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Yu GZ, Ly M, Karim HT, Muppidi N, Aizenstein HJ, Ibinson JW. Accelerated brain aging in chronic low back pain. Brain Res 2021; 1755:147263. [PMID: 33422525 DOI: 10.1016/j.brainres.2020.147263] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/20/2020] [Accepted: 12/20/2020] [Indexed: 12/15/2022]
Abstract
Chronic low back pain (CLBP) is a leading cause of disability and is associated with neurodegenerative changes in brain structure. These changes lead to impairments in cognitive function and are consistent with those seen in aging, suggesting an accelerated aging pattern. In this study we assessed this using machine-learning estimated brain age (BA) as a holistic metric of morphometric changes associated with aging. Structural imaging data from 31 non-depressed CLBP patients and 32 healthy controls from the Pain and Interoception Imaging Network were included. Using our previously developed algorithm, we estimated BA per individual based on grey matter density. We then conducted multivariable linear modeling for effects of group, chronological age, and their interaction on BA. We also performed two voxel-wise analyses comparing grey matter density between CLBP and control individuals and the association between gray matter density and BA. There was an interaction between CLBP and greater chronological age on BA such that the discrepancy in BA between healthy and CLBP individuals was greater for older individuals. In CLBP individuals, BA was not associated with sex, current level of pain, duration of CLBP, or mild to moderate depressive symptoms. CLBP individuals had lower cerebellar grey matter density compared to healthy individuals. Brain age was associated with lower gray matter density in numerous brain regions. CLBP was associated with greater BA, which was more profound in later life. BA as a holistic metric was sensitive to differences in gray matter density in numerous regions which eluded direct comparison between groups.
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Affiliation(s)
- Gary Z Yu
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria Ly
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - Helmet T Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nishita Muppidi
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Howard J Aizenstein
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - James W Ibinson
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA.
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Stahl ST, Jung C, Weiner DK, Peciña M, Karp JF. Opioid Exposure Negatively Affects Antidepressant Response to Venlafaxine in Older Adults with Chronic Low Back Pain and Depression. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:1538-1545. [PMID: 31633789 PMCID: PMC7530569 DOI: 10.1093/pm/pnz279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly co-prescribed with opioids for chronic pain. The purpose of this study was to describe pain and mood response to venlafaxine among older adults with chronic low back pain (CLBP) and depression relative to opioid exposure. DESIGN Secondary analyses were collected from a randomized clinical trial testing a stepped-care approach to comorbid pain and depression in older patients: the Addressing Depression and Pain Together study (ADAPT: 2010-2016). SETTING University-based late-life mental health research clinic. SUBJECTS Two hundred twenty-seven adults aged 65+ years with CLBP and depression. METHODS Participants received six weeks of lower-dose venlafaxine (≤150 mg/d). Pain and depression were measured each week. Response for both pain and depression at the end of six weeks was defined by a ≥30% improvement on a 0-20 numeric rating scale for low back pain and a Patient Health Questionnaire-9 score ≤5. Opioid exposure was analyzed as prescribed (yes or no) and by morphine equivalent dosing (MED). RESULTS Patients co-prescribed an opioid were less likely to report a pain response to venlafaxine. MED was negatively correlated with pain response. Depression response was not impacted. CONCLUSIONS Opioids are negatively associated with older adults' early analgesic response to lower-dose venlafaxine. These findings suggest that clinicians may wish to consider either nonopioid or alternative antidepressant approaches to pain management in these complex patients. It is reassuring that opioids do not prevent depression response. Future research should examine both longer duration of treatment and a wider range of doses.
