The impact of chronic pain-European patients' perspective over 12 months

Balancing between being the most valuable player (MVP) and passing the ball: a qualitative study of support when living with chronic pain in Sweden

OBJECTIVE

This study aimed to elucidate the meaning of lived experiences of support from social networks and the healthcare sector in persons with chronic pain.

DESIGN

A qualitative, phenomenological hermeneutic method was used to analyse interview data.

SETTING

Participants were recruited from patient organisations in Sweden.

PARTICIPANTS

Ten (seven women, two men and one non-binary) individuals with chronic musculoskeletal pain were included.

FINDINGS

The meaning of lived experiences of support in persons with chronic pain involves balancing between being the most valuable player (MVP) and passing the ball, meaning balancing between being a capable person and accepting support to be that capable person.

CONCLUSION

For participants who lived with chronic pain, support means balancing between being capable (the MVP) and willing to accept support (passing the ball), which aligns with the concept of person-centred care. Our findings may be useful for policy-makers, managers and clinical professionals when planning and performing care for persons with chronic pain. Future research should focus on how the healthcare sector can create support to enable persons with chronic pain to be the MVP while being able to pass the ball to their social networks and the healthcare sector.

Pain and Menthol Use Are Related to Greater Nicotine Dependence Among Black Adults Who Smoke Cigarettes at Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health (PATH) Study

Burdens related to pain, smoking/nicotine dependence, and pain-smoking comorbidity disproportionately impact Black Americans, and menthol cigarette use is overrepresented among Black adults who smoke cigarettes. Menthol may increase nicotine exposure, potentially conferring enhanced acute analgesia and driving greater dependence. Therefore, the goal of the current study was to examine associations between pain, menthol cigarette use, and nicotine dependence. Data was drawn from Black adults who were current cigarette smokers (n = 1370) at Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health Study. Nicotine dependence was assessed using the Wisconsin Inventory of Smoking Dependence Motives. ANCOVA revealed that moderate/severe pain (vs. no/low pain) was associated with greater overall nicotine dependence (p < .001) and greater negative reinforcement, cognitive enhancement, and affiliative attachment smoking motives (ps < .001). Menthol smokers with moderate/severe pain also endorsed greater cigarette craving and tolerance, compared to non-menthol smokers with no/low pain (ps < .05). Findings support the notion that among Black individuals who smoke cigarettes, the presence of moderate/severe pain (vs. no/low pain) and menthol use may engender greater physical indices of nicotine dependence relative to non-menthol use. Compared to no/low pain, moderate/severe pain was associated with greater emotional attachment to smoking and greater proclivity to smoke for reducing negative affect and enhancing cognitive function. Clinical implications include the need to address the role of pain and menthol cigarette use in the assessment and treatment of nicotine dependence, particularly among Black adults. These data may help to inform evolving tobacco control policies aimed at regulating or banning menthol tobacco additives.

Longitudinal Associations Between Pain and Use of Cigarettes and E-cigarettes in the Population Assessment of Tobacco and Health (PATH) Study

INTRODUCTION

Pain has been implicated in the onset and maintenance of nicotine addiction, and there is initial cross-sectional evidence of covariation between pain and the use of cigarettes and e-cigarettes. The goals of the current study were to: (1)test pain severity as a predictor of initiating co-use of cigarettes and e-cigarettes, (2)examine longitudinal associations between pain and use/co-use of cigarettes and e-cigarettes, (3)generate the first prevalence rate data regarding cigarette and e-cigarette use as a function of pain, and (4)examine gender as a moderator of these associations.

AIMS AND METHODS

Data were drawn from Waves 1-4 of the Population Assessment of Tobacco and Health Study (2013-2018).

RESULTS

Among exclusive cigarette smokers at Wave 1 (n = 7719), pain severity was associated with a greater likelihood of and faster trajectory to initiating co-use of cigarettes and e-cigarettes (ps < .05). A significant pain × gender interaction (p < .05) revealed this prospective relationship was stronger among women. Among adult respondents who provided at least three waves of data (n = 24 255), greater Wave 1 pain severity was positively associated with e-cigarette use, cigarette smoking, and co-use of cigarettes and e-cigarettes at Waves 2, 3, and 4 (ps < .001). At Wave 4 (n = 33 822), adults with moderate or severe pain endorsed rates of e-cigarette and cigarette use almost two times greater versus no or low pain (ps < .001).

CONCLUSIONS

Collectively, these findings provide evidence that pain likely serves as an important candidate risk factor for the initiation and maintenance of cigarette and e-cigarette use.

IMPLICATIONS

This is the first prospective study to show that pain serves as an important risk factor for initiation and maintenance of cigarette and e-cigarette use over time. Weighted prevalence estimates further demonstrated that individuals with moderate or severe pain endorsed rates of cigarette and e-cigarette use and co-use approximately two times greater compared to those with no or low pain. These findings highlight a subpopulation of nicotine users more susceptible to greater healthcare burden, nicotine dependence, and physical impairment. Nicotine users with comorbid pain may benefit from integrated interventions that address pain in the context of cessation.

Lysophosphatidylcholine 16:0 mediates chronic joint pain associated to rheumatic diseases through acid-sensing ion channel 3

ABSTRACT

Rheumatic diseases are often associated to debilitating chronic pain, which remains difficult to treat and requires new therapeutic strategies. We had previously identified lysophosphatidylcholine (LPC) in the synovial fluids from few patients and shown its effect as a positive modulator of acid-sensing ion channel 3 (ASIC3) able to induce acute cutaneous pain in rodents. However, the possible involvement of LPC in chronic joint pain remained completely unknown. Here, we show, from 2 independent cohorts of patients with painful rheumatic diseases, that the synovial fluid levels of LPC are significantly elevated, especially the LPC16:0 species, compared with postmortem control subjects. Moreover, LPC16:0 levels correlated with pain outcomes in a cohort of osteoarthritis patients. However, LPC16:0 do not appear to be the hallmark of a particular joint disease because similar levels are found in the synovial fluids of a second cohort of patients with various rheumatic diseases. The mechanism of action was next explored by developing a pathology-derived rodent model. Intra-articular injections of LPC16:0 is a triggering factor of chronic joint pain in both male and female mice, ultimately leading to persistent pain and anxiety-like behaviors. All these effects are dependent on ASIC3 channels, which drive sufficient peripheral inputs to generate spinal sensitization processes. This study brings evidences from mouse and human supporting a role for LPC16:0 via ASIC3 channels in chronic pain arising from joints, with potential implications for pain management in osteoarthritis and possibly across other rheumatic diseases.

Maximal aerobic capacity is associated with lifting capacity, but not with self-reported functioning measures in patients with primary chronic low back pain: a cross-sectional study

Objective

Maximal exercise testing is considered the gold standard to assess V̇O₂max. However, maximal exercise testing was previously deemed unfeasible and unsafe in chronic low back pain (CLBP) patients. Consequently, most previous studies on aerobic capacity and functioning in patients with CLBP were performed with submaximal testing protocols. A recent study demonstrated the safety, feasibility and tolerance of maximal exercise testing in patients with CLBP. Therefore, the relation between aerobic capacity and functioning should be reevaluated. This cross-sectional study aims to determine the relationship between maximal aerobic capacity and four measures of functioning: lifting capacity, work ability, pain-related disability and physical functioning in patients with CLBP.

Methods

The maximal aerobic capacity of patients with CLBP was assessed with a maximal cardiopulmonary exercise test. Functioning was measured with a floor-to-waist lifting capacity test and three questionnaires: Work Ability Score, Pain Disability Index and Physical Functioning subscale of RAND-36. The associations between maximal aerobic capacity and each of the functioning measures were analysed with multiple linear regression analyses while controlling for potential confounders.

Results

Data of n=74 patients with CLBP were analysed. After controlling for potential confounders, maximal aerobic capacity was moderately associated with lifting capacity (β=0.32, p=0.006), but not with any of the other functioning measures (β=−0.08 to 0.12, p>0.288).

Conclusion

A higher level of maximal aerobic capacity is moderately associated with a higher lifting capacity, but not with self-reported work ability, pain-related disability and physical functioning.

