Age-related differences in the qualities but not the intensity of chronic pain

Impact of Ultrasound-Guided Foam Sclerotherapy for Pain Control in Patients with Chronic Venous Disease and Great Saphenous Vein Reflux

Chronic venous disease (CVD) associated with great saphenous vein (GSV) reflux has a higher prevalence of pain in the lower limbs. This study evaluates the impact of ultrasound-guided foam sclerotherapy (UGFS) for GSV and symptom control, accessed by the visual analogue scale (VAS). Patients with CVD who underwent GSV-UGFS were included in this retrospective cohort (417 limbs). The pain was measured before and after the treatment. The scale alteration was assessed as a function of age, sex, Clinical Etiologic Anatomic Pathophysiologic (CEAP) classes, total of sclerotherapy sessions, GSV occlusion patterns, and ulcer healing. Majority of patients were female (59.2%), and the mean age was 56 ± 11.5 years. In the total sample, 78.2% of the GSVs were fully occluded, 19.7% had partial occlusion, 2.2% remained open, and 3.2 ± 1.9 (median = 3.0) sessions were performed. The reduction of symptoms occurred in 88.3% of participants (VAS drop median = 4.8). Patients younger than 50 years and females had the greatest VAS decreases. When comparing the outcomes of complete occlusion versus partial occlusion, there was no significant difference in VAS pain reduction ( p  = 0.14). The comparison between CEAP clinical classes also did not show statistically significant differences in delta VAS ( p  = 0.71). GSV-UGFS was effective for pain control. However, this improvement does not appear to be related to the pattern of occlusion, indicating that in the short term, the outcomes of total and partial occlusion suggest successful management of symptoms. Other aspects such as gender, age, pretreatment pain intensity, and CEAP classes seem to play a role in the clinical outcome.

Neuropsychiatric Outcomes in Intensive Care Unit Survivors

BACKGROUND

Over the last two decades, there has been phenomenal advancement in critical care medicine and patient management. Many patients recover from life-threatening illnesses that they might not have survived a decade ago. Despite a decrease in mortality, these survivors endure long-lasting sequelae like physical, mental, and emotional symptoms.

METHODS

Patients after intensive care unit (ICU) discharge were assessed in a follow-up outpatient department (OPD) clinic for anxiety, stress, and depression. Patients were asked to fill out the questionnaires Depression, Anxiety and Stress Scale-21 (DASS-21) and Short Form-36 (SF-36) for assessment of health-related quality of life (HRQOL) at 4th, 6th, and 8th months after discharge. ICU data were recorded, including patients' demographics, severity of illness and length of stay, and duration of mechanical ventilation. Patients who failed to follow-up in OPD on designated dates were assessed telephonically.

RESULTS

Depression showed a positive, strong, and moderate correlation between length of stay and mechanical ventilation duration. A positive correlation was found between stress and length of stay and duration of mechanical ventilation. A positive strong correlation was found between anxiety and length of ICU stay, and a moderate positive correlation was found between anxiety and duration of mechanical ventilation. A weak correlation was found between age and neuropsychiatric outcomes.

CONCLUSION

The severity of depression, anxiety, and stress was significantly higher at four months compared to six months. Severity decreased with time. Prolonged ICU stay increased levels of anxiety, depression, and stress. HRQOL improved from four to six months.

Relationship between the affective dimension of pain and site of the disorder: A cross-sectional study

BACKGROUND

Pain is a complex experience with both sensory and affective dimensions, and the affective dimension can increase the risks of chronic pain development. It is thus critical to identify factors influencing the affective dimension of pain.

OBJECTIVE

This study aimed to identify the relationship between the affective dimension of pain and disorder site (primary pain source).

METHODS

Study participants were recruited from patients referred for physical therapy at an orthopedic outpatient clinic. Pain quality including the affective dimension, disorder site from descriptive medical diagnosis, pain intensity, duration from pain onset, and demographic data, was collected. A multivariable logistic regression model was constructed to analyze the relationship between the affective dimension of pain and the disorder site.

RESULTS

A total of 282 participants were included. Cervical and lumbar spine disorders were significantly associated with an affective dimension of pain compared to limbs disorders when adjusted for age, sex, pain intensity, and duration from the onset in the regression model.

CONCLUSIONS

Regardless of duration from the onset and other confounding factors, disorder site is correlated with the affective dimension of pain. Multidimensional pain assessment is crucial when clinicians evaluate patients with cervical and lumbar spine disorders, even in the acute phase.

Long-term opioid use in patients treated with head and neck intensity-modulated radiotherapy

PURPOSE

Acute and chronic pain during and after radiotherapy is an important driver of poor quality of life. We aimed to identify risk factors associated with increased chronic opioid use in head and neck squamous cell cancer survivors.

METHODS

We performed a retrospective cohort analysis on head and neck squamous cell cancer patients treated with definitive or adjuvant intensity-modulated radiotherapy. We tracked their oncologic opioid prescription profile from initial presentation to the last follow-up date. We determined the incidences of 1- and 2-year opioid use and performed multivariate logistic regression for both outcomes.

RESULTS

Our analytic cohort consisted of 403 head and neck squamous cell cancer survivors. The numbers of patients requiring opioids at 3 months, 6 months, and 1 year after treatment were 316 (78%), 203 (50%), and 102 (25%), respectively. On multivariate logistic regression, positive smoking history (95% CI 1.86 [1.03, 3.43], p = 0.04), unemployment (95% CI 2.33 [1.16, 4.67], p = 0.02), prior psychiatric illness (95% CI 2.15 [1.05, 4.40], p = 0.03), and opiate use before radiotherapy (95% CI 2.75 [1.49, 5.20], p = 0.01) were independently associated with significantly greater odds of opioid use at 1 year.

CONCLUSIONS

Our institutional analysis has shown that a substantial amount of head and neck cancer survivors are chronically dependent on opioids following radiotherapy. We have identified a cohort at highest risk for long-term use, for whom early interventions should be targeted.

