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Springborg AH, Kehlet H, Nielsen NI, Gromov K, Troelsen A, Varnum C, Foss NB. Predictors of subacute postoperative pain after total knee arthroplasty: A secondary analysis of two randomized trials. Eur J Pain 2024. [PMID: 39001706 DOI: 10.1002/ejp.4703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 06/21/2024] [Accepted: 07/05/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Methods for identifying high-pain responders undergoing total knee arthroplasty remain important to improve individualized pain management. This study aimed at evaluating pre- and perioperative predictors of pain on Days 2-7 after total knee arthroplasty. METHODS This is a secondary analysis of data from 227 patients participating in two randomized trials. Pain outcomes were mean pain during walking on Days 2-7 and on Days 2, 4 and 7. Multivariable linear and logistic regressions were carried out in two steps. First, only preoperative available variables including demographics, comorbidities, pain catastrophizing scale and preoperative pain were evaluated while controlling for trial intervention and recruitment site. In the second step, perioperative variables and pain during walking 24 h postoperatively were added. RESULTS The model with only preoperative predictors for mean pain Days 2-7 showed preoperative pain (R-squared 0.097) as the only predictor. In the second model, adding postoperative available variables, only pain 24 h postoperatively (R-squared 0.248) was significant, with a significant main effect of recruitment site. Results for the separate day analysis similarly showed preoperative pain and pain during walking 24 h postoperatively as predictors. The overall best sensitivity (60%) and specificity (74%) for predicting a high-subacute postoperative pain response on Days 2-7 was with cut-off values of VAS 45.5 (out of 100) for pain during walking 24 h postoperatively. CONCLUSIONS Postoperative pain during walking at 24 h is predictive of subacute postoperative pain on Days 2-7 after total knee arthroplasty, while preoperative pain was only a weak predictor. SIGNIFICANCE STATEMENT This study investigated factors associated with pain after total knee arthroplasty beyond the immediate postoperative period. The analysis revealed significant associations between preoperative pain levels and, particularly, pain 24 h postoperatively, with subsequent subacute pain the following week. These findings can assist in identifying patients who would benefit from enhanced, individualized analgesic interventions to facilitate postoperative recovery.
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Affiliation(s)
- Anders H Springborg
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, 7621, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niklas I Nielsen
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kirill Gromov
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Nicolai B Foss
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Einhorn LM, Krishnan P, Poirier C, Ingelmo P. Chronic Postsurgical Pain in Children and Adolescents: A Call for Action. J Pain Res 2024; 17:1967-1978. [PMID: 38828088 PMCID: PMC11144433 DOI: 10.2147/jpr.s464009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024] Open
Abstract
Chronic postsurgical pain (CPSP) affects a significant proportion of children and adolescents after major surgery and is a detriment to both short- and long-term recovery outcomes. While clinical characteristics and psychosocial risk factors for developing CPSP in children and adults are well established in the literature, there has been little progress on the prevention and management of CPSP after pediatric surgery. Limited evidence to support current pharmacologic approaches suggests a fundamentally new paradigm must be considered by clinicians to both conceptualize and address this adverse complication. This narrative review provides a comprehensive evaluation of both the known and emerging mechanisms that support our current understanding of CPSP. Additionally, we discuss the importance of optimizing perioperative analgesic strategies to mitigate CPSP based on individual patient risks. We highlight the importance of postoperative pain trajectories to identify those most at risk for developing CPSP, the early referral to multi-disciplinary pain clinics for comprehensive evaluation and treatment of CPSP, and additional work needed to differentiate CPSP characteristics from other chronic pain syndromes in children. Finally, we recognize ongoing challenges associated with the universal implementation of available knowledge about pediatric CPSP into practically useful care plans for clinicians.
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Affiliation(s)
- Lisa M Einhorn
- Department of Anesthesiology, Division of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Padmaja Krishnan
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Cassandra Poirier
- Department of Anesthesiology, University of British Columbia, Kelowna, BC, Canada
| | - Pablo Ingelmo
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, McGill University Health Center, Montreal, QC, Canada
- Research Institute, McGill University Health Center, Montreal, QC, Canada
- Department of Anesthesia, McGill University, Montreal, QC, Canada
- Alan Edwards Center for Research in Pain, Montreal, QC, Canada
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Pergolizzi JV, LeQuang JA, Magnusson P, Varrassi G. Identifying risk factors for chronic postsurgical pain and preventive measures: a comprehensive update. Expert Rev Neurother 2023; 23:1297-1310. [PMID: 37999989 DOI: 10.1080/14737175.2023.2284872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION Chronic postsurgical pain (CPSP) is a prevalent condition that can diminish health-related quality of life, cause functional deficits, and lead to patient distress. Rates of CPSP are higher for certain types of surgeries than others (thoracic, breast, or lower extremity amputations) but can occur after even uncomplicated minimally invasive procedures. CPSP has multiple mechanisms, but always starts as acute postsurgical pain, which involves inflammatory processes and may encompass direct or indirect neural injury. Risk factors for CPSP are largely known but many, such as female sex, younger age, or type of surgery, are not modifiable. The best strategy against CPSP is to quickly and effectively treat acute postoperative pain using a multimodal analgesic regimen that is safe, effective, and spares opioids. AREAS COVERED This is a narrative review of the literature. EXPERT OPINION Every surgical patient is at some risk for CPSP. Control of acute postoperative pain appears to be the most effective approach, but principles of good opioid stewardship should apply. The role of regional anesthetics as analgesics is gaining interest and may be appropriate for certain patients. Finally, patients should be better informed about their relative risk for CPSP.