Central Neuropathic Pain Syndromes: Current and Emerging Pharmacological Strategies

Central neuropathic pain is caused by a disease or lesion of the brain or spinal cord. It is difficult to predict which patients will develop central pain syndromes after a central nervous system injury, but depending on the etiology, lifetime prevalence may be greater than 50%. The resulting pain is often highly distressing and difficult to treat, with no specific treatment guidelines currently available. This narrative review discusses mechanisms contributing to central neuropathic pain, and focuses on pharmacological approaches for managing common central neuropathic pain conditions such as central post-stroke pain, spinal cord injury-related pain, and multiple sclerosis-related neuropathic pain. Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and gabapentinoids have some evidence for efficacy in central neuropathic pain. Medications from other pharmacologic classes may also provide pain relief, but current evidence is limited. Certain non-pharmacologic approaches, neuromodulation in particular, may be helpful in refractory cases. Emerging data suggest that modulating the primary afferent input may open new horizons for the treatment of central neuropathic pain. For most patients, effective treatment will likely require a multimodal therapy approach.

A Qualitative Study of the Impact of the COVID-19 Pandemic on a Sample of Patients With Chronic Pain

This qualitative phenomenological study examined the impact of the COVID-19 pandemic on the lives of patients living with chronic pain. Patients referred to an intensive interdisciplinary pain management program between June 2020 to June 2021 were asked, “How did the COVID-19 pandemic affect your life?” as part of their interdisciplinary assessment. Ninety patients (50 Veterans, 40 civilians) provided comments to this question, which were independently organized into themes using an inductive approach by 4 researchers. Nine main themes emerged: (1) changed psychological state, (2) minimal to no effect, (3) affected personal life activities, (4) changes in accessing care, (5) changes in work/education situation, (6) changes in family dynamics, (7) experiencing more annoyances, (8) COVID-19 pandemic is a barrier to making positive changes, and (9) got COVID-19. Themes are consistent with topics of interest in light of this ongoing, global stressor. Most commonly reported themes reflected changes in psychological well-being and changes in access to care, highlighting similarities between life with chronic pain and life under the pandemic for this group.

Development of a bedside tool-kit for assessing sensitization in patients with chronic osteoarthritis knee pain or chronic knee pain after total knee replacement

ABSTRACT

Different pathophysiological mechanisms contribute to the pain development in osteoarthritis (OA). Sensitization mechanisms play an important role in the amplification and chronification of pain and may predict the therapeutic outcome. Stratification of patients according to their pain mechanisms could help to target pain therapy. This study aimed at developing an easy-to-use, bedside tool-kit to assess sensitization in patients with chronic painful knee OA or chronic pain after total knee replacement (TKR). In total, 100 patients were examined at the most affected knee and extrasegmentally by the use of 4 standardized quantitative sensory testing parameters reflecting sensitization (mechanical pain threshold, mechanical pain sensitivity, dynamic mechanical allodynia, and pressure pain threshold), a bedside testing battery of equivalent parameters including also temporal summation and conditioned pain modulation, and pain questionnaires. Machine learning techniques were applied to identify an appropriate set of bedside screening tools. Approximately half of the patients showed signs of sensitization (46%). Based on machine learning techniques, a composition of tests consisting of 3 modalities was developed. The most adequate bedside tools to detect sensitization were pressure pain sensitivity (pain intensity at 4 mL pressure using a 10-mL blunted syringe), mechanical pinprick pain sensitivity (pain intensity of a 0.7 mm nylon filament) over the most affected knee, and extrasegmental pressure pain sensitivity (pain threshold). This pilot study presents a first attempt to develop an easy-to-use bedside test to probe sensitization in patients with chronic OA knee pain or chronic pain after TKR. This tool may be used to optimize individualized, mechanism-based pain therapy.

Medicinal Cannabis for the Treatment of Chronic Refractory Pain: An Investigation of the Adverse Event Profile and Health-Related Quality of Life Impact of an Oral Formulation

INTRODUCTION

Medicinal cannabis is prescribed in Australia for patients with chronic refractory pain conditions. However, measures of safety and effectiveness of different cannabinoids are lacking. We designed an observational study to capture effectiveness, adverse events (AEs), and health-related quality of life (HRQoL) measures in patients prescribed an oral medicinal cannabis formulation at Cannabis Access Clinics through the Cannabis Access Clinics Observational study (CACOS).

OBJECTIVES

We aimed to evaluate effectiveness, reported AEs, and change in patient-reported outcomes in individuals prescribed a cannabinoid oil formulation for management of chronic pain.

METHODS

A cross-sectional analysis was conducted on patients prescribed an oil formulation of Δ9-tetrahydrocannabinol and cannabidiol for pain symptoms of at least 3-month duration. Clinician-reported AEs were organized by system, organ, class, and frequency. Analysis of patient-reported responses to a questionnaire was conducted using published minimal clinically important differences to determine meaningful change in HRQoL over time.

RESULTS

More than half (n = 91/151, 60.3%) of the participants experienced at least one AE during the observation period (mean 133 ± 116 days). No serious AEs were reported. Patient-reported pain impact scores were significantly reduced across the cohort (p = 0.034), and pain intensity scores verged on significance (p = 0.053). The majority of patients saw meaningful improvements in sleep (49.3%) and fatigue (35.6%).

CONCLUSION

This analysis presents real-world data collected as part of standard of care. More than one-third of patients benefited from oral medicinal cannabis, which is impactful given the refractory nature of their pain. Amelioration of the impact of pain confirms continued prescribing of this formulation and validates our observational methodology as a tool to determine the therapeutic potency of medicinal cannabinoids.

Impairment of electrical activation of wrist flexor and extensor muscles during gripping and functional activities in the early stage of hand osteoarthritis: A cross-sectional study

STUDY DESIGN

This is a cross-sectional study.

INTRODUCTION

The wrist extensor muscles have a fundamental role in the stabilization of the wrist while performing manual activities. However, it is unknown if the clinical signs of hand osteoarthritis (HOA) cause impairment in the activation of these muscles PURPOSE OF THE STUDY: The purpose of this study was to investigate whether early-stage HOA affects the magnitude of activation and coactivation between the wrist extensor and flexor muscles METHODS: Thirty-two subjects were divided into two groups: control group (n = 16; 55 ± 7.42 years) and a group with HOA grades 2 or 3 (HOAG; n = 16; 57 ± 7.82 years). Muscle activation was measured in m. flexor digitorum superficialis, m. flexor carpi ulnaris (FCU) and extensors (EXT) during the evaluation of grip strength and three manual activities (write, cut a paper with scissors, and close and open a bottle). The coactivation index was calculated between the electromyography of the flexors (FCU and FSD) and wrist EXT.

RESULTS

HOAG presented reduced muscle activation in all tasks, with a statistical difference for the flexor digitorum superficialis and EXT in the scissors activity, and for the FCU in the bottle activity. No differences were found between groups for the coactivation index and grip strength.

DISCUSSION

The reduced muscle activity may be due to an inability of the patients of the HOAG to recruit all motor units or to an inhibition related to the presence of pain.

CONCLUSION

In the early stages of HOA, there is a functional deficit associated with a reduced muscle activity of the wrist muscles during manual activities.

The Role of Mesostriatal Dopamine System and Corticostriatal Glutamatergic Transmission in Chronic Pain

There is increasing recognition of the involvement of the nigrostriatal and mesolimbic dopamine systems in the modulation of chronic pain. The first part of the present article reviews the evidence indicating that dopamine exerts analgesic effects during persistent pain by stimulating the D2 receptors in the dorsal striatum and nucleus accumbens (NAc). Thereby, dopamine inhibits striatal output via the D2 receptor-expressing medium spiny neurons (D2-MSN). Dopaminergic neurotransmission in the mesostriatal pathways is hampered in chronic pain states and this alteration maintains and exacerbates pain. The second part of this article focuses on the glutamatergic inputs from the medial prefrontal cortex to the NAc, their activity changes in chronic pain, and their role in pain modulation. Finally, interactions between dopaminergic and glutamatergic inputs to the D2-MSN are considered in the context of persistent pain. Studies using novel techniques indicate that pain is regulated oppositely by two independent dopaminergic circuits linking separate parts of the ventral tegmental area and of the NAc, which also interact with distinct regions of the medial prefrontal cortex.

