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Gomez-Rice A, Capdevila-Bayo M, Núñez-Pereira S, Haddad S, Pérez-Grueso F, Kleinstück F, Obeid I, Alanay A, Pellise F, Pizones J. Influence of smoking on patient-reported outcome measures (PROMs) in patients undergoing surgery for adult spinal deformity: a propensity score-matched analysis. Spine Deform 2024; 12:819-827. [PMID: 38329602 DOI: 10.1007/s43390-024-00821-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/31/2023] [Indexed: 02/09/2024]
Abstract
PURPOSE The purpose of this study was to determine the isolated influence of smoking in patient-reported outcome measures (PROMs) for adult spinal deformity (ASD) surgery excluding known tobacco-related complications. METHODS Retrospective analysis of a prospective multicenter ASD database. Patients operated on ASD with 2 year post-operative follow-up were included. Former smokers (non-active smokers) and patients developing mechanical or infectious complications were excluded. Changes of PROMs over time were analyzed using mixed models for repeated measures (MMRM). Propensity score matching (PSM) (1:1 ratio, caliper 0.10) was performed without replacement using optimum algorithm, tolerance ≤ 0.001, and estimated with 95% confidence interval (CI). PROMS in both groups were compared by paired t test or Wilcoxon signed-rank test. RESULTS 692 out of 1246 surgical patients met our inclusion criteria. 153 smokers were matched with 153 non-smokers according to age, BMI, number of fused levels, and global tilt. After PSM both groups were homogeneous regarding baseline parameters, surgical data, and complications (mechanical complications and infection excluded). Smokers had worse baseline results for SRS-total, SRS-pain COMI-back, and ODI; smokers also showed worse 2-year outcomes for SRS-total, SRS-function, SRS-pain, SRS-self-image, and ODI. However, no differences between the two groups were found in the improvement from baseline to 2-year follow-up or in the timing of this improvement (MMRM). The proportion of patients reaching the minimal clinically important difference (MCID) after surgery was similar in the two groups, but the proportion of patients reaching patient acceptable symptom state (PASS) was significantly lower in smokers for SRS-Subtotal, SRS-function, and SRS-image. CONCLUSION Even in the absence of smoking-related complications, smokers had worse PROMs at baseline and 2 years after surgery with less patients achieving PASS, but similar degrees on improvement compared to non-smokers. The proportion achieving MCID was also similar between the two cohorts.
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Affiliation(s)
- Alejandro Gomez-Rice
- Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo Km 9, 100, 28034, Madrid, Spain.
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Tieppo Francio V, Alm J, Leavitt L, Mok D, Yoon BV, Nazir N, Lam C, Latif U, Sowder T, Braun E, Sack A, Khan T, Sayed D. Variables associated with nonresponders to high-frequency (10 kHz) spinal cord stimulation. Pain Pract 2024; 24:584-599. [PMID: 38078593 DOI: 10.1111/papr.13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
INTRODUCTION The use of spinal cord stimulation (SCS) therapy to treat chronic pain continues to rise. Optimal patient selection remains one of the most important factors for SCS success. However, despite increased utilization and the existence of general indications, predicting which patients will benefit from neuromodulation remains one of the main challenges for this therapy. Therefore, this study aims to identify the variables that may correlate with nonresponders to high-frequency (10 kHz) SCS to distinguish the subset of patients less likely to benefit from this intervention. MATERIALS AND METHODS This was a retrospective single-center observational study of patients who underwent 10 kHz SCS implant. Patients were divided into nonresponders and responders groups. Demographic data and clinical outcomes were collected at baseline and statistical analysis was performed for all continuous and categorical variables between the two groups to calculate statistically significant differences. RESULTS The study population comprised of 237 patients, of which 67.51% were responders and 32.49% were nonresponders. There was a statistically significant difference of high levels of kinesiophobia, high self-perceived disability, greater pain intensity, and clinically relevant pain catastrophizing at baseline in the nonresponders compared to the responders. A few variables deemed potentially relevant, such as age, gender, history of spinal surgery, diabetes, alcohol use, tobacco use, psychiatric illness, and opioid utilization at baseline were not statistically significant. CONCLUSION Our study is the first in the neuromodulation literature to raise awareness to the association of high levels of kinesiophobia preoperatively in nonresponders to 10 kHz SCS therapy. We also found statistically significant differences with greater pain intensity, higher self-perceived disability, and clinically relevant pain catastrophizing at baseline in the nonresponders relative to responders. It may be appropriate to screen for these factors preoperatively to identify patients who are less likely to respond to SCS. If these modifiable risk factors are present, it might be prudent to consider a pre-rehabilitation program with pain neuroscience education to address these factors prior to SCS therapy, to enhance successful outcomes in neuromodulation.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - John Alm
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Logan Leavitt
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Daniel Mok
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - B Victor Yoon
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Niaman Nazir
- Department of Population Health, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Usman Latif
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Timothy Sowder
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Edward Braun
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrew Sack
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Talal Khan
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
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Yang QH, Zhang YH, Du SH, Wang YC, Wang XQ. Association Between Smoking and Pain, Functional Disability, Anxiety and Depression in Patients With Chronic Low Back Pain. Int J Public Health 2023; 68:1605583. [PMID: 36960408 PMCID: PMC10027735 DOI: 10.3389/ijph.2023.1605583] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/27/2023] [Indexed: 03/09/2023] Open
Abstract
Objectives: Chronic low back pain (CLBP) accounts for a majority of the disability associated with LBP, which can produce long-term negative effects. This cross-sectional study aimed to investigate the association between smoking and pain, dysfunction and psychological status in patients with CLBP. Methods: The 54 patients with CLBP were recruited and divided into smoking and non-smoking groups. Their pain, dysfunction, anxiety, depression, fear and quality of life were evaluated. The amount of cigarettes smoked daily was recorded. Results: Significant differences in VAS, ODI, RMDQ and FABQ and the impact of LBP on life and work were found between smoking and non-smoking patients. In addition, a correlation was found between the daily cigarette smoking amount and VASmax, FABQtotal, SDS and FABQ-W. Moreover, a correlation was observed between the amount of cigarettes smoked daily and the degree of impact of low back pain on work. Conclusion: The study found that smoking affected the aggravation of symptoms in patients with CLBP, which indicated that patients with CLBP and people at risk of LBP should be aware of the harm caused by smoking.
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Affiliation(s)
- Qi-Hao Yang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Yong-Hui Zhang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Shu-Hao Du
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Yu-Chen Wang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Xue-Qiang Wang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
- Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China
- *Correspondence: Xue-Qiang Wang,
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Mehendiratta D, Patel P, Bhambhu V, Chaudhary K, Dalvie S. Effect of Preoperative Parameters on Outcomes of Lumbar Microdiscectomy: A Retrospective Analysis. Asian J Neurosurg 2022; 17:248-254. [PMID: 36120625 PMCID: PMC9473808 DOI: 10.1055/s-0042-1750839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective
The objective of this study was to characterize the effect of preoperative variables on outcomes after minimally invasive lumbar microdiscectomy.
Materials and Methods
This study was done from January 2019 to May 2020. This included medical records of all patients who were diagnosed with lumbar disc herniation and treated surgically by microdiscectomy. The medical records of such patients from January 2016 to January 2018 were included in this study. Postoperative outcomes were analyzed by Oswestry Disability Index (ODI), visual analog scale (VAS) leg, and VAS back scores, that were noted at preoperative, immediate postoperative, 6 months postoperative, and 1 year after operation. Difference in each outcomes score was calculated postoperatively with respect to the preoperative readings. Minimal clinically important difference was further calculated for each outcome score.
Results
On analyzing the ODI, VAS leg, and VAS back scores across various age groups, genders, body mass indexes, addictions, comorbidities, preoperative epidural steroid injection and physiotherapy, and levels of disc herniation, and it was found that there was no statistically significant difference across these categories. However, the ODI scores (∼ ODI) at all time points showed greater difference in the younger age group, that is, 18 to 30 years, males, nonsmokers, those with symptom duration of less than 6 weeks, and with disc herniation at L3 to L4.
Conclusion
The findings of this study will help to properly counsel patients with regard to the factors mentioned above so as to set realistic expectations, to help improve the outcomes, and for appropriate surgical decision making, that is, at which point should a surgical intervention be made.
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Affiliation(s)
- Dhanish Mehendiratta
- Spine Surgery Unit, Department of Orthopaedics, PD Hinduja Hospital & Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Pratik Patel
- Spine Surgery Unit, Department of Orthopaedics, PD Hinduja Hospital & Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Vivek Bhambhu
- Spine Surgery Unit, Department of Orthopaedics, PD Hinduja Hospital & Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Kshitij Chaudhary
- Spine Surgery Unit, Department of Orthopaedics, PD Hinduja Hospital & Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
| | - Samir Dalvie
- Spine Surgery Unit, Department of Orthopaedics, PD Hinduja Hospital & Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India
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Wade SM, Fredericks DR, Elsenbeck MJ, Morrissey PB, Sebastian AS, Kaye ID, Butler JS, Wagner SC. The Incidence, Risk Factors, and Complications Associated With Surgical Delay in Multilevel Fusion for Adult Spinal Deformity. Global Spine J 2022; 12:441-446. [PMID: 32975455 PMCID: PMC9121150 DOI: 10.1177/2192568220954395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective database review. OBJECTIVES The incidence and risk factors for surgical delay of multilevel spine fusion for adult spinal deformity (ASD), and the complications corresponding therewith, remain unknown. The objectives of this study are to assess the incidence and risk factors for unexpected delay of elective multilevel spinal fusions on the date of surgery as well as the postoperative complications associated with these delays. METHODS We conducted a retrospective review of the ACS-NSQIP database on patients undergoing elective spinal instrumentation of greater than 7 levels for ASD between the years 2005 and 2015. Preoperative risk factors for delay and postoperative complications were compared between the cohorts of patients with and without surgical delays. RESULTS Multivariate analysis of 1570 (15.6%) patients identified advanced age, male sex, American Society of Anesthesiologists (ASA) Class 4, and history of smoking as independent risk factors for delay. Patients experiencing surgical delay demonstrated longer operative times, increased intraoperative bleeding, longer hospitalizations, and significantly higher rates of postoperative complications. Patients experiencing delay demonstrated an almost 7-fold increase in mortality rate (3.4% vs 0.5%, P < .001). CONCLUSIONS Delays in elective surgical care for spinal deformity are negatively related to patient outcomes. Advanced age, male sex, increased ASA class, and a history of smoking cigarettes place patients at risk for surgical delay of multilevel spinal fusion. Patients experiencing surgical delay are at higher risk for postoperative complications, including a 7-fold increase in mortality. These findings suggest that ASD surgery should be postponed in patients experiencing a delay, until modifiable risk factors can be medically optimized, and perhaps postponed indefinitely in those with nonmodifiable risk factors.
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Affiliation(s)
- Sean M. Wade
- Uniformed Services University—Walter Reed National Military Medical Center, Bethesda, MD, USA,Sean M. Wade, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, America Building, 2nd Floor, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
| | - Donald R. Fredericks
- Uniformed Services University—Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Michael J. Elsenbeck
- Uniformed Services University—Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Patrick B. Morrissey
- Naval Medical Center San Diego, San Diego, CA, USA,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - I. David Kaye
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph S. Butler
- Mater Misericordiae University Hospital, Mater Private Hospital, Dublin, Ireland
| | - Scott C. Wagner
- Uniformed Services University—Walter Reed National Military Medical Center, Bethesda, MD, USA,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Li W, Zhang S, Wang D, Zhang H, Shi Q, Zhang Y, Wang M, Ding Z, Xu S, Gao B, Yan M. Exosomes Immunity Strategy: A Novel Approach for Ameliorating Intervertebral Disc Degeneration. Front Cell Dev Biol 2022; 9:822149. [PMID: 35223870 PMCID: PMC8870130 DOI: 10.3389/fcell.2021.822149] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022] Open
Abstract
Low back pain (LBP), which is one of the most severe medical and social problems globally, has affected nearly 80% of the population worldwide, and intervertebral disc degeneration (IDD) is a common musculoskeletal disorder that happens to be the primary trigger of LBP. The pathology of IDD is based on the impaired homeostasis of catabolism and anabolism in the extracellular matrix (ECM), uncontrolled activation of immunologic cascades, dysfunction, and loss of nucleus pulposus (NP) cells in addition to dynamic cellular and biochemical alterations in the microenvironment of intervertebral disc (IVD). Currently, the main therapeutic approach regarding IDD is surgical intervention, but it could not considerably cure IDD. Exosomes, extracellular vesicles with a diameter of 30–150 nm, are secreted by various kinds of cell types like stem cells, tumor cells, immune cells, and endothelial cells; the lipid bilayer of the exosomes protects them from ribonuclease degradation and helps improve their biological efficiency in recipient cells. Increasing lines of evidence have reported the promising applications of exosomes in immunological diseases, and regarded exosomes as a potential therapeutic source for IDD. This review focuses on clarifying novel therapies based on exosomes derived from different cell sources and the essential roles of exosomes in regulating IDD, especially the immunologic strategy.
