Using Daily Ratings to Examine Treatment Dose and Response in Cognitive Behavioral Therapy for Chronic Pain: A Secondary Analysis of the Co-Operative Pain Education and Self-Management Clinical Trial

BACKGROUND

Cognitive behavioral therapy for chronic pain (CBT-CP) has a strong evidence base, but little is known about when treatment benefits are achieved. The present study is a secondary analysis of individuals with chronic back pain recruited for a noninferiority trial comparing interactive voice response (IVR) CBT-CP with in-person CBT-CP.

METHODS

On the basis of data from daily IVR surveys, a clinically meaningful change was defined as a 30% reduction in pain intensity (n = 108) or a 45% increase in daily steps (n = 104) compared with the baseline week. We identified individuals who achieved a meaningful change at any point during treatment, and then we compared those who maintained a meaningful change in their final treatment week (i.e., responders) with those who did not or who achieved a meaningful change but lapsed (i.e., nonresponders).

RESULTS

During treatment, 46% of participants achieved a clinically meaningful decrease in pain intensity, and 66% achieved a clinically significant increase in number of steps per day. A total of 54% of patients were classified as responders in terms of decreases in pain intensity, and 70% were responders in terms of increases in step count. Survival analyses found that 50% of responders first achieved a clinically meaningful change by week 4 for pain intensity and week 2 for daily steps. Dropout and demographic variables were unrelated to responder status, and there was low agreement between the two measures of treatment response.

CONCLUSIONS

Collectively, results suggest that most responders improve within 4 weeks. Evaluating treatment response is highly specific to the outcome measure, with little correlation across outcomes.

Spinal Cord Stimulation for Failed Back Surgery Syndrome: to Trial or Not to Trial?

Spinal cord stimulation (SCS) is a recommended therapy to treat failed back surgery syndrome (FBSS). A trial period is practiced to enhance patient selection. However, its fundamental evidence is limited, especially concerning long-term benefit and therapy safety. We compared the long-term (5.3 ± 4.0 years) clinical outcome and therapy safety of a trialed and nontrialed implantation strategy, including multidimensional variables and pain intensity fluctuations over time. A multicenter cohort analysis was performed in 2 comparable groups of FBSS patients. Regarding eligibility, patients had to be treated with SCS for at least 3 months. While the Trial group comprised patients who underwent an SCS implantation after a successful trial, the No-Trial group encompassed patients who underwent complete implantation within 1 session. The primary outcome measures were pain intensity scores and complications. The Trial and No-Trial groups consisted of 194 and 376 patients (N = 570), respectively. A statistically but not clinically significant difference in pain intensity (P = .003; effect = 0.506 (.172-.839)) was found in favor of the Trial group. No interaction between a time dependency effect and pain intensity was noted. Whereas trialed SCS patients were more likely to cease opioid usage (P = .003; OR = .509 (.326-.792)), patients in the No-Trial group endured fewer infections (P = .006; proportion difference = .43 (.007-.083)). Although the clinical relevance of our findings should be proven in future studies, this long-term real-world data study indicates that patient-centered assessments on whether an SCS trial should be performed have to be investigated. According to the current ambiguous evidence, SCS trials should be considered on a case-by-case basis. PERSPECTIVE: The currently available comparative evidence, together with our results, remains ambiguous on which SCS implantation strategy might be deemed superior. An SCS trial should be considered on a case-by-case basis, for which further investigation of its clinical utility in certain patient populations or character traits is warranted.

Analyses of Cross-Sectional Data to Link the PEG With the Patient Reported Outcomes Measurement and Information System (PROMIS) Global Physical Health Scale

It is challenging to synthesize findings across studies of pain impact. This study develops a link to estimate the Patient-Reported Outcomes Measurement Information System (PROMIS) global health measure from the 3-item Pain intensity, interference with Enjoyment of life, interference with General activity (PEG) scale. The PROMIS and PEG items were administered to 795 adults (average age = 51; 54% female, 79% White). We estimated correlations among the PEG and PROMIS items and conducted factor analysis to identify the best subset of PROMIS items for linking to the PEG. An item response theory graded response model was estimated to link the PEG with the 4-item PROMIS global physical health scale. A categorical single-factor model and a bifactor model provided support for a single dimension for the PEG and PROMIS global physical health items. The product-moment correlation between estimated PROMIS global physical health scale from the PEG and the actual global physical health score was .74. The mean difference between estimated PROMIS global physical health scale score from the PEG and the observed global physical health score was less than a T-score point. This study makes it possible to estimate the average global physical health for group-level comparisons in research that includes the PEG. PERSPECTIVE: This article describes an empirical link of the PEG to the PROMIS global physical health scale that makes it possible to estimate the average global physical health in studies that include the PEG. This link can facilitate comparisons among studies that have not administered the PEG or the PROMIS global health scale.

Effects of Neural Mobilization on Pain Intensity, Disability, and Mechanosensitivity: An Umbrella Review With Meta-Meta-Analysis

OBJECTIVE

The purpose of this study was to assess the current evidence for the effects of neural mobilization (NM) treatments.