Maximal cardiopulmonary exercise test in patients with chronic low back pain: feasibility, tolerance and relation with central sensitization. An observational study

PURPOSE

To analyze the feasibility of and pain-related tolerance to a maximal cardiopulmonary exercise test (CPET), and the relationship between the aerobic capacity and central sensitization (CS) in patients with chronic low back pain (CLBP).

METHODS

An observational study, combining a cross-sectional and a prospective 24-hour follow-up was performed. Participants underwent a maximal CPET on a cycle ergometer and were assessed with three measures of CS (CS Inventory, quantitative sensory testing and heart rate variability). Before the CPET, immediately afterwards and 24 h after, the Pain Response Questionnaire (PRQ) was filled out. The CPET was considered feasible when >80% performed maximally, and tolerable when <20% reported relevant pain increase, body reactions and additional pain medication use in the PRQ. Multiple regression analyses were applied to assess the relationship between the aerobic capacity (VO2max) and CS measures, corrected for confounders.

RESULTS

74 patients with CLBP participated of which 30 were male, mean age was 40.4 years (SD: 12.4) and median VO2max was 23.9 ml/kg/min (IQR: 18.2-29.4). CPET was completed by 92%. No serious adverse events occurred. A relevant pain increase was reported in the upper legs by 40% immediately after CPET and by 28% 24 h afterwards, 27% reported body reactions after 24 h, and 22% increased pain medication use 24 h after CPET. Very weak and not significant relations (r_partial=-0.21 to 0.05; p > 0.10) were observed between aerobic capacity and CS measures.

CONCLUSIONS

A maximal CPET is feasible in patients with CLBP. Most, but not all, tolerated it well. CS was not related to aerobic capacity.Implications for rehabilitationMaximal CPET is feasible in patients with CLBP and well tolerated by most patients.Maximal CPET can be safely applied to assess the aerobic capacity of patients with CLBP.Aerobic capacity is unrelated to central sensitization.Outcomes of a maximal CPET and the pain response to straining activity can be used to provide valid information for the decision-making of exercise therapy.

Combination Therapy for Neuropathic Pain: A Review of Recent Evidence

Pharmacological treatment is not very effective for neuropathic pain (NP). A progressive decrease in the estimated effect of NP drugs has been reported, giving rise to an increase in the use of the multimodal analgesic approach. We performed a new independent review to assess whether more and better-quality evidence has become available since the last systematic review. We evaluated the efficacy, tolerability, and safety of double-blinded randomized controlled trials involving only adult participants and comparing combination therapy (CT: ≥2 drugs) with a placebo and/or at least one other comparator with an NP indication. The primary outcome assessed was the proportion of participants reporting ≥50% pain reductions from baseline. The secondary outcome assessed was the proportion of drop-outs due to treatment-emergent adverse events. After removing duplicates, 2323 citations were screened, with 164 articles assessed for eligibility, from which 16 were included for qualitative analysis. From the latter, only five lasted for at least 12 weeks and only six complied with the required data for complete analysis. CT has been adopted for years without robust evidence. Efforts have been made to achieve better-quality evidence, but the quality has not improved over the years. In this regard, guidelines for NP should attempt to make recommendations about CT research, prioritizing which combinations to analyze.

Spousal Care and Pain Among the Population Aged 65 Years and Older: A European Analysis

Background: Spousal care is the most important source of informal care in old age. Nevertheless, despite the growing importance of this issue, the association between providing spousal care inside the household and pain remains unexplored in Europe. Objective and Methods: This study aims to estimate the prevalence of pain reported by spouse caregivers aged 65 plus that provide care inside the household and to investigate the association between providing spousal care and pain. Data from 17 European countries that participated in wave 6 of the Survey of Health, Aging and Retirement in Europe (SHARE) is used. The analyses are based on 26,301 respondents aged 65 years and older who provide informal care inside the household to their spouse/partner exclusively (N = 1,895) or do not provide any informal care (inside or outside the household) (24,406). Descriptive statistics and multilevel logistic regressions (individual-level as level 1, and country as level 2) were performed. Results: Overall, spouse caregivers report pain more often (63.4%) than their non-caregiver's counterparts (50.3%). Important differences in the prevalence of pain among spouse caregivers were found between countries, with Portugal (80.3%), Spain (74.6%), France (73%), Italy (72.4%), and Slovenia (72.1) showing the highest prevalence of pain, and Denmark (36%), Switzerland (41.5) and Sweden (42.3%), the lowest. Results from multilevel logistic regressions show that European individuals aged 65+ who provide spousal care have an increased likelihood of reporting pain (OR 1.30; CI = 1.13-1.48). Conclusion: Our results suggest that in Europe, spouse caregivers aged 65+ are at greater risk of experiencing pain. Therefore, European policymakers should consider spouse caregivers as a health priority group, and take measures to ensure they receive comprehensive health and socio-economic support.

Cryoneurolysis for the management of chronic pain in patients with knee osteoarthritis; a double-blinded randomized controlled sham trial

Objective

Pain is the principal symptom in knee osteoarthritis (OA). Current non-operative treatment options have only moderate effects and often patients experience persistent pain or side-effects. Novel advances in the field of cryoneurolysis applies low temperatures to disrupt nerve signaling at the painful area, providing pain relief. The primary aim of this randomized controlled trial (RCT) is to investigate if cryoneurolysis is superior to sham at decreasing pain intensity 2 weeks after the intervention in patients with knee OA. Secondary aims are to explore effects on pain, quality of life and functional performance over 24 months.

Methods

This two-arm, parallel-group RCT, approved by the Regional Ethics Committee, will randomly allocate patients (n = 94) to a cryoneurolysis intervention group + standardized education and exercise (CRYO) or a sham group + standardized education and exercise (SHAM) (1:1 ratio). Both groups will be assessed at baseline, 2 weeks post intervention, post education and exercise and at 6, 12 and 24 months after cryoneurolysis. The primary outcome is the NRS knee pain intensity score assessed 2 weeks post the intervention. Secondary outcome measures include functional performance (chair-stand test, 40 m walk, stair test and maximum voluntary contraction of the knee), patient reported outcomes (quality of life (EQ5D), Knee and osteoarthritis outcome scores (KOOS), among others), use of analgesics, and adverse events over 24 months.

Impact statement

Cryoneurolysis could potentially provide an effective, safe and non-pharmacological therapeutic option to treat pain in OA patients. The potential benefits include increased functional capacity and quality of life as a result of significant pain relief and improved benefits of physical exercise.

Trial registration

Clinicaltrials.gov, NCT03774121, registered 3 March 2018, http://www.clinicaltrials.gov

[Spirituality and health care. The perspective of patients with chronic pain]

Hintergrund

Chronischer Schmerz betrifft alle menschlichen Lebensdimensionen und wirft auch spirituelle Fragen auf, die im Rahmen eines multimodalen Behandlungsmodells berücksichtigt werden sollten.

Ziel der Arbeit

Wir untersuchten die Perspektive von Patienten mit chronischen Schmerzen zu spirituellen Themen und deren möglicher Integration in den Behandlungsprozess.

Material und Methoden

Es wurden fünf Fokusgruppen- und zwei Kleingruppeninterviews an fünf Studienzentren durchgeführt. Daran nahmen 42 Patienten mit chronischen Schmerzen teil, die aktuell in ambulanter oder stationärer Schmerzbehandlung waren. Die Interviews wurden transkribiert und einer thematischen Analyse unterzogen.

Ergebnisse

Drei Themen traten hervor: 1. Chronischer Schmerz durchdringt die gesamte menschliche Existenz. 2. Spirituelle Ressourcen stellen eine Möglichkeit im Umgang mit chronischen Schmerzen dar. 3. Patienten ist es ein Anliegen, mit Fachpersonen in einen Dialog treten zu können, der auch für spirituelle Themen offen ist. Diese haben aus Sicht der Teilnehmenden große Relevanz. Sie verknüpften sie vielfach, aber nicht ausschließlich mit religiösen Überzeugungen. Häufig wurde geschildert, in der Schmerzerfahrung nicht ernst genommen zu werden.