Assessing Pain Research: A Narrative Review of Emerging Pain Methods, Their Technosocial Implications, and Opportunities for Multidisciplinary Approaches

Pain research traverses many disciplines and methodologies. Yet, despite our understanding and field-wide acceptance of the multifactorial essence of pain as a sensory perception, emotional experience, and biopsychosocial condition, pain scientists and practitioners often remain siloed within their domain expertise and associated techniques. The context in which the field finds itself today-with increasing reliance on digital technologies, an on-going pandemic, and continued disparities in pain care-requires new collaborations and different approaches to measuring pain. Here, we review the state-of-the-art in human pain research, summarizing emerging practices and cutting-edge techniques across multiple methods and technologies. For each, we outline foreseeable technosocial considerations, reflecting on implications for standards of care, pain management, research, and societal impact. Through overviewing alternative data sources and varied ways of measuring pain and by reflecting on the concerns, limitations, and challenges facing the field, we hope to create critical dialogues, inspire more collaborations, and foster new ideas for future pain research methods.

Evaluation of the psychometric properties of patient-reported and clinician-reported outcome measures of chemotherapy-induced peripheral neuropathy: a COSMIN systematic review protocol

INTRODUCTION

Chemotherapy-induced peripheral neuropathy (CIPN) is a poorly understood side effect of many antineoplastic agents. Patients may experience sensory, motor and autonomic symptoms, negatively impacting quality of life. A gold-standard assessment methodology has yet to be determined, limiting efforts to identify effective agents to prevent or treat CIPN.

METHODS AND ANALYSIS

This is a protocol of a systematic review of psychometric analyses of CIPN Clinician Reported Outcome Measures (ClinROM) and Patient-Reported Outcome Measures (PROM) among adults receiving, or who had previously received chemotherapy for cancer. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) quality ratings will be compared across studies and across ClinROMs and PROMs. Studies reporting psychometric proprieties of CIPN ClinROMs and/or PROMs among adults aged ≥18 years will be eligible for inclusion, with no restriction on language or year of publication. MEDLINE, Embase, CINAHL and APA PsycINFO databases will be searched from inception to 31 December 2021. Study characteristics, measurement properties of the ClinROMs and/or PROMs and the CIPN definitions will be extracted. The Synthesis Without Meta-analysis guideline will be used to guide data synthesis. The COSMIN Risk of Bias checklist will be used by two independent raters to assess methodological quality. Subgroup analyses by age, chemotherapy type, and study timing in relation to the delivery of chemotherapy will be carried out where data are available. An adapted version of Outcome Measures in Rheumatology filter 2.1 will be used to provide a best-evidence synthesis of CIPN ClinROMs and PROMs and to recommend a CIPN assessment tool for clinical and research settings.

ETHICS AND DISSEMINATION

Ethical approval is not necessary to be obtained for this systematic review protocol. Results will be disseminated to clinicians and policy-makers by publication in a peer-reviewed journal and by presenting at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42021278168.

A Randomized controlled trial of the Sources of Meaning Card Method: A new meaning-oriented approach predicts depression, anxiety, pain acceptance, and crisis of meaning in chronic pain patients

OBJECTIVE

Although considered the first-line psychological treatment of chronic pain, cognitive behavioural therapy has recently been criticized as being too limited, insufficient, and sometimes ineffective in the treatment of chronic pain patients. Moreover, important existential perspectives are sparsely or not at all integrated into CBT. We therefore propose to complement chronic pain treatment with a meaning-based intervention, the Sources of Meaning Card Method (SoMeCaM). This study tested its efficacy.

DESIGN

A randomized controlled trial was conducted with 42 chronic pain patients, comparing an intervention group (standard care and participation in the SoMeCaM, a meaning-oriented approach) with a control group (standard care). We evaluated both groups at baseline, 1 (t1) and 2 months (t2) after the intervention. The primary outcome assessed was pain acceptance, while depression, anxiety, pain intensity, pain medication, satisfaction with life, meaningfulness, and crisis of meaning were examined as secondary outcomes.

RESULTS

Comparisons within and between groups showed significant treatment effects at t1. Higher increases in pain acceptance and decreases in anxiety, depression and crisis of meaning were observed in the intervention group. Improvements in pain acceptance and anxiety persisted until t2, when pain intensity was also lower. Effect sizes at t2 were medium to large.

CONCLUSION

Our preliminary work demonstrates the importance of the existential perspective in chronic pain therapy.

Evaluating the impact of age and inflammatory duration on behavioral assessments of nociception

Pain is a prevalent issue for elderly individuals. Unfortunately, it remains unclear how acute and chronic pain differs as a function of age, and surprisingly, there is even disagreement on how the sensory and affective dimensions of pain change with age. Therefore, the current investigation evaluated such age differences with behavioral methodology using a preclinical model of arthritis. The primary factors of interest were age and chronicity of pain using behavioral assessments designed to measure sensory and affective dimensions of pain processing. Mechanical and thermal paw withdrawal thresholds demonstrated unique outcomes associated with sensory processing across age. The processing of pain affect measured by the Place Escape/Avoidance Paradigm (PEAP testing) also demonstrated age related effects. Overall, younger animals appeared more sensitive to nociceptive stimuli than older animals. However, the results from the current study suggest that chronicity of pain can be impactful for how older animals process pain related affect and avoidance. The finding of unique patterns of pain across age and duration of pain highlights the clinical literature. Future research should aim to elucidate mechanisms for affective processing of chronic pain in older subjects.