METHODS

Three umbrella reviews with meta-meta-analyses were conducted to determine the effects of NM on pain intensity and disability in people with musculoskeletal disorders and on mechanosensitivity in participants who were asymptomatic. The study used the grading criteria proposed by the Physical Activity Guidelines Advisory Committee to assess the quality of evidence.

RESULTS

One meta-meta-analysis revealed a statistically significant moderate effect on pain intensity (standardized mean difference [SMD] = -0.75, 95% CI = -1.12 to -0.38) but with evidence of heterogeneity (Q = 14.13; I2 = 65%). The study found a significantly large effect of NM on disability (SMD = -1.22, 95% CI = -2.19 to -0.26), again with evidence of heterogeneity (Q = 31.57; I2 = 87%). The third meta-meta-analysis showed a statistically significant moderate effect of NM on mechanosensitivity (SMD = 0.96, 95% CI = 0.35 to 1.57), with no evidence of heterogeneity (Q = 2.73; I2 = 63%). For all examined outcomes, the quality of evidence was limited.

CONCLUSION

Overall, the results indicated that although NM treatment had a moderate to large beneficial clinical effect on pain intensity and disability in people with musculoskeletal disorders and on mechanosensitivity in individuals who were asymptomatic, the quality of evidence was limited.

IMPACT

Neural mobilization treatments showed positive results on the pain intensity and disability in individuals with musculoskeletal conditions. Neural mobilization could be integrated into the physical therapy management, although more research is needed.

Prevalence of Dysmenorrhea and Determinants of Pain Intensity Among University-Age Women

OBJECTIVE

The study was conducted to determine the prevalence of dysmenorrhea and investigate factors associated with dysmenorrhic pain among university students in Lahore, Pakistan.

DESIGN AND SETTING

A cross-sectional study was conducted across various public and private sector universities in Lahore.

METHODS

A self-administered structured questionnaire was used to collect data from 600 randomly selected female university students.

RESULTS

The prevalence of dysmenorrhea was 91.5%. Age at menarche (odds ratio [OR] = 1.96, 95% confidence interval [CI] = 1.10-3.50) was the only significant factor associated with dysmenorrhea. The mean pain severity score among dysmenorrhic students was 5.62 ± 2.28. Most of the participants (65.8%) were experiencing moderate/severe pain. Univariate analysis showed that irregular cycle (OR [95% CI] = 1.62 [1.13-2.33]), age at menarche of ≤14 years (OR [95% CI] = 1.46 [1.05-2.04]), duration of menses of more than 5 days (OR [95% CI] = 1.42 [1.02-1.99]), stress (OR [95% CI] = 2.16 [1.54-3.03]), moderate meat/protein consumption (OR [95% CI] = 1.55 [1.08-2.21]), and medical specialization (OR [95% CI] = 1.72 [1.17-2.52]) were significantly associated with pain severity among dysmenorrhic female students. Multivariate binary logistic regression analysis revealed that medical specialization (OR [95% CI] = 1.83 [1.22-2.73]), age at menarche (OR [95% CI] = 0.603 [0.42-0.86]), regularity of menses (OR [95% CI] = 1.52 [1.04-2.22]), moderate meat/protein consumption (OR [95% CI] = 1.69 [1.16-2.45]), and stress (OR [95% CI] = 1.87 [1.32-2.66]) were independent predictors of moderate/severe dysmenorrhic pain.

CONCLUSION

The study revealed an alarmingly high prevalence of dysmenorrhea among university students. High levels of stress and early menarche were the potent determinants of moderate/severe dysmenorrhea that disturbs quality of life.

Pain Intensity Predicts Pain Catastrophizing During the Postpartum Period: A Longitudinal Random Intercept Cross-Lagged Panel Study

OBJECTIVE

Pain catastrophizing is an important psychological predictor of pain. Recent evidence suggests the relationship between catastrophizing and pain intensity could be bidirectional, but most studies have been conducted on chronic pain patients and using criticized statistical methods. The present study aimed to examine if the relationship between pain intensity and catastrophizing was bidirectional in the context of childbirth.

METHODS

A total of 504 women without chronic pain were recruited on their 32-37 gestational week. They completed measures of catastrophizing and pain intensity on the first encounter and then again at 1, 3, and 6 months postpartum. The temporal relationship between the variables was assessed using a random intercept cross-lagged panel model.

RESULTS

The hypothesis of reciprocal association did not receive support, as pain intensity predicted catastrophizing during the postpartum period, but catastrophizing did not show an effect over pain intensity at any moment.

CONCLUSIONS

Pain intensity predicting catastrophizing is consistent with previous literature, while the lack of effect of catastrophizing over pain intensity is an unexpected result, which may suggest that catastrophizing plays a different role in the postpartum period. These results highlight the importance of timely efforts for pain management during the postpartum period and contribute to the theoretical conceptualization of catastrophizing.

Depression Partially Mediates the Association of Adverse Childhood Experiences with Pain Intensity in Patients with Chronic Pelvic Pain Syndrome: Results from a Cross-Sectional Patient Survey

OBJECTIVE

Adverse childhood experiences (ACEs), such as emotional and physical maltreatment, are linked to chronic pelvic pain syndrome (CPPS) in adults. Psychological factors are important in understanding CPPS. We aimed to determine the nature and frequency of ACEs in male and female patients with CPPS and to investigate whether somatic symptoms and psychological comorbidities mediate the relationship of ACE severity with pain intensity.