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Affiliation(s)
| | | | - Peter Magnusson
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Cardiology, Center for Clinical Research, Falun, Sweden
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Zimney K, Van Bogaert W, Louw A. The Biology of Chronic Pain and Its Implications for Pain Neuroscience Education: State of the Art. J Clin Med 2023; 12:4199. [PMID: 37445234 DOI: 10.3390/jcm12134199] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/06/2023] [Accepted: 06/14/2023] [Indexed: 07/15/2023] Open
Abstract
Pain is an individualized experience for the person suffering from chronic pain. Significant strides have been made in the last few decades in understanding various biological changes that coincide with chronic pain. This state-of-the-art overview looks at the current evidence related to the biology of chronic pain and the implications these findings have on the delivery of pain neuroscience education (PNE). The paper summarizes the various (epi)genetic, neural, endocrine, and immune factors discovered and explored in the scientific literature concerning chronic pain. Each of these biological factors has various implications for the content and delivery of PNE. We discuss the future directions these biological factors have for the clinical implementation of PNE by linking the importance of behavior change, optimizing the learning environment, and using an individualized multimodal treatment approach with PNE. In addition, future directions for research of PNE based on these biological factors are provided with importance placed on individualized patient-centered care and how PNE can be used with traditional modes of care and growing trends with other care methods. PNE was originally and continues to be rooted in understanding chronic pain biology and how that understanding can improve patient care and outcomes.
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Affiliation(s)
- Kory Zimney
- Department of Physical Therapy, University of South Dakota, 414 East Clark St., Vermillion, SD 57069, USA
| | - Wouter Van Bogaert
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 121, 1000 Brussels, Belgium
- Research Foundation-Flanders (FWO), Leuvenseweg 38, 1000 Brussels, Belgium
- Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1000 Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Laarbeeklaan 101, 1000 Brussels, Belgium
| | - Adriaan Louw
- Evidence in Motion, 618 Broad Street, Suite B, Story City, IA 50248, USA
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Dourson AJ, Willits A, Raut NG, Kader L, Young E, Jankowski MP, Chidambaran V. Genetic and epigenetic mechanisms influencing acute to chronic postsurgical pain transitions in pediatrics: Preclinical to clinical evidence. Can J Pain 2022; 6:85-107. [PMID: 35572362 PMCID: PMC9103644 DOI: 10.1080/24740527.2021.2021799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 12/02/2022]
Abstract
Background Chronic postsurgical pain (CPSP) in children remains an important problem with no effective preventive or therapeutic strategies. Recently, genomic underpinnings explaining additional interindividual risk beyond psychological factors have been proposed. Aims We present a comprehensive review of current preclinical and clinical evidence for genetic and epigenetic mechanisms relevant to pediatric CPSP. Methods Narrative review. Results Animal models are relevant to translational research for unraveling genomic mechanisms. For example, Cacng2, p2rx7, and bdnf mutant mice show altered mechanical hypersensitivity to injury, and variants of the same genes have been associated with CPSP susceptibility in humans; similarly, differential DNA methylation (H1SP) and miRNAs (miR-96/7a) have shown translational implications. Animal studies also suggest that crosstalk between neurons and immune cells may be involved in nociceptive priming observed in neonates. In children, differential DNA methylation in regulatory genomic regions enriching GABAergic, dopaminergic, and immune pathways, as well as polygenic risk scores for enhanced prediction of CPSP, have been described. Genome-wide studies in pediatric CPSP are scarce, but pathways identified by adult gene association studies point to potential common mechanisms. Conclusions Bench-to-bedside genomics research in pediatric CPSP is currently limited. Reverse translational approaches, use of other -omics, and inclusion of pediatric/CPSP endophenotypes in large-scale biobanks may be potential solutions. Time of developmental vulnerability and longitudinal genomic changes after surgery warrant further investigation. Emergence of promising precision pain management strategies based on gene editing and epigenetic programing emphasize need for further research in pediatric CPSP-related genomics.
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Affiliation(s)
- Adam J. Dourson
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
| | - Adam Willits
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Namrata G.R. Raut
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
| | - Leena Kader
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Erin Young
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael P. Jankowski
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Vidya Chidambaran
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
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