Personalized Virtual Reality Human-Computer Interaction for Psychiatric and Neurological Illnesses: A Dynamically Adaptive Virtual Reality Environment That Changes According to Real-Time Feedback From Electrophysiological Signal Responses

Virtual reality (VR) constitutes an alternative, effective, and increasingly utilized treatment option for people suffering from psychiatric and neurological illnesses. However, the currently available VR simulations provide a predetermined simulative framework that does not take into account the unique personality traits of each individual; this could result in inaccurate, extreme, or unpredictable responses driven by patients who may be overly exposed and in an abrupt manner to the predetermined stimuli, or result in indifferent, almost non-existing, reactions when the stimuli do not affect the patients adequately and thus stronger stimuli are recommended. In this study, we present a VR system that can recognize the individual differences and readjust the VR scenarios during the simulation according to the treatment aims. To investigate and present this dynamically adaptive VR system we employ an Anxiety Disorder condition as a case study, namely arachnophobia. This system consists of distinct anxiety states, aiming to dynamically modify the VR environment in such a way that it can keep the individual within a controlled, and appropriate for the therapy needs, anxiety state, which will be called "desired states" for the study. This happens by adjusting the VR stimulus, in real-time, according to the electrophysiological responses of each individual. These electrophysiological responses are collected by an external electrodermal activity biosensor that serves as a tracker of physiological changes. Thirty-six diagnosed arachnophobic individuals participated in a one-session trial. Participants were divided into two groups, the Experimental Group which was exposed to the proposed real-time adaptive virtual simulation, and the Control Group which was exposed to a pre-recorded static virtual simulation as proposed in the literature. These results demonstrate the proposed system's ability to continuously construct an updated and adapted virtual environment that keeps the users within the appropriately chosen state (higher or lower intensity) for approximately twice the time compared to the pre-recorded static virtual simulation. Thus, such a system can increase the efficiency of VR stimulations for the treatment of central nervous system dysfunctions, as it provides numerically more controlled sessions without unexpected variations.

Knee Osteoarthritis Grade does not Correlate with Quadriceps Muscle Strength or Bone Properties of the Calcaneus in Men Aged 80 Years or More who Can Walk independently

Purpose: Muscle weakness and bone deterioration in the elderly are related to falls and fractures, resulting in decreased mobility. Knee osteoarthritis also may contribute to falls and fractures and thereby affect mortality rates. The Kellgren–Lawrence (KL) classification is widely used in the radiographic evaluation of knee osteoarthritis. Aims: This study aimed to evaluate the quadriceps strength and bone properties of the calcaneus for each KL grade, and to clarify the impact of knee osteoarthritis grade on quadriceps strength and bone properties. Methods: This prospective cross-sectional study included data on 108 male patients (213 knees), aged ≥80 years, who could walk independently. A handheld dynamometer was used to measure quadriceps strength. Bone properties were evaluated using broadband ultrasound attenuation with a portable bone densitometer. Weight-bearing standing knee radiographs were evaluated using KL classification. Quadriceps strength and bone properties were evaluated for each KL grade and the correlations between the grade and quadriceps strength and bone properties were assessed simultaneously. Results: The numbers of participants in KL grades I–IV were 46, 102, 45, and 20, respectively. There were no differences among grades for either quadriceps strength or bone properties. Conclusions: Participants exhibited good quadriceps strength and bone properties regardless of their KL grade. Relatively high mechanical loading of muscle and bone incurred while walking independently, likely explaining this result. Clinically, this study demonstrated the absence of correlations between KL grade and quadriceps strength and bone properties, as was previously reported in studies showing the absence of a correlation between KL grade and pain.

The impact of aging on pressure pain thresholds: are men less sensitive than women also in older age?

PURPOSE

Men have generally demonstrated higher pressure pain thresholds (PPT) than women. However, the possible impact of aging on the gender differences in pain perception has not been fully evaluated. In this study, we aimed to investigate the gender differences in PPT over the life course, in young, middle-aged and older adults.

METHODS

This cross-sectional study involved 355 pain-free healthy individuals aged 19-95 years, divided into < 45, 45-64 and ≥ 65 years age groups. PPT were measured using Fisher's algometer. Data on anthropometry, formal education and occupation were collected for each participant, and a multidimensional geriatric assessment was performed in older individuals.

RESULTS

Lower PPT values were observed in old vs young adults (21.8 ± 8.7 N/cm² vs 59.5 ± 31.6, p < 0.0001) and in women vs men (16.3 ± 6.1 vs 42.8 ± 19.6 N/cm², p = 0.0003). A significant interaction emerged between age and sex in influencing PPT (p_interaction = 0.03). Although women had lower mean PPT values than men in all age groups, such gender difference diminished with aging, from 42.8 ± 19.6 vs 59.5 ± 31.6 N/cm² (p = 0.001) to 16.3 ± 6.1 vs 21.8 ± 8.7 vs N/cm² (p = 0.003) in younger and older women vs men, respectively.

CONCLUSIONS

Female gender and older age are associated with lower PPT, but such gender difference seems to decrease with aging.

Pain in Head and Neck Cancer Survivors: Prevalence, Predictors, and Quality-of-Life Impact

Objectives

Pain is common among patients with cancer, stemming from both malignancy and side effects of treatment. The extent to which pain persists after treatment has received little attention. We examined the prevalence, predictors, and impact on quality of life (QOL) caused by pain among survivors of head and neck cancer.

Study Design

Cohort study.

Setting

Tertiary head and neck cancer survivorship clinic.

Subjects and Methods

We identified survivors of head and neck cancer ≥1 year after diagnosis and examined the prevalence and risk factors for development of pain. Pain and QOL were assessed with multiple QOL instruments. Ordinal regression modeling examined predictors of pain in survivors.

Results

We identified 175 patients at a median of 6.6 years after diagnosis. Among survivors, 45.1% reported pain, and 11.5% reported severe pain. Among patients with current pain, 46% reported low overall QOL versus only 12% of those without pain ( P < .001). On multivariable analysis after adjustment for age, sex, and stage of disease, pain was associated with trimodality treatment (odds ratio [OR], 3.55; 95% CI, 1.06-12.77). Multivariable analysis of QOL issues revealed that pain was associated with major depression (OR, 3.91; 95% CI, 1.68-9.11), anxiety (OR, 4.22; 95% CI, 2.28-7.81), poor recreation (OR, 3.31; 95% CI, 1.70-6.48), and low overall QOL (OR, 2.20; 95% CI, 1.12-4.34).