DESIGN

Cross-sectional study.

SETTING

Interdisciplinary outpatient clinic for CPPS in Hamburg, Germany.

SUBJECTS

Individuals with CPPS (n = 234) who were 18 to 84 years of age.

METHODS

Using a self-administered questionnaire, we assessed the history of ACEs (ACE Scale), pain intensity (McGill Pain Questionnaire), somatic symptoms (Patient Health Questionnaire-15]), depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder Scale). Parallel mediation analysis was conducted to examine whether the association of ACE severity with pain intensity is mediated by somatic symptoms, depression, and anxiety.

RESULTS

Emotional abuse and neglect were reported more than twice as often as physical abuse and neglect (37.2% vs 17.1%). Depression partially mediated the association of ACE severity with pain intensity in the whole study population. In sex-stratified analyses, different patterns of associations were observed, but somatic symptoms predicted pain intensity in both sexes.

CONCLUSIONS

Emotional maltreatment was highly prevalent, supporting an increased consideration of psychological factors in CPPS and indicating the need to screen for ACEs in patients with CPPS. Findings further suggest that depression and somatic symptoms may be important targets for therapeutic interventions in patients with CPPS who have a history of childhood adversity.

Effect of Manual Therapy and Therapeutic Exercise Applied to the Cervical Region on Pain and Pressure Pain Sensitivity in Patients with Temporomandibular Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the effectiveness of cervical manual therapy (MT) on patients with temporomandibular disorders (TMDs) and to compare cervico-craniomandibular MT vs cervical MT.

DESIGN

Systematic review and meta-analysis (MA).

METHODS

A search in PubMed, EMBASE, PEDro, and Google Scholar was conducted with an end date of February 2019. Two independent reviewers performed the data analysis, assessing the relevance of the randomized clinical trials regarding the studies' objectives. The qualitative analysis was based on classifying the results into levels of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

Regarding cervical MT, MA included three studies and showed statistically significant differences in pain intensity reduction and an increase in masseter pressure pain thresholds (PPTs), with a large clinical effect. In addition, the results showed an increase in temporalis PPT, with a moderate clinical effect. MA included two studies on cervical MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain intensity reduction and pain-free maximal mouth opening, with a large clinical effect.

CONCLUSIONS

Cervical MT treatment is more effective in decreasing pain intensity than placebo MT or minimal intervention, with moderate evidence. Cervico-craniomandibular interventions achieved greater short-term reductions in pain intensity and increased pain-free MMO over cervical intervention alone in TMD and headache, with low evidence.

Type 2 Diabetes Affects Joint Pain Severity in People with Localized Osteoarthritis: A Retrospective Study

OBJECTIVE

To examine the association between type 2 diabetes (T2D) and pain severity in people with localized osteoarthritis (OA) and to explore the association between glycemic control, measured by hemoglobin A1c (HbA1c) level, and pain severity in people with localized OA and T2D.

DESIGN

Retrospective study.

SETTING

A tertiary medical center.

SUBJECTS

Data from 819 patients (mean age = 65.08±9.77 years, 54.3% women) were used.

METHODS

Patients were grouped to localized OA only (N = 671) and localized OA+T2D (N = 148) based on diagnosis codes. An index date was set as the first diagnosis date of localized OA and linked to pain severity, measured by numeric rating scale from 0 to 10. HbA1c values were obtained for patients with T2D within six months of the index date. Multiple linear regression was used.

RESULTS

After controlling for age, gender, body mass index (BMI); diagnoses of depression, hypertension, dyslipidemia; OA locations; and medication list (+/- 90 days of the index date), T2D was significantly associated with increased pain severity (B = 1.07, 95% confidence interval [CI] = 0.25 to 1.88, P = 0.014). For patients with T2D and localized OA with available data for HbA1c (N = 87), the results showed that an increased HbA1c value was significantly associated with higher pain severity (B = 0.36, 95% CI = 0.036 to 0.67, P = 0.029) after controlling for age, gender, BMI, medications, and OA locations.

CONCLUSION

T2D was associated with higher pain severity in people with localized OA, and poor glycemic control was associated with higher pain severity in people with localized OA+T2D. Clinicians should emphasize that better HbA1c control might help with pain management in people with T2D and OA.

Behavioral Activation and Inhibition Systems: Further Evaluation of a BIS-BAS Model of Chronic Pain

OBJECTIVES

The role of the behavioral inhibition system (BIS) and behavioral activation system (BAS) in function has been evaluated in a wide range of populations. However, research on the role of the BIS and BAS in pain is in its early stages. This study sought to evaluate the utility of a BIS-BAS model of chronic pain.

METHODS

Participants were 164 individuals with chronic pain who responded to an online survey. Participants provided information about pain location, intensity, and frequency and completed questionnaires assessing behavioral inhibition and activation sensitivity, pain catastrophizing, pain interference, activity engagement, pain willingness, hope, and pain self-efficacy. Seven hierarchical regression analyses were conducted to test hypothesized associations between BIS and BAS sensitivity and measures of participant function.

