tests and exercises, pressure pain tolerance (PTT) were assessed with computerized cuff-algometry at the non-dominant lower-leg and upper arm. Subjects reaching maximum stimulation intensity at baseline were excluded from the analysis. PTTs were analysed with repeated measures ANOVA and multiple comparisons.

Results

Immediately and 10 min after the cold pressor test in the dominant hand and foot significantly increased PTTs were found at the non-dominant upper arm and lower leg (P < 0.05). Both intensities of dominant biceps brachii isometric contractions produced a significant increase in the PTT at the non-dominant lower leg immediately after and 10 min after contractions (P < 0.05). After the 30% dominant quadriceps isometric contraction the PTT at the non-dominant lower leg was significantly increased (P < 0.05).

Conclusion

Cold pressor pain produced a contralateral and extrasegmental increase in deep tissue pain tolerance. Isometric arm exercise produced an extrasegmental increase in pain tolerance, whereas isometric leg contractions produced a contralateral effect. Aerobic exercise had no effect on pain tolerance. Thus, exercise and pain related inhibitory effects were not comparable.

Acknowledgment/disclosures

H.B. Madsen was supported by grants from the philanthropic foundation TrygFonden (7-11-0990), The Danish Rheumatism Association 8R95-A1871), The Research Foundation of the Danish Physiotherapy Association and The Fund for Physiotherapy in Private Practice.

Health care costs, work productivity and activity impairment in non-malignant chronic pain patients

This study explores the costs of non-malignant chronic pain in patients awaiting treatment in a multidisciplinary pain clinic in a hospital setting. Health care costs due to chronic pain are particular high during the first year after pain onset, and remain high compared with health care costs before pain onset. The majority of chronic pain patients incur the costs of alternative treatments. Chronic pain causes production losses at work, as well as impairment of non-work activities.

No morphine sparing effect of ketamine added to morphine for patient-controlled intravenous analgesia after uterine artery embolization

BACKGROUND

Pain following embolization of the uterine arteries (UAEs) is variable and may be very severe requiring large doses of parenteral opioids for relief. The present study tested the hypothesis that the addition of ketamine to i.v. patient-controlled morphine reduces the amount of morphine required for pain-control during the first 24 h after UAE embolization.

METHODS

Fifty-six patients undergoing UAE embolization for treatment of symptomatic uterine leiomyomata were randomized to receive either 2 mg/ml of morphine (Control group, n=30) or 2 mg/ml of both morphine and ketamine (Ketamine group, n=26) by i.v. patient-controlled analgesia (IV-PCA). Pump settings were bolus dose 1 ml, lockout 10 min, no background infusion. In addition, all patients received diclofenac and acetaminophen for pain relief. Pain scores, morphine consumption and adverse events like nausea, vomiting, itching, visual disturbances, anxiety, dreaming and hallucinations, if any, were recorded for 24 h after embolization.

RESULTS

The mean +/- SD 24-h consumption of patient-controlled morphine was 38.3 +/- 21.0 mg in the Ketamine group vs. 33.3 +/- 18.3 mg in the Control group (NS). The difference between the means was 5.0 mg (95% confidence interval: -5.7; 15.6). One patient in the Ketamine group vs. none in the Control group experienced auditory hallucinations.

CONCLUSION

Studying an unselected group of patients undergoing embolization of the UAEs for treatment of symptomatic uterine leiomyomata under conditions of basal analgesia with acetaminophen and diclofenac, we failed to demonstrate any morphine-sparing effect of IV-PCA ketamine and morphine compared with IV-PCA morphine alone.

[Opioids for chronic pain patients. What are the consequences of following the Nordic recommendations?]

INTRODUCTION

In this study the consequences of following the Nordic recommendation for treating chronic pain patients with opioids are illustrated with regard to how many patients started and how many ended opioid treatment, what was the success rate for going from short-acting to long-acting opioids and what were the consequences for the daily doses of going from short-acting to long-acting opioids.

MATERIALS AND METHODS

During the study period patients revisited the Pain Centre 6 months after treatment had ended. It was documented whether each patient was treated with opioids initially as well as any changes in the opioid prescription during their treatment.

RESULTS

2/3 of the patients were initially in opioid treatment, 1 patient began while 25% were weaned off opioids during treatment. 88% percent of the patients initially on opioids were changed from short-acting to long-acting opioids. The number of patients who had their opioid doses increased with this change was approximately the same as the number of patients who had their doses reduced and the percent of changes was almost identical.