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Affiliation(s)
- Weihang Li
- Department of Orthopedic Surgery, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Shilei Zhang
- Department of Orthopedic Surgery, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Dong Wang
- Department of Orthopedic Surgery, Xijing Hospital, Air Force Medical University, Xi’an, China
- Department of Orthopaedics, Affiliated Hospital of Yanan University, Yanan, China
| | - Huan Zhang
- Department of Orthopedic Surgery, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Quan Shi
- Department of Orthopedic Surgery, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Yuyuan Zhang
- Department of Critical Care Medicine, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Mo Wang
- The First Brigade of Basic Medical College, Air Force Military Medical University, Xi’an, China
| | - Ziyi Ding
- Department of Orthopedic Surgery, Xijing Hospital, Air Force Medical University, Xi’an, China
| | - Songjie Xu
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
- *Correspondence: Songjie Xu, ; Bo Gao, ; Ming Yan,
| | - Bo Gao
- Department of Orthopedic Surgery, Xijing Hospital, Air Force Medical University, Xi’an, China
- *Correspondence: Songjie Xu, ; Bo Gao, ; Ming Yan,
| | - Ming Yan
- Department of Orthopedic Surgery, Xijing Hospital, Air Force Medical University, Xi’an, China
- *Correspondence: Songjie Xu, ; Bo Gao, ; Ming Yan,
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Tobacco smoking is associated with more pain and worse functional outcomes after torsional ankle fracture. OTA Int 2022; 5:e175. [PMID: 35059563 PMCID: PMC8765575 DOI: 10.1097/oi9.0000000000000175] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
Objective: The purpose of this study was to assess the impact of current and remote tobacco smoking on clinical and functional outcomes after torsional ankle fracture. Methods: Nine hundred thirty-five patients treated surgically for torsional ankle fracture over 9 years were reviewed. Tobacco smoking status at the time of injury was defined as current (48.3%), former (11.7%), and nonsmoker (40.0%). Complications, unplanned secondary procedures, pain medication use, and functional outcome scores, as measured by Foot Function Index and Short Musculoskeletal Function Assessment (SMFA) surveys. Results: Mean age was 44.8 years, with 50.3% male. More than 6 months following injury current smokers were more likely than former smokers and nonsmokers to report ankle pain (67.8% vs 45.8% vs 47.5%) and to use prescription pain medicines (23.0% vs 10.4% vs 6.3%), all P < .05. Multiple logistic regression found current tobacco use to be an independent predictor for prescription pain medication use, and worse scores for the Foot Function Index, SMFA Dysfunction, and SMFA Bothersome scores, all P < .05. Complications occurred in 15.5% of all patients, and 10.7% underwent unplanned secondary operations. Tobacco smoking was not associated with more complications or secondary procedures. Conclusion: Current smokers are more likely to use prescription pain medications several months after injury and have worse patient-reported functional outcome scores after surgical treatment of torsional ankle fractures than former smokers and nonsmokers.
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İnaltekin A, Bozkurt E, Kıvrak Y. Factors Associated with Pain Level in Patients Receiving Intravitreal Injection. J Curr Ophthalmol 2021; 33:323-329. [PMID: 34765822 PMCID: PMC8579782 DOI: 10.4103/joco.joco_6_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose: To identify the factors associated with the pain level in patients receiving intravitreal injection. Methods: A total of 120 patients were prospectively evaluated, and 104 were included in the study. Patients were asked to rate their pain intensity from 0 to 10 on the visual analog scale. Factors that were possibly associated with pain level were evaluated using a sociodemographic data form, state anxiety inventory, and the hospital anxiety and depression scale. Results: Of the participants, 54 (51.9%) were female, and 50 (48.1%) were male, with a mean age of 65 ± 9.01 years. There was a positive correlation between pain level and state anxiety scores (r = 0.30; P < 0.001) and a negative correlation between hospital anxiety score (r = −0.23; P = 0.02) and hospital depression score (r = −0.27; P = 0.01). The correlation between pain score and education level was significantly higher in primary and secondary school graduates (P < 0.01). Smokers were observed to have higher pain scores (6.50 ± 2.21 in smokers and 4.87 ± 2.50 in nonsmokers; P = 0.01). Among diagnostic groups, pain scores were found to be significantly lower in the diabetic retinopathy (DR) group (6.82 ± 1.99 in age-related macular degeneration, 5.94 ± 2.27 in retinal vein occlusion, and 3.58 ± 1.97 in DR; P < 0.001). When pain scores were evaluated according to the drug injected, the group receiving bevacizumab injection was observed to have higher pain scores (7.32 ± 1.81 in bevacizumab, 4.00 ± 2.08 in aflibercept, and 3.92 ± 1.96 in ranibizumab; P < 0.001). Based on the multiple regression analysis, the state anxiety score, hospital anxiety score, hospital depression score, and smoking status were observed not to be significant predictors. The level of education, diagnosis, and active substance were found to have a statistically significant effect on pain perception. Conclusion: In this study, pain levels have been found to be high in smokers, those with a low educational level, individuals receiving bevacizumab for intravitreal injection, and those having a higher level of state anxiety, whereas patients with DR have lower pain scores.
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Affiliation(s)
- Ali İnaltekin
- Department of Psychiatry, Oltu State Hospital, Erzurum, Turkey
| | - Erdinç Bozkurt
- Department of Ophthalmology, Umraniye Training and Research Hospital, İstanbul, Turkey
| | - Yüksel Kıvrak
- Department of Psychiatry, Afyonkarahisar Health Sciences University School of Medicine, Afyonkarahisar, Turkey
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Hu H, Liu W, Zhang S, Pan J, Zheng X. Depression mediates the relationship between smoking and pain: Evidence from a nationally representative study in a low- and middle-income country. Addict Behav 2021; 119:106937. [PMID: 33848759 DOI: 10.1016/j.addbeh.2021.106937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/10/2021] [Accepted: 03/25/2021] [Indexed: 02/03/2023]
Abstract
Evidence from high-income countries suggests that depressive symptoms may mediate the relationship between smoking and pain. However, the relationship remains poorly understood for the population in low- and middle-income countries (LMICs), who account for 80% of the current tobacco consumers. Using cross-sectional data from a nationally representative longitudinal survey in China, this study conducted the mediation analysis within the structural equation model (SEM) framework. It tested the indirect effect using the Monte Carlo method. Among the 16,575 participants, 29.2% (n = 4,839) reported being current smokers, 8.5% (n = 1,412) being former smokers, and 62.3% (n = 10,324) being never smokers. Phenotypic characteristics of smokers revealed some distinct characteristics concerning smoking rates, gender, and education attainment compared with results from high-income countries. Besides, current smokers reported significantly higher pain severity than never and former smokers and more depressive symptoms compared with never smokers. The mediation analysis indicated that the self-reported pain was mediated by depressive symptoms 62.7% of the association with smoking and 82.1% of the connection to the number of years quit. However, no mediation effect of depressive symptoms was found for the relationship between the amount smoked and pain severity. This study may fill the literature gap in examining depressive symptoms' mediating role in the relationship between smoking and pain severity for LMICs.
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Croghan IT, Hurt RT, Ganesh R, Bhagra O, Fischer KM, Vincent A, Hays JT, Bierle DM, Schroeder DR, Fuehrer DL, Nanda S. The Association of Current Tobacco Status With Pain and Symptom Severity in Fibromyalgia Patients. Mayo Clin Proc Innov Qual Outcomes 2021; 5:614-624. [PMID: 34195553 PMCID: PMC8240153 DOI: 10.1016/j.mayocpiqo.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To describe current tobacco use among patients with newly confirmed fibromyalgia and evaluate the association between tobacco use status and severity of reported pain and other fibromyalgia symptoms. Patients and Methods Participants in this study were adult patients (N=1068) with fibromyalgia who met American College of Rheumatology 2010/2011 clinical criteria for fibromyalgia at the time of initial presentation to a Midwest fibromyalgia clinic (June 1, 2018, through May 31, 2019). Multiple linear regression analyses were performed to assess the association of tobacco use status with the Widespread Pain Index (WPI) and Symptom Severity Scale (SSS) scores. Covariates included in these analyses included age, sex, body mass index, depression, opioid medication use, and use of fibromyalgia-specific pharmacotherapy. Results The patients were largely women (87.0%; n=929), white (87.9%; n=939), and with an average ± SD age of 46.6±13.9 years. The WPI and SSS scores were significantly greater in current tobacco users compared with never tobacco users (WPI effect estimate [EE] = 1.03; 95% CI, 0.30 to 1.76; type III P=.020; SSS EE = 0.47; 95% CI, 0.11 to 0.84; type III P=.036). The WPI score was negatively associated with age (EE = −0.02 per year; 95% CI, −0.03 to −0.001 per year; P=.037) and no use of opioid medication (EE = −1.08; 95% CI, −1.59 to −0.57; P<.001) while positively associated with higher body mass index (EE = 0.03 per 1 kg/m2; 95% CI, 0.001 to 0.06 per kg/m2; P=.04) and higher Patient Health Questionnaire-9 score (EE = 0.12; 95% CI, 0.08 to 0.16; P<.001). Conclusion The results of our study suggest that tobacco use is associated with greater pain and other symptom severity in patients with fibromyalgia. These findings have important clinical and research implications for patients with fibromyalgia who use tobacco and who may benefit from early identification and timely implementation of tobacco cessation treatment to decrease pain and improve overall quality of life.
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Affiliation(s)
- Ivana T Croghan
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Ryan T Hurt
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ravindra Ganesh
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ojas Bhagra
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Karen M Fischer
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Ann Vincent
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - J Taylor Hays
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Dennis M Bierle
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Debbie L Fuehrer
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Sanjeev Nanda
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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Smuck M, Schneider BJ, Ehsanian R, Martin E, Kao MCJ. Smoking Is Associated with Pain in All Body Regions, with Greatest Influence on Spinal Pain. PAIN MEDICINE 2021; 21:1759-1768. [PMID: 31578562 DOI: 10.1093/pm/pnz224] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Examine the interrelationship between smoking and pain in the US population. DESIGN A cross-sectional population-based study. SETTING Nationwide survey. METHODS Comprehensive pain reports categorically defined as head, spine, trunk, and limb pain; smoking history; demographics; medical history from a total of 2,307 subjects from the 2003-2004 National Health and Nutrition Examination Survey obtained from the Centers for Disease Control were analyzed. Unpaired t tests were used to analyze independent continuous variables, and chi-square tests were used to analyze categorical variables between smoker and nonsmoker groups. Weighted multivariate logistic regression analyses determined the association of current smoking with the presence of pain in various body regions. RESULTS Smoking is most strongly associated with spine pain (odds ratio [OR] = 2.89, 95% confidence interval [CI] = 2.21-3.77), followed by headache (OR = 2.47, 95% CI = 1.73-3.53), trunk pain (OR = 2.17, 95% CI = 1.45-2.74), and limb pain (OR = 1.99, 95% CI = 1.45-2.73). CONCLUSIONS Current smoking is associated with pain in every region of the body. This association is strongest for spine and head pain. Given that pain is a strong motivator and that current smoking was associated with pain in all body regions, we recommend that these results be used to further raise public awareness about the potential harms of smoking.