Diskussion

Strategien für einen effektiven Umgang mit chronischem Schmerz zu finden, stellt einen Wendepunkt im Leben dar. In diesem Prozess unterstützt ein offener Dialog mit Fachpersonen, der auch spirituellen Themen Rechnung trägt.

Retrato da Dor: um caminho para entender o sofrimento do indivíduo

Resumo Este estudo tem por objetivo verificar o sofrimento associado às dores crônicas, por meio do instrumento projetivo “Retrato da Dor”. Trata-se de um estudo descritivo, realizado com 126 pacientes com dores crônicas de diversas etiologias. As respostas foram analisadas de acordo com o método de análise de conteúdo de Bardin e testes estatísticos. Foram encontrados pacientes: que acreditam que nenhum sofrimento se compara com a sua dor (34,9%); que comparam sua dor a outras dores ou doenças já experienciadas (16,6%); e os que comparam a dor a situações de sofrimento emocional (48,4%). Este estudo evidenciou que os aspectos emocionais desempenham um papel importante na maneira como o indivíduo irá interpretar e utilizar recursos próprios para lidar com suas dores.

[Pain management for older care receivers in the ambulatory care setting]

PAIN AND PAIN IMPACTS

Chronic pain experienced by care receivers who live in their own homes is an issue of great importance, due to its frequency and intensity. The impacts of pain in this vulnerable group are manifested particularly in the form of marked adverse effects on mobility and activity.

COMMUNICATING ABOUT PAIN IN AMBULATORY CARE SERVICES

Both physicians and staff of the ambulatory care services involved communicate too rarely about pain, its intensity and duration, with the pain-affected care receiver.

MEDICATION-BASED PAIN THERAPY

The deficient pain therapy provided by ambulatory care services for pain-affected care receivers needs to be checked to ensure that medication is appropriate, that the simultaneous prescription of continuous and acute medication, and the clear information on dosage and dosing intervals is given on binding medication charts.

INTERDISCIPLINARY RESOURCES

Too little attention has been paid up to now to the challenges of interdisciplinary care for older care receivers in the ambulatory care setting, although interdisciplinarity in pain management has long been a stated requirement. Multidisciplinary action based on agreed guidelines and standards is the key to appropriate pain management. The interface communication between professional groups needs to be optimized in order to provide adequate care for the care receiver.

The FUTUREPAIN study: Validating a questionnaire to predict the probability of having chronic pain 7-10 years into the future

OBJECTIVES

The FUTUREPAIN study develops a short general-purpose questionnaire, based on the biopsychosocial model, to predict the probability of developing or maintaining moderate-to-severe chronic pain 7-10 years into the future.

METHODS

This is a retrospective cohort study. Two-thirds of participants in the National Survey of Midlife Development in the United States were randomly assigned to a training cohort used to train a predictive machine learning model based on the least absolute shrinkage and selection operator (LASSO) algorithm, which produces a model with minimal covariates. Out-of-sample predictions from this model were then estimated using the remaining one-third testing cohort to determine the area under the receiver operating characteristic curve (AUROC). An optimal cut-point that maximized sensitivity and specificity was determined.

RESULTS

The LASSO model using 82 variables in the training cohort, yielded an 18-variable model with an out-of-sample AUROC of 0.85 (95% Confidence Interval (CI): 0.80, 0.91) in the testing cohort. The sum of sensitivity (0.88) and specificity (0.76) was maximized at a cut-point of 17 (95% CI: 15, 18) on a 0-100 scale where the AUROC was 0.82.

DISCUSSION

We developed a short general-purpose questionnaire that predicts the probability of an adult having moderate-to-severe chronic pain in 7-to-10 years. It has diagnostic ability greater than 80% and can be used regardless of whether a patient is currently experiencing chronic pain. Knowing which patients are likely to have moderate-to-severe chronic pain in the future allows clinicians to target preventive treatment.

"No one wants you" - a qualitative study on the experiences of receiving rejection from tertiary care pain centres

Background and aims Four out of 10 referrals to tertiary care pain centres in Norway are not granted pain centre treatment, confirming earlier research on that this group of patients struggle to access the highest standard of care. Still, no study investigating how people with chronic pain experience rejections from pain centres was found. The aim of the study was therefore to investigate how people with chronic pain experience receiving a rejection from tertiary care pain centres after being referred by their general practitioners (GPs). Methods This was a qualitative study with semi-structured individual interviews with 12 persons, seven men and five women, rejected from the four different pain centres in Norway. The data were analysed thematically using systematic text condensation. Results The pain centre rejection created strong reactions, partly because the rejection was perceived as a refusal from the health care system as a whole. This was especially so because the pain centre was regarded as the last remaining treatment option, and given the rejection, they were now declined help by the experts in the field. Even though some informants had received an explanation for why they had not been granted pain centre treatment, a prominent experience was that the informants found it difficult to understand why their referral had been rejected given the severity of their pain. The incomprehensibility of the rejection together with a feeling of lack of future treatment options, increased the hopelessness and frustration of their situation and made it challenging to move on and search for help elsewhere. Conclusions The experiences with the pain centre rejections indicate that the rejection can have grave consequences for each individual in the following months. An improved system for how to handle expectations towards referrals, including prepare for the possibility of rejection and how to follow up a rejection, seems warranted. Implications Because a pain centre rejection most likely is received by persons in a vulnerable position, there should be available health care services to help them understand the rejections. And furthermore, help them to move from disappointment and hopelessness, towards an experience of empowerment and reorientation, by for instance planning further actions and interventions, and thereby, acknowledge their need for help.

Spiritual Care und chronischer Schmerz: Die Sicht von Fachpersonen. Eine qualitative Untersuchung

Chronischer Schmerz ist ein komplexes Phänomen, das alle Lebensdimensionen betrifft: die psychische, soziale und spirituelle nicht weniger als die physische. Diesem Umstand muss in der Behandlung dieser Patientengruppe Rechnung getragen werden. Wir untersuchten, an welche Voraussetzungen dafür im Deutschschweizer Raum bereits angeknüpft werden kann. An fünf Studienzentren wurden insgesamt 34 Fachpersonen in interprofessionell gemischten Fokusgruppen dazu interviewt, welche spirituellen Anliegen und Bedürfnisse von Patient/-innen mit chronischen Schmerzen sie wahrnehmen und wie diese im Behandlungsprozess berücksichtigt werden können. Eine thematische Analyse zeigte drei Kernthemen: die Relevanz spiritueller Aspekte in der multimodalen Schmerztherapie, handlungsleitende Überzeugungen und die Kompetenz zu Spiritual Care. Die Befragten waren der spirituellen Thematik gegenüber generell aufgeschlossen. Aus ihrer Sicht stellt die Integration spiritueller Anliegen und Bedürfnisse im Behandlungsprozess einen Mehrwert für die Behandlungsqualität in dieser Patientengruppe dar. Dies konsequent umzusetzen, stellt sie jedoch vor teilweise ungelöste Herausforderungen. Hier braucht es Befähigung und institutionelle Unterstützung, um Spiritual Care den entsprechenden Raum zu geben.

Central Sensitisation and functioning in patients with chronic low back pain: protocol for a cross-sectional and cohort study

INTRODUCTION

A relevant subsample of patients with chronic low back pain (CLBP) have manifested augmented central pain processing, central sensitisation (CS). Patients with CLBP have limited functioning and participation. Theoretically, physical functioning in patients with CLBP can plausibly be linked to CS; however, evidence to explain such association is scarce. Moreover, there is no gold standard for CS diagnosis. The objectives of the study are: (1) to analyse the association between instruments assessing reference symptoms and signs attributed to CS; (2) to analyse whether reference symptoms and signs attributed to CS are associated with functioning measurement outcomes; and (3) to analyse whether changes (between baseline and discharge) in reference symptoms and signs attributed to CS are related to changes in each of the functioning measurement outcomes.