RESULTS

BIS scores were significantly and positively associated with pain catastrophizing, anxiety, depression, and pain interference and were negatively associated with activity engagement, hope, and pain self-efficacy (P<0.01). BAS scores showed significant and positive associations with activity engagement and hope and showed significant negative associations with pain catastrophizing and anxiety (P<0.05). Furthermore, BIS sensitivity evidenced stronger associations with all the other study measures than did BAS sensitivity.

CONCLUSIONS

The findings provide important new information regarding the utility of the BIS-BAS model of chronic pain. Our results support the idea that BIS activation is more important than BAS activation in explaining a variety of pain-related outcomes, including positive and negative responses to pain, and suggest that modification of the model may be indicated. These results have several theoretical and clinical implications.

Associations of Pain Numeric Rating Scale Scores Collected during Usual Care with Research Administered Patient Reported Pain Outcomes

OBJECTIVE

The purpose of this study is to examine the extent to which numeric rating scale (NRS) scores collected during usual care are associated with more robust and validated measures of pain, disability, mental health, and health-related quality of life (HRQOL).

DESIGN

We conducted a secondary analysis of data from a prospective cohort study.

SUBJECTS

We included 186 patients with musculoskeletal pain who were prescribed long-term opioid therapy.

SETTING

VA Portland Health Care System outpatient clinic.

METHODS

All patients had been screened with the 0-10 NRS during routine outpatient visits. They also completed research visits that assessed pain, mental health and HRQOL every 6 months for 2 years. Accounting for nonindependence of repeated measures data, we examined associations of NRS data obtained from the medical record with scores on standardized measures of pain and its related outcomes.

RESULTS

NRS scores obtained in clinical practice were moderately associated with pain intensity scores (B's = 0.53-0.59) and modestly associated with pain disability scores (B's = 0.33-0.36) obtained by researchers. Associations between pain NRS scores and validated measures of depression, anxiety, and health related HRQOL were low (B's = 0.09-0.26, with the preponderance of B's < .20).

CONCLUSIONS

Standardized assessments of pain during usual care are moderately associated with research-administered measures of pain intensity and would be improved from the inclusion of more robust measures of pain-related function, mental health, and HRQOL.

Personalized Pain Goals and Responses in Advanced Cancer Patients

OBJECTIVE

To assess the personalized pain intensity goal (PPIG), the achievement of a personalized pain goal response (PPGR), and patients' global impression (PGI) in advanced cancer patients after a comprehensive pain and symptom management.

DESIGN

Prospective, longitudinal.

SETTING

Acute pain relief and palliative/supportive care.

SUBJECTS

689 advanced cancer patients.

METHODS

Measurement of Edmonton Symptom Assessment Score (ESAS) and personalized pain intensity goal (PPIG) at admission (T0). After a week (T7) personalized pain goal response (PPGR) and patients' global impression (PGI) were evaluated.

RESULTS

The mean PPIG was 1.33 (SD 1.59). A mean decrease in pain intensity of - 2.09 was required on PPIG to perceive a minimal clinically important difference (MCID). A better improvement corresponded to a mean change of - 3.41 points, while a much better improvement corresponded to a mean of - 4.59 points. Patients perceived a MCID (little worse) with a mean increase in pain intensity of 0.25, and a worse with a mean increase of 2.33 points. Higher pain intensity at T0 and lower pain intensity at T7 were independently related to PGI. 207 (30.0%) patients achieved PPGR. PPGR was associated with higher PPIG at T0 and T7, and inversely associated to pain intensity at T0 and T7, and Karnofsky level. Patients with high pain intensity at T0 achieved a favorable PGI, even when PPIG was not achieved by PPGR.

CONCLUSION

PPIG, PPGR and PGI seem to be relevant for evaluating the effects of a comprehensive management of pain, assisting decision-making process according to patients' expectations. Some factors may be implicated in determining the individual target and the clinical response.

Ethnic Differences in the Association Between Pain and Social Support in Iraq and Afghanistan Veterans

OBJECTIVE

Although past research has identified differences in pain between non-Latino white (NLW) and Latino persons, few studies have focused on the influence of social support. The purpose of the present study was to determine if the association between the number of social support sources and ratings of pain intensity and pain interference differed as a function of ethnicity.

DESIGN

Cross-sectional.

SETTING

Veterans Affairs San Diego Healthcare System.

SUBJECTS

Participants were NLW (N = 389) and Latino (N = 207) Iraq and Afghanistan veterans.

METHODS

Linear regression analyses were used to examine the interaction between ethnicity and number of social support sources on pain intensity and pain interference as measured by the Patient-Reported Outcomes Measurement Information System pain inventory.

RESULTS

The association between number of social support sources and pain intensity and interference significantly differed by ethnicity (P < 0.01 and P = 0.01, respectively). Among NLW veterans, there was a significant negative association between number of social support sources and pain intensity. Among Latino veterans, there was a significant positive association between number of social support sources and pain intensity and interference.

CONCLUSIONS

These findings suggest important differences between NLW and Latino Iraq and Afghanistan veterans in the association between social support and pain. Future research should examine ethnic differences in pain-specific support received from the social environment.