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Affiliation(s)
- Matthew Smuck
- Physical Medicine and Rehabilitation, Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee.,Vanderbilt University Medical Center, Center for Musculoskeletal Research
| | - Reza Ehsanian
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee.,Department of Neurosurgery, Stanford University, Palo Alto, California.,Division of Physical Medicine and Rehabilitation, Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Elizabeth Martin
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee.,Division of Physical Medicine and Rehabilitation, Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Ming-Chih J Kao
- Physical Medicine and Rehabilitation, Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Stanford University, Stanford, California
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12
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Senker W, Stefanits H, Gmeiner M, Trutschnig W, Radl C, Gruber A. The influence of smoking in minimally invasive spinal fusion surgery. Open Med (Wars) 2021; 16:198-206. [PMID: 33585696 PMCID: PMC7863003 DOI: 10.1515/med-2021-0223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/10/2020] [Accepted: 12/05/2020] [Indexed: 11/15/2022] Open
Abstract
Background The impact of smoking on spinal surgery has been studied extensively, but few investigations have focused on minimally invasive surgery (MIS) of the spine and the difference between complication rates in smokers and non-smokers. We evaluated whether a history of at least one pack-year preoperatively could be used to predict adverse peri- and postoperative outcomes in patients undergoing minimally invasive fusion procedures of the lumbar spine. In a prospective study, we assessed the clinical effectiveness of MIS in an unselected population of 187 patients. Methods We evaluated perioperative and postoperative complication rates in MIS fusion techniques of the lumbar spine in smoking and non-smoking patients. MIS fusion was performed using interbody fusion procedures and/or posterolateral fusion alone. Results Smokers were significantly younger than non-smokers. We did not encounter infection at the site of surgery or severe wound healing disorder in smokers. We registered no difference between the smoking and non-smoking groups with regard to peri- or postoperative complication rate, blood loss, or length of stay in hospital. We found a significant influence of smoking (p = 0.049) on the overall perioperative complication rate. Conclusion MIS fusion techniques seem to be a suitable tool for treating degenerative spinal disorders in smokers.
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Affiliation(s)
- Wolfgang Senker
- Department of Neurosurgery, Kepler University Hospital, Neuromed Campus, Linz, Austria
| | - Harald Stefanits
- Department of Neurosurgery, Kepler University Hospital, Neuromed Campus, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Neuromed Campus, Linz, Austria
| | | | - Christian Radl
- Department of Neurosurgery, Kepler University Hospital, Neuromed Campus, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Neuromed Campus, Linz, Austria
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13
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Saragiotto BT, Kamper SJ, Hodder R, Silva PV, Wolfenden L, Lee H, Oliveira VC, Robson E, Wiggers J, Williams CM. Interventions Targeting Smoking Cessation for Patients With Chronic Pain: An Evidence Synthesis. Nicotine Tob Res 2020; 22:135-140. [PMID: 30481320 DOI: 10.1093/ntr/nty255] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/20/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Smoking is a risk factor for chronic pain conditions. Epidemiological evidence suggests that smoking cessation may be an important treatment target in people with chronic pain. The aim of this study was to examine the effectiveness of smoking cessation interventions in people with chronic pain. METHODS We systematically searched for clinical trials investigating the effectiveness of smoking cessation interventions for people with chronic pain, compared with any control comparator. Primary outcomes were pain and physical function. Secondary outcomes were smoking status, quality of life, psychological and cognitive function, and adverse events. We assessed risk of bias using the Cochrane Risk of Bias criteria and the quality of evidence with GRADE. RESULTS Searches retrieved 3845 records and identified two trials for inclusion (total n = 99 participants). There was low-quality evidence of no effect of smoking cessation programs on pain and very low-quality evidence of no effect on function at short-term follow-up. There was conflicting evidence on the effect of smoking cessation interventions for changing the smoking status and number of cigarettes consumed per day. There was no effect on depression and anxiety. CONCLUSION Current evidence does not indicate clinically important effects of smoking cessation interventions in people with chronic pain. There is a need for high-quality trials in this area. IMPLICATIONS Our review highlights an important evidence gap. We found only two studies investigating smoking cessation programs for chronic pain conditions providing very low- to low-quality evidence.
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Affiliation(s)
- Bruno T Saragiotto
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,Masters and Doctoral Program in Physical Therapy, Universidade Cidade de Sao Paulo, Sao Paulo, Brazil.,Centre for Pain, Health and Lifestyle, New South Wales, Australia
| | - Steven J Kamper
- Centre for Pain, Health and Lifestyle, New South Wales, Australia.,Sydney School of Public Health, Faculty of Medicine and Health, The University of, Sydney, Sydney, Australia
| | - Rebecca Hodder
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,Centre for Pain, Health and Lifestyle, New South Wales, Australia
| | - Priscilla V Silva
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,Centre for Pain, Health and Lifestyle, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
| | - Hopin Lee
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,Centre for Pain, Health and Lifestyle, New South Wales, Australia.,Centre for Statistics in Medicine, Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - Vinicius C Oliveira
- Postgraduate Program in Rehabilitation and Functional Performance, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Brazil
| | - Emma Robson
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,Centre for Pain, Health and Lifestyle, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
| | - John Wiggers
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
| | - Christopher M Williams
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia.,Centre for Pain, Health and Lifestyle, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Local Health District, Wallsend, Australia
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14
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Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE To identify the differences in inpatient pain scores, narcotic consumption, and patient-reported outcomes (PROs) between tobacco users and nonusers following an anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Previous studies have investigated tobacco use as a risk factor for negative postsurgical outcomes following spine surgery; however, few studies have analyzed the effects of tobacco on pain following ACDF. METHODS Patients undergoing primary, 1-level, or 2-level ACDF were retrospectively reviewed and stratified by tobacco use at the time of surgery. Inpatient pain scores and narcotic consumption were collected. Neck Disability Index and Visual Analogue Scale (VAS) neck and arm pain scores were collected preoperatively and at 6-week, 3-month, and 6-month follow-up visits. Differences in demographics and perioperative characteristics were assessed using χ analysis and multivariate linear regression. An association between immediate postoperative pain, narcotics consumption, and long-term PROs was tested for using multivariate linear regression. RESULTS A total of 192 patients were included and stratified by tobacco use: tobacco (n=25) and nontobacco (n=167). There were no significant differences in demographic and perioperative characteristics. No statistical differences were observed in inpatient VAS pain scores and narcotic consumption on postoperative day 0 and postoperative day 1. Preoperative VAS neck pain and arm pain was greater in tobacco users, however, improvements in neck and arm pain were similar in the postoperative period through 6-month follow-up. In addition, no statistical differences in Neck Disability Index were observed preoperatively or at any postoperative time points. CONCLUSIONS Our study suggests that tobacco use does not influence inpatient pain scores, narcotic consumption, and improvements in PROs following ACDF. As such, tobacco users and nonusers should receive similar postoperative pain management protocols following surgery. LEVEL OF EVIDENCE Level III.
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15
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Mekhail N, Costandi S, Mehanny DS, Armanyous S, Saied O, Taco‐Vasquez E, Saweris Y. The Impact of Tobacco Smoking on Spinal Cord Stimulation Effectiveness in Complex Regional Pain Syndrome Patients. Neuromodulation 2019; 23:133-139. [DOI: 10.1111/ner.13058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Nagy Mekhail
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Shrif Costandi
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Diana S. Mehanny
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Sherif Armanyous
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Ogena Saied
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Erika Taco‐Vasquez
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Youssef Saweris
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
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16
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Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth 2019; 123:e273-e283. [PMID: 31079836 PMCID: PMC6676152 DOI: 10.1016/j.bja.2019.03.023] [Citation(s) in RCA: 687] [Impact Index Per Article: 137.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/22/2019] [Indexed: 12/18/2022] Open
Abstract
Chronic pain is a common, complex, and distressing problem that has a profound impact on individuals and society. It frequently presents as a result of a disease or an injury; however, it is not merely an accompanying symptom, but rather a separate condition in its own right, with its own medical definition and taxonomy. Studying the distribution and determinants of chronic pain allows us to understand and manage the problem at the individual and population levels. Targeted and appropriate prevention and management strategies need to take into account the biological, psychological, socio-demographic, and lifestyle determinants and outcomes of pain. We present a narrative review of the current understanding of these factors.
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Affiliation(s)
- Sarah E E Mills
- Population Health and Genomics Division, University of Dundee School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK.
| | - Karen P Nicolson
- Population Health and Genomics Division, University of Dundee School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Blair H Smith
- Population Health and Genomics Division, University of Dundee School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK
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17
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Schlaeger JM, Pauls HA, Powell-Roach KL, Thornton PD, Hartmann D, Suarez ML, Kobak WH, Hughes TL, Steffen AD, Patil CL. Vulvodynia, "A Really Great Torturer": A Mixed Methods Pilot Study Examining Pain Experiences and Drug/Non-drug Pain Relief Strategies. J Sex Med 2019; 16:1255-1263. [PMID: 31204266 DOI: 10.1016/j.jsxm.2019.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/15/2019] [Accepted: 05/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Women with vulvodynia, a chronic pain condition, experience vulvar pain and dyspareunia. Few studies examine the range and combination of treatment strategies that women are actually using to reduce vulvodynia. AIM To describe pain experiences and pain relief strategies of women with vulvodynia. METHODS Convenience sample, 60 women with vulvodynia (median age 32.5 [interquartile range {IQR} 8.5] years; 50 white, 10 racial/ethnic minorities) completed PAINReportIt and reported use of drugs and alcohol and responded to open-ended questions. Univariate descriptive statistics and bivariate inferential tests were used to describe average pain intensity scores, alcohol use, smoking, number of pain relief strategies, and their associations. Women's open-ended responses about their pain experiences and drug and non-drug pain relief strategies (NDPRS) were analyzed for patterns. OUTCOMES Our mixed methods analysis connected data from pain measures, prescribed treatments and self-reported behaviors with women's free responses. This enabled nuanced insights into women's vulvodynia pain experiences. RESULTS Women's descriptions of their pain and suffering aligned with their reported severe pain and attempts to control their pain, with a median pain intensity of 6.7 (IQR 2.0) despite use of adjuvant drugs (median 2.0 [IQR 2.0]), and opioids (median 1.0 [IQR 2.0]). 36 women (60%) used alcohol to lessen their pain. 26 women (43%) listed combining analgesics and alcohol to relieve their pain. 30 women (50%) smoked cigarettes. 54 women (90%) used ≥1 NDPRS. The mean number of NDPRS used was 2.1 ± 1.3 (range 0-6). The 5 most common NDPRS from women's comments were herbal medicine (40%), acupuncture (27%), massage (22%), hypnosis (15%), and mental healthcare (13%). CLINICAL IMPLICATIONS Severe pain in women with vulvodynia may be a clinical indicator of those at higher risk of combining prescription pain medications with alcohol, which are all central nervous system depressants and may potentiate overdose. STRENGTHS AND LIMITATIONS This pilot study demonstrated that the mixed methods approach to help understand the complexity of vulvodynia was feasible. We identified data showing a reliance on a high-risk mix of prescriptions and alcohol to reduce vulvodynia pain and a high prevalence of cigarette smoking. However, as a pilot study, these results are considered preliminary; the sample may not be representative. Perhaps only women at the extreme end of the pain continuum participated, or women took the survey twice because identifiers were not collected. CONCLUSION Despite attempts to reduce pain using multiple therapies, including alcohol, women's vulvodynia pain is severe and not controlled. Schlaeger JM, Pauls HA, Powell-Roach KL, et al. Vulvodynia, "A Really Great Torturer": A Mixed Methods Pilot Study Examining Pain Experiences and Drug/Non-drug Pain Relief Strategies. J Sex Med 2019;16:1255-1263.
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Affiliation(s)
- Judith M Schlaeger
- University of Illinois at Chicago, College of Nursing, Department of Women, Children and Family Health Science, Chicago, IL, USA.
| | - Heather A Pauls
- University of Illinois at Chicago, College of Nursing, Office of Research Facilitation, Chicago, IL, USA
| | - Keesha L Powell-Roach
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, Chicago, IL, USA
| | - Patrick D Thornton
- University of Illinois at Chicago, College of Nursing, Department of Women, Children and Family Health Science, Chicago, IL, USA
| | - Dee Hartmann
- Dee Hartmann Physical Therapy, Effingham, IL, USA
| | - Marie L Suarez
- University of Illinois at Chicago, College of Nursing, Department of Women, Children and Family Health Science, Chicago, IL, USA
| | - William H Kobak
- University of Illinois at Chicago, College of Medicine, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Tonda L Hughes
- Columbia University School of Nursing, New York, NY, USA
| | - Alana D Steffen
- University of Illinois at Chicago, College of Nursing, Department of Health Systems Science, Chicago, IL, USA
| | - Crystal L Patil
- University of Illinois at Chicago, College of Nursing, Department of Women, Children and Family Health Science, Chicago, IL, USA
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18
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Predicting Pain Levels Following Vaginal Reconstructive Surgery: Who Is at Highest Risk? Female Pelvic Med Reconstr Surg 2019; 24:172-175. [PMID: 29474293 DOI: 10.1097/spv.0000000000000522] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES An ability to anticipate individuals at increased risk of postoperative pain would improve coordination of care and patient satisfaction. We sought to describe predictive factors of postoperative pain following vaginal reconstructive surgery. METHODS This institutional review board-approved, retrospective study used previously collected data from research performed at 1 center from 2009 to 2015. Eligible trials enrolled subjects undergoing vaginal reconstructive surgery for pelvic organ prolapse. All studies used a validated visual analog scale (VAS) for pain on postoperative day 1. Other information collected included pain medication use, medical and surgical history, and demographics. Linear regression analyses, multiple regression analyses, Mann-Whitney U, and Kruskal-Wallis tests were used to analyze the relationship between VAS scores and other variables. RESULTS Six studies were analyzed with a total of 364 patients. The median age was 60 years (interquartile range, 16 years), and the median pain score on postoperative day 1 was 35 mm on a 100-mm VAS. Patients younger than 60 years (P < 0.001), those who used tobacco (P = 0.014), those who used pain medication prior to surgery (P = 0.007), and those who did not have a concomitant midurethral sling (P = 0.018) had significantly higher pain scores postoperatively. A trend was also noted with operating times greater than 210 minutes (P = 0.057) and preexisting history of depression (P = 0.065). Multiple regression was performed, and age, depression, tobacco use, and concomitant sling were found to be independent factors predictive of postoperative pain scores. CONCLUSIONS Age, depression, tobacco use, and concomitant midurethral sling are significant independent factors predictive of postoperative pain following vaginal reconstructive surgery.