METHODS AND ANALYSIS

A cross-sectional and longitudinal observational study is performed with measurements taken at baseline and discharge of an interdisciplinary rehabilitation programme. A sample size of 110 adult patients with CLBP has been calculated for the study. CS measurements are: Central Sensitisation Inventory, quantitative sensory testing and heart rate variability. Functioning measurements are: lifting capacity, maximal aerobic capacity, accelerometry and reported functioning. Statistical analyses to be performed are: (1) correlation between CS measurements, (2) multiple regression between functioning (dependent variable) and CS measurements (independent variable), and (3) multiple regression between changes in scores of functioning (dependent variable) and CS measurements (independent variable), and corrected for sex and age.

ETHICS AND DISSEMINATION

The study obtained the clearance to its implementation from the Medical Research Ethics Committee of the University Medical Center Groningen in July 2017. The results will be disseminated through scientific publications in peer-reviewed journals, presentations at relevant conferences, and reports to stakeholders.

TRIAL REGISTRATION NUMBER

NTR7167/NL6980.

'A lifebuoy' and 'a waste of time': patients' varying experiences of multidisciplinary pain centre treatment- a qualitative study

Background

The recognition of chronic pain as a biopsychosocial phenomenon has led to the establishment of multidisciplinary pain treatment facilities, such as pain centres. Previous studies have focussed on inpatient, group-based or time-limited multidisciplinary pain programmes. The aim was to investigate variation in patients’ experiences of attending individual outpatient multidisciplinary treatment at pain centres in Norway.

Methods

This was a qualitative study using semi-structured individual interviews with 19 informants. The informants were recruited among persons who after referral by their general practitioners 12 months prior had attended multidisciplinary pain treatment at a pain centre. The data were analysed thematically using systematic text condensation.

Results

The informants had received different treatments at the pain centres. Some had undergone only one multidisciplinary assessment in which a physician, a psychologist and a physiotherapist had been present, whereas others had initially been to a multidisciplinary assessment and then continued treatment by one or more of the professionals at the centre. Their experiences ranged from the pain centre as being described as a lifebuoy by some informants who had attended treatment over time, to being described as a waste of time by others who had only attended one or two multidisciplinary sessions. Prominent experiences included being met with understanding and a perception of receiving the best possible treatment, but also included disappointment over not being offered any treatment and perceiving the multidisciplinary approach as unnecessary.

Conclusions

There were large variations in the informants’ experiences in the pain centres. The findings indicate that the pain centres’ multidisciplinary approach can represent a new approach to living with chronic pain but may also not provide anything new. Efforts should be devoted to ensuring that the pain centres’ multidisciplinary treatment approach is aligned with their patients’ actual needs.

The contribution of purpose in life to psychological morbidity and quality of life in chronic pain patients

Chronic pain is a cause of morbidity, interference with daily functioning, decreased health and quality of life. Purpose in life acts as a protective factor and mitigates these consequences. This cross-sectional study aimed to determine whether purpose in life contributed to psychological morbidity and quality of life in patients with chronic pain by controlling psychological variables related to health (pain severity and interference, pain perceptions, pain catastrophizing and coping). The sample included 103 patients diagnosed with chronic pain. Results showed that purpose in life independently contributed to psychological morbidity and to mental quality of life, but not to physical quality of life, after controlling for pain-related variables. Results showed the relevance of purpose in life to identify patients at risk of developing psychological morbidity and decreased quality of life, suggestting the need to intervene in chronic pain, specifically on purpose in life, to prevent psychological morbidity and promote quality of life, in this population.

Clinical validation of a non-invasive electrodermal biofeedback device useful for reducing chronic perceived pain and systemic inflammation

BACKGROUND

This study was performed to evaluate the potential clinical usefulness of a new non-invasive electrodermal biofeedback device in reducing perceived pain levels and chronic systemic inflammation.

MATERIALS AND METHODS

This multicenter study was designed and coordinated by BioTekna, included 20 general practice medical centers, took place between June 2010 and January 2011, and was validated clinically at the National and Kapodistrian University of Athens, Greece. The study participants were 1015 Caucasian men (401) and women (614), while the placebo-treated controls were 950 Caucasian men (500) and women (450). Patients were aged between 30 and 86 years (average age about 50 years) and all suffered from chronic pain and other medically unexplained symptoms (MUS). The RegMatEx electrodermal biofeedback device (brand BioTekna - Biomedical Technologies, Marcon, Venice, Italy) was used to evaluate the clinical efficacy of electrodermal biofeedback in reducing the level of pain perceived by decreasing the chronic systemic inflammation of the subjects. All subjects received 6 × 30 min sessions of electrodermal or placebo biofeedback given twice a week over 3 weeks. Perceived pain was evaluated using the Numeric Rating Scale (NRS) for pain, while systemic inflammation was examined with measurements of morning circulating C-reactive protein (CRP) concentrations.

RESULTS

Perceived pain in the treatment group was significantly lessened in the NRS scale (p < 005), while circulating CRP concentrations were also decreased (p < 0.05). Parallel placebo studies showed no changes in perceived pain or morning serum CRP concentrations.

DISCUSSION

Use of the electrodermal biofeedback RegMatEx device was associated with reduced pain perception and decreased chronic systemic inflammation, with stability over time. This did not occur in the placebo-treated group. The symptomatology of the treated patients significantly improved in terms of pain relief as shown on the NRS scale, and this was accompanied by reported improvements in mobility, mood, and quality of life.

CONCLUSIONS

The RegMatEx electrodermal biofeedback procedure is a non-invasive and easy to use therapeutic method, free of side effects, with high patient acceptability, excellent efficacy, and duration of effect, and, hence, a valuable tool in the treatment of chronic pain and inflammation.

Twelve-month effect of chronic pain self-management intervention delivered in an easily accessible primary healthcare service - a randomised controlled trial

Background

To investigate the effects after twelve months related to patient activation and a range of secondary outcomes on persons with chronic pain of a chronic pain self-management course compared to a low-impact outdoor physical activity, delivered in an easily accessible healthcare service in public primary care.

Methods

An open, pragmatic, parallel group randomised controlled trial was conducted. The intervention group was offered a group-based chronic pain self-management course with 2.5-h weekly sessions for a period of six weeks comprising education that included cognitive and behavioural strategies for pain management, movement exercises, group discussions and sharing of experiences among participants. The control group was offered a drop-in, low-impact, outdoor physical activity in groups in one-hour weekly sessions that included walking and simple strength exercises for a period of six weeks. The primary outcome was patient activation assessed using the Patient Activation Measure (PAM-13). Secondary outcomes included assessments of pain, anxiety and depression, pain self-efficacy, sense of coherence, health-related quality of life, well-being and the 30-s Chair to Stand Test. Analyses were performed using a linear mixed model.

Results

After twelve months, there were no statistically significant differences between the intervention group (n = 60) and the control group (n = 61) for the primary or the secondary outcomes. The estimated mean difference between the groups for the primary outcome PAM was 4.0 (CI 95% -0.6 to 8.6, p = 0.085). Within both of the groups, there were statistically significant improvements in pain experienced during the previous week, the global self-rated health measure and the 30-s Chair to Stand Test.

Conclusions

No long-term effect of the chronic pain self-management course was found in comparison with a low-impact physical activity intervention for the primary outcome patient activation or for any secondary outcome.

Trial registration

ClinicalTrials.gov: NCT02531282. Registered on August 212,015

Short-term effect of a chronic pain self-management intervention delivered by an easily accessible primary healthcare service: a randomised controlled trial

OBJECTIVES

To investigate the effects on persons with chronic pain after 3 months of a group-based chronic pain self-management course compared with a drop-in, low-impact outdoor physical group activity on patient activation and a range of secondary outcomes.

DESIGN

An open, pragmatic, parallel group randomised controlled trial. Analyses were performed using a two-level linear mixed model.

SETTING

An easily accessible healthcare service provided by Norwegian public primary healthcare.

PARTICIPANTS

A total of 121 participants with self-reported chronic pain for 3 months or more were randomised with 60 participants placed in the intervention group and 61 placed in the control group (mean age 53 years, 88% women, 63% pain for 10 years or more).