The Utility and Construct Validity of Four Measures of Pain Intensity: Results from a University-Based Study in Spain

OBJECTIVE

Pain intensity is the most commonly assessed domain in pain research and clinical settings. To facilitate cross-cultural research, knowledge regarding the psychometric properties of pain intensity measures in individuals from different countries is needed. However, the majority of this research has been conducted in English-speaking countries.

DESIGN

Survey study.

SETTING

University.

SUBJECTS

Four hundred nineteen college students.

METHODS

Participants were asked to complete four measures assessing average pain intensity: 1) the 0-10 numerical rating scale (NRS-11), 2) the 100-mm visual analog scale (VAS), 3) the four-point verbal rating scale (VRS-4), and 4) the Faces Pain Scale-Revised (FPS-R).

RESULTS

The rates of incorrect completion of the four scales were uniformly low (range = 1-2%). The NRS-11 had the highest preference rate (31%), although a substantial number of participants also preferred each of the other three scales (range = 22-24%). The findings support the utility and construct validity of all four pain intensity scales in this Spanish-speaking sample.

CONCLUSIONS

When considered in light of research from other non-English-speaking samples indicating significant psychometric weaknesses for the NRS-11 and VAS and relative strengths of the FPS-R in some groups, the findings suggest that the FPS-R might be the most appropriate pain intensity scale to use when comparisons across populations from different countries is a goal. More research is needed to determine the extent to which demographic (i.e., age, education levels, socioeconomic status) vs cultural factors (i.e., country of origin) influence the reliability, validity, and utility of different pain measures.

Color Hurts. The Effect of Color on Pain Perception

Background Research suggests that colors may have an effect on human behavior, cognition, and emotions; however, little is known about their influence on pain perception. The aim of these two studies was to investigate whether colors have an impact on pain perception and to find the mechanism that underlies the influence of colors on pain. Methods In both studies, participants received electrocutaneous pain stimuli of the same intensity preceded by one of six colors (red, green, orange, blue, pink, or yellow) or a blank slide, which served as a control condition. In the first study, the intensity of experienced pain was measured; in the second study, both experienced and expected pain was measured. Results The studies revealed that colors increased the intensity of experienced pain in comparison with the noncolor condition (blank slide), regardless of both the sex of participants and whether they noticed a relationship between colors and pain intensity. Particularly, participants rated pain stimuli preceded by red as being more painful compared with pain stimuli preceded by other colors, especially green and blue. Conclusions It is concluded that colors have an impact on pain perception. Our results have important implications for the color lights paradigm applied in studies on placebo effects.

Assessment of Factors Predicting Inadequate Pain Management in Chronic Pain Patients

Background

Inadequate pain management is highly prevalent and is associated with significant costs and socioeconomic problems, which can lead to disparities in patient care. Specific groups are at higher risk of this problem. A few studies have evaluated the predictive risk factors of inadequate pain management.

Objectives

This study evaluated the prevalence and predictive risk factors of inadequate pain management at the primary and secondary care centers with large sample size.

Methods

Patients who had been managed in primary and secondary care clinics were asked to report their personal characteristics, pain intensity, pain duration, and analgesics they were receiving in their first visit at our pain clinic. Zelman pain management index was calculated for each patient by analgesic potency minus mean pain intensity. The negative index showed incongruence between pain intensity and analgesic potency score (pain stronger than medication), indicating inadequate pain management.

Results

A negative pain management index was reported in 77% of the 511 recruited patients. Patients with more severe pain were more likely to experience inadequate pain management. A logistic model demonstrated women, people aged 45 - 65 years, illiterates, and obese patients were at higher risks of inadequate pain management. The pain management index was affected by sex and education (via higher pain intensities) and by age and BMI (via lower analgesic potency).

Conclusions

Age, sex, education, and BMI are predictive risk factors of inadequate pain management as a prevalent problem in chronic pain patients.

Identification of Functioning Domains in the Presurgical Period and Their Relationships with Opioid Use and Pain Catastrophizing

OBJECTIVES

The National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) is a multidimensional screening system evaluating biopsychosocial factors affecting pain and functioning. Using a military sample, the current study 1) examined the structure and domains of the PROMIS, the Defense and Veterans Pain Rating Scale 2.0 (DVPRS), and the Pain Catastrophizing Scale (PCS) within a presurgical setting and 2) examined the relationship of these variables to pre- and postsurgical opioid use.

METHODS

This cross-sectional study included 279 adult patients scheduled for surgery at the Walter Reed National Military Medical Center and a validation sample of 79 additional patients from the Naval Medical Center, San Diego. PROMIS, DVPRS, PCS, and opioid use data were collected before surgery. Exploratory factor analysis and confirmatory factor analysis identified the latent structure for the measures. A structural equation model (SEM) examined their relationship to pre- and postsurgical opioid use.

RESULTS

Two latent factors represented Psychosocial Functioning (PROMIS Depression, PROMIS Anxiety, and PROMIS Social Isolation) and Pain Impact (DVPRS, PROMIS Pain Interference, PROMIS Physical Functioning). The remaining PROMIS scales did not load onto a single factor. In the SEM, the two latent factors and PCS were significantly related to pre- and postsurgical opioid use.