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Affiliation(s)
| | - Changgi Jung
- Departments of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Debra K Weiner
- Departments of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Geriatric Research, Education and Clinic Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Candlish J, Teare MD, Cohen J, Bywater T. Statistical design and analysis in trials of proportionate interventions: a systematic review. Trials 2019; 20:151. [PMID: 30819224 PMCID: PMC6396459 DOI: 10.1186/s13063-019-3206-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 01/17/2019] [Indexed: 12/23/2022] Open
Abstract
Background In proportionate or adaptive interventions, the dose or intensity can be adjusted based on individual need at predefined decision stages during the delivery of the intervention. The development of such interventions may require an evaluation of the effectiveness of the individual stages in addition to the whole intervention. However, evaluating individual stages of an intervention has various challenges, particularly the statistical design and analysis. This review aimed to identify the use of trials of proportionate interventions and how they are being designed and analysed in current practice. Methods We searched MEDLINE, Web of Science and PsycINFO for articles published between 2010 and 2015 inclusive. We considered trials of proportionate interventions in all fields of research. For each trial, its aims, design and analysis were extracted. The data synthesis was conducted using summary statistics and a narrative format. Results Our review identified 44 proportionate intervention trials, comprising 28 trial results, 13 protocols and three secondary analyses. These were mostly described as stepped care (n=37) and mainly focussed on mental health research (n=30). The other studies were aimed at finding an optimal adaptive treatment strategy (n=7) in a variety of therapeutic areas. Further terminology used included adaptive intervention, staged intervention, sequentially multiple assignment trial or a two-phase design. The median number of decision stages in the interventions was two and only one study explicitly evaluated the effect of the individual stages. Conclusions Trials of proportionate staged interventions are being used predominantly within the mental health field. However, few studies consider the different stages of the interventions, either at the design or the analysis phase, and how they may interact with one another. There is a need for further guidance on the design, analyses and reporting across trials of proportionate interventions. Trial registration Prospero, CRD42016033781. Registered on 2 February 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3206-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jane Candlish
- ScHARR, University of Sheffield, 30 Regent Court, Sheffield, S1 4DA, UK.
| | - M Dawn Teare
- ScHARR, University of Sheffield, 30 Regent Court, Sheffield, S1 4DA, UK
| | - Judith Cohen
- ScHARR, University of Sheffield, 30 Regent Court, Sheffield, S1 4DA, UK.,Hull Health Trials Unit, University of Hull/Hull York Medical School, York, UK
| | - Tracey Bywater
- Department of Health Sciences, University of York, Area 2, Seebohm, Rowntree Building, York, Y010 5DD, UK
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Wei W, Karim HT, Lin C, Mizuno A, Andreescu C, Karp JF, Reynolds CF, Aizenstein HJ. Trajectories in Cerebral Blood Flow Following Antidepressant Treatment in Late-Life Depression: Support for the Vascular Depression Hypothesis. J Clin Psychiatry 2018; 79:18m12106. [PMID: 30358242 PMCID: PMC6419103 DOI: 10.4088/jcp.18m12106] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 04/28/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Studies have identified longitudinally that there exists an association between depression, cerebral blood flow (CBF), and white matter hyperintensities that are thought to be due to vascular pathologies in the brain. However, the changes in CBF, a measure that reflects cerebrovascular integrity, following pharmacotherapy are not well understood. In this study, we investigated the dynamic CBF changes over the course of antidepressant treatment and the association of these changes with depressive symptoms. METHODS We used pseudocontinuous arterial spin labeling to investigate CBF changes in a sample of older patients (≥ 50 years of age; N = 46; 29 female) with a DSM-IV diagnosis of major depressive disorder. Participants had 5 magnetic resonance imaging scans (at baseline, the day after receiving a placebo, the day after receiving a first dose of venlafaxine, a week after starting venlafaxine treatment, and at the end of trial [12 weeks]). Montgomery-Asberg Depression Rating Scale (MADRS) was used to evaluate depression severity and treatment outcome. We investigated the association between changes in depression severity with changes in voxel-wise CBF while adjusting for potential confounding factors. RESULTS Increased CBF in the middle and posterior cingulate between baseline and end of treatment was significantly associated with percent decrease in MADRS score, independent of sex and Mini-Mental State Examination score (5,000 permutations, cluster forming threshold P < .005, family-wise error P < .05). No significant effects were detected between baseline and other scans (ie, placebo, acute [single dose], or subacute [after a week]). CONCLUSIONS Regional CBF increases were associated with decreases in depressive symptoms. This observation is consistent with the vascular depression hypothesis in late-life depression. TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT00892047 and NCT01124188.