CONCLUSION

Following the Nordic recommendations for treating chronic pain patients with opioids can help to minimise the number of opioid users. The recommendation for going from short-acting to long-acting opioids can be accomplished in daily routine and in this study there is no indication that changing from short-acting to long-acting opioids per se increases daily doses.

[Methadone in the treatment of chronic non-malignant pain]

INTRODUCTION

The use of methadone may be difficult and its use in the treatment of chronic non-malignant pain is only sparsely described in literature, whereas several works have shown the advantage of methadone in the treatment of cancer pain. The aim of this analysis is to assess the advantages and disadvantages of methadone in the treatment of chronic pain and to evaluate the method used in The Pain Centre of the Funen Region when initiating treatment.

MATERIALS AND METHOD

The analysis is retrospective and includes 83 patients in an ambulatory setting with chronic pain who were treated with methadone either as the primary choice of opioid or by rotation with another opioid using a rotation ratio of 10:1 (morphine:methadone) initially and subsequently titrating to maximum effect with fewest adverse events.

RESULTS

Among rotated patients 59% had good pain relief on methadone with a daily dose of 20.5 (1.5-82.5) mg: the frequency for dropping methadone because of adverse events was 24% and 17% because of lack of effect. Among opioid-naive 12% had good pain relief. The daily dose was 3.75 (3.5-4) mg. Here adverse events caused 76% of the cases to discontinue and a lack of effect caused 12% to discontinue.

CONCLUSION

Opioid treated chronic pain patients with insufficient pain relief may benefit from conversion to methadone, as 59% in our analysis achieved better pain relief, while the rotation was generally opioid-saving at the same time. The method used was safe and acceptable to the patients. The analyses did not result in any fundamental changes to the procedure.

[Paracetamol. New knowledge about pharmaceutical action, analgesic relief and anti-inflammatory effects compared with non-steroidal anti-inflammatory effect]

Paracetamol is usually termed a peripheral analgesic from the common belief that its site of action is near the injury. In this review a possible central action is summarised. Furthermore the analgesic effect of paracetamol is compared to non-steroidal anti-inflammatory drugs and the possible anti-inflammatory effect of paracetamol is discussed.

[The effect of suxamethonium on intracranial pressure]

The literature concerning the effect of suxamethonium on intracranial pressure in animals and in humans is presented. The studies have not provided firm indications that suxamethonium per se increases the intracranial pressure. Patients with increased intracranial pressure who are to receive suxamethonium should first be deeply anaesthetized and given a defasciculating dose of a non-depolarizing blocker.

[Patient categories and use of staff in transportation of patients between hospitals in Denmark]

Questions about how many and how far patients are transported from one hospital to another in Denmark were put to assistant matrons of anaesthesiological wards. They were also asked about what type of patients they accompanied on interhospital transports. Every year roughly 4500 patients are moved from one hospital to another. The patients are mostly neurosurgical and paediatric patients. Apart from the nurse from the anaesthesiological ward, there is usually also a doctor from another ward who accompanies the patient.

[Prospective registration of injuries to the staff during interhospital patient transportation]

A prospective registration was carried out of all injuries or near-injuries to hospital staff that took place while the staff were engaged in transporting patients between hospitals. A total of 480 transports were registered over one year. Of these, 146 took place as emergencies, 60 with police escort. Four accidents to staff were registered (0.86% of all transports), where the staff in two cases suffered light bruising. Equipment that is brought along in order to treat and monitor patients should be able to be securely fastened during transport with a view to optimizing safety during transportation for patients and staff.

[Work and safety conditions in transportation of patients between hospitals in Denmark]

Questions on the safety and comfort for the staff on interhospital transports were put to assistant matrons of anaesthesiological wards in Denmark. The investigation shows that ambulances leave with unattached equipment on the floor or in the patient's bed and that the staff either sit without safety belts or stand up beside the patient during transport. The ambulance interior is organized in such a way that the staff's working positions are negatively affected.

[Spinal analgesia in young patients using the Whitacre needle G25]

A material of 100 patients aged 20-50 years was assessed after spinal analgesia with the Whitacre cannula G 25. None of the patients developed post-dural-puncture headache.