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19
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Substance-related disorders: A review of prevalence and correlates among patients with chronic pain. Prog Neuropsychopharmacol Biol Psychiatry 2018; 87:245-254. [PMID: 28669582 DOI: 10.1016/j.pnpbp.2017.06.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/26/2017] [Accepted: 06/27/2017] [Indexed: 01/25/2023]
Abstract
Over the past few decades, research has revealed high rates of substance-related disorders among patients with chronic pain. In addition to their potentially deleterious health consequences, substance-related disorders have consistently been associated with negative pain-related outcomes among patients with chronic pain. The goal of this narrative review was to provide an overview of studies that have examined the prevalence and correlates of substance-related disorders among patients with chronic pain. A particular focus was placed on opioids, sedatives/hypnotics, cannabis, tobacco, and alcohol given that these substances have received the bulk of research attention among patients with pain. Research conducted to date suggests that a host of biological and psychological factors are likely to contribute to the elevated rates of substance-related disorders among patients with chronic pain. In this review, in addition to reviewing the prevalence and correlates of substance-related disorders among patients with pain, we briefly discussed the changes that were recently made from the DSM-4 to the DSM-5 in the diagnostic criteria for substance-related disorders, and the implications of these changes for the assessment of patients with chronic pain. We also provided a brief overview of instruments that can be used for the assessment of these disorders in clinical and research settings.
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20
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Riley MS, Lenke LG, Chapman TM, Sides BA, Blanke KM, Kelly MP. Clinical and Radiographic Outcomes After Posterior Vertebral Column Resection for Severe Spinal Deformity with Five-Year Follow-up. J Bone Joint Surg Am 2018; 100:396-405. [PMID: 29509617 DOI: 10.2106/jbjs.17.00597] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Short-term studies have shown improved outcomes and alignment after posterior vertebral column resection for severe spinal deformity. Our goal was to report long-term changes in radiographic and health-related quality-of-life measures in a consecutive series of pediatric and adult patients undergoing posterior vertebral column resection with a minimum follow-up of 5 years. METHODS We reviewed all patients undergoing posterior vertebral column resection by a single surgeon prior to January 1, 2010, at a single institution. Standard preoperative and perioperative data were collected, including the Scoliosis Research Society (SRS)-22/24 instrument. Radiographic and health-related quality-of-life measures changes were evaluated at a minimum follow-up of 5 years. RESULTS One hundred and nine patients underwent posterior vertebral column resection prior to January 2010, and 54 patients (49.5%) were available for analysis: 31 (57.4%) were pediatric patients, and 23 (42.6%) were adult patients. The mean age (and standard deviation) was 12.5 ± 3 years for the pediatric cohort and 39.3 ± 20 years for the adult cohort. Improvements in the mean major Cobb angle at a minimum follow-up of 5 years were seen: 61.6% correction for the pediatric cohort and 53.9% correction for the adult cohort. The rates of proximal junctional kyphosis, defined as proximal junctional kyphosis of >10°, were 16.1% for the pediatric cohort and 34.8% for the adult cohort, but none underwent a revision surgical procedure for symptomatic proximal junctional kyphosis. Of the 54 patients, 30 (55.6%) sustained complications, 5 (9.3%) experienced postoperative neurological deficits, and 7 (13.0%) required a revision by 5 years postoperatively. Significant improvements were observed in the SRS-Self Image with regard to the pediatric cohort at 0.9 (p = 0.017) and the adult cohort at 1.3 (p = 0.002) and in the SRS-Satisfaction with regard to the pediatric cohort at 1.8 (p = 0.008) and the adult cohort at 1.3 (p = 0.005). CONCLUSIONS Posterior vertebral column resection offers substantial, sustained improvements in global radiographic alignment and patient outcome scores at 5 years. The major radiographic deformity was reduced by 61.6% in the pediatric cohort and by 53.9% in the adult cohort. Despite the high rate of complications, patients experienced significant improvement in the SRS-Self Image and SRS-Satisfaction domains. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Max S Riley
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Brenda A Sides
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Kathy M Blanke
- Department of Orthopaedic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, Missouri
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21
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Vieira LA, Dos Santos AA, Peluso C, Barbosa CP, Bianco B, Rodrigues LMR. Influence of lifestyle characteristics and VDR polymorphisms as risk factors for intervertebral disc degeneration: a case-control study. Eur J Med Res 2018; 23:11. [PMID: 29467039 PMCID: PMC5822660 DOI: 10.1186/s40001-018-0309-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/13/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Intervertebral disc degeneration (DD) is an important cause of low back pain and its precise aetiology is not fully understood, being attributed to cumulative environmental, biomechanical and genetic effects. The vitamin D plays a key role in regulation of calcium homeostasis and bone mineralization, exerting its biological activities by binding to a high-affinity receptor (VDR). Polymorphisms in VDR gene were previously associated with DD process, however with conflicting results. Here, we aimed to investigate the influence of lifestyle characteristics and VDR TaqI, BsmI, ApaI and FokI polymorphisms as risk factors for DD process. METHODS Retrospective case-control study involving 231 participants: 119 with confirmed DD and 112 healthy controls. Genotyping of VDR polymorphisms was performed by PCR-RFLP and real-time PCR using TaqMan methodology. All patients answered a questionnaire regarding lifestyle characteristics, such as educational level, pain localization, smoking habits, engagement of physical activity, postural and load weight at work and familial history of disc degeneration. The variables were compared between groups and adjusted by age and gender. RESULTS The case group was composed by 52% female and 48% male and the mean age was 40.0 years old, while in the control group 79% was female and 21% male and the mean age was 32.0 years old. Although gender distribution and mean age were different between groups, in the control group all participants were less than 45 years old and there was a prevalence of women in both groups. The factors that could be possibly associated to DD in the Brazilian population studied included smoking habits (26% in cases and 9% in controls, p = 0.003), lack of engagement in physical activity (observed in 77% of cases and 62% of controls, p = 0.018), and loading weight during work routine (58% in cases and 24% in controls, p ≤ 0.001). However, after adjusting by age and gender, only smoking habits remained associated to disc degeneration (p = 0.027). Considering the educational level, 35.2% of cases and 15.6% of controls had only the Elementary School, and 5.5% of DD group and 28.6% of control group had completed College (p = 0.025). In addition, educational level was directly associated to load weight at work (p = 0.012). Regarding VDR polymorphisms, no significant difference in genotype and allele frequencies between groups was observed. The haplotype analysis revealed that the combined wild-type alleles of TaqI, ApaI and FokI polymorphisms-TGT-was observed in a higher frequency in control group (p = 0.039). CONCLUSION The findings suggested that smoking habits was a risk factor for disc degeneration in the population studied. Single analysis revealed no significant effects of VDR polymorphisms in disc degeneration process, while the combination of wild-type alleles of TaqI, ApaI and FokI polymorphisms, TGT haplotype, decreased the risk of the disease.
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Affiliation(s)
- Luiz Angelo Vieira
- Discipline of Orthopaedics and Traumatology, Department of Surgery, Faculdade de Medicina do ABC, Santo André, Brazil
| | - Aline Amaro Dos Santos
- Laboratory of Genetics, Human Reproduction and Genetics Center, Faculdade de Medicina do ABC, Av. Lauro Gomes, 2000, Santo André, SP, CEP 09060-870, Brazil
| | - Carla Peluso
- Laboratory of Genetics, Human Reproduction and Genetics Center, Faculdade de Medicina do ABC, Av. Lauro Gomes, 2000, Santo André, SP, CEP 09060-870, Brazil
| | - Caio Parente Barbosa
- Discipline of Sexual and Reproductive Health, and Populational Genetics, Department of Collective Health, Faculdade de Medicina do ABC, Santo André, Brazil
| | - Bianca Bianco
- Laboratory of Genetics, Human Reproduction and Genetics Center, Faculdade de Medicina do ABC, Av. Lauro Gomes, 2000, Santo André, SP, CEP 09060-870, Brazil. .,Discipline of Sexual and Reproductive Health, and Populational Genetics, Department of Collective Health, Faculdade de Medicina do ABC, Santo André, Brazil.
| | - Luciano Miller Reis Rodrigues
- Discipline of Orthopaedics and Traumatology, Department of Surgery, Faculdade de Medicina do ABC, Santo André, Brazil
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Predictors of Recovery After Conservative Treatment of AO-Type A Thoracolumbar Spine Fractures Without Neurological Deficit. Spine (Phila Pa 1976) 2018; 43:141-147. [PMID: 20736893 DOI: 10.1097/brs.0b013e3181cdb5fc] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, correlational, exploratory, clinical research. OBJECTIVE To identify the factors determining a patient's recovery after conservative treatment of compression fractures of the thoracolumbar spine. SUMMARY OF BACKGROUND DATA The reported results of compression fractures are poor. These results are not influenced by the severity of compression, the fracture site, or the residual deformity. Otherwise, the factors that determine a patient's recovery are unknown. METHODS In 48 conservatively treated patients the preinjury versus the 12-month follow-up differences (Δ) in back pain (visual analogue scale for pain), Oswestry disability index (ODI), and the Greenough and Fraser low back outcome scale were prospectively recorded. For these differences and for time lost from work and satisfaction, multiple linear regressions with combinations of 16 factors were performed. RESULTS At 1 year, patients with an income-insurance were 9% (P = 0.096) more disabled than those without. They reported a 15% less favorable global outcome and 27% less participation. Smokers were 13% (P = 0.010) more disabled and 11% (P = 0.044) less satisfied. With each increase of the AO-fracture type from A1 to A3 the disability was 8% worse. Patients with pre-existent chronic low back pain (CLBP) returned two points (on a visual analogue scale [VAS] pain total of 10) more closely (P = 0.041) to their preinjury pain level than those without but were 21% (P = 0.001) less satisfied. Our model offers an explanation for more than 25% of the variability of ΔODI and of the satisfaction. For sick leave, no significant predictors were found. CONCLUSION Smoking and insurance status are the strongest negative predictors for recovery. LBP patients returned more closely to their preinjury back pain level, but were less satisfied. The AO fracture type had a marked influence on disability, the sagittal deformity had not. The time lost from work did not depend on patient or injury-related factors. LEVEL OF EVIDENCE N/A.
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Riley MS, Bridwell KH, Lenke LG, Dalton J, Kelly MP. Health-related quality of life outcomes in complex adult spinal deformity surgery. J Neurosurg Spine 2017; 28:194-200. [PMID: 29171797 DOI: 10.3171/2017.6.spine17357] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Significant health-related quality of life (HRQOL) benefits have been observed for patients undergoing primary and revision adult spinal deformity (ASD) surgery. The purpose of this study was to report changes in HRQOL measures in a consecutive series of patients undergoing complex spinal reconstructive surgery, using Scoli-RISK-1 (SR-1) inclusion criteria. METHODS This was a single-center, retrospective cohort study. The SR-1 inclusion criteria were used to define patients with complex ASD treated between June 1, 2009, and June 1, 2011. Standard preoperative and perioperative data were collected, including the Scoliosis Research Society (SRS)-22r instrument. The HRQOL changes were evaluated at a minimum 2-year follow-up. Standardized forms were used to collect surgery-related complications data for all patients. Complications were defined as minor, transient major, or permanent major. Patients who achieved a minimum 2-year follow-up were included in the analysis. RESULTS Eighty-four patients meeting SR-1 criteria were identified. Baseline demographic and surgical data were available for 74/84 (88%) patients. Forty-seven of 74 (64%) patients met the additional HRQOL criteria with a minimum 2-year follow-up (mean follow-up 3.4 years, range 2-6.5 years). Twenty-one percent of patients underwent posterior fusion only, 40% of patients had a posterior column osteotomy, and 38% had a 3-column osteotomy. Seventy-five percent of patients underwent a revision procedure. Significant improvements were observed in all SRS-22r domains: Pain: +0.8 (p < 0.001); Self-Image: +1.4 (p < 0.001); Function: +0.46 (p < 0.001); Satisfaction: +1.6 (p < 0.001); and Mental Health: +0.28 (p = 0.04). With the exception of Mental Health, more than 50% of patients achieved a minimum clinically important difference (MCID) in SRS-22r domain scores (Mental Health: 20/47, 42.6%). A total of 65 complications occurred in 31 patients. This includes 29.8% (14/47) of patients who suffered a major complication and 17% (8/47) who suffered a postoperative neurological deficit, most commonly at the root level (10.6%, 5/47). Of the 8 patients who suffered a neurological deficit, 1 (13%) was able to achieve MCID in the SRS Function domain. CONCLUSIONS The majority of patients experienced clinically relevant improvement in SRS-22r HRQOL scores after complex ASD surgery. The greatest improvements were seen in the SRS Pain and SRS Self-Image domains. Although 30% of patients suffered a major or permanent complication, benefits from surgery were still attained. Patients sustaining a neurological deficit or major complication were unlikely to achieve HRQOL improvements meeting or exceeding MCID for the SRS Function domain.