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Affiliation(s)
- Wenjing Wei
- The Third Xiangya Hospital of Central South University, Changsha, Hunan, China,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Helmet T. Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Chemin Lin
- Department of Psychiatry, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Akiko Mizuno
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Carmen Andreescu
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jordan F. Karp
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Howard J. Aizenstein
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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Effect of Problem-Solving Therapy Versus Supportive Management in Older Adults with Low Back Pain and Depression While on Antidepressant Pharmacotherapy. Am J Geriatr Psychiatry 2018; 26:765-777. [PMID: 29724663 DOI: 10.1016/j.jagp.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 01/06/2018] [Accepted: 01/08/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Testing stepped-care approaches that address both depression and low back pain are needed to optimize outcomes in older adults. METHODS This university-based late-life depression research center assessed 227 adults aged ≥ 60 years with chronic low back pain and depression. In Phase 1 participants received 6 weeks of low-dose venlafaxine (≤150 mg/day). Nonresponders were randomized to 10 weeks of high-dose venlafaxine (up to 300 mg/day) plus problem-solving therapy (PST) or high-dose venlafaxine with supportive management. Definition of response was 2 weeks of Patient Health Questionnaire-9 ≤ 5 and ≥30% pain reduction on a numeric rating scale. Function was measured with the Short Physical Performance Battery (SPPB) and Roland Morris Disability Questionnaire (RMDQ). RESULTS Of those who completed Phase 1 (N = 209), 78.5% (N = 164) were nonresponders and 139 proceeded to Phase 2, with 68 randomized to venlafaxine/PST and 71 randomized to venlafaxine/supportive management. Of those in venlafaxine/PST, 41.2% (28/68) responded, and of those in venlafaxine/supportive management, 39.4% (28/71) responded. Cumulative proportion responding over time did not differ across the two arms (hazard ratio: 1.07; 95% confidence interval: 0.63-1.80). We observed clinically significant improvements in physical performance (SPPB) and disability (RMDQ) across both Phase 1 and 2, independent of intervention. Over 12 months of follow-up there was no difference between groups for stability of depression, pain, or disability. CONCLUSION The combination of antidepressant pharmacotherapy and PST was not superior to antidepressant pharmacotherapy and supportive management. Clinically, the rates of response and stability of response over 1 year observed in both groups suggest that these approaches may have clinical utility in these chronically suffering patients.
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Peterson K, Anderson J, Bourne D, Mackey K, Helfand M. Effectiveness of Models Used to Deliver Multimodal Care for Chronic Musculoskeletal Pain: a Rapid Evidence Review. J Gen Intern Med 2018; 33:71-81. [PMID: 29633140 PMCID: PMC5902347 DOI: 10.1007/s11606-018-4328-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Primary care providers (PCPs) face many system- and patient-level challenges in providing multimodal care for patients with complex chronic pain as recommended in some pain management guidelines. Several models have been developed to improve the delivery of multimodal chronic pain care. These models vary in their key components, and work is needed to identify which have the strongest evidence of clinically-important improvements in pain and function. Our objective was to determine which primary care-based multimodal chronic pain care models provide clinically relevant benefits, define key elements of these models, and identify patients who are most likely to benefit. METHODS To identify studies, we searched MEDLINE® (1996 to October 2016), CINAHL, reference lists, and numerous other sources and consulted with experts. We used predefined criteria for study selection, data abstraction, internal validity assessment, and strength of evidence grading. RESULTS We identified nine models, evaluated in mostly randomized controlled trials (RCTs). The RCTs included 3816 individuals primarily from the USA. The most common pain location was the back. Five models primarily coupling a decision-support component-most commonly algorithm-guided treatment and/or stepped care-with proactive ongoing treatment monitoring have the best evidence of providing clinically relevant improvement in pain intensity and pain-related function over 9 to 12 months (NNT range, 4 to 13) and variable improvement in quality of life, depression, anxiety, and sleep. The strength of the evidence was generally low, as each model was only supported by a single RCT with imprecise findings. DISCUSSION Multimodal chronic pain care delivery models coupling decision support with proactive treatment monitoring consistently provide clinically relevant improvement in pain and function. Wider implementation of these models should be accompanied by further evaluation of clinical and implementation effectiveness.