Conclusions

Years after head and neck cancer treatment, pain remains a significant problem and is associated with worse QOL. Future efforts should focus on preventing pain from treatment and comprehensive management.

Physical, Emotional, and Social Impacts of Restricting Back Pain in Older Adults: A Qualitative Study

Objective

Back pain is the most common type of pain reported by older adults, yet current management strategies often do not address the multi-dimensional impacts on older adults who face unique challenges as compared with younger populations. The objective of this qualitative study was to assess the physical, psychological, and social impacts of back pain (severe enough to restrict activity, hereafter referred to as restricting back pain) on older adults.

Design

This was a qualitative study using semi-structured interviews and focus groups.

Setting and Patients

This study was comprised of a diverse sample of 93 community-living older adults (median age 83) with restricting back pain.

Methods

We used a semi-structured guide in 23 interviews and 16 focus groups to discuss the various ways that restricting back pain impacted participants. Transcripts were analyzed in an iterative process to develop thematic categories.

Results

Restricting back pain affected participants physically (inability to execute routine tasks, disruption of sleep and exercise), psychologically (feelings of sadness and irritability, fears about worsening health, loss of hope towards recovery or pain relief), and socially (experiences of isolation, inability to pursue hobbies).

Conclusions

These data inform which outcomes should be measured in studies evaluating treatments for older adults with restricting back pain.

Age Differences in the Correlates of Physical Functioning in Patients With Chronic Pain

OBJECTIVES

Pain-related disability in the elderly is a major contributor to poor quality of life. In this study, the author examined age-related differences in the factors associated with physical disability in the context of chronic pain.

METHOD

A large cohort of chronic pain patients was categorized into four age groups, and correlates of physical disability were evaluated within each age category.

RESULTS

Several important age differences in the predictors of physical disability were noted. Affective distress was unrelated to physical disability among the elderly, whereas this association was quite strong among younger patients. In contrast, pain severity was a weak predictor of disability within the younger group, but it accounted for more than one fourth of the variance in physical disability in those older than 65.

DISCUSSION

These data suggest that the determinants of functioning may vary across the life span, implying a potential for pain management programs tailored to a patient's age.

Impaired recognition memory and cognitive flexibility in the rat L5-L6 spinal nerve ligation model of neuropathic pain

BACKGROUND AND AIMS

Although neuropathic pain is known to negatively affect cognition, the neural mechanisms involved are poorly understood. Chronic pain is associated with changes in synaptic plasticity in the brain which may impact on cognitive functioning. The aim of this study was to model neuropathic pain in mid-aged rats using spinal nerve ligation (SNL). Following establishment of allodynia and hyperalgesia, behaviour was assessed in a battery of cognitive tests. Expression of the presynaptic protein, synaptophysin, and its colocalisation with the vesicular GABA and glutamate transporters (vGAT and vGLUT, respectively), was investigated in the medial prefrontal cortex (mPFC) and hippocampus.

METHODS

Nine month old male Sprague Dawley rats underwent L5-L6 spinal nerve ligation or a sham procedure. Mechanical and cold allodynia and thermal hyperalgesia were assessed using von Frey, acetone and Hargreaves tests, respectively. Cognition was assessed in the novel-object recognition, air-puff passive avoidance and Morris water maze behavioural tasks. Immunohistochemistry was used to examine the expression of synaptophysin in the mPFC and CA1 region of the hippocampus and double labelling of synaptophysin and the vesicular transporters vGAT and vGlut was used to investigate the distribution of synaptophysin on GABAergic and glutamatergic neurons.

RESULTS

SNL rats displayed impaired performance in the novel-object recognition task. Passive-avoidance responding, and spatial learning and memory in the Morris water maze, were unaffected by SNL surgery. However, in the water maze reversal task, pain-related impairments were evident during training and probe trials. SNL surgery was not associated with any differences in the expression of synaptophysin or its colocalisation with vGAT or vGLUT in the mPFC or the hippocampal CA1 region.

CONCLUSIONS

These results suggest that the SNL model of neuropathic pain is associated with deficits in recognition memory and cognitive flexibility, but these deficits are not associated with altered synaptophysin expression or distribution in the mPFC and CA1.

IMPLICATIONS

Cognitive complaints are common amongst chronic pain patients. Here we modelled cognitive impairment in a well-established animal model of neuropathic pain and investigated the neural mechanisms involved. A better understanding of this phenomenon is an important prerequisite for the development of improved treatment of patients affected.

Transcutaneous electrical nerve stimulation for pain relief after liposuction: a randomized controlled trial

BACKGROUND

Liposuction is a common cosmetic surgical procedure, which requires analgesia for postoperative pain. Transcutaneous electrical nerve stimulation (TENS) has been used for postoperative pain relief; however, there is no evidence of its effectiveness in liposuction patients and this is the focus of this paper.

METHODS

A prospective, randomized, double-blind, controlled trial was conducted with 42 adult patients who underwent liposuction. Patients were randomly allocated to either the TENS group (active TENS) or control group (sham TENS). All patients received morphine (0.1 mg/kg) and dipyrone 1 g immediately after surgery; TENS was delivered 2 h later. The primary outcome was pain intensity. Secondary outcomes were analgesic requirement, number and types of adverse effects of TENS, quality of pain, treatment success, and patient satisfaction. Postoperative pain was measured using a visual analog scale (VAS) and the Brazilian version of the McGill Pain Questionnaire (Br-MPQ).