CONCLUSIONS

This study highlights the utility and relative ease of using a convenient multidimensional assessment in presurgical settings. Using such an assessment can help provide targeted interventions for individuals who may be at greatest risk for negative postsurgical outcomes.

Comparison of the Effects of Lidocaine-Prilocaine Cream and Lidocaine Injection on the Reduction of Perineal Pain While Doing and Repairing Episiotomy in Natural Vaginal Delivery: Randomized Clinical Trial

Background

Doing and repairing episiotomy in a natural vaginal delivery is a painful phenomenon and various methods have been used to reduce its pain. Nowadays, topical ointments are being increasingly used due to low systemic absorption and ease of use.

Objectives

The present study aimed to compare the effects of lidocaine-prilocaine cream (XYLA cream) and lidocaine injection on the reduction of pain while doing and repairing episiotomy.

Methods

This randomized clinical trial was conducted on 98 pregnant women with the gestational age of > 37 weeks. In the intervention group that contained 50 women, 5 gr XYLA cream was applied to the episiotomy area one hour prior to delivery. It was also applied to healthy wound edges to numb the area while repairing episiotomy. In the control group, lidocaine 2% injection was used at the time of delivery. The two groups were compared regarding demographic characteristics, delivery characteristics, pain intensity based on visual analogue scale (VAS), and satisfaction with the applied technique.

Results

The results showed no significant differences between the two groups with respect to age, occupation, mother’s weight and education level, gestational age, parity, number of deliveries, and infant’s weight and head circumference (P > 0.05). Also, no significant difference was found between the two groups concerning the length of the active, second, and third phases of labor (P > 0.05). Considering postpartum complications (episiotomy wound infection), the infection was detected in three participants in the XYLA cream group and four individuals in the lidocaine group, but the difference was not statistically significant (P = 0.376). It should be noted that the application of XYLA cream did not cause eye irritation in any of the infants. The results also revealed no significant differences between the two groups regarding pain intensity and satisfaction with the applied technique after doing and repairing episiotomy (P = 0.288).

Conclusions

The results indicated that XYLA cream had no specific complications and had an effect similar to lidocaine injection while doing the episiotomy.

Pain and Cognition in Multiple Sclerosis

Objective

The goal of the present study was to examine the relationship between pain and cognition in patients with multiple sclerosis.

Design

Cross-sectional.

Setting

Nursing home and personal environment of the investigators.

Subjects

Two groups of participants were included: 91 patients with multiple sclerosis and 80 matched control participants.

Methods

The level of pain was measured by the following pain scales: Number of Words Chosen-Affective, Colored Analogue Scale for pain intensity and suffering from pain, and the Faces Pain Scale. Mood was tested by administering the Beck Depression Inventory and the Symptom Check List-90 anxiety and depression subscale. Global cognitive functioning was assessed by the Mini Mental State Examination. Memory and executive functions were assessed by several neuropsychological tests.

Results

Multiple sclerosis (MS) patients scored significantly lower than control participants on the majority of the neuropsychological tests. The MS patients experienced more pain compared with control participants, despite the fact that they were taking significantly more pain medication. No significant correlation was observed between cognition and pain in MS patients. Verbal working memory explained 10% of pain intensity (trend). Mood appeared to be a significant predictor of pain in patients with multiple sclerosis.

Conclusion

The lack of a relationship between cognition and pain might be explained by the fact that, compared with control participants, patients with multiple sclerosis activate other non-pain-related areas to perform executive functions and memory tasks.

Effects of Calcium-Vitamin D and Calcium-Alone on Pain Intensity and Menstrual Blood Loss in Women with Primary Dysmenorrhea: A Randomized Controlled Trial

Objective

There is limited evidence on effectiveness of calcium and vitamin D on dysmenorrhea. The authors aimed to determine the effect of combined calcium-vitamin D and calcium-alone on pain intensity and menstrual blood loss in women with primary dysmenorrhea.

Design

A randomized double-blind trial.

Setting

Dormitories of Tabriz University of Medical Sciences.

Subjects

85 students with moderate or severe primary dysmenorrhea.

Methods

Participants were randomized into three groups: receiving one tablet/day of 1000 mg calcium + 5000 IU vitamin D3, calcium-alone 1000 mg, or matched placebo, from 15th cycle day until menstrual pain disappearance in the following cycle, for three cycles. Pain intensity and menstrual blood loss were assessed one cycle before, three cycles under, and one cycle following intervention using 10-cm visual analog scale and pictorial blood loss assessment chart, respectively. The groups were compared using repeated measures ANOVA.

Results

Time after intervention and interaction of time with group had no significant effects on the outcomes. Compared to the placebo group, mean pain intensity was lower in the both calcium-vitamin D (adjusted difference -0.7, 95% confidence interval -1.6 to 0.3) and calcium-alone (-1.6, -2.6 to -0.6) groups, but the difference was statistically significant only in the calcium-alone group. Menstrual blood loss was not significantly different in the either calcium-vitamin D (-4.7, -21.9 to 12.4) or calcium-alone (-0.4, -17.4 to 16.4) groups compared to placebo.