INTERVENTIONS

The intervention group was offered a group-based chronic pain self-management course with 2.5-hour weekly sessions for a period of 6 weeks. The sessions consisted of education, movement exercises and emphasised group discussions. The control group was offered a low-impact outdoor group physical activity in 1-hour weekly sessions that consisted of walking and simple strength exercises for a period of 6 weeks.

MAIN OUTCOMES

The primary outcome was patient activation assessed using the Patient Activation Measure. Secondary outcomes measured included assessments of pain, anxiety and depression, pain self-efficacy, sense of coherence, health-related quality of life, well-being and the 30 s chair to stand test.

RESULTS

There was no effect after 3 months of the group-based chronic pain self-management course compared with the control group for the primary outcome, patient activation (estimated mean difference: -0.5, 95% CI -4.8 to 3.7, p=0.802).

CONCLUSIONS

There was no support for the self-management course having a better effect after 3 months than a low-impact outdoor physical activity offered the control group.

TRIAL REGISTRATION NUMBER

NCT02531282; Results.

Participants and developers experiences with a chronic pain self-management intervention under development: A qualitative study

Background:

Non-pharmacological interventions aim to promote health and self-management for people with chronic pain.

Objective:

The aim of this study was to explore if the participants’ experiences with a self-management intervention under development were aligned with the developers’ rationale and desired outcome of the intervention.

Methods:

This was a qualitative study interviewing both participants and developers of a chronic pain self-management intervention. Seven participants, six females and one male in the age from early thirties to mid-seventies attended the chronic pain self-management intervention developed by the staff at a Healthy Life Centre. The data were analysed by the systematic text condensation method.

Results:

The analyses showed that the participants evaluated the intervention as valuable. They described using coping techniques to manage their chronic pain better, and the developers stated that the aim with the intervention was to provide the participants with coping techniques. The intervention was built upon the developers’ professional knowledge and experience in cognitive techniques, health theories, models for behavioural change, and service user involvement.

Conclusion:

This study found that the chronic pain self-management intervention was in concordance with theory of health promotion and empowerment. The participants experienced the intervention as targeting their resources, capacities, and fulfilling social needs, which aligned with the developers aim with the intervention. The participants found the intervention evocative; they learned new ways to manage their pain through theory/education, movement exercises, homework, and sharing their experiences with each other.

Usefulness of the pain sensitivity questionnaire to discriminate the pain behaviour of chronic pain patients

BACKGROUND

Chronic pain is no longer an effective warning system, but a syndrome with co-morbidities and many causes, needing a careful evaluation. Questions remain about the pain behaviour of chronic pain patients compared with patients with acute pain, or healthy subjects that we investigated.

METHODS

We compared three populations: healthy (HS, n=280), with acute pain (AP=110 patients), and chronic pain (CP=280 patients) by assessing their pain behaviour with the pain sensitivity questionnaire (PSQ-total and PSQ-minor). The influence of central sensitisation syndrome (CSS) on chronic pain behaviour, including catastrophising, was further investigated by using the central sensitisation inventory.

RESULTS

Compared with the AP patients and HS, the CP patients exhibited significantly higher catastrophising scores; higher PSQ-minor scores [29.0 (21.0-39.0), than for AP 24.0 (14.0-32.5), and for healthy subjects 25.0 (17.0-34.0); and PSQ-total scores of for CP, 63.5 for AP, and 64.0 for HS. No significant difference was observed between the HS and AP populations. Significant differences were observed between the CP patients with and without CSS. The median PSQ-minor for patients with CSS was 33.0 and without CSS was 25.0 (P<0.05); the median PSQ-total for patients with CSS was 82.0 and without CSS was 65 (P<0.05). The CP patients without CSS did not show any significant difference compared with the AP and HS groups, except for catastrophising.

CONCLUSIONS

This study highlights the influence of CSS in the results of PSQ and catastrophising by chronic pain patients in comparison with healthy controls and acute pain patients.

CLINICAL TRIAL REGISTRATION

P2014/134.

Why and when social support predicts older adults' pain-related disability: a longitudinal study

Pain-related social support has been shown to be directly associated with pain-related disability, depending on whether it promotes functional autonomy or dependence. However, previous studies mostly relied on cross-sectional methods, precluding conclusions on the temporal relationship between pain-related social support and disability. Also, research on the behavioral and psychological processes that account for such a relationship is scarce. Therefore, this study aimed at investigating the following longitudinally: (1) direct effects of social support for functional autonomy/dependence on pain-related disability, (2) mediating role of physical functioning, pain-related self-efficacy, and fear, and (3) whether pain duration and pain intensity moderate such mediating processes. A total of 168 older adults (Mage = 78.3; SDage = 8.7) participated in a 3-month prospective design, with 3 moments of measurement, with a 6-week lag between them. Participants completed the Formal Social Support for Autonomy and Dependence in Pain Inventory, the Brief Pain Inventory, the 36-SF Health Survey, behavioral tasks from the Senior Fitness Test, the Pain Self-Efficacy Questionnaire, and the Tampa Scale for Kinesiophobia. Moderated mediation analyses showed that formal social support for functional dependence (T1) predicted an increase in pain-related disability (T3), that was mediated by self-reported physical functioning (T2) and by pain-related self-efficacy (T2) at short to moderate pain duration and at low to moderate pain intensity, but not at higher levels. Findings emphasized that social support for functional dependence is a risk factor for pain-related disability and uncovered the "why" and "when" of this relationship. Implications for the design of social support interventions aiming at promoting older adults' healthy aging despite chronic pain are drawn.

Pain associated with health and economic burden in France: results from recent National Health and Wellness Survey data

Purpose

This study aimed to estimate the prevalence of pain among French adults and assess the impact of pain on health-related quality of life (HRQoL), activity impairment, and health care resource use (HRU).

Patients and methods

Respondents from the 2015 France National Health and Wellness Survey (N=19,173) were categorized by self-reported pain (experienced pain in the past 12 months vs no pain) and compared on HRQoL (36-Item Short Form Health Survey version 2: Mental Component Summary, Physical Component Summary, and Short Form-6 Dimensions health utilities), activity impairment (Work Productivity and Activity Impairment questionnaire), employment status, and HRU (health care provider visits, emergency room visits, and hospitalizations). Bivariate analyses examined differences between pain groups stratified by age, sex, income, and Charlson comorbidity index (CCI) scores.

Results

Pain prevalence was 20.2% (n=4007). Mean Physical Component Summary decrements with pain ranged from 3.4 to 8.1 points among those aged <35 years to those aged 45-54 years, respectively. Results for Mental Component Summary and Short Form-6 Dimensions scores followed similar patterns. Regardless of income, sex, or CCI group, pain was associated with significant decrements on all HRQoL measures (for all, p<0.05). The impact of pain on activity impairment was lowest among those <35 years; this impact was higher in middle age and then tapered off among those aged ≥75 years. Pain was associated with greater activity impairment and more health care provider visits across income, sex, and CCI groups (for all, p<0.05). Generally, emergency room visits were more common among those with pain across age, sex, and CCI, but they were only significantly associated with pain in the lower income group (p<0.01). Pain was associated with significantly more hospitalizations across age and income groups.

Conclusion

Results suggest pain negatively affects HRQoL, activity impairment, and HRU across demographic subgroups. These findings help underscore the considerable health and economic burden of pain in France.