RESULTS

Patients in the TENS group reported significantly lower pain intensity (P < 0.001, effect size = 0.92) compared with those in the control group. TENS significantly decreased the consumption of analgesics in the postoperative period (P < 0.001). No withdrawals or adverse effects were observed in the TENS group, but 33.3% of patients in the control group reported drowsiness and nausea. About 95 and 38% of patients in the TENS and control groups, respectively, were satisfied with the analgesic treatment.

CONCLUSION

The results indicate that TENS is effective as an adjunct to analgesics for pain relief after liposuction.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Illness representations of restricting back pain: the older Person’s perspective

OBJECTIVE

Back pain is the most common type of pain reported by older adults, leading to considerable morbidity and cost. Yet little is known about the segment of the population ≥80 years old that can be used to guide care in this age group. Illness representations provide a useful framework to understand older adults' beliefs and perceptions of their back pain. The objective of this study was to understand illness representations of back pain, severe enough to restrict activity (restricting back pain).

DESIGN

Qualitative research using semi-structured interviews.

SUBJECTS

Twenty-three community-living older adults ≥80 years old with restricting back pain.

METHODS

We used an interview guide to stimulate discussion about how older adults understand and perceive living with restricting back pain. Thematic codes were created to categorize the nuances of participants' restricting back pain experiences.

RESULTS

Participants reported five important components of illness representation: 1) identity,the label and symptoms individuals assign to the illness; 2) timeline, the individual's perceived clinical course of the illness; 3) cause, the individual's perceived etiology of the illness; 4) consequences,the perceived impact of the illness; and 5) cure control,the perceived degree to which cure or management is possible/likely.

CONCLUSIONS

Thematic analysis revealed that restricting back pain in older adults has variable and noteworthy physical, psychological and social consequences.There are several components of the illness representation of restricting back pain, specifically,the perceptions of consequences and control that may offer potential targets for clinical intervention.

Effects of continuous epidural anesthesia and postoperative epidural analgesia on pain management and stress response in patients undergoing major spinal surgery

STUDY DESIGN

A prospective, randomized study was used to compare 2 anesthesia/analgesia methods for reconstructive spine surgery.

OBJECTIVE

To assess the efficacy and influence of 2 anesthetic methods on clinical outcome and stress response during reconstructive spine surgery.

SUMMARY OF BACKGROUND DATA

Pain control is an important goal of the postoperative care after spinal surgery. Some prior studies have suggested that epidural anesthesia with or without postoperative epidural analgesia may blunt the surgical stress response after major surgery. This treatment approach has not been fully investigated for patients undergoing major spinal surgery. We hypothesized that the stress response after major spine surgery would be attenuated by continuous epidural anesthesia/analgesia with ropivacaine, fentanyl, and epinephrine.

METHODS

Eighty-five patients were randomly allocated to 2 groups as follows: group E (n = 45) had epidural anesthesia and endotracheal anesthesia with sevoflurane during surgery and continuous epidural analgesia with ropivacaine, fentanyl, and epinephrine after surgery; group G (n = 40) had general anesthesia with sevoflurane and fentanyl and systemically administered opioids after surgery. Patient pain, nausea, mobility, and satisfaction were measured after surgery along with levels of cortisol, glucose, interleukin (IL)-1β, IL-6, and IL-10 during and after surgery.

RESULTS

In group E, there were significantly less pain, less nausea, earlier mobility, and higher satisfaction than those in group G. Group E also experienced significantly less introperative and postoperative blood loss. Group E demonstrated lower levels of glucose, cortisol, IL-1β, IL-6, and IL-10 during the postoperative period.

CONCLUSION

Combined epidural/general anesthesia and postoperative epidural analgesia produced better pain control, less bleeding, and a lower surgical stress response than general anesthesia with postoperative systemically administered narcotic analgesia. This technique deserves further study in the setting of major spinal surgery.

Differences in the symptom experience of older versus younger oncology outpatients: a cross-sectional study

Background

Mortality rates for cancer are decreasing in patients under 60 and increasing in those over 60 years of age. The reasons for these differences in mortality rates remain poorly understood. One explanation may be that older patients received substandard treatment because of concerns about adverse effects. Given the paucity of research on the multiple dimensions of the symptom experience in older oncology patients, the purpose of this study was to evaluate for differences in ratings of symptom occurrence, severity, frequency, and distress between younger (< 60 years) and older ( ≥ 60 years) adults undergoing cancer treatment. We hypothesized that older patients would have significantly lower ratings on four symptom dimensions.

Methods

Data from two studies in the United States and one study in Australia were combined to conduct this analysis. All three studies used the MSAS to evaluate the occurrence, severity, frequency, and distress of 32 symptoms.

Results

Data from 593 oncology outpatients receiving active treatment for their cancer (i.e., 44.4% were < 60 years and 55.6% were ≥ 60 years of age) were evaluated. Of the 32 MSAS symptoms, after controlling for significant covariates, older patients reported significantly lower occurrence rates for 15 (46.9%) symptoms, lower severity ratings for 6 (18.9%) symptoms, lower frequency ratings for 4 (12.5%) symptoms, and lower distress ratings for 14 (43.8%) symptoms.

Conclusions

This study is the first to evaluate for differences in multiple dimensions of symptom experience in older oncology patients. For almost 50% of the MSAS symptoms, older patients reported significantly lower occurrence rates. While fewer age-related differences were found in ratings of symptom severity, frequency, and distress, a similar pattern was found across all three dimensions. Future research needs to focus on a detailed evaluation of patient and clinical characteristics (i.e., type and dose of treatment) that explain the differences in symptom experience identified in this study.