Conclusions

Intake of the calcium-alone was effective in reducing menstrual pain intensity. The results could not indicate significant effects of calcium-vitamin D on the pain or any of the interventions on menstrual blood loss.

Clinical trial registration

This study was approved by the Ethics committee of Tabriz University of Medical Sciences (code 92145) and registered at the Iranian Registry of Clinical Trials with IRCT201402043706N21.

The Effect of 2 Different Exercise Programs on Pain Intensity and Muscle Dimensions in Patients With Chronic Low Back Pain: A Randomized Controlled Trial

OBJECTIVES

The purpose of this study was to compare the effect of 2 exercise programs combined with electrotherapy on pain intensity and lumbar stabilizer muscles dimensions in patients with nonspecific chronic low back pain.

METHODS

A randomized controlled clinical trial was performed with 41 patients with chronic LBP. Participants were randomly allocated into 2 groups: an experimental group (n = 20) received stabilization exercises plus electrotherapy, and a control group (n = 21) received routine exercises plus electrotherapy. Pain intensity, using a visual analog scale, and muscle dimensions of both right and left transverse abdominis and lumbar multifidus muscles, using rehabilitative ultrasonography, were assessed before and immediately after 4 weeks of intervention.

RESULTS

Significant improvement was identified after interventions on pain intensity and muscle size measurements in both groups (P < .01 in all instances). The only exception was the right-side lumbar multifidus cross-sectional area of the control group, which was not statistically significant (P = .081). No significant differences were found between the 2 exercise groups on pain intensity and muscle dimensions (P > .05 in all instances).

CONCLUSIONS

The results of this study suggest that a combination of electrotherapy with either routine or stabilization exercise programs may improve pain intensity and muscle dimensions in patients with nonspecific chronic low back pain.

Patients Presenting to the Emergency Department with Acute Pain: The Significant Role of Pain Catastrophizing and State Anxiety

OBJECTIVE

Pain is one of the most common reasons for emergency department (ED) visits. Given the significant association of psychological variables and pain experience, it is critical to examine the relation of such factors with ED pain reports. This study sought to analyze the association of reported pain intensity in ED with pain catastrophizing and state anxiety.

METHODS

One hundred participants presenting with a primary complaint of acute pain in an urban ED completed the study. The measures included a demographic survey with questions pertaining to pain intensity, type and duration of present pain, the Pain Catastrophizing Scale (PCS), and the State-Trait Anxiety Inventory-State Subscale (STAI-S).

RESULTS

Pain intensity was significantly and positively associated with pain catastrophizing and state anxiety. Follow-up PROCESS mediation analysis revealed a significant indirect effect of pain catastrophizing on the relationship between state anxiety and pain intensity.

CONCLUSIONS

The results suggest that it is important to assess the psychological distress due to anxiety and pain catastrophizing of patients presenting to EDs with acute pain. Setting-appropriate brief behavioral interventions in conjunction with pharmacological interventions could improve outcomes.

Day-to-Day Changes of Auricular Point Acupressure to Manage Chronic Low Back Pain: A 29-day Randomized Controlled Study

OBJECTIVE

The purpose of this study was to determine the effects of a 4-week auricular point acupressure (APA) treatment on chronic low back pain (CLBP) outcomes and examine the day-to-day variability of CLBP in individuals receiving APA for CLBP over 29 days.

DESIGN

This was a prospective, randomized controlled trial (RCT). Data were collected at baseline, during each of the four office visits for APA treatment, after the completion of the 4-week intervention, and 1 month after the last treatment. A daily diary was given to each participant to record his or her APA practices, analgesic use, and pain intensity.

INTERVENTIONS

APA was used to manage CLBP. The participants received one APA treatment per week for 4 weeks.

PATIENTS AND SETTING

Sixty-one participants with CLBP were randomized into either a real APA or sham APA treatment group. Participants were recruited from primary care offices and clinics or through the Research Participant Registry at the University of Pittsburgh.

RESULTS

Among participants in the real APA group, a 30% reduction of worst pain was exhibited after the first day of APA treatment, and continuous reduction in pain (44%) was reported by the completion of the 4-week APA. This magnitude of pain reduction reached the clinically significant level of improvement reported in other clinical trials of chronic pain therapies. Analgesic use by participants in the real APA group also was reduced compared with use by participants in the sham group.

CONCLUSION

This study shows that APA is a promising pain management strategy that is not invasive and can be self-managed by participants for CLBP. Given the day-to-day fluctuation in ratings, the tighter ecologic assessment of pain scores and other treatment parameters are an important pragmatic aspect of the design of chronic pain studies.

Chronic pain in "probable" vascular dementia: preliminary findings

BACKGROUND

In a previous study, the levels of pain reported by patients with "possible" vascular dementia (VaD) were higher than those reported by older individuals without dementia.

OBJECTIVE

To examine experienced pain in patients with "probable" VaD, confirmed by brain imaging.

STUDY DESIGN

Observational, cross sectional.

SETTING

Nursing home.