Phenotype, disease severity and pain are major determinants of quality of life in Fabry disease: results from a large multicenter cohort study

Quality of life (QoL) is decreased in patients with Fabry disease (FD). To improve QoL, it is important to understand the influence of FD related characteristics, symptoms, and complications. In this retrospective cohort study we explored the effect of pain (measured by the Brief Pain Inventory), phenotype, treatment, and FD-related complications on QoL. QoL data of Fabry patients as assessed by the EuroQol five dimension questionnaire (EQ-5D) from two international centers of excellence were collected. The aim of this study was to evaluate the effect of sex, phenotype, age, different states of disease severity, pain, and ERT on EQ-5D utilities. For 286 adult FD patients (mean age 42.5 years, 40% men, 60% classical phenotype) 2240 EQ-5Ds were available. QoL is decreased in men as well as women with FD, especially in older men with a classical phenotype. At age 50, utility was lower in men with classical FD compared to those with non-classical disease (β = -0.12, 95% CI: -0.23 - 0.01, p = 0.037) with further difference in the years thereafter. Cardiovascular complications, stroke or transient ischemic attacks, multiple FD-related complications and pain were also associated with decreased utilities. Overall, no change in utility was seen in patients on ERT over a mean follow-up of 6.1 years. FD leads to a decreased QoL compared to the general population. Disease complications and pain both negatively influence QoL. Adequate assessment and treatment of pain as well as improved strategies to prevent disease complications are needed to improve QoL in the FD population.

Expectations towards participation in easily accessible pain management interventions: a qualitative study

BACKGROUND

People with chronic pain use a range of healthcare services, but they also report a high degree of dissatisfaction with treatments. One reason for dissatisfaction might be participants' expectations towards treatments. The aim of this study was to explore expectations of people with chronic pain towards participation in easily accessible pain management interventions delivered in public primary care.

METHODS

A qualitative study using semi-structured individual face-to-face interviews with 21 informants. The informants were recruited among participants enrolled in a randomised controlled trial on the effect of an easily accessible self-management course for people with chronic pain. The data were analysed thematically using Systematic Text Condensation.

RESULTS

Having experienced pain for a long time, there was no specific expectation of a cure or a significant alleviation of the pain. The informants' expectations mainly concerned a hope that participation could lead to a better everyday life. The informants said that hope was important as it motivated them to keep going and continue self-care activities. The hope acted as a driving force towards trying new interventions and maintaining motivation to do activities they experienced as beneficial. Both concrete aspects of the current intervention and an understanding of what interventions in general could offer contributed to the informants hope. The expectations centred about the interventions being something new, as they had not previously tried this service, an opportunity to gain and reinforce skills, to help them continue to grow as a person, to meet others in similar situations, and to access professional support in an easy manner. Participating in interventions provided by healthcare services was seen by some as an act of self-care, where they did something active to manage their health.

CONCLUSIONS

Expectations towards the interventions were related to a hope for participation leading to a better everyday life. The role of hope for peoples' motivation to self-care implies that service providers should be aware of and help to maintain hope for a better everyday life. The importance of social support as part of self-care should be acknowledged when developing interventions targeting chronic pain.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02531282 . Registered on August 21 2015.

Pain in osteoarthritis. Implications for optimal management

Pain is an ubiquitous symptom in osteoarticular diseases, occurring much more commonly than stiffness or disability. OA of the knee, hand, or hip affects around 20% of adults in various populations and is dramatically increasing in many countries, mostly related to age and obesity, leading to an increased number of people having OA pain, and creating a huge burden related to disability and health care costs. OA-related pain, has been classically considered to be a nociceptive pain condition. Clinicians have considered pain to be an alarm signal, correlated to the intensity of joint degradation. In OA, most authors have focused their studies on joint architecture and local degradation, considering pain as only a symptom, a consequence of joint damage. However, OA-related pain is a specific disease, with a complex pathophysiology, including neuropathic peripheral and central abnormalities, together with local inflammation involving all joint structures. Clinical findings emphasize that it is not a stable and linear condition, that pain experience is independent of structural modifications, and that the quality of pain in OA is important to consider, aside from its intensity. OA-related pain is modulated by many factors, including the individual patient's psychological and genetic factors, as well as the theoretical role of meteorological influences. Recent neuroimaging findings have improved our knowledge about central mechanisms of OA pain, especially in persistent cases.

Pain management intervention targeting nursing staff and general practitioners: Pain intensity, consequences and clinical relevance for nursing home residents

AIM

Although chronic pain is common in older adults, its treatment is frequently inappropriate. This problem is particularly prevalent in nursing home residents. We therefore developed an intervention to optimize pain management and evaluated its effects on pain intensity and pain interference with function in nursing home residents in Germany.

METHODS

In a cluster-randomized controlled intervention, 195 residents of 12 Berlin nursing homes who were affected by pain were surveyed at three points of measurement. A modified German version of the Brief Pain Inventory was used to assess pain sites, pain intensity and pain interference with function in various domains of life. The intervention consisted of separate training measures for nursing staff and treating physicians.

RESULTS

The primary objective of reducing the mean pain intensity by 2 points was not achieved, partly because the mean pain intensity at baseline was relatively low. However, marginal reductions in pain were observed in the longitudinal assessment at 6-month follow up. The intervention and control groups differed significantly in the intensity sum score and in the domain of walking. Furthermore, the proportion of respondents with pain scores >0 on three pain intensity items decreased significantly.

CONCLUSIONS

Given the multifocal nature of the pain experienced by nursing home residents, improving the pain situation of this vulnerable group is a major challenge. To achieve meaningful effects not only in pain intensity, but especially in pain interference with function, training measures for nursing staff and physicians need to be intensified, and long-term implementation appears necessary. Geriatr Gerontol Int 2017; 17: 1534-1543.

Expectations, effect and experiences of an easily accessible self-management intervention for people with chronic pain: study protocol for a randomised controlled trial with embedded qualitative study

BACKGROUND

People struggling with chronic pain may benefit from different types of non-pharmacological interventions such as self-management courses. Self-management courses aim to increase participants' skills and knowledge in managing chronic conditions. Community health-care services in Norway have increasingly established Healthy Life Centres (HLCs) to offer easily accessible interventions to people in need of support to better handle a life with chronic illness. The aim of this trial is to investigate the expectations, effect and experience of an easily accessible, group-based self-management course delivered at a HLC for people with chronic pain.

METHODS/DESIGN

This is an open pragmatic two-armed randomised controlled trial with an embedded qualitative study. The intervention is a self-management course comprising education, discussions, exchange of experiences between the participants, and physical movement exercises. The control group is offered a drop-in outdoor physical activity. The intervention period is 6 weeks. The primary outcome is patient activation measured by the patient activation measure (PAM). The secondary outcomes include measures of self-efficacy, pain and quality of life. Data will be collected at baseline, and after 3, 6 and 12 months. Using a mixed linear model, the number needed in each arm to achieve a power of 80 % becomes 55. To allow for dropout, the aim is to include 120 participants. Analysis will be done using mixed linear models. In the embedded qualitative study, we will perform semi-structured face-to-face interviews with a sample from both trial arms before randomisation and after 3 and 12 months. The topics elaborated will be motivation for participation and experiences with the activity related to possible changes in managing and coping with chronic pain.

DISCUSSION

There is need for more knowledge on interventions delivering self-care support in an easily accessible way that aim to reach those in need of this kind of health service. This trial will produce important knowledge on the effect and the experiences of participants in such an easily accessible self-management course delivered in Norwegian public primary care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02531282 . Registered on 21 August 2015.

Quality of life and coping strategies among immigrant women living with pain in Denmark: a qualitative study

OBJECTIVE

To examine quality of life and coping strategies among immigrant women living with chronic pain.

DESIGN

Qualitative content analysis based on in-depth semistructured interviews.

SETTING

A clinic specifically targeting immigrants at a larger university hospital in Copenhagen, Denmark.

PARTICIPANTS

Non-western female immigrant patients suffering from chronic pain (n=13).

MAIN OUTCOME MEASURES

Experiences of the impact of chronic pain on quality of life.

RESULTS

Chronic pain was perceived to have an extensive, adverse effect on all aspects of quality of life, including physical health, mental well-being and social relations. This included the ability to maintain activities of daily living and the ability to work. Chronic pain was further experienced as a cause of emotional distress, depression and altered personalities, which all had great consequences on women's social interactions, causing change and loss of social relations. A variety of coping strategies were used to cope with the pain, manage its consequences, and restore a level of health that would enable women to function and fulfil social roles. Many participants coped with the pain by altering everyday life, keeping daily activities to a minimum and taking pain-killing drugs, offering temporary relief. Seeking healthcare was another coping strategy used as an active means to assert agency and as a temporary distraction from pain. However, accessing healthcare also involved a risk of disagreement and disappointments.

