Assessment and management of pain in older adults with dementia: a review of current practice and future directions

Phosphorylation of KRT8 (keratin 8) by excessive mechanical load-activated PKN (protein kinase N) impairs autophagosome initiation and contributes to disc degeneration

Excessive mechanical load (overloading) is a well-documented pathogenetic factor for many mechano stress-induced pathologies, i.e. intervertebral disc degeneration (IDD). Under overloading, the balance between anabolism and catabolism within nucleus pulposus (NP) cells are badly thrown off, and NP cells undergo apoptosis. However, little is known about how the overloading is transduced to the NP cells and contributes to disc degeneration. The current study shows that conditional knockout of Krt8 (keratin 8) within NP aggravates load-induced IDD in vivo, and overexpression of Krt8 endows NP cells greater resistance to overloading-induced apoptosis and degeneration in vitro. Discovery-driven experiments shows that phosphorylation of KRT8 on Ser43 by overloading activated RHOA-PKN (protein kinase N) impedes trafficking of Golgi resident small GTPase RAB33B, suppresses the autophagosome initiation and contributes to IDD. Overexpression of Krt8 and knockdown of Pkn1 and Pkn2, at an early stage of IDD, ameliorates disc degeneration; yet only knockdown of Pkn1 and Pkn2, when treated at late stage of IDD, shows a therapeutic effect. This study validates a protective role of Krt8 during overloading-induced IDD and demonstrates that targeting overloading activation of PKNs could be a novel and effective approach to mechano stress-induced pathologies with a wider window of therapeutic opportunity.Abbreviations: AAV: adeno-associated virus; AF: anulus fibrosus; ANOVA: analysis of variance; ATG: autophagy related; BSA: bovine serum albumin; cDNA: complementary deoxyribonucleic acid; CEP: cartilaginous endplates; CHX: cycloheximide; cKO: conditional knockout; Cor: coronal plane; CT: computed tomography; Cy: coccygeal vertebra; D: aspartic acid; DEG: differentially expressed gene; DHI: disc height index; DIBA: dot immunobinding assay; dUTP: 2'-deoxyuridine 5'-triphosphate; ECM: extracellular matrix; EDTA: ethylene diamine tetraacetic acid; ER: endoplasmic reticulum; FBS: fetal bovine serum; GAPDH: glyceraldehyde-3-phosphate dehydrogenase; GPS: group-based prediction system; GSEA: gene set enrichment analysis; GTP: guanosine triphosphate; HE: hematoxylin-eosin; HRP: horseradish peroxidase; IDD: intervertebral disc degeneration; IF: immunofluorescence staining; IL1: interleukin 1; IVD: intervertebral disc; KEGG: Kyoto encyclopedia of genes and genomes; KRT8: keratin 8; KD: knockdown; KO: knockout; L: lumbar vertebra; LBP: low back pain; LC/MS: liquid chromatograph mass spectrometer; LSI: mouse lumbar instability model; MAP1LC3/LC3: microtubule associated protein 1 light chain 3; MMP3: matrix metallopeptidase 3; MRI: nuclear magnetic resonance imaging; NC: negative control; NP: nucleus pulposus; PBS: phosphate-buffered saline; PE: p-phycoerythrin; PFA: paraformaldehyde; PI: propidium iodide; PKN: protein kinase N; OE: overexpression; PTM: post translational modification; PVDF: polyvinylidene fluoride; qPCR: quantitative reverse-transcriptase polymerase chain reaction; RHOA: ras homolog family member A; RIPA: radio immunoprecipitation assay; RNA: ribonucleic acid; ROS: reactive oxygen species; RT: room temperature; TCM: rat tail compression-induced IDD model; TCS: mouse tail suturing compressive model; S: serine; Sag: sagittal plane; SD rats: Sprague-Dawley rats; shRNA: short hairpin RNA; siRNA: small interfering RNA; SOFG: safranin O-fast green; SQSTM1: sequestosome 1; TUNEL: terminal deoxynucleotidyl transferase dUTP nick end labeling; VG/ml: viral genomes per milliliter; WCL: whole cell lysate.