Mild, moderate, and severe pain in patients recovering from major abdominal surgery

Pain interferes with various activities, such as coughing, deep breathing, and ambulation, designed to promote recovery and prevent complications after surgery. Determining appropriate cutpoints for mild, moderate, and severe pain is important, because specific interventions may be based on this classification. The purpose of this research was to determine optimal cutpoints for postoperative patients based on their worst and average pain during hospitalization and after discharge to home, and whether the optimal cutpoints distinguished patients with mild, moderate, or severe pain regarding patient outcomes. This secondary analysis consisted of 192 postoperative patients aged ≥60 years. Multivariate analyses of variance were used to stratify the sample into mild, moderate, and severe pain groups using eight cutpoint models for worst and average pain in the last 24 hours. One-way analyses of variance were conducted to determine whether patients experiencing mild, moderate, or severe pain were different in outcome. Optimal cutpoints were similar to those previously reported, with the boundary between mild and moderate pain ranging from 3 to 4 and the boundary between moderate and severe pain ranging from 5 to 7. Worst pain cutpoints were most useful in distinguishing patients regarding fatigue, depression, pain's interference with function, and morphine equivalent administered in the previous 24 hours. A substantial proportion of patients experienced moderate to severe pain. The results suggest a narrow boundary between mild and severe pain that interferes with function. The findings indicate that clinicians should seek to aggressively manage postoperative pain ratings greater than 3.

The relationship of demographic and psychosocial variables to pain-related outcomes in a rural chronic pain population

Rural residency and low socioeconomic status (SES) are associated with increased likelihood of chronic pain. Other demographics are also differentially associated with the experience of pain. This study examines the relations between demographic and pain-related variables in a virtually unstudied population of rural Alabama chronic pain patients. One hundred and fifteen patients completed validated measures of pain catastrophizing, depression, pain intensity, pain interference, perceived disability, and life satisfaction. Average age of study participants was 52-years, 79% were female, 74% were African-American, 72% reported annual income between 00,000-12,999, and 61% were unemployed. Although average years of reported education was 12.26, reading level percentile (primary literacy indicant) was 17.33. Cross-sectional multivariate and univariate analyses were conducted to examine associations among demographic and psychosocial variables in relation to various pre-treatment pain-related variables. The mediating role of pain catastrophizing and depression was investigated. Results indicate that race was significantly associated with pain intensity and pain interference, such that African-Americans reported higher scores than White-Americans. Pain catastrophizing was uniquely associated with pain intensity, pain interference, and perceived disability; depression was uniquely associated with pain interference and life satisfaction. Pain catastrophizing mediated the relation between primary literacy and pain intensity; age effects were differentially mediated by either pain catastrophizing or depression. These analyses provide an insight into the specific demographic and psychosocial factors associated with chronic pain in a low-literacy, low-SES rural population.

Replicability and reliability of pain assessment forms in geriatrics

Aim of the study was to investigate the replicability and reliability of the multi-dimensional health assessment questionnaire (MDHAQ) and visual analog scale (VAS) in young and elderly individuals with chronic pain. Ambulatory patients, 20 of them aged above 65 years and complaining about chronic pain and 20 patients with the age of 40 and younger working in a factory were assessed with VAS and MDHAQ. The assessment was repeated to investigate the replicability and reliability of both tests. According to MDHAQ disability index (DI), the elderly had more complains on the first and second day of the study (p<0.001). In terms of changes between first and second days, DI scores of the elderly group (r=0.634; p=0.003) and the younger group (r=0.888; p<0.001) had quite similar responses. Criteria for the assessment of pain, fatigue and general condition according to MDHAQ were similar in both groups in terms of changes between first and second day of the study, there was no significant differences between the groups. But while responses in the younger group according to these 3 parameters were highly reliable, the elderly group's responses were reliable only for their last week pain assessment. Both tests were replicable in the elderly group, VAS and MDHAQ were especially applicable for the last time phase of their pain; while fatigue, general health condition and DI indicated diminished reliability in the elderly group, compared to the young group.

Pain assessment in non-communicative patients: the Italian version of the Non-Communicative Patient's Pain Assessment Instrument (NOPPAIN)

BACKGROUND AND AIMS

Although pain in the elderly is a common and important problem, it is frequently underestimated and undertreated. Pain assessment in elderly people is often more difficult than in the general population, because of the occurrence of dementia and other cognitive impairments that may compromise the ability to communicate the presence and the intensity of pain to hospital staff. Recently, several observational tools have been developed in order to assess pain behaviors in non-communicative patients. The aim of the present study was to verify if the Italian version of the Non- Communicative Patient's Pain Assessment Instrument (NOPPAIN) could be used in a hospital setting.

METHODS

Sixty severely demented patients (MMSE </=12, language test score </=3) and 42 cognitively intact ones (MMSE >/=23, language test score >/=4) were selected on the basis of their cognitive status and language skills. NOPPAIN forms were filled in at the same time by two nursing staff members after patients' daily care activities; behavioral indicators of the affective state and communicative patients' reports of pain were also collected.

RESULTS

Significant interrater agreement was found in the subscores of the four main sections of the NOPPAIN and also in the total score. In addition, in cognitively intact patients there was a moderate (about 0.50) but significant correlation between NOPPAIN ratings and pain self-reports. A positive correlation between pain scores and negative affective state scores was also found, especially in cognitively impaired patients.

CONCLUSIONS

The preliminary data of the present study support the reliability and validity of the Italian version of the NOPPAIN, which appears to be an easy-to-use tool in the assessment of pain in hospitalized non-communicative patients.