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Affiliation(s)
- Kim Peterson
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA.
| | - Johanna Anderson
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA
| | - Donald Bourne
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA
| | - Katherine Mackey
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA
| | - Mark Helfand
- Department of Veterans Affairs, VA Portland Health Care System, Evidence-based Synthesis Program (ESP) Coordinating Center, Portland, OR, USA
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7
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Helstrom A, Haratz J, Chen S, Benson A, Streim J, Oslin D. Telephone-based management of chronic pain in older adults in an integrated care program. Int J Geriatr Psychiatry 2018; 33:779-785. [PMID: 29498774 DOI: 10.1002/gps.4860] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 12/15/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Few studies have explored behavioral strategies for managing chronic pain in older adults. Pain Care Management (PCM) is a telephone-based behavioral intervention for chronic pain. The present study examined chronic pain characteristics among older adults and tested the delivery of PCM as an adjunct to depression and anxiety care management. METHODS Participants were drawn from a state-sponsored program offering care management services to community members aged 65 and older who were prescribed a psychotropic medication by a primary care provider. Chronic pain information was collected for all participants in the state program (N = 250) and treatment outcome data were collected for a subset with significant chronic pain. Eighty participants with high chronic pain interference were offered PCM and compared to 80 participants with chronic pain who received monitoring only on depression, anxiety, and pain interference outcomes. RESULTS Chronic pain was identified in 14% of older adults newly prescribed a psychotropic medication. Compared to monitoring only, PCM participants had higher odds of seeing a reduction of 2 or more points in pain interference at 6 months. Pain care management participants' anxiety scores significantly decreased over the study period. CONCLUSIONS Older adults treated with psychotropic medications often also experience chronic pain that interferes with daily activities. A telephone-based care management intervention is acceptable and feasible with an older community-based population and can lead to improvements in anxiety symptoms and interference from chronic pain. Further research will help to refine interventions that may help improve symptoms and increase functioning with this population.
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Affiliation(s)
- Amy Helstrom
- VISN4 Mental Illness Research, Education, and Clinical Center, Cpl Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Josh Haratz
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Shirley Chen
- VISN4 Mental Illness Research, Education, and Clinical Center, Cpl Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Amy Benson
- VISN4 Mental Illness Research, Education, and Clinical Center, Cpl Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joel Streim
- VISN4 Mental Illness Research, Education, and Clinical Center, Cpl Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David Oslin
- VISN4 Mental Illness Research, Education, and Clinical Center, Cpl Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Advancing the screening of fibromyalgia in late-life depression: practical implications for psychiatric settings. Int Psychogeriatr 2015; 27:1513-21. [PMID: 25907254 PMCID: PMC4521974 DOI: 10.1017/s1041610215000666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fibromyalgia (FM) is common in older adults suffering from mood disorders. However, clinical diagnosis of FM is challenging, particularly in psychiatric settings. We examined the prevalence of FM and the sensitivity of three simple screeners for FM. METHODS Using cross-sectional data, we evaluated three tests against the American College of Rheumatology (ACR) 1990 Criteria for the Classification of FM: a "Do you often feel like you hurt all over?" question, a pain map score, and the Pope and Hudson (PH) interview for FM. Participants were 185 community-dwelling adults ≥ 60 years old with comorbid depression and chronic low back pain evaluated at a late-life mental health clinic. RESULTS Fifty three of 185 participants (29%) met the ACR 1990 FM criteria. Compared to those without FM, the FM group had more "yes" answers to the "hurt all over?" question and higher pain map scores. To reach a sensitivity of at least 0.90, the cut-off score for the pain map was 8. The sensitivity of the pain map, "hurt all over?" question, and PH criteria were 0.92 [95%CI 0.82-0.98], 0.91 [95%CI 0.79-0.97], and 0.94 [95%CI 0.843-0.99] respectively. CONCLUSIONS Nearly one in three older adults suffering from depression and chronic low back pain met ACR 1990 FM criteria. Three short screening tests showed high sensitivity when compared to the ACR 1990 FM criteria. Implementation of one of the simple screeners for FM in geriatric psychiatry settings may guide the need for further diagnostic evaluation.