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Affiliation(s)
- Max S Riley
- 1Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Keith H Bridwell
- 1Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Lawrence G Lenke
- 2Department of Orthopedic Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jonathan Dalton
- 1Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Michael P Kelly
- 1Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri; and
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ADAMTS5 Deficiency Protects Mice From Chronic Tobacco Smoking-induced Intervertebral Disc Degeneration. Spine (Phila Pa 1976) 2017; 42:1521-1528. [PMID: 28570296 PMCID: PMC5633483 DOI: 10.1097/brs.0000000000002258] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN ADAMTS5-deficient and wild type (WT) mice were chronically exposed to tobacco smoke to investigate effects on intervertebral disc degeneration (IDD). OBJECTIVE The aim of this study was to demonstrate a role for ADAMTS5 in mediating tobacco smoking-induced IDD. SUMMARY OF BACKGROUND DATA We previously demonstrated that chronic tobacco smoking causes IDD in mice because, in part, of proteolytic destruction of disc aggrecan. However, it was unknown which matrix proteinase(s) drive these detrimental effects. METHODS Three-month-old WT (C57BL/6) and ADAMTS5 mice were chronically exposed to tobacco smoke (four cigarettes/day, 5 day/week for 6 months). ADAMTS-mediated cleavage of disc aggrecan was analyzed by Western blot. Disc total glycosaminoglycan (GAG) content was assessed by dimethyl methylene blue assay and safranin O/fast green histology. Vertebral osteoporosity was measured by microcomputed tomography. Human nucleus pulposus (hNP) cell cultures were also exposed directly to tobacco smoke extract (TSE), a condensate containing the water-soluble compounds inhaled by smokers, to measure ADAMTS5 expression and ADAMTS-mediated cleavage of aggrecan. Activation of nuclear factor (NF)-κB, a family of transcription factors essential for modulating the cellular response to stress, was measured by immunofluorescence assay. RESULTS Genetic depletion of ADAMTS5 prevented vertebral bone loss, substantially reduced loss of disc GAG content, and completely obviated ADAMTS-mediated proteolysis of disc aggrecan within its interglobular domain (IGD) in mice following exposure to tobacco smoke. hNP cell cultures exposed to TSE also resulted in upregulation of ADAMTS5 protein expression and a concomitant increase in ADAMTS-mediated cleavage within aggrecan IGD. Activation of NF-κB, known to be required for ADAMTS5 gene expression, was observed in both TSE-treated hNP cell cultures and disc tissue of tobacco smoke-exposed mice. CONCLUSION The findings demonstrate that ADAMTS5 is the primary aggrecanase mediating smoking-induced disc aggrecanolysis and IDD. Mouse models of chronic tobacco smoking are important and useful for probing the mechanisms of disc aggrecan catabolism and IDD. LEVEL OF EVIDENCE N/A.
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Gaudin D, Krafcik BM, Mansour TR, Alnemari A. Considerations in Spinal Fusion Surgery for Chronic Lumbar Pain: Psychosocial Factors, Rating Scales, and Perioperative Patient Education—A Review of the Literature. World Neurosurg 2017; 98:21-27. [DOI: 10.1016/j.wneu.2016.10.124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/22/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
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The Effect of Smoking Status on Successful Arthrodesis After Lumbar Instrumentation Supplemented with rhBMP-2. World Neurosurg 2017; 97:459-464. [DOI: 10.1016/j.wneu.2016.10.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 11/18/2022]
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The Effects of Smoking and Smoking Cessation on Spine Surgery: A Systematic Review of the Literature. Global Spine J 2016; 6:695-701. [PMID: 27781190 PMCID: PMC5077710 DOI: 10.1055/s-0036-1571285] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 12/15/2015] [Indexed: 11/20/2022] Open
Abstract
Study Design Literature review. Objective The aim of this literature review was to detail the effects of smoking in spine surgery and examine whether perioperative smoking cessation could mitigate these risks. Methods A review of the relevant literature examining the effects of smoking and cessation on surgery was conducted using PubMed, Google Scholar, and Cochrane databases. Results Current smokers are significantly more likely to experience pseudarthrosis and postoperative infection and to report lower clinical outcomes after surgery in both the cervical and lumbar spines. Smoking cessation can reduce the risks of these complications depending on both the duration and timing of tobacco abstinence. Conclusion Smoking negatively affects both the objective and subjective outcomes of surgery in the lumbar and cervical spine. Current literature supports smoking cessation as an effective tool in potentially mitigating these unwanted outcomes. Future investigations in this field should be directed toward developing a better understanding of the complex relationship between smoking and poorer outcomes in spine surgery as well as developing more efficacious cessation strategies.
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Mody RR, Smith MJ. Smoking Status and Health-Related Quality of Life: Findings from the 2001 Behavioral Risk Factor Surveillance System Data. Am J Health Promot 2016; 20:251-8. [PMID: 16555798 DOI: 10.4278/0890-1171-20.4.251] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose. To examine the relationship between smoking status and health-related quality of life (HRQOL). Design. Our study used a cross-sectional analysis with self-reported data from the 2001 Behavioral Risk Factor Surveillance System (BRFSS). Setting. United States. Subjects. Subjects were a representative sample of noninstitutionalized adults aged 18 years and older. After excluding respondents who reported being pregnant and for whom smoking status could not be determined, we included 209,031 respondents. Measures. Multiple logistic regressions were performed to examine the associations of smoking status with the four HRQOL items, controlling for demographic and health-related characteristics. Results. Current smokers had a higher likelihood of reporting poor general health status compared with nonsmokers and ex-smokers. Compared with nonsmokers, current smokers had a higher likelihood of reporting ≥ 14 days of poor physical health (odds ratio [OR] = 1.64, 95% confidence interval [CI] = 1.51–1.77), poor mental health (OR = 1.99, 95% CI = 1.84–2.16), and activity limitations (OR = 1.80, 95% CI = 1.63–2.00). Similarly, compared with ex-smokers, current smokers had a higher likelihood of reporting ≥ 14 days of poor physical health (OR = 1.30, 95% CI = 1.19–1.42), poor mental health (OR = 1.65, 95% CI = 1.50–1.81), and activity limitations (OR = 1.48, 95% CI = 1.32–1.65). Age, income, and presence of comorbidities also significantly explained variation in HRQOL. Conclusions. Our study reaffirms the significant association between smoking and HRQOL in a large nationally representative sample. Poor health associated with smoking persists as a major public health problem, and effective preventive and smoking cessation efforts should be undertaken.
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Affiliation(s)
- Reema R Mody
- Department of Pharmaceutical Systems and Policy, Robert C. Byrd Health Sciences Center, PO Box 9510, West Virginia University, School of Pharmacy, Morgantown, WV 26506, USA.
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A Subtle Threat to Urban Populations in Developing Countries: Low Back Pain and its Related Risk Factors. Spine (Phila Pa 1976) 2016; 41:618-27. [PMID: 27018901 DOI: 10.1097/brs.0000000000001269] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional, population-based survey. OBJECTIVE The aim of this study was to estimate the prevalence, and biological and psychological correlates of low back pain (LBP) in large, populated urban areas. SUMMARY OF BACKGROUND DATA LBP is a common and costly medical problem all around the world. Currently, there are limited data available on prevalence as well as biological and psychological correlates of LBP in large urban populations in developing countries. METHODS Here, in a cross-sectional, population-based survey, we analyzed data obtained from 22,952 subjects living in Tehran. RESULTS Chronic, 1-year, and point prevalence of LBP among subjects were 12.2%, 42.1%, and 36.2%, respectively. LBP was more prevalent among older population, women, housewives, and obese people after adjustment for confounding factors using logistic regression models. In addition, persons with a general health questionnaire (GHQ-28) score ≥6 were about 2 times more likely to experience LBP in comparison with others. Both subjects with higher educational levels and those who were never married reported significantly less LBP. Furthermore, we could not find any significant correlation between smoking and physical activity level with LBP. CONCLUSION LBP is prevalent among the general population of Tehran. Our findings can help health care providers regarding logical assignment of limited resources, in order to create multidimensional prevention plans according to potentially modifiable associated factors. LEVEL OF EVIDENCE 3.
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Harris SA, Rampersaud YR. The importance of identifying and modifying unemployment predictor variables in the evolution of a novel model of care for low back pain in the general population. Spine J 2016; 16:16-22. [PMID: 26409414 DOI: 10.1016/j.spinee.2015.09.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 07/13/2015] [Accepted: 09/14/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Care for low back pain (LBP) is costly, fragmented and, in non-compensation populations, rarely specifically addresses factors associated with maintaining employment status or return to work (RTW). PURPOSE This study aimed to identify modifiable independent risk factors for (1) a negative work status at presentation and (2) a change in work status during treatment in a cohort of LBP patients. The results are intended to inform improvement in best-evidence care pathways to maximize societal outcomes and overall value of a new model of care. STUDY DESIGN/SETTING A prospective observational study was carried out. INCLUSION CRITERIA Work-eligible, non-workers compensation patients with recurrent or persistent LBP ≥6 weeks and ≤12 months. SETTING The Inter-professional Spine Assessment and Education Clinics (ISAEC)-a novel Government-funded shared-care model of management for LBP. METHODS This study used the following methods: (1) Cross-sectional analysis of baseline data from the initial ISAEC consultation (t0) from December 2012 to April 2014. Work status at t0 was dichotomized as employed (E) or underemployed (UE; unemployed, modified work duty, or disability). Multivariate logistic regression modeling was used to determine independent predictors of UE status at t0. (2) Bivariate analysis of longitudinal data from t0 to 6 months (t1) to identify risk factors for work status change. Employment journey categorized into four groups: Et0/Et1-employed at t0 and employed at t1; Et0/UEt1-employed at t0 and underemployed at t1; UEt0/Et1-underemployed at t0 and employed at t1; UEt0/UEt1-underemployed at t0 and underemployed at t1. RESULTS This study yielded the following results: (1) Initial consultation data on 462 consecutive patients (Et0=344, UEt0=118). Multivariate logistic regression identified legal claim, depression, smoking, and higher STarT Back (or Oswestry Disability Index [ODI]) score as independent risk factors for UEt0. (2) Overall UE rate did not significantly change during longitudinal analysis (n=178, UEt0=25.5%, UEt1=22.9%). However, 10.5% of Et0 became UEt1 (Et0/Et1=102, Et0/UEt1=12). Bivariate analysis identified elevated baseline ODI score as the only significant predictor variable for UEt1 in Et0 cohort (p=.0101). Conversely, ISAEC improved the employment status in 41% of UEt0 to Et1 (UEt0/Et1=16, UEt0/UEt1=23), and the absence of depression was significant for predicting RTW (p=.0001). CONCLUSIONS From a societal perspective, employment status as an outcome measure is paramount in assessing the value of a new model of care for LBP. Mitigation strategies for the predictor variables identified will be included in ISAEC pathways to translate clinical improvement into societal added value.