Demographic, clinical and treatment related predictors for event-free probability following low-dose radiotherapy for painful heel spurs - a retrospective multicenter study of 502 patients

A total of 502 patients treated between 1990 and 2002 with low-dose radiotherapy (RT) for painful heel spurs were analysed for prognostic factors for long-term treatment success. The median follow-up was 26 months, ranging from 1 to 103 months. Events were defined as (1) slightly improved or unchanged pain after therapy, or (2) recurrent pain sensations during the follow-up period. Overall 8-year event-free probability was 60.9%. Event-free probabilities of patients with one/two series (414/88) were 69.7%/32.2% (p<0.001); >58/ < or = 58 years (236/266), 81.3%/47.9% (p=0.001); high voltage/orthovoltage (341/161), 67.9%/60.6% (p=0.019); pain anamnesis < or = 6 months/ >6 months (308/194), 76.3%/43.9% (p=0.001); single dose 0.5/1.0 Gy (100/401), 86.2%/55.1% (p=0.009); without/with prior treatment (121/381), 83.1%/54.9% (p=0.023); men/women (165/337), 61.2%/61.5% (p=0.059). The multivariate Cox regression analysis with inclusion of the number of treatment series, age, photon energy, pain history, single-dose and prior treatments revealed patients with only one treatment series (p<0.001), an age >58 years (p=0.011) and therapy with high voltage photons (p=0.050) to be significant prognostic factors for pain relief. Overall low-dose RT is a very effective treatment in painful heel spurs.

The self-administered 24-item geriatric pain measure (GPM-24-SA): psychometric properties in three European populations of community-dwelling older adults

OBJECTIVE

To explore the feasibility and psychometric properties of a self-administered version of the 24-item Geriatric Pain Measure (GPM-24-SA).

DESIGN

Secondary analysis of baseline data from the Prevention in Older People-Assessment in Generalists' practices trial, an international multi-center study of a health-risk appraisal system.

PARTICIPANTS

One thousand seventy-two community dwelling nondisabled older adults self-reporting pain from London, UK; Hamburg, Germany; and Solothurn, Switzerland.

OUTCOME MEASURES

GPM-24-SA as part of a multidimensional Health Risk Appraisal Questionnaire including self-reported demographic and health-related information.

RESULTS

Among the 1,072 subjects, 655 had complete GPM-24-SA data, 404 had <or=30% missing GPM-24-SA data, and 13 had >30% missing GPM-24-SA data. In psychometric analyses across the three European populations with complete GPM-24-SA data, the measure exhibited stable internal consistency, good convergent, divergent and discriminant validity, and produced stable pain measurements. However, factor analysis indicated differences in the GPM-24-SA across sites with discrepancies mainly related to items of a single subscale that failed to load appropriately. Analyses including imputation for subjects with <or=30% missing data demonstrated psychometric properties comparable to complete data analyses suggesting that imputation in cases with <or=30% missing GPM-24-SA data provides sufficient information to generate a valid score.

CONCLUSION

The GPM-24-SA is a promising tool for self-administered assessment of pain in community dwelling older adults. However, because of incomplete response and uncertainty in factor structure, further refinement and psychometric evaluation of the GPM-24-SA is needed before it could be recommended for widespread use.

Pain assessment in persons with dementia: relationship between self-report and behavioral observation

OBJECTIVES

To investigate the relationship between self-report and behavioral indicators of pain in cognitively impaired and intact older adults.

DESIGN

Quasi-experimental, correlational study of older adults.

SETTING

Data were collected from residents of nursing homes, assisted living, and retirement apartments in north-central Florida.

PARTICIPANTS

One hundred twenty-six adults, mean age 83; 64 cognitively intact, 62 cognitively impaired.

MEASUREMENTS

Pain interviews (pain presence, intensity, locations, duration), pain behavior measure, Mini-Mental State Examination, analgesic medications, and demographic characteristics. Participants completed an activity-based protocol to induce pain.

RESULTS

Eighty-six percent self-reported regular pain. Controlling for analgesics, cognitively impaired participants reported less pain than cognitively intact participants after movement but not at rest. Behavioral pain indicators did not differ between cognitively intact and impaired participants. Total number of pain behaviors was significantly related to self-reported pain intensity (beta=0.40, P=.000) in cognitively intact elderly people.

CONCLUSION

Cognitively impaired elderly people self-report less pain than cognitively intact elderly people, independent of analgesics, but only when assessed after movement. Behavioral pain indicators do not differ between the groups. The relationship between self-report and pain behaviors supports the validity of behavioral assessments in this population. These findings support the use of multidimensional pain assessment in persons with dementia.

Metallic taste phantom predicts oral pain among 5-year survivors of head and neck cancer

Chronic pain following cancer-related treatment is emerging as a major concern. Heretofore, the pain level among 5-year survivors of head and neck cancer has received limited attention. This study proposes a predictive model for understanding factors associated with the elevated levels of chronic oral pain. Cancer survivors were drawn from a pool of 5-year survivors. A listed sample matched on sex, age, and zip code was purchased and served as a comparison group. Telephone interviews were conducted by a professional call center. Oral pain levels and the presence of metallic taste phantoms were significantly higher in the cancer survivor group than among the comparison group. The prevalence of chronic oral pain among the 5-year survivors was 43% compared to 13% for the comparison group. Hierarchical linear regression showed that among the 5-year survivors, the predictive model for spontaneous pain accounted for 24% of the variance, and for function-related pain the model accounted for 34% of the variance, with the presence of a phantom metallic taste making a significant independent contribution in both models. In the function-related pain model, depression and level of oral function quality of life (QOL) made significant independent contributions. The presence of oral pain is a significant problem among head and neck cancer survivors. The presence of metallic phantoms is an important new piece of evidence suggesting neural damage following cancer-directed treatment. Routine assessment of oral pain levels could improve current analgesic approaches among head and neck cancer survivors.

Correlates of postoperative pain and intravenous patient-controlled analgesia use in younger and older surgical patients

OBJECTIVE

Age-related patterns in postoperative pain are unclear with reports of no age differences and less pain with age. The objective of this study was to identify correlates of pain and intravenous patient-controlled analgesia (i.v. PCA) morphine use in younger and older patients.

DESIGN

24 hours after surgery, patients completed measures of pain intensity and pain qualities. Surgical factors, i.v. PCA morphine intake, anticholinergic load, polypharmacy, physical status, previous chronic and postoperative pain, and PCA experience were measured.

SETTING

Two academic general hospitals. PATIENTS. Two hundred forty-six general surgery patients ranging in age from 18 to 82 years old.

