A paradigm shift from a tissue- and disease-based approach towards multimodal lifestyle interventions for chronic pain: 5 steps to guide clinical reasoning

Prescription time trends in patients with high-impact chronic pain: A National Patient Registry Study

BACKGROUND

High-impact chronic pain (HICP), defined as chronic pain with a significant impact on daily function, affects approximately 8% of the Western population. In Denmark, HICP still remains to be described at the population level. Some patients with HICP are referred to the Danish pain centres, where they are registered with a procedural code. We conducted a nationwide registry-based study of all Danish patients registered with a visit to a pain centre from January 2005 to March 2022, to explore time trends in the prescription of analgesics and sedatives in this HICP subpopulation. Furthermore, data on socioeconomics and hospital diagnoses are reported.

METHODS

We used data from the Central Person Registry, the Danish National Patient Registry, the Danish National Prescription Registry, combined with data on socioeconomic information from Statistics Denmark. Data was collected on prescriptions 3 months before the first visit to a pain centre. Prescriptions were stratified into five calendar periods: before 2011, 2011-2013, 2014-2016, 2017-2019, and 2020-2022.

RESULTS

We identified 66,577 patients referred to a pain centre. Over 15 years, prescriptions before referral declined for opioids (from 53.2% to 31.7%), NSAIDs (from 28.3% to 23.5%), antidepressants (from 20.5% to 16.8%), anxiolytics (from 12.3% to 3.2%), and sleep medication (from 15.8% to 7.6%). In contrast, prescriptions increased for paracetamol (from 31.1% to 48.9%) and gabapentinoids (from 19.2% to 27.7%).

CONCLUSIONS

In patients with HICP visiting Danish pain centres, prescriptions before referral decreased for opioids over 15 years, with a simultaneously increased prescription of gabapentinoids (gabapentin and pregabalin).

SIGNIFICANCE STATEMENT

This nationwide study of 66,577 Danish patients with high-impact chronic pain reveals a significant decrease in filled opioid prescriptions over the past 15 years, with a simultaneous rise in gabapentinoid use before referral to pain centres. These findings suggest a shift in clinical practice towards alternative pain management strategies. The study underscores the need for continued research into the long-term effects of these changes and their impact on patient outcomes.

Age-threshold for increased risk of developing back disorders: prospective cohort with 74 000 individuals from the UK Biobank

OBJECTIVE

To investigate the prospective associations between age and the risk of low back disorders (LBD), dorsal disorders (DD), and cervical disorders (CD), and to identify a potential age-threshold for increased risk of back disorders.

METHODS

Prospective cohort from the UK Biobank comprising adults with no history of back disorders. We examined different ages and their association with the risk of back disorders derived from diagnoses of hospital registers. Associations were investigated using restricted cubic splines adjusted for sex, racial and ethnic background, tobacco use, Townsend Deprivation Index, alcohol consumption, educational attainment, employment status, self-reported health, diet quality, body mass index, medication use, physical activity, and handgrip strength.

RESULTS

The analytic sample comprised 74,191 participants (mean [SD] age, 55.2 [7.8] years; 57%women) who were followed-up for 7.9 years (IQR = 7.3-8.4). Overall, 3297 (4.3%) cases of incident LBD, 1224 (1.6%) cases of DD, and 792 (1.0%) of CD were documented. The association between age and LBD showed a curvilinear shape with significant higher risk within the range of 61 (hazard ratio [HR] = 1.39 [95%CI,1.02-1.49]) and 70 (HR = 1.71 [95%CI,1.38-2.12]) years (reference:40 years). Similarly, the association of age with DD exhibited a significant curvilinear association within the range of 60 (HR = 1.31 [95%CI,1.01-1.92]) and 70 (HR = 2.74 [95%CI,1.94-3.86]) years. The association between age and CD was not significant.

CONCLUSIONS

The risk of LBD and DD, but not CD, increases beyond 60 years of age. Targeting people at this critical age-threshold to prevent risk for LBD and DD may be warranted for future interventions and preventive health programmes.

Physical inactivity is the most important unhealthy lifestyle factor for pain severity in older adults with pain: A SHARE-based analysis of 27,528 cases from 28 countries

BACKGROUND

Limited knowledge exists on the association between lifestyle factors and pain severity in older adults.

OBJECTIVE

To assess the associations between unhealthy lifestyle variables and pain severity in the European population of older adults with pain.

DESIGN

Cross-sectional.

METHODS

Data were retrieved from the ninth wave of the Survey of Health, Ageing and Retirement in Europe (SHARE), a representative survey of individuals aged >50 years living in 27 European countries and Israel. Associations between lifestyle factors (sleep, smoking, diet and physical inactivity) and pain severity (mild, moderate, severe) were assessed using multivariable multinomial regression adjusted for age, sex, geographic region, education, history of chronic disease and mutually adjusted for each lifestyle.

RESULTS

27,528 cases were included (73.1 ± 9.76 years; 63.3% female). A significant association was observed between those who hardly ever or never engaged in activities that required a moderate level of energy and severe pain (OR: 4.35; 95% CI: 3.85 to 4.92). Sleep problems (OR: 1.83; 95% CI: 1.69 to 1.99), smoking (OR: 1.21; 95% CI: 1.13 to 1.34) and an inadequate diet (OR: 1.78: 95% CI: 1.22 to 2.61) were also significantly associated with severe pain, but with lower odds. Given the cross-sectional design, the bidirectionality of these relationships should be considered.

CONCLUSION

Physically inactive older adults were particularly more likely to experience severe pain, while other lifestyle factors were more weakly associated with pain. As these lifestyle factors are modifiable, the results may be useful in prioritising appropriate preventive measures to attenuate pain and ensure healthy ageing.

Comparing physical therapy students' attitudes and beliefs regarding chronic low back pain and knee osteoarthritis: an international multi-institutional comparison between 2013 and 2020 academic years

BACKGROUND

In 2013, physical therapy students demonstrated low guideline-adherent recommendations regarding chronic low back pain (CLBP) for spinal pathology, activity, and work.

OBJECTIVES

To assess the differences in physical therapy students' attitudes, beliefs, and adherence to guideline recommendations regarding CLBP and knee osteoarthritis between 2013 and 2020.

METHODS

In 2013 and 2020, second and fourth-year physical therapy students were recruited from 6 Belgian and 2 Dutch institutions. Attitudes and beliefs regarding CLBP and knee OA were evaluated using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), and a questionnaire regarding therapeutic exercise and knee osteoarthritis. A clinical vignette was used to measure guideline-adherent recommendations regarding spinal pathology, activity, and work.

RESULTS

In 2013, 927 second-year and 695 fourth-year students; in 2020, 695 second-year and 489 fourth-year students; were recruited to participate in the study. Compared to 2013, students had less biomedical and stronger biopsychosocial attitudes and beliefs regarding CLBP, more guideline-adherent recommendations for activity, and more biopsychosocial beliefs regarding the benefits of exercise for patients with knee osteoarthritis in both the second and fourth year. Only fourth-year students in 2020 scored significantly better on HC-PAIRS and guideline-adherent recommendation relating to spinal pathology. No differences were found regarding work recommendations.

CONCLUSIONS

Between 2013 and 2020, physical therapy students made a positive shift towards a more biopsychosocial approach to CLBP and knee osteoarthritis management. Guideline-adherent recommendations for CLBP concerning activity improved, however, concerning work and spinal pathology, it remained low.