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Affiliation(s)
- Simon A Harris
- Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, University Health Network, 399 Bathurst St East Wing, 1-441, Toronto, Ontario M5T-2S8, Canada; Arthritis Program, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Y Raja Rampersaud
- Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, University Health Network, 399 Bathurst St East Wing, 1-441, Toronto, Ontario M5T-2S8, Canada; Arthritis Program, Toronto Western Hospital, Toronto, Ontario, Canada; Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, Toronto, Ontario, Canada; University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Manchikanti L, Singh V, Falco FJE, Benyamin RM, Hirsch JA. Epidemiology of low back pain in adults. Neuromodulation 2015; 17 Suppl 2:3-10. [PMID: 25395111 DOI: 10.1111/ner.12018] [Citation(s) in RCA: 314] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 11/07/2012] [Accepted: 11/25/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Low back pain affects many individuals. It has profound effects on well-being and is often the cause of significant physical and psychological health impairments. Low back pain also affects work performance and social responsibilities, such as family life, and is increasingly a major factor in escalating health-care costs. A global review of the prevalence of low back pain in the adult general population has shown its point prevalence to be approximately 12%, with a one-month prevalence of 23%, a one-year prevalence of 38%, and a lifetime prevalence of approximately 40%. Furthermore, as the population ages over the coming decades, the number of individuals with low back pain is likely to increase substantially. This comprehensive review is undertaken to assess the increasing prevalence of low back pain and the influence of comorbid factors, along with escalating costs. MATERIALS AND METHODS A narrative review with literature assessment. RESULTS In the USA, low back pain and related costs are escalating. Based on the available literature, it appears that the prevalence of low back pain continues to increase, along with numerous modalities and their application in managing low back pain. Comorbid factors with psychological disorders and multiple medical problems, including obesity, smoking, lack of exercise, increasing age, and lifestyle factors, are considered as risk factors for low back pain. CONCLUSION Although it has been alleged that low back pain resolves in approximately 80% to 90% of patients in about six weeks, irrespective of the administration or type of treatment, with only 5% to 10% of patients developing persistent back pain, this concept has been frequently questioned as the condition tends to relapse and most patients experience multiple episodes years after the initial attack.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY, USA; University of Louisville, Louisville, KY, USA
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Orhurhu VJ, Pittelkow TP, Hooten WM. Prevalence of smoking in adults with chronic pain. Tob Induc Dis 2015; 13:17. [PMID: 26185492 PMCID: PMC4504349 DOI: 10.1186/s12971-015-0042-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 07/08/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction Cigarette smoking is common among adults with chronic pain. The primary objective of this study was to determine the period prevalence of smoking in patients with chronic pain. A secondary objective was to determine the prevalence of smoking among patients with commonly occurring pain diagnoses including fibromyalgia, low back pain, and headache. Methods This population study included 5350 patients (1256 smokers, 4094 nonsmokers) admitted to the Mayo Comprehensive Pain Rehabilitation Center from January 1998 through December 2012. Smoking status was determined using a self-report questionnaire. Results During the 15 year study period, the overall prevalence of smoking was 23.5 % (95 % CI 22.4 – 24.6). The prevalence of smoking in 2000, 2005, and 2010 was 24.2, 25.7, and 28.3 % respectively. The overall prevalence of smoking in patients with fibromyalgia, low back pain, and headache was 25.2 % (95 % CI 22.8 – 28.3), 22.8 % (95 % CI 21.3 – 25.9), and 21.2 % (95 % CI 17.9 – 24.7), respectively. In a multiple variable logistic model adjusted for age and sex, opioid use was significantly associated with status as a current smoker. Conclusion The prevalence of smoking in patients with chronic pain has not declined when compared to the general population. The higher prevalence of smoking was consistently observed in commonly occurring pain diagnoses including fibromyalgia, back pain, and headache. Further research is needed to identify the potential factors that contribute to the high prevalence of smoking in this patient population.
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Affiliation(s)
| | - Thomas P Pittelkow
- Department of Anesthesiology, Division of Pain Medicine, Mayo Graduate School of Medicine, Rochester, MN 55902 USA
| | - W Michael Hooten
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905 USA
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Goesling J, Brummett CM, Meraj TS, Moser SE, Hassett AL, Ditre JW. Associations Between Pain, Current Tobacco Smoking, Depression, and Fibromyalgia Status Among Treatment-Seeking Chronic Pain Patients. PAIN MEDICINE (MALDEN, MASS.) 2015; 16:1433-42. [PMID: 25801019 PMCID: PMC4765172 DOI: 10.1111/pme.12747] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE As smoking impacts physiological pathways in the central nervous system, it is important to consider the association between smoking and fibromyalgia, a pain condition caused predominantly by central nervous system dysfunction. The objectives were to assess the prevalence of current smoking among treatment-seeking chronic pain patients with (FM+) and without (FM-) a fibromyalgia-like phenotype; test the individual and combined influence of smoking and fibromyalgia on pain severity and interference; and examine depression as a mediator of these processes. METHODS Questionnaire data from 1566 patients evaluated for a range of conditions at an outpatient pain clinic were used. The 2011 Survey Criteria for Fibromyalgia were used to assess the presence of symptoms associated with fibromyalgia. RESULTS Current smoking was reported by 38.7% of FM+ patients compared to 24.7% of FM- patients. FM+ smokers reported higher pain and greater interference compared to FM+ nonsmokers, FM- smokers, and FM- nonsmokers. There was no interaction between smoking and fibromyalgia. Significant indirect effects of fibromyalgia and smoking via greater depression were observed for pain severity and interference. CONCLUSIONS Current smoking and positive fibromyalgia status were associated with greater pain and impairment among chronic pain patients, possibly as a function of depression. Although FM+ smokers report the most negative clinical symptomatology (i.e., high pain, greater interference) smoking does not appear to have a unique association with pain or functioning in FM+ patients, rather the effect is additive. The 38.7% smoking rate in FM+ patients is high, suggesting FM+ smokers present a significant clinical challenge.
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Affiliation(s)
- Jenna Goesling
- Department of Anesthesiology, University of Michigan, Ann Arbor MI
| | - Chad M. Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor MI
| | - Taha S. Meraj
- Medical School, University of Michigan, Ann Arbor, MI
| | | | - Afton L. Hassett
- Department of Anesthesiology, University of Michigan, Ann Arbor MI
| | - Joseph W. Ditre
- Department of Psychology, Syracuse University, Syracuse, New York, USA
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Adjacent segment pathology requiring reoperation after anterior cervical arthrodesis: the influence of smoking, sex, and number of operated levels. Spine (Phila Pa 1976) 2015; 40:E571-7. [PMID: 25705959 DOI: 10.1097/brs.0000000000000846] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE The purpose of this study was to determine, using survivorship analysis, the rate of adjacent segment pathology (ASP) development and to identify the risk factors for reoperation. SUMMARY OF BACKGROUND DATA The study of Hilibrand defined "adjacent segment disease" as symptomatic radiculopathy or myelopathy due to an adjacent segment documented on 2 consecutive office visits. In addition to being somewhat subjective, their criterion is not as practical as identifying the rate of adjacent pathology by the need for reoperation. METHODS This was a retrospective analysis of 1038 consecutive patients who underwent primary anterior cervical spine arthrodesis for radiculopathy and/or myelopathy by 1 surgeon. Annual incidence and prevalence of ASP requiring surgery were calculated and survivorship was determined. We used the Cox regression for risk factor analysis. RESULTS Secondary surgery on adjacent segments occurred at a relatively constant rate of 2.4% per year (95% confidence interval, 1.9-3.0). The Kaplan-Meier analysis predicted that 22.2% of patients would need reoperation at adjacent segments by 10 years postoperatively. Factors increasing the risk were smoking, female sex, and the number of arthrodesis segments. One or 2-segment arthrodesis had an 1.8 times greater risk than arthrodesis involving 3 or more segments. Age, neurological diagnosis, diabetes, Klippel-Feil syndrome, and noncontiguous segmental-type ossification of posterior longitudinal ligament were not significant risks. CONCLUSION Patients treated with 1- or 2-segment anterior cervical arthrodesis are more likely to develop ASP than those treated with arthrodesis involving 3 or more segments. Smokers and women had a higher ASP reoperation rate. Our series, the largest in the literature, predicts that 22.2% of patients will require reoperation for ASP within 10 years, substantially higher than the Hilibrand study. LEVEL OF EVIDENCE 3.
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Unrod M, Gironda RJ, Clark ME, White KE, Simmons VN, Sutton SK, Brandon TH. Smoking behavior and motivation to quit among chronic pain patients initiating multidisciplinary pain treatment: a prospective study. PAIN MEDICINE (MALDEN, MASS.) 2014; 15:1294-303. [PMID: 24528473 PMCID: PMC4374596 DOI: 10.1111/pme.12364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The primary aim of this study was to assess smoking characteristics and cessation motivation prior to and after initiation of multidisciplinary chronic pain treatment. A secondary aim was to identify predictors of cessation motivation among smokers initiating treatment for chronic pain. DESIGN We used a prospective, nonrandomized, repeated measures design. SETTING The study was conducted in a multidisciplinary specialty pain treatment program at a veterans hospital. PATIENTS Smokers (N = 90) referred to a multidisciplinary pain program for the treatment of chronic pain. MEASURES Patients completed questionnaires assessing pain-related and smoking-related factors prior to (baseline) and 8 weeks post (follow-up) specialty pain treatment initiation. Primary outcome measures were the Contemplation Ladder and the Stages of Change (SOC) algorithm. RESULTS At baseline, patients reported moderate levels of cessation motivation, and 69% were in the contemplation stage or higher on the SOC. Motivation to quit smoking was higher at follow-up compared with baseline on both continuous, t(89) = 2.11, P < 0.05, and stage-based, z = 3.69, P < 0.01, measures. At follow-up, participants reported greater interest in receiving cessation interventions, and 7.8% of patients had quit smoking. Pain-related predictors of motivation (e.g., pain intensity) were subsumed by more general predictors (e.g., nicotine dependence). CONCLUSIONS Patients in this sample were more motivated to quit smoking a few weeks after, as compared with before initiating specialty pain treatment. Future research into pain-specific predictors of cessation motivation is warranted to inform the development of interventions that address pain patients' unique needs.
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Affiliation(s)
- Marina Unrod
- H. Lee Moffitt Cancer Center & Research Institute
- University of South Florida
| | | | | | | | - Vani N. Simmons
- H. Lee Moffitt Cancer Center & Research Institute
- University of South Florida
| | - Steven K. Sutton
- H. Lee Moffitt Cancer Center & Research Institute
- University of South Florida
| | - Thomas H. Brandon
- H. Lee Moffitt Cancer Center & Research Institute
- University of South Florida
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Alan N, Seicean A, Seicean S, Schiltz NK, Neuhauser D, Weil RJ. Smoking and postoperative outcomes in elective cranial surgery. J Neurosurg 2014; 120:811-9. [DOI: 10.3171/2014.1.jns131852] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The goal in this study was to assess whether a current or prior history of smoking and the number of smoking pack years affect the risk for adverse outcomes in the 30-day postoperative period in patients who undergo elective cranial surgery.
Methods
Data from the 2006–2011 American College of Surgeons' National Surgical Quality Improvement Project were used in this study. The authors identified 8296 patients who underwent elective cranial surgery, of whom 1718 were current smokers, 854 were prior smokers, and 5724 were never smokers. Using propensity scores and age, the authors matched current and prior smokers to never smokers. Odds ratios for adverse postoperative outcomes were predicted with logistic regression. The relationship between number of pack years and poor outcomes was also examined.
Results
In unadjusted analyses, prior and current smokers did not differ from never smokers for having poor outcomes postoperatively. Similarly, in matched analyses, no association was found between smoking and adverse outcomes. Number of pack years in propensity-matched analyses did not predict worse outcomes in prior or current smokers versus never smokers.
Conclusions
The authors did not find smoking to be associated with 30-day postoperative morbidity or mortality. Although smoking cessation is beneficial for overall health, it may not improve the short-term (≤ 30 days) outcome of elective cranial surgery. Thus postponement of elective cranial cases only for smoking cessation may not be necessary.