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Abstract
IMPORTANCE Persistent pain is highly prevalent, costly, and frequently disabling in later life. OBJECTIVE To describe barriers to the management of persistent pain among older adults, summarize current management approaches, including pharmacologic and nonpharmacologic modalities; present rehabilitative approaches; and highlight aspects of the patient-physician relationship that can help to improve treatment outcomes. This review is relevant for physicians who seek an age-appropriate approach to delivering pain care for the older adult. EVIDENCE ACQUISITION Search of MEDLINE and the Cochrane database from January 1990 through May 2014, using the search terms older adults, senior, ages 65 and above, elderly, and aged along with non-cancer pain, chronic pain, persistent pain, pain management, intractable pain, and refractory pain to identify English-language peer-reviewed systematic reviews, meta-analyses, Cochrane reviews, consensus statements, and guidelines relevant to the management of persistent pain in older adults. FINDINGS Of the 92 identified studies, 35 evaluated pharmacologic interventions, whereas 57 examined nonpharmacologic modalities; the majority (n = 50) focused on older adults with osteoarthritis. This evidence base supports a stepwise approach with acetaminophen as first-line therapy. If treatment goals are not met, a trial of a topical nonsteroidal anti-inflammatory drug, tramadol, or both is recommended. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. Careful surveillance to monitor for toxicity and efficacy is critical, given that advancing age increases risk for adverse effects. A multimodal approach is strongly recommended-emphasizing a combination of both pharmacologic and nonpharmacologic treatments to include physical and occupational rehabilitation, as well as cognitive-behavioral and movement-based interventions. An integrated pain management approach is ideally achieved by cultivating a strong therapeutic alliance between the older patient and the physician. CONCLUSIONS AND RELEVANCE Treatment planning for persistent pain in later life requires a clear understanding of the patient's treatment goals and expectations, comorbidities, and cognitive and functional status, as well as coordinating community resources and family support when available. A combination of pharmacologic, nonpharmacologic, and rehabilitative approaches in addition to a strong therapeutic alliance between the patient and physician is essential in setting, adjusting, and achieving realistic goals of therapy.
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Affiliation(s)
- Una E Makris
- Department of Internal Medicine, Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, Texas2Department of Medicine, Division of Rheumatology, Veterans Administration Medical Center, Dallas, Texas
| | - Robert C Abrams
- Department of Psychiatry, Weill Cornell Medical College, New York, New York4Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York
| | - Barry Gurland
- Stroud Center, Columbia University, New York, New York
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, New York
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Kroenke K, Yu Z, Wu J, Kean J, Monahan PO. Operating characteristics of PROMIS four-item depression and anxiety scales in primary care patients with chronic pain. PAIN MEDICINE 2014; 15:1892-901. [PMID: 25138978 DOI: 10.1111/pme.12537] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Depression and anxiety are prevalent in patients with chronic pain and adversely affect pain, quality of life, and treatment response. The purpose of this psychometric study was to determine the reliability and validity of the four-item Patient Reported Outcomes Measurement Information System (PROMIS) depression and anxiety scales in patients with chronic pain. DESIGN Secondary analysis of data from the Stepped Care to Optimize Pain care Effectiveness study, a randomized clinical trial of optimized analgesic therapy. SETTING Five primary care clinics at the Roudebush VA Medical Center (RVAMC) in Indianapolis, Indiana. SUBJECTS Two hundred forty-four primary care patients with chronic musculoskeletal pain. METHODS All patients completed the four-item depression and anxiety scales from the PROMIS 29-item profile, as well as several other validated psychological measures. The minimally important difference (MID) using the standard error of measurement (SEM) was calculated for each scale, and convergent validity was assessed by interscale correlations at baseline and 3 months. Operating characteristics of the PROMIS measures for detecting patients who had probable major depression or were anxiety-disorder screen-positive were calculated. RESULTS The PROMIS scales had good internal reliability, and the MID (as represented by two SEMs) was 2 points for the depression scale and 2.5 points for the anxiety scale. Convergent validity was supported by strong interscale correlations. The optimal screening cutpoint on the 4- to 20-point PROMIS scales appeared to be 8 for both the depression and anxiety scales. CONCLUSIONS The PROMIS four-item depression and anxiety scales are reasonable options as ultra-brief measures for screening in patients with chronic pain.