METHODS

The participants were 20 nursing home residents (14 females, 6 males) who met the NINDS-AIREN criteria for "probable" VaD and 22 nursing home residents with a normal mental status (18 females, 4 males). The patients were in a mild to moderate stage of dementia. All of the participants were suffering from arthritis/arthrosis or osteoporosis. Global cognitive functioning was measured by the Mini-Mental State Examination. Pain was assessed by the Coloured Analogue Scale (CAS: original and modified version) and the Faces Pain Scale. The Geriatric Depression Scale and the Symptom Checklist-90 were used to assess mood.

RESULTS

The main finding was that, after controlling for mood, the pain levels indicated by patients with "probable" VaD (M = 102.32; standard deviation [SD] = 53.42) were significantly higher than those indicated by the control group (M = 59.17; SD = 38.75), only according to the CAS modified version (F[1,29]) = 5.62, P = 0.01, η2  = 0.16).

CONCLUSION

As VaD patients may experience greater pain than controls, it is essential for prescribers to be aware of the presence of this neuropathology if these patients are to receive adequate treatment.

Somatosensory and affective contributions to emotional, social, and daily functioning in chronic pain patients

OBJECTIVE

The present study tested the independent and interactive contributions of the somatosensory component of pain (pain intensity) and the affective component of pain (pain unpleasantness) on emotional, social, and daily functioning in chronic pain patients.

SUBJECTS

Participants were 472 patients seeking treatment for chronic orofacial pain. Mean age of the sample was 46.0 years (standard deviation [SD] = 14.67, range 18-78), with 82.2% female. Average pain duration at the time of initial appointment was 75.7 months (SD = 106.66).

METHODS

Participants completed self-report measures of pain intensity, unpleasantness, and functional outcomes at the time of their first appointment. These data were later extracted from participant's de-identified medical records. Multivariate linear regression was used to test the interaction of pain intensity and unpleasantness on outcome measures of emotional, social, and daily functioning.

RESULTS

Results revealed that pain intensity contributed to poorer functional outcomes but higher levels of social support even after controlling for pain unpleasantness. After controlling for pain intensity, unpleasantness was associated with higher pain interference and affective distress. There was also pain intensity by unpleasantness interaction on pain interference. Specifically, at lower levels of pain unpleasantness, changes in pain intensity produced greater changes in pain interference than they did at higher levels of pain unpleasantness.

CONCLUSIONS

Results suggest that both intensity and unpleasantness contribute unique variance to functional outcomes. The results highlight the importance of interventions that not only try to reduce pain levels but also reduce levels of pain unpleasantness.

Reliability and validity of the pain on movement questionnaire (POM) in chronic neck pain

OBJECTIVE

This analysis aimed to determine reliability, validity, and responsiveness of the pain on movement (POM) questionnaire, an instrument developed to determine pain intensity induced by head movement.

DESIGN

Data from nine randomized controlled trials for the treatment of chronic nonspecific neck pain were reanalyzed to determine reliability and validity of the POM questionnaire.

METHODS

POM was assessed as ratings of pain intensity induced by head movement in six different directions. The instrument's structure was assessed using a factor analysis. Reliability (internal consistency) was determined using Cronbach's alpha, and validity (convergent validity) was determined by correlating the POM with pain at rest on a visual analog scale (VAS), the neck disability index (NDI), quality of life (short-form 36 health survey questionnaire [SF-36]) and range of motion. Responsiveness was indicated by sensitivity to changes over time in a subsample of 49 patients.

RESULTS

Overall, 482 patients (mean age 50.3 ± 12.4 years, 72.3% female) were included in the analysis, and 458 of them provided complete data set for the POM. Average POM was 43.9 ± 20.8 mm on the VAS. The POM showed very good reliability as indicated by high internal consistency and moderate validity as indicated by significant correlations with the pain at rest, the NDI, and the SF-36. No correlations were found for POM with range of motion. The POM further proved to be responsive as it was sensitive to changes over time, and those changes were correlated to changes in pain intensity and NDI.

CONCLUSIONS

The POM seems to be a reliable and valid instrument to assess POM in patients with chronic nonspecific neck pain.

Prediction of Quality of life by Self-Efficacy, Pain Intensity and Pain Duration in Patient with Pain Disorders

The quality of life (QOL) has been defined as "a person's sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to him/her". It is generally accepted that pain intensity and duration have a negative impact on the QOL. One specific type of control is "self-efficacy", or the belief that one has the ability to successfully engage in specific actions. The ability to adapt to pain may play an important role in maintaining the QOL. In this study, we investigated the role of self-efficacy, pain intensity, and pain duration in various domains of quality of life such as physical, psychological, social and environmental domains. In this study, 290 adult patients (146 men, 144 women) completed coping self-efficacy and the WHOQOL-BREF Questionnaire. Moreover, we illustrated numerical rating scale for pain intensity. The results were analyzed using SPSS version of 19.0 and means, descriptive correlation, and regression were calculated. Our data revealed that self-efficacy but not the pain duration could significantly anticipate the QOL and its four related domains (P<0.001). In addition, it is noticeable that the effect of self-efficacy on the prediction of QOL is much more obvious in the psychological domain. However, the pain intensity could predict all of the QOL domains (P<0.001) except social and environmental ones. In conclusion, to predict the quality of life (QOL) in person suffering from chronic pain, self-efficacy and pain intensity are more important factors than the pain duration and demographic variables.