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Affiliation(s)
- Nima Alan
- 1Case Western Reserve University School of Medicine, Cleveland
| | - Andreea Seicean
- 1Case Western Reserve University School of Medicine, Cleveland
- 2Department of Epidemiology and Biostatistics, Case Western Reserve University
| | - Sinziana Seicean
- 3Departments of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals, Cleveland
- 4Heart and Vascular Institute, Cleveland Clinic; and
| | - Nicholas K. Schiltz
- 2Department of Epidemiology and Biostatistics, Case Western Reserve University
| | - Duncan Neuhauser
- 2Department of Epidemiology and Biostatistics, Case Western Reserve University
| | - Robert J. Weil
- 5The Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, and Department of Neurosurgery, the Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Hooten WM, Townsend CO, Hays JT, Ebnet KL, Gauvin TR, Gehin JM, Laures HJ, Patten CA, Warner DO. A cognitive behavioral smoking abstinence intervention for adults with chronic pain: a randomized controlled pilot trial. Addict Behav 2014; 39:593-9. [PMID: 24333035 DOI: 10.1016/j.addbeh.2013.11.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/30/2013] [Accepted: 11/13/2013] [Indexed: 11/28/2022]
Abstract
Current evidence suggests it may be difficult for patients with chronic pain to quit smoking and, based on previous formative work, a 7-session individual and group-based cognitive behavioral (CB) intervention was developed. The primary aim of this randomized controlled pilot trial was to test the hypothesis that abstinence at month 6 would be greater among patients with chronic pain who received the CB intervention compared to a control condition. Upon admission to a 3-week interdisciplinary pain treatment (IPT) program, patients were randomized to receive the CB intervention (n=30) or the control condition (n=30). The 7-day point prevalence of self-reported smoking status was assessed at week 3 (upon completion of the 3-week IPT program) and at month 6 in an intent-to-treat analysis. At week 3, 30% (n=9) of patients in the CB condition were abstinent from smoking compared to 10% (n=3) in the control group (P=.104). At month 6, 20% (n=6) of patients who received the CB intervention were abstinent compared to none in the control group (P=.024). At week 3, a significant group by time interaction effect was found where the CB patients experienced greater improvements in self-efficacy from baseline compared to the control group (P=.002). A greater proportion of patients randomized to the CB group completed the IPT program (P=.052). The findings of this pilot trial suggest that integration of a CB-based smoking abstinence intervention into ongoing pain therapy may be an effective treatment for smokers with chronic pain.
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Affiliation(s)
- W Michael Hooten
- Department of Anesthesiology, Mayo College of Medicine, Rochester, MN, United States.
| | - Cynthia O Townsend
- Department of Psychiatry and Psychology, Mayo College of Medicine, Rochester, MN, United States
| | - J Taylor Hays
- Department of Internal Medicine, Mayo College of Medicine, Rochester, MN, United States
| | - Kaye L Ebnet
- Department of Nursing, Mayo Clinic, Rochester, MN, United States
| | - Thomas R Gauvin
- Department of Internal Medicine, Mayo College of Medicine, Rochester, MN, United States
| | - Jessica M Gehin
- Department of Nursing, Mayo Clinic, Rochester, MN, United States
| | - Heidi J Laures
- Department of Psychiatry and Psychology, Mayo College of Medicine, Rochester, MN, United States
| | - Christi A Patten
- Department of Psychiatry and Psychology, Mayo College of Medicine, Rochester, MN, United States
| | - David O Warner
- Department of Anesthesiology, Mayo College of Medicine, Rochester, MN, United States
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van Hecke O, Torrance N, Cochrane L, Cavanagh J, Donnan PT, Padmanabhan S, Porteous DJ, Hocking L, Smith BH. Does a history of depression actually mediate smoking-related pain? Findings from a cross-sectional general population-based study. Eur J Pain 2014; 18:1223-30. [PMID: 24577799 DOI: 10.1002/j.1532-2149.2014.00470.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Smokers report more pain and worse functioning. The evidence from pain clinics suggests that depression affects this relationship: The association between smoking and chronic pain is weakened when controlling for depression. This study explored the relationship between smoking, pain and depression in a large general population-based cohort (Generation Scotland: Scottish Family Health Study). METHODS Chronic pain measures (intensity, disability), self-reported smoking status and a history of major depressive disorder (MDD) were analysed. A multivariate analysis of covariance determined whether smoking status was associated with both pain measures and a history of depressive illness. Using a statistical mediation model any mediating effect of depression on the relationship between smoking and chronic pain was sought. RESULTS Of all 24,024 participants, 30% (n = 7162) reported any chronic pain. Within this chronic pain group, 16% (n = 1158) had a history of MDD; 7108 had valid smoking data: 20% (n = 1408) were current smokers, 33% (n = 2351) former and 47% (n = 3349) never smokers. Current smokers demonstrated higher pain intensity and pain-related disability scores compared with former and non-smokers (p < 0.001 for all analyses). From the mediation model, the effect on pain intensity decreased (p < 0.001), indicating that the relationship between smoking and a history of depression contributes significantly to the effect of smoking on pain intensity. When applied to smoking-related pain disability, there was no mediation effect. CONCLUSIONS In contrast to smokers treated in pain clinics, a history of MDD mediated the relationship between smoking and pain intensity, but not pain-related disability in smokers in the community.
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Affiliation(s)
- O van Hecke
- Medical Research Institute, University of Dundee, UK
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39
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van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology - where do lifestyle factors fit in? Br J Pain 2013; 7:209-17. [PMID: 26516524 PMCID: PMC4590163 DOI: 10.1177/2049463713493264] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Chronic pain is common and complex and has a large impact on individuals and society. Good epidemiological pain data provide key information on the use of resources (both in general practice and in specialist clinics), insight into factors that lead to or favour chronicity and the design of interventions aimed at reducing or preventing the effects of chronic pain. This review aims to highlight the important factors associated with chronic pain, including those factors which are amenable to lifestyle intervention.
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Affiliation(s)
| | - Nicola Torrance
- Medical Research Institute, University of Dundee, Dundee, UK
| | - Blair H Smith
- Medical Research Institute, University of Dundee, Dundee, UK
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Stipelman BA, Augustson E, McNeel T. The relationship among smoking, sleep, and chronic rheumatic conditions commonly associated with pain in the National Health Interview Survey. J Behav Med 2013; 36:539-48. [PMID: 22864597 PMCID: PMC3858964 DOI: 10.1007/s10865-012-9447-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 07/20/2012] [Indexed: 12/21/2022]
Abstract
Chronic rheumatic conditions are typically characterized by chronic pain and are uniquely associated with increased rates of cigarette smoking and poor sleep quality. However, no study has examined the possible additive or interactive effects of these two health behaviors in individuals diagnosed with a chronic rheumatic condition. The goal of this study is to examine the relationship between cigarette smoking and sleep in a population sample of individuals diagnosed with a chronic rheumatic condition and related functional impairment. Cross sectional survey data was obtained from the 2007 National Health Interview Survey. Individuals diagnosed with a chronic rheumatic condition were more likely to be a former or current smoker compared to non-diagnosed individuals. Individuals with a chronic rheumatic condition were more likely to report <6 h of sleep per night and endorsed significantly more insomnia and daytime sleepiness. There was no interaction between diagnosis of a chronic rheumatic condition and smoking status on any of the sleep outcomes assessed. Finally, an interaction was observed suggesting individuals with a chronic rheumatic condition who currently smoke are more likely to report averaging <6 h of sleep per night and frequent insomnia compared to individuals with a chronic rheumatic condition who never smoked. These results suggest both a unique and additive relationship between smoking and sleep in individuals with a chronic rheumatic condition. Findings can likely be generalized to other conditions commonly associated with chronic pain.
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Affiliation(s)
- Brooke A Stipelman
- Science of Research and Technology Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD 20892-7326, USA.
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Abstract
STUDY DESIGN Retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement database. OBJECTIVE We assessed whether preoperative cigarette smoking and smoking duration predicted adverse, early, perioperative outcomes in patients undergoing elective spine surgery. SUMMARY OF BACKGROUND DATA Prior studies have assessed the association of smoking and long-term outcomes for a number of spine surgery procedures, with conflicting findings. The association between smoking and 30-day outcomes for spine surgery is unknown. METHODS A total 14,500 adults, classified as current (N = 3914), prior (N = 2057), and never smokers. Using propensity scores, current and prior smokers were matched to never smokers. Logistic regression was used to predict adverse postoperative outcomes. The relationship between pack-years and adverse outcomes was tested. Sensitivity analyses were conducted limiting the study sample to patients who underwent spine fusion (N = 4663), and using patient subgroups by procedure. RESULTS In unadjusted analyses, prior smokers were significantly more likely to have prolonged hospitalization (1.2, 95% confidence interval [CI]: 1.1-1.3) and major complications (1.3, 95% CI: 1.1-1.6) compared with never smokers. No association was found between smoking status and adverse outcomes in adjusted, matched patient models. Current smokers with more than 60 pack-years were more likely to die within 30 days of surgery (3.0, 95% CI, 1.1-7.8), compared with never smokers. Sensitivity analyses confirmed these findings. CONCLUSION The large National Surgical Quality Improvement population was carefully matched for a wide range of baseline comorbidities, including 29 variables previously suggested to influence perioperative outcomes. Although previous studies conducted in subgroups of spine surgery patients have suggested a deleterious effect for smoking on long-term outcomes in patients undergoing spine surgery, our analysis did not find smoking to be associated with early (30 d) perioperative morbidity or mortality.
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Holley AL, Law EF, Tham SW, Myaing M, Noonan C, Strachan E, Palermo TM. Current smoking as a predictor of chronic musculoskeletal pain in young adult twins. THE JOURNAL OF PAIN 2013; 14:1131-9. [PMID: 23810151 DOI: 10.1016/j.jpain.2013.04.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 04/08/2013] [Accepted: 04/18/2013] [Indexed: 12/19/2022]
Abstract
UNLABELLED Chronic pain is common during adolescence and young adulthood and is associated with poor quality of life, depression, and functional disability. Recognizing that chronic pain has significant consequences, it is important to identify modifiable health behaviors that may place young adults at risk for chronic pain. This study examines associations between chronic musculoskeletal pain and smoking in young adult twins (n = 1,588, ages 18-30) participating in a statewide twin registry. Twins completed questionnaires assessing smoking, mood (anxiety, depressive symptoms, and stress), and chronic musculoskeletal pain. Analyses examined associations between chronic pain and smoking, particularly the role of genetics/shared familial factors and psychological symptoms. As predicted, results revealed a near-2-fold increased risk for chronic musculoskeletal pain in twins who currently smoked compared to nonsmokers, even when accounting for psychological factors. Results of within-pair analyses were only minimally attenuated, suggesting that associations between smoking and chronic musculoskeletal pain are better accounted for by nonshared factors than by shared familial factors/genetic effects. Future twin research is needed to identify what nonshared factors (eg, attitudes, direct effects of smoking on pain) contribute to these associations to further understand comorbidity. Longitudinal studies and recruitment of participants prior to smoking initiation and chronic pain onset will better identify causal associations. PERSPECTIVE This article describes associations between musculoskeletal pain and smoking in young adult twins, taking into account psychological symptoms. Findings highlight the importance of nonshared factors in associations between pain and smoking and the need to explore the roles of lifestyle, individual attitudes, and direct effects of smoking on pain.
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Affiliation(s)
- Amy Lewandowski Holley
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington.
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Abstract
➤ Cigarette smoking decreases bone mineral density and increases the risk of sustaining a fracture or tendon injury, with partial reversibility of these risks with long-term cessation of smoking. ➤ Cigarette smoking increases the risk for perioperative complications, nonunion and delayed union of fractures, infection, and soft-tissue and wound-healing complications. ➤ Brief preoperative cessation of smoking may mitigate these perioperative risks. ➤ Informed-consent discussions should include notification of the higher risk of perioperative complications with cigarette smoking and the benefits of temporary cessation of smoking.
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Affiliation(s)
- John J Lee
- Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, 1500 East Medical Center Drive SPC 5328, Ann Arbor, MI 48109, USA
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Behrend C, Prasarn M, Coyne E, Horodyski M, Wright J, Rechtine GR. Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care. J Bone Joint Surg Am 2012; 94:2161-6. [PMID: 23095839 DOI: 10.2106/jbjs.k.01598] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Smoking is associated with low back pain, intervertebral disc disease, inferior patient outcomes following surgical interventions, and increased rates of postoperative complications. The purpose of the present study was to examine the effect of smoking and smoking cessation on pain and disability in patients with painful spinal disorders. METHODS We examined a prospectively maintained database of records for 5333 patients with axial or radicular pain from a spinal disorder with regard to smoking history and the patient assessment of pain on four visual analog scales during the course of care. Confounding factors, including secondary gain, sex, age, and body mass index, were also examined. The mean duration of follow-up was eight months. Multivariate statistical analysis was performed with variables including smoking status, secondary gain status, sex, depression, and age as predictors of pain and disability. RESULTS Compared with patients who had never smoked, patients who were current smokers reported significantly greater pain in all visual analog scale pain ratings (p < 0.001). The mean improvement in reported pain over the course of care was significantly different between nonsmokers and current smokers (p <0.001). Compared with patients who had continued to smoke, those who had quit smoking during the course of care reported significantly greater improvement in pain in visual analog scale pain ratings for worst (p = 0.013), current (p < 0.05), and average weekly pain (p = 0.024). The mean improvement in the visual analog scale pain ratings was clinically important in patients in all three groups of nonsmokers. As a group, those who had continued smoking during treatment had no clinically important improvement in reported pain. CONCLUSIONS Given a strong association between improved patient-reported pain and smoking cessation, this study supports the need for smoking cessation programs for patients with a painful spinal disorder.