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Affiliation(s)
- Kurt Kroenke
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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Rej S, Dew MA, Karp JF. Treating concurrent chronic low back pain and depression with low-dose venlafaxine: an initial identification of "easy-to-use" clinical predictors of early response. PAIN MEDICINE 2014; 15:1154-62. [PMID: 25040462 DOI: 10.1111/pme.12456] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Depression and chronic low back pain (CLBP) are both frequent and commonly comorbid in older adults seeking primary care. Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine may be effective in treating comorbid depression and CLBP. For patients with comorbid depression and CLBP, our goal was to identify "easy-to-use" early clinical variables associated with response to 6 weeks of low-dose venlafaxine pharmacotherapy that could be used to construct a clinically useful predictive model in future studies. METHODS We report data from the first 140 patients completing phase 1 of the Addressing Depression and Pain Together clinical trial. Patients aged ≥60 with concurrent depression and CLBP received 6 weeks of open-label venlafaxine 150 mg/day and supportive management. Using univariate and multivariate methods, we examined a variety of clinical predictors and their association with response to both depression and CLBP; change in depression; and change in pain scores at 6 weeks. RESULTS About 26.4% of patients responded for both depression and pain with venlafaxine. Early improvement in pain at 2 weeks predicted improved response rates (P = 0.027). Similarly, positive changes in depression and pain at 2 weeks independently predicted continued improvement at 6 weeks in depression and pain, respectively (P < 0.001). CONCLUSIONS An important minority of patients benefitted from 6 weeks of venlafaxine 150 mg/day. Early improvement in depression and pain at 2 weeks may predict continued improvement at week 6. Future studies must examine whether patients who have a poor initial response may benefit from increasing the SNRI dose, switching, or augmenting with other treatments after 2 weeks of pharmacotherapy.
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Affiliation(s)
- Soham Rej
- Department of Psychiatry, McGill University, Montreal, Quebec, Canada
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12
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Abstract
We systematically reviewed randomized clinical trials of problem-solving therapy (PST) in older adults. Our results indicate that PST led to greater reduction in depressive symptoms of late-life major depression than supportive therapy (ST) and reminiscence therapy. PST resulted in reductions in depression comparable with those of paroxetine and placebo in patients with minor depression and dysthymia, although paroxetine led to greater reductions than placebo. In home health care, PST was more effective than usual care in reducing symptoms of depression in undiagnosed patients. PST reduced disability more than ST in patients with major depression and executive dysfunction. Preliminary data suggest that a home-delivered adaptation of PST that includes environmental adaptations and caregiver involvement is efficacious in reducing disability in depressed patients with advanced cognitive impairment or early dementia. In patients with macular degeneration, PST led to improvement in vision-related disability comparable to that of ST, but PST led to greater improvement in measures of vision-related quality of life. Among stroke patients, PST participants were less likely to develop a major or minor depressive episode than those receiving placebo treatment, although the results were not sustained in a more conservative statistical analysis. Among patients with macular degeneration, PST participants had significantly lower 2-month incidence rates of major depression than usual care participants and were less likely to suffer persistent depression at 6 months. Finally, among stroke patients, PST participants were less likely to develop apathy than those receiving placebo treatment. PST also has been delivered via phone, Internet, and videophone, and there is evidence of feasibility and acceptability. Further, preliminary data indicate that PST delivered through the Internet resulted in a reduction in depression comparable with that of in-person PST in home-care patients. PST delivered via videophone results in an improvement in hospice caregivers' quality of life and a reduction in anxiety comparable to those of in-person PST. PST-treated patients with cognitive impairment may require additional compensatory strategies, such as written notes, memory devices, environmental adaptations, and caregiver involvement.