CONCLUSIONS

Chronic pain had a severe negative impact on quality of life and necessitated alterations in everyday life and active health-seeking strategies. Implications for practice imply a need for a more holistic approach to immigrant women with chronic pain, including a family-centred approach. Further research is needed to explore similarities or differences in and between populations with diverse ethnic, socioeconomic and psychosocial backgrounds, and to assess how ethnicity and culture might influence the experiences of chronic pain.

Osteoarthritis pain

Osteoarthritis (OA) represents one of the most frequently occurring painful conditions. Pain is the major OA symptom, involving both peripheral and central neurological mechanisms. OA pain is initiated from free axonal endings located in the synovium, periosteum bone, and tendons, but not in the cartilage. The nociceptive message involves not only neuromediators and regulating factors such as neuronal growth factor (NGF) but also central modifications of pain pathways. OA pain is a mixed phenomenon where nociceptive and neuropathic mechanisms are involved in both the local and central levels. OA pain perception is influenced by multiple environmental, psychological, or constitutional factors, and OA pain intensity is not correlated with joint degradation. OA pain may present with different clinical features: constant and intermittent pain, with or without a neuropathic component, and with or without central sensitization. Finally, OA pain should be considered as a complex and not unique pain condition, where precise clinical assessment may drive specific therapeutic approaches.

A holistic approach to chronic pain management that involves all stakeholders: change is needed

Chronic pain affects a large proportion of the population, imposing significant individual distress and a considerable burden on society, yet treatment is not always instituted and/or adequate. Comprehensive multidisciplinary management based on the biopsychosocial model of pain has been shown to be clinically effective and cost-efficient, but is not widely available. A literature review of stakeholder groups revealed many reasons for this, including: i) many patients believe healthcare professionals lack relevant knowledge, and consultations are rushed, ii) general practitioners consider that pain management has a low priority and is under-resourced, iii) pain specialists cite non-adherence to evidence-based treatment, sub-optimal prescribing, and chronic pain not being regarded as a disease in its own right, iv) nurses', pharmacists' and physiotherapists' skills are not fully utilized, and v) psychological therapy is employed infrequently and often too late. Many of the issues relating to physicians could be addressed by improving medical training, both at undergraduate and postgraduate levels - for example, by making pain medicine a compulsory core subject of the undergraduate medical curriculum. This would improve physician/patient communication, increase the use of standardized pain assessment tools, and allow more patients to participate in treatment decisions. Patient care would also benefit from improved training for other multidisciplinary team members; for example, nurses could provide counseling and follow-up support, psychologists offer coping skills training, and physiotherapists have a greater role in rehabilitation. Equally important measures include the widespread adoption of a patient-centered approach, chronic pain being recognized as a disease in its own right, and the development of universal guidelines for managing chronic non-cancer pain. Perhaps the greatest barrier to improvement is lack of political will at both national and international level. Some powerful initiatives and collaborations are currently lobbying policy-making bodies to raise standards and reduce unnecessary pain - it is vital they continue.

Persistent postsurgical pain: evidence from breast cancer surgery, groin hernia repair, and lung cancer surgery

The prevalences of severe persistent postsurgical pain (PPP) following breast cancer surgery (BCS), groin hernia repair (GHR), and lung cancer surgery (LCS) are 13, 2, and 4-12 %, respectively. Estimates indicate that 80,000 patients each year in the U.S.A. are affected by severe pain and debilitating impairment in the aftermath of BCS, GHR, and LCS. Data across the three surgical procedures indicate a 35-65 % decrease in prevalence of PPP at 4-6 years follow-up. However, this is outweighed by late-onset PPP, which appears following a pain-free interval. The consequences of PPP include severe impairments of physical, psychological, and socioeconomic aspects of life. The pathophysiology underlying PPP consists of a continuing inflammatory response, a neuropathic component, and/or a late reinstatement of postsurgical inflammatory pain. While the sensory profiles of PPP-patients and pain-free controls are comparable with hypofunction on the surgical side, this seems to be accentuated in PPP-patients. In BCS-patients and GHR-patients, the sensory profiles indicate inflammatory and neuropathic components with contribution of central sensitization. A number of surgical factors including increased duration of surgery, repeat surgery, more invasive surgical techniques, and intraoperative nerve lesion have been associated with PPP. One of the most consistent predictive factors for PPP is high intensity acute postsurgical pain, but also psychological factors including anxiety, catastrophizing trait, depression, and psychological vulnerability have been identified as significant predictors of PPP. The quest to identify improved surgical and anesthesiological techniques to prevent severe pain and functional impairment in patients after surgery continues.

"Let's talk about OA pain": a qualitative analysis of the perceptions of people suffering from OA. Towards the development of a specific pain OA-Related questionnaire, the Osteoarthritis Symptom Inventory Scale (OASIS)

INTRODUCTION

Pain is the primary outcome measurement in osteoarthritis, and its assessment is mostly based on its intensity. The management of this difficult chronic condition could be improved by using pain descriptors to improve analyses of painful sensations. This should help to define subgroups of patients based on pain phenotype, for more adapted treatment. This study draws upon patients' descriptions of their pain, to identify and understand their perception of osteoarthritis pain and to categorize pain dimensions.

METHODS

This qualitative study was conducted with representative types of patients suffering from osteoarthritis. Two focus groups were conducted with a sample of 14 participants, with either recent or chronic OA, at one or multiple sites. Focus groups were semi-structured and used open-ended questions addressing personal experiences to explore the experiences of patients with OA pain and the meanings they attributed to these pains.

RESULTS

TWO MAIN POINTS EMERGED FROM CONTENT ANALYSES: -A major difficulty in getting patients to describe their osteoarthritis pain: perception that nobody wants to hear about it; necessity to preserve one's self and social image; notion of self-imposed stoicism; and perception of osteoarthritis as a complex, changing, illogical disease associated with aging. -Osteoarthritis pains were numerous and differed in intensity, duration, depth, type of occurrence, impact and rhythm, but also in painful sensations and associated symptoms. Based on analyses of the verbatim interviews, seven dimensions of OA pain emerged: pain sensory description, OA-related symptoms, pain variability profile, pain-triggering factors, pain and physical activity, mood and image, general physical symptoms.

SUMMARY

In osteoarthritis, pain analysis should not be restricted to intensity. Our qualitative study identified pain descriptors and defined seven dimensions of osteoarthritis pain. Based on these dimensions, we aim to develop a specific questionnaire on osteoarthritis pain quality for osteoarthritis pain phenotyping: the OsteoArthritis Symptom Inventory Scale (OASIS).

The costs and consequences of adequately managed chronic non-cancer pain and chronic neuropathic pain

BACKGROUND

Chronic pain is distressing for patients and a burden on healthcare systems and society. Recent research demonstrates different aspects of the negative impact of chronic pain and the positive impact of successful treatment, making an overview of the costs and consequences of chronic pain appropriate.

OBJECTIVE

To examine recent literature on chronic noncancer and neuropathic pain prevalence, impact on quality and quantity of life, societal and healthcare costs, and impact of successful therapy.

METHODS

Systematic reviews (1999 to February 2012) following PRISMA guidelines were conducted to identify studies reporting appropriate outcomes.

RESULTS

Chronic pain has a weighted average prevalence in adults of 20%; 7% have neuropathic pain, and 7% have severe pain. Chronic pain impeded activities of daily living, work and work efficiency, and reduced quality and quantity of life. Effective pain therapy (pain intensity reduction of at least 50%) resulted in consistent improvements in fatigue, sleep, depression, quality of life, and work.

CONCLUSION

Strenuous efforts should be put into obtaining good levels of pain relief for people in chronic pain, including the opportunity for multiple drug switching, using reliable, validated, and relatively easily applied patient-centered outcomes. Detailed, thoughtful and informed decision analytic policy modeling would help understand the key elements in organizational change or service reengineering to plan the optimum pain management strategy to maximize pain relief and its stream of benefits against budgetary and other constraints. This paper contains the information on which such models can be based.