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Affiliation(s)
- Caleb Behrend
- Department of Orthopaedics,University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14625, USA.
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Prasarn ML, Horodyski MB, Behrend C, Wright J, Rechtine GR. Negative effects of smoking, workers' compensation, and litigation on pain/disability scores for spine patients. Surg Neurol Int 2012; 3:S366-9. [PMID: 23248756 PMCID: PMC3520074 DOI: 10.4103/2152-7806.103870] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 09/10/2012] [Indexed: 11/30/2022] Open
Abstract
Background: When initiating treatment for patients with spinal disorders, we examined the impact of smoking, workers compensation, and litigation on disability and pain scores. Methods: With Institutional Review Board approval, the medical records of 13,704 consecutive patients with spinal disorders treated at two university spine centers were reviewed. Particular attention was focused on the pretreatment impact of three variables: smoking, workers compensation, and litigation. All patients completed a questionnaire that included a modified Oswestry Disability Index (ODI), a visual analog pain scale (VAS) and a history of smoking, workers compensation, and/or litigation issues. Analysis of Variance (ANOVA) with Bonferroni (when appropriate) was used to analyze the data. Results: ODI scores significantly correlated with a smoking history: Current Smoker > Previous Smoker > Never Smoked (44.22 > 38.11 > 36.02, respectively). Pain scores and ODI scores had a direct correlation to workers compensation and litigation status. Workers compensation, litigation and smoking combined created even higher scores. There was no significant difference between previous smokers and nonsmokers. Conclusions: This study demonstrates that a history of smoking, workers compensation, and/or litigation, considered alone or worse, combined, negatively impacted outcomes for patients seeking treatment at our spine centers. For optimal outcomes in spine patients, cessation of smoking and treatment of attendant psychological and social factors prove critical.
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Affiliation(s)
- Mark L Prasarn
- Department of Orthopaedics and Rehabilitation, University of Texas Health Science Center, Ironman Sports Medicine Institute, Houston, TX, USA
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46
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Ditre JW, Brandon TH, Zale EL, Meagher MM. Pain, nicotine, and smoking: research findings and mechanistic considerations. Psychol Bull 2012; 137:1065-93. [PMID: 21967450 DOI: 10.1037/a0025544] [Citation(s) in RCA: 237] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Tobacco addiction and chronic pain represent 2 highly prevalent and comorbid conditions that engender substantial burdens upon individuals and systems. Interrelations between pain and smoking have been of clinical and empirical interest for decades, and research in this area has increased dramatically over the past 5 years. We conceptualize the interaction of pain and smoking as a prototypical example of the biopsychosocial model. Accordingly, we extrapolated from behavioral, cognitive, affective, biomedical, and social perspectives to propose causal mechanisms that may contribute to the observed comorbidity between these 2 conditions. The extant literature was 1st dichotomized into investigations of either effects of smoking on pain or effects of pain on smoking. We then integrated these findings to present a reciprocal model of pain and smoking that is hypothesized to interact in the manner of a positive feedback loop, resulting in greater pain and increased smoking. Finally, we proposed directions for future research and discussed clinical implications for smokers with comorbid pain disorders. We observed modest evidence that smoking may be a risk factor in the multifactorial etiology of some chronically painful conditions and that pain may come to serve as a potent motivator of smoking. We also found that whereas animal studies yielded consistent support for direct pain-inhibitory effects of nicotine and tobacco, results from human studies were much less consistent. Future research in the emerging area of pain and smoking has the potential to inform theoretical and clinical applications with respect to tobacco smoking, chronic pain, and their comorbid presentation. (PsycINFO Database Record (c) 2011 APA, all rights reserved).
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Affiliation(s)
- Joseph W Ditre
- Department of Psychology, Texas A&M University, College Station, USA.
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Abstract
INTRODUCTION Smokers are at increased risk of developing chronic pain and suffering higher pain intensity. However, nicotine has analgesic properties, and smokers may view smoking as a means to cope with pain. Smoking cessation is clearly beneficial to the long-term health of smokers. However, it is not known how abstinence from smoking affects pain. The aim of this study was to determine the association between smoking cessation and changes in pain symptoms by secondary analysis of a large longitudinal dataset of older adults. METHODS Secondary analyses were performed of longitudinal biennial survey data (1992 through 2006) from the nationally representative Health and Retirement Study of United States adults older than 50 years. Multivariate logistic regressions were utilized to determine the relationship between the changes in smoking status and changes in pain symptoms, controlling for demographics, depression, self-rated health, history of arthritis, and body mass index. RESULTS In multivariate analyses, among the 4,695 smokers who reported no pain or mild pain at enrollment, smoking status was not independently associated with exacerbation of pain (odds ratio [OR]: 0.95, 95% CI: 0.84, 1.08). Among the 1,118 smokers who reported moderate to severe pain at enrollment, smoking status was not independently associated with improvement of pain (OR: 0.87, 95% CI: 0.70, 1.08). CONCLUSIONS Smoking cessation was not independently associated with changes in pain symptoms in older adults. These results suggest that concerns regarding the effects of abstinence from smoking on pain should not pose a barrier to offering tobacco use interventions to smokers with chronic pain.
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Affiliation(s)
- Yu Shi
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
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48
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Hooten WM, Vickers KS, Shi Y, Ebnet KL, Townsend CO, Patten CA, Warner DO. Smoking cessation and chronic pain: patient and pain medicine physician attitudes. Pain Pract 2011; 11:552-63. [PMID: 21518246 DOI: 10.1111/j.1533-2500.2011.00462.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Although previous studies suggest that the clinical setting of an interdisciplinary pain treatment program may provide an optimal environment to promote smoking cessation, currently available smoking cessation interventions may be less effective for adults with chronic pain due, in part, to unrecognized clinical factors related to chronic pain. The specific aim of this qualitative study was to solicit information from adult smokers with chronic pain participating in an interdisciplinary pain treatment program regarding their perceptions of how smoking affects pain symptoms, and how these beliefs, cognitions, and emotions may either impede or facilitate smoking cessation. Similar information was solicited from a group of pain specialty physicians. The study involved 18 smokers with chronic pain, and seven physicians. Patients reported that smoking was an important coping strategy for pain and distress, primarily by offering an opportunity for distraction and avoidance, respectively. The majority of patients using opioids reported that opioid consumption stimulated smoking. Important barriers were identified toward making a quit attempt during pain treatment including quitting smoking while making changes in opioid use, and perceived difficulty managing multiple treatment-related stressors. Several pain-related benefits of smoking cessation were identified by physicians, but important barriers to providing smoking cessation services were recognized including lack of time and knowledge about how to help patients quit smoking. The findings of this study identified several novel and important clinical factors that should be incorporated into a targeted smoking cessation intervention for adults with chronic pain.
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Affiliation(s)
- W Michael Hooten
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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Weaver FM, Smith B, LaVela SL, Evans CT, Ullrich P, Miskevics S, Goldstein B, Strayer J, Burns SP. Smoking behavior and delivery of evidence-based care for veterans with spinal cord injuries and disorders. J Spinal Cord Med 2011; 34:35-45. [PMID: 21528625 PMCID: PMC3066496 DOI: 10.1179/107902610x12911165975061] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE Little is known about those veterans with spinal cord injuries and disorders (SCI/D) who smoke cigarettes. This study identified the factors associated with smoking in this population, motivations for smoking, and the readiness for smoking cessation. Current practices for the delivery of evidence-based tobacco cessation were also examined. DESIGN Methods included surveys of veterans with SCI/D, medical record reviews of current smokers, and telephone interviews with SCI/D providers. SETTING Six Veterans Health Administration facilities with SCI centers and one SCI clinic. PARTICIPANTS Survey data were analyzed for 1210 veterans, 256 medical records were reviewed, and 15 providers served as key informants. INTERVENTIONS Observational study. OUTCOME MEASURES Veterans self-reported smoking status, quit attempts, methods and care received, motivation for smoking, and health care conditions. Medical record review and informant interviews examined the tobacco cessation care provided. RESULTS Whereas 22% of the respondents were current smokers; 51% were past smokers. Current smokers more often reported respiratory illnesses and/or symptoms, alcohol use, pain, and depression than past or never smokers, and approximately half made quit attempts in the past year. Smokers received referral to counseling (57%) and/or prescription for medication/nicotine replacement (23%). Key informants identified difficulty of providing follow-up and patients' unwillingness to consider quitting as barriers. CONCLUSION Veterans with SCi/D who smoke also had other health problems. Providers offer counseling and medication, but often have difficulty following patients to arrange/provide support. Identifying other support methods such as telehealth, considering the use of combination cessation therapies, and addressing other health concerns (e.g., depression) may affect tobacco cessation in this population.
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Affiliation(s)
- Frances M. Weaver
- Center for Management of Complex Chronic Care and the Spinal Cord Injury Quality Enhancement Research Initiative, Hines VA Hospital, Hines, IL,Program in Health Services Research, Department of Medicine, Loyola University, Maywood, IL,Correspondence to: Frances M. Weaver, Center for Management of Complex Chronic Care and the Spinal Cord Injury Quality Enhancement Research Initiative, Hines VA Hospital, Hines, IL 60141, USA. E-mail:
| | - Bridget Smith
- Center for Management of Complex Chronic Care and the Spinal Cord Injury Quality Enhancement Research Initiative, Hines VA Hospital, Hines, IL,Program in Health Services Research, Department of Medicine, Loyola University, Maywood, IL
| | - Sherri L. LaVela
- Center for Management of Complex Chronic Care and the Spinal Cord Injury Quality Enhancement Research Initiative, Hines VA Hospital, Hines, IL,Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Charlesnika T. Evans
- Center for Management of Complex Chronic Care and the Spinal Cord Injury Quality Enhancement Research Initiative, Hines VA Hospital, Hines, IL,Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Philip Ullrich
- Spinal Cord Injury Quality Enhancement Research Initiative, VA Puget Sound Healthcare System, Seattle, WA
| | - Scott Miskevics
- Center for Management of Complex Chronic Care and the Spinal Cord Injury Quality Enhancement Research Initiative, Hines VA Hospital, Hines, IL
| | - Barry Goldstein
- Spinal Cord Injury Quality Enhancement Research Initiative, VA Puget Sound Healthcare System, Seattle, WA,Harborview Injury Prevention and Research Center and Department of Rehabilitation Medicine, University of Washington
| | | | - Stephen P. Burns
- Spinal Cord Injury Quality Enhancement Research Initiative, VA Puget Sound Healthcare System, Seattle, WA,Harborview Injury Prevention and Research Center and Department of Rehabilitation Medicine, University of Washington
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50
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Gordon JS, Istvan J, Haas M. Tobacco cessation via doctors of chiropractic: results of a feasibility study. Nicotine Tob Res 2010; 12:305-8. [PMID: 20097840 DOI: 10.1093/ntr/ntp203] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION There is a sizeable and growing body of empirical literature on the effects of physician advice to quit smoking. Because of the association between tobacco use and the health problems that may provoke referral to chiropractic care, doctors of chiropractic (DCs) may be able to give patients personalized proximal health feedback that may motivate them to quit. However, DCs have not been utilized in this role. The primary aim of this study was to design and refine a brief office-based tobacco intervention for use within chiropractic settings. METHODS This study was conducted in 20 private chiropractic practices in 2 phases: (a) intervention development, in which we created and focus tested practitioner and patient materials, and (b) feasibility, in which we evaluated the impact of the intervention on 210 tobacco-using chiropractic patients. RESULTS Analyses were conducted on 156 patients who exclusively smoked cigarettes. Using an intent-to-treat approach, assuming all nonresponders to be smokers, 13 (8.3%) reported 7-day abstinence at 6 weeks, 22 (14.1%) at the 6-month follow-up, and 35 (22.4%) at the 12-month assessment. Eleven participants (7.1%) reported prolonged abstinence at the 6-month follow-up, and 15 (9.6%) reported prolonged abstinence at 12 months. CONCLUSIONS To our knowledge, this is the first study to refine a brief office-based treatment for tobacco dependence for use in chiropractic settings. The results of this study were promising and will lead to a randomized clinical trial. If found to be effective, this model could be disseminated to chiropractic practitioners throughout the United States.
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Affiliation(s)
- Judith S Gordon
- Department of Family & Community Medicine, University of Arizona, 1450 North Cherry Avenue, Tucson, AZ 85719, USA.
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