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Affiliation(s)
- Dimitris N Kiosses
- Weill-Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College
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13
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Makris UE, Fraenkel L, Han L, Leo-Summers L, Gill TM. Risk factors for restricting back pain in older persons. J Am Med Dir Assoc 2014; 15:62-7. [PMID: 24239445 PMCID: PMC3872215 DOI: 10.1016/j.jamda.2013.09.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/09/2013] [Accepted: 09/12/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To identify risk factors for back pain leading to restricted activity (restricting back pain) in older persons. DESIGN Prospective cohort study. SETTING Greater New Haven, Connecticut. PARTICIPANTS A total of 731 men and women aged 70 years or older, who were community living and nondisabled in essential activities of daily living at baseline. MEASUREMENTS Candidate risk factors were ascertained every 18 months for 108 months during comprehensive home-based assessments. Restricting back pain was assessed during monthly telephone interviews for up to 126 months. Incident episodes of (1) short-term (1 episode lasting 1 month) restricting back pain; and (2) persistent (1 episode lasting 2 or more months) or recurrent (2 or more episodes of any duration) restricting back pain were determined during each 18-month interval. The associations between the candidate risk factors and short-term and persistent/recurrent restricting back pain, respectively, were evaluated using a multivariable Cox model. RESULTS The cumulative incidence was 21.3% (95% confidence interval [CI] 19.6%-23.1%) for short-term restricting back pain and 20.6% (CI 18.6%-22.9%) for persistent/recurrent restricting back pain over a median follow-up of 109 months. In a recurrent event multivariable analysis, female sex (hazard ratio [HR] 1.30; 1.07-1.58), weak grip strength (HR 1.24; 1.01-1.52), and hip weakness (HR 1.19; 1.07-1.32) were independently associated with an increased likelihood of having short-term restricting back pain, whereas female sex (HR 1.48; CI 1.13-1.94), depressive symptoms (HR 1.57; 1.23-2.00), 2 or more chronic conditions (HR 1.38; 1.08-1.77), and arthritis (HR 1.66; 1.31-2.09) were independently associated with persistent/recurrent restricting back pain. CONCLUSION In this prospective study, several factors were independently associated with restricting back pain, including some that may be modifiable and therefore potential targets for interventions to reduce this common and often recurrent condition in older persons.
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Affiliation(s)
- Una E Makris
- Department of Internal Medicine, Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, TX; Department of Medicine, Division of Rheumatology, Veterans Administration Medical Center, Dallas, TX.
| | - Liana Fraenkel
- Department of Medicine, Yale School of Medicine, New Haven, CT; Department of Internal Medicine, Division of Rheumatology, Veterans Administration Medical Center, West Haven, CT
| | - Ling Han
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | | | - Thomas M Gill
- Department of Medicine, Yale School of Medicine, New Haven, CT
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Karp JF, Yu L, Friedly J, Amtmann D, Pilkonis PA. Negative affect and sleep disturbance may be associated with response to epidural steroid injections for spine-related pain. Arch Phys Med Rehabil 2013; 95:309-15. [PMID: 24060493 DOI: 10.1016/j.apmr.2013.09.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/11/2013] [Accepted: 09/12/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To describe whether negative affect and sleep impairment are associated with the clinical effect of epidural steroid injections (ESIs) for low back pain. DESIGN Observational study; patients were evaluated before ESI and 1 and 3 months after ESI. SETTING Spine center and related treatment sites. PARTICIPANTS Participants (N=158) seeking treatment for low back pain with or without radiculopathy. INTERVENTION ESI for low back pain with or without radiculopathy. MAIN OUTCOME MEASURES We assessed the dependent (global pain severity for back and leg pain, pain behavior, pain interference) and independent variables (depression, sleep disturbance, and covariates of back pain response) with the Patient-Reported Outcome Measurement Information System (PROMIS) and legacy measures. Outcome was assessed cross-sectionally using multiple regression and longitudinally with path analysis. RESULTS After 1 month, sleep disturbance was the only predictor for the global ratings of improvement in back pain (R(2)=16.8%) and leg pain (R(2)=11.4%). The proportions of variance explained by sleep disturbance and negative affect for all dependent variables were greater at 3 months than 1 month. Mediation analysis was significant for negative affect for the 3-month outcomes on PROMIS pain behavior (β=.87, P<.01) and pain interference (β=.37, P<.01). There was no evidence of mediation by sleep disturbance for any outcome. CONCLUSIONS Negative affect and sleep disturbance are associated with worse outcomes after ESI. Further research is needed to determine if treatment of negative affect and sleep disturbance prior to or concurrently with ESI will improve outcomes.
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Affiliation(s)
- Jordan F Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Lan Yu
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Janna Friedly
- Department of Rehabilitation, University of Washington, Seattle, WA
| | - Dagmar Amtmann
- Department of Rehabilitation, University of Washington, Seattle, WA
| | - Paul A Pilkonis
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
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