Non-Specific Low Back Pain: An Inductive Exploratory Analysis through Factor Analysis and Deep Learning for Better Clustering

Non-specific low back pain (NSLBP) is a significant and pervasive public health issue in contemporary society. Despite the widespread prevalence of NSLBP, our understanding of its underlying causes, as well as our capacity to provide effective treatments, remains limited due to the high diversity in the population that does not respond to generic treatments. Clustering the NSLBP population based on shared characteristics offers a potential solution for developing personalized interventions. However, the complexity of NSLBP and the reliance on subjective categorical data in previous attempts present challenges in achieving reliable and clinically meaningful clusters. This study aims to explore the influence and importance of objective, continuous variables related to NSLBP and how to use these variables effectively to facilitate the clustering of NSLBP patients into meaningful subgroups. Data were acquired from 46 subjects who performed six simple movement tasks (back extension, back flexion, lateral trunk flexion right, lateral trunk flexion left, trunk rotation right, and trunk rotation left) at two different speeds (maximum and preferred). High-density electromyography (HD EMG) data from the lower back region were acquired, jointly with motion capture data, using passive reflective markers on the subject's body and clusters of markers on the subject's spine. An exploratory analysis was conducted using a deep neural network and factor analysis. Based on selected variables, various models were trained to classify individuals as healthy or having NSLBP in order to assess the importance of different variables. The models were trained using different subsets of data, including all variables, only anthropometric data (e.g., age, BMI, height, weight, and sex), only biomechanical data (e.g., shoulder and lower back movement), only neuromuscular data (e.g., HD EMG activity), or only balance-related data. The models achieved high accuracy in categorizing individuals as healthy or having NSLBP (full model: 93.30%, anthropometric model: 94.40%, biomechanical model: 84.47%, neuromuscular model: 88.07%, and balance model: 74.73%). Factor analysis revealed that individuals with NSLBP exhibited different movement patterns to healthy individuals, characterized by slower and more rigid movements. Anthropometric variables (age, sex, and BMI) were significantly correlated with NSLBP components. In conclusion, different data types, such as body measurements, movement patterns, and neuromuscular activity, can provide valuable information for identifying individuals with NSLBP. To gain a comprehensive understanding of NSLBP, it is crucial to investigate the main domains influencing its prognosis as a cohesive unit rather than studying them in isolation. Simplifying the conditions for acquiring dynamic data is recommended to reduce data complexity, and using back flexion and trunk rotation as effective options should be further explored.

Comparative efficacy of 12 non-drug interventions on non-specific chronic low back pain in nurses: A systematic review and network meta-analysis

BACKGROUND

Many non-drug interventions for decreasing non-specific chronic low back pain (NSCLBP) in nurses have been extensively studied, but the most effective approach is still unclear.

OBJECTIVE

This systematic review and network meta-analysis evaluated the efficacies of 12 non-drug interventions in reducing NSCLBP in nurses.

METHODS

PubMed, ScienceDirect, Web of Science, Cochrane, EMBASE, CINAHL, Medline, WANFANG, VIP, China Knowledge Integrated, and SinoMed were searched from their establishment to July 2019. Randomized controlled trials (RCTs) comparing non-drug interventions for NSCLBP in nurses were included and analyzed using Stata v15 statistical software.

RESULTS

A total of 31 RCTs (n= 7116) and 12 non-drug interventions were included. The first three results with the highest surface areas under the curve ranking area (SUCRAs) were low back exercise plus healthy education, single low back exercise, and yoga (SUCRAs: 79.4%, 76.2%, and 75.1%, respectively). In addition, single yoga was inferior to protective equipment (standardized mean difference [SMD] = 3.88, 95% confidence interval [CI]: 0.92 to 6.84) and multidisciplinary intervention (SMD =-4.06, 95% CI: -7.33 to -0.78).

CONCLUSIONS

Low back exercise plus health education may be the best approach to reduce NSCLBP in nurses. Considering the heterogeneity, our findings need to be confirmed in future multicenter large sample RCTs in different countries.

Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis

Objective

To assess the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes.

Design

A systematic review of the literature with network meta-analysis.

Data sources

Medline, Embase and CENTRAL databases were searched from inception until 17 October 2020.

Eligibility criteria for selecting studies

Randomised clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute).

Results

Forty-six RCTs (n=8765) were included; risk of bias was low in 9 trials (19.6%), unclear in 20 (43.5%), and high in 17 (36.9%). At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were: exercise (standardised mean difference (SMD) −1.40; 95% confidence interval (CI) −2.41 to –0.40), heat wrap (SMD −1.38; 95% CI −2.60 to –0.17), opioids (SMD −0.86; 95% CI −1.62 to –0.10), manual therapy (SMD −0.72; 95% CI −1.40 to –0.04) and non-steroidal anti-inflammatory drugs (NSAIDs) (SMD −0.53; 95% CI −0.97 to –0.09). Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants (SMD -0.24; 95% CI -0.43 to -0.04). Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%) and steroids (46.9%) trial arms.

Conclusion

With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm–benefit balance.

Effectiveness of treatments for acute and sub-acute mechanical non-specific low back pain: protocol for a systematic review and network meta-analysis

BACKGROUND

Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute LBP usually has a good prognosis, with rapid improvement within the first 6 weeks. However, the majority of patients develop chronic LBP and suffer from recurrences. For clinical management, a plethora of treatments is currently available but evidence of the most effective options is lacking. The objective of this study will be to identify the most effective interventions to relieve pain and reduce disability in acute and sub-acute non-specific LBP.

METHODS/DESIGN

We will search electronic databases (MEDLINE, Embase, CENTRAL) from inception onwards. The eligible population will be individuals with non-specific LBP older than 18 years, both males and females, who experience pain less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Eligible interventions and comparators will include all conservative rehabilitation or pharmacological treatments provided by any health professional; the only eligible study design will be a randomized controlled trial. The primary outcomes will be pain intensity and back-specific functional status. Secondary outcomes will be any adverse events. Studies published in languages other than English will also potentially be included. Two reviewers will independently screen the titles and abstracts retrieved from a literature search, as well as potentially relevant full-text articles. General characteristics, potential effect modifiers, and outcome data will be extracted from the included studies, and the risk of bias will be appraised. Conflicts at all levels of screening and abstraction will be resolved through team discussions. After describing the results of the review, if appropriate, a random effects meta-analysis and network meta-analysis will be conducted in a frequentist setting, assuming equal heterogeneity across all treatment comparisons and accounting for correlations induced by multi-arm studies using a multivariate normal model.

DISCUSSION

Our systematic review will address the uncertainties in the use of pharmacological or non-pharmacological treatments, and their relative efficacy, for acute and subacute LBP. These findings will be useful for patients, healthcare providers, and policymakers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018102527.

Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study

Background

Pain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.

Aims and objectives

Two studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.

Methods

For the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.

Results

Data from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.

Limitations

Grey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.

Conclusions

No single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Initial testing of a behavioural pain assessment tool within trauma units

Pain is common in trauma patients who may be older and also may have cognitive impairment leading to reduced communication about their pain. A number of observational pain assessment tools are available and have been found to have limited clinical usefulness. The Bolton Pain Assessment Tool (BPAT) was developed following a trial of three established tools and includes a section to involve family and/or close carers in the pain assessment process. The aim of this paper is to present the findings of initial testing of BPAT. BPAT was used and evaluated by clinical staff in four trauma units in the UK. Forty-six staff evaluations were completed and 98% indicated it was easy to use; it took between one and two minutes to complete by 69.5% and led to pain management interventions by 93.5% of the respondents. It was rated highly by the clinical staff, but the involvement of families and close carers in the assessment process was different at each unit, with one unit not involving the family/close carer. There remains the need for a simple and practical way of assessing pain. This initial testing of the clinical feasibility of BPAT suggests that it is easy to use and helps to identify pain, but further testing of its reliability and validity is required.

Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools

BACKGROUND

There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment.

METHODS

We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach.

RESULTS

We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a 'gold standard' significantly hinders the evaluation of tools' validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations.

CONCLUSIONS

There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence.

"I feel so stupid because I can't give a proper answer…" How older adults describe chronic pain: a qualitative study

BACKGROUND

Over 50% of older adults experience chronic pain. Poorly managed pain threatens independent functioning, limits social activities and detrimentally affects emotional wellbeing. Yet, chronic pain is not fully understood from older adults' perspectives; subsequently, pain management in later life is not necessarily based on their priorities or needs. This paper reports a qualitative exploration of older adults' accounts of living with chronic pain, focusing on how they describe pain, with a view to informing approaches to its assessment.

METHODS

Cognitively intact men and women aged over sixty-five who lived in the community opted into the study through responding to advertisements in the media and via contacts with groups and organisations in North-East Scotland. Interviews were transcribed and thematically analysed using a framework approach.

RESULTS

Qualitative individual interviews and one group interview were undertaken with 23 older adults. Following analysis, the following main themes emerged: diversity in conceptualising pain using a simple numerical score; personalising the meaning of pain by way of stories, similes and metaphors; and, contextualising pain in relation to its impact on activities.

CONCLUSIONS

The importance of attending to individuals' stories as a meaningful way of describing pain for older adults is highlighted, suggesting that a narrative approach, as recommended and researched in other areas of medicine, may usefully be applied in pain assessment for older adults. Along with the judicious use of numerical tools, this requires innovative methods to elicit verbal accounts, such as using similes and metaphors to help older adults describe and discuss their experience, and contextualising the effects of pain on activities that are important to them.

[Brazilian version of the Non-communicative Patient's Pain Assessment Instrument (NOPPAIN): conceptual, item, and semantic equivalence]

The evaluation and measurement of pain in individuals with dementia and unable to communicate verbally has been a challenging experience. The Non-communicative Patient's Pain Assessment Instrument (NOPPAIN) is an instrument that evaluates this phenomenon by observing behaviors that express pain. Considering the lack of instruments for this purpose in Brazil, the current study was designed to translate the NOPPAIN instrument into Brazilian Portuguese and culturally adapt it to the Brazilian reality. This was a methodological study, with Guillemin et al. as the theoretical reference. The study included four steps: translation; obtaining a consensus version; back-translation; and evaluation of the translation and back-translation by an expert panel. In this initial approach, the NOPPAIN-Br showed semantic equivalence to the original instrument and is now available in Brazilian Portuguese for further validation.

A collaborative expert literature review of pain education, assessment and management

Pain assessment and management in older adults requires a special emphasis on the needs of this population, which is often not considered within general education. The purpose of this study was twofold: to determine the availability of education on pain in older adults around the world, and to present a review and synthesis of published guidelines and key papers on pain assessment and management in older adults. Following on from this study we intend to make recommendations on what work needs to be carried out in future to inform the development of a curriculum or curriculum content specifically dedicated to pain management for older adults. A discussion forum was set up through the Pain in Older Adults Special Interest Group of the International Association for the Study of Pain (IASP) at the end of 2009. This forum was initiated to determine the current level and availability of education available around the world for health professionals on pain in older adults. A number of IASP members from countries around the world participated in the discussion and identified educational courses on pain in older adults from their member country. Following on from this discussion, a number of leading experts agreed to collate guidelines and key papers and conduct a critical review using Appraisal of Guidelines Research and Evaluation (AGREE) criteria. A total of 14 guideline documents on pain assessment and management were reviewed by the group. The papers were reviewed and graded and then agreed between reviewers. From the guideline review, some recommendations can be made, but primarily, the key recommendation from this work was to develop collaboration and a review of key evidence on which future research may be developed so an educational focus may be highlighted. This article presents a summary of those documents along with recommendations for improved and consistent education informed by the guidelines currently developed, and consistent evidence-based assessment and management of chronic pain in older adults.