RESULTS

In older patients, higher pain scores were associated with female gender and previous experience of postoperative PCA. In younger patients, higher pain scores were associated with female gender, previous surgery without PCA, and greater morphine intake. Lower pain was associated with being male, and no previous surgical experience in older patients, and lower morphine intake in younger patients. Morphine intake was higher in patients who were younger, had better physical status, higher anticholinergic load, and experience with PCA. Among younger patients, increased morphine use also was associated with surgical procedure and duration. Higher pain scores were more strongly associated with morphine use among younger than older patients.

CONCLUSIONS

The correlates of postoperative pain and morphine use may differ with age, and the same factor may have different effects across age groups. Research is needed into the mechanisms of these age-specific profiles.

Chronic pain and depression among geriatric psychiatry inpatients

OBJECTIVES

We examined whether chronic pain among depressed geriatric inpatients was associated with several clinical variables-comorbid psychiatric and medical diagnoses, length of hospitalization, suicidal ideation, and sleep duration.

METHODS

Medical charts of inpatients admitted to a geriatric psychiatry unit over 2 years were examined retrospectively; 148 patients with a depressive disorder were identified. Admission pain assessments were used to classify whether patients had chronic pain. Other variables of interest were collected from charts.

RESULTS

62% of patients reported chronic pain. In multivariate regression analysis, depressed older adults with chronic pain were more likely to report suicidal ideation, be diagnosed with personality disorder, have higher medical burden, and experience decreased total sleep time compared to depressed older adults without chronic pain.

CONCLUSIONS

Chronic pain--common in depressed older adults--may influence clinical features of depression and should be assessed as a possible suicide risk factor. Prospective studies should examine causal relationships and determine the effects of adequate pain treatment on depression course and suicide risk in older adults.

Cancer pain and depression: a systematic review of age-related patterns

BACKGROUND

Pain is a common and debilitating symptom experienced by cancer patients of all ages. Cancer pain is associated with elevated levels of depression; however, age-related patterns in this relationship remain unclear. This information is important to provide effective palliation of pain and depression to the growing numbers of older cancer patients.

OBJECTIVE

To provide a systematic review of the literature regarding age-related patterns in the intensity or prevalence of depression among cancer patients with pain.

METHODS

Medical and psychological literature databases were searched to identify eligible studies. The methodological quality and outcomes of the studies were compiled and systematically reviewed.

RESULTS

Five articles, describing four studies, met the inclusion and exclusion criteria. Due to high levels of cross-study methodological variability, a qualitative review was undertaken. Three of the four studies did not find evidence for age-related patterns in depression. The fourth study found that depression increased with age.

CONCLUSION

The weight of the evidence suggests that younger and older cancer patients with pain report comparable levels of depression. However, this conclusion remains preliminary due to the methodological limitations of the available studies. Research is needed to more adequately address this important issue.

High prevalence of pain in patients with cancer in a large population-based study in The Netherlands

At present, no definite conclusions can be drawn about the real extent of the pain suffered by cancer patients. A population-based study was conducted to obtain reliable information about the prevalence and severity of pain in cancer patients (all phases) and about predictors of pain. A representative sample of cancer patients was recruited in the area from a cancer registry. Pain was assessed by the Brief Pain Inventory (BPI). Adequacy of pain treatment was assessed with the Pain Management Index (PMI). We found that 55% of the 1429 respondents had experienced pain past week; in 44% (n=351), the pain was moderate to severe (BPI score>or= 4). Total prevalence of pain/moderate to severe pain was present in 49%/41% in patients with curative treatment >or=6 months ago, 57%/43% in patients with current curative treatment or treatment <6 months ago, 56%/43% in patients with current palliative anti-cancer treatment and in 75%/70% in patients for whom treatment was no longer feasible. Positive predictors of the prevalence of pain were lower education level, more advanced disease and haematological (excluding (non)-Hodgkin lymphoma), gastro-intestinal, lung, or breast malignancies. According to the PMI, analgesic treatment was inadequate in 42% of the patients. Negative predictors of adequate treatment were current curative anti-cancer treatment and low education level.

CONCLUSION

A substantial proportion of cancer patients does suffer from moderate to severe pain and does not receive adequate pain treatment.

Impact of age on presentation of chronic rhinosinusitis and outcomes of endoscopic sinus surgery

BACKGROUND

As the population ages, the mean age of patients with chronic rhinosinusitis (CRS) likely will increase as will the frequency of endoscopic sinus surgery (ESS) in the older population. The purpose of this study was to compare symptom presentation, CT scores, endoscopy scores, and quality of life (QOL) measures in patients >60 years of age as compared with younger patients.

METHODS

A prospective cohort of 18 patients >60 years and 121 patients < or =60 years undergoing ESS for CRS were studied. Patient factors, symptom severity, and CT scores were examined preoperatively. Endoscopy and QOL scores were compared pre- and postoperatively between the two groups.

RESULTS

The prevalence of allergies, polyps, asthma, aspirin sensitivity, and revision surgery was similar in each age group. There was no statistically significant difference in the visual analog scale scores of symptom severity in each age group. Older patients had scores that were similar to younger patients with regard to CT (13.11 versus 11.63; p = 0.419), preoperative endoscopy (8.22 versus 7.96; p = 0.828), postoperative endoscopy (3.06 versus 4.82; p = 0.100), and change in endoscopy (-5.17 versus -3.15; p = 0.083). Older patients had similar preoperative, postoperative, and change scores when compared with younger patients on the Rhinosinusitis Disability Index (-15.33 versus -20.63; p = 0.318) and Chronic Sinusitis Survey (14.35 versus 23.11; p = 0.126).

CONCLUSION

Older patients with CRS present with symptoms and patient factors that are comparable with younger patients and have a similar degree of improvement on endoscopy scores and QOL measures after ESS.