Deconstructing Pain Disability through Concept Analysis

OBJECTIVE

Pain disability is a complex and challenging problem that impacts the daily lives of individuals living with persistent pain. Although this concept is measured throughout pain populations, conceptual clarity is needed to identify the defining characteristics and further understand what comprises this experience for clinical translation.

DESIGN

We completed a concept analysis to identify major attributes and provide a broad framework of pain disability for improved recognition throughout the discipline of nursing.

DATA SOURCES

Literature searches in PubMed, CINAHL, PsychINFO, and Scopus identified 39 relevant cross-disciplinary articles published between January 1990 and November 2017.

REVIEW/ANALYSIS METHODS

We implemented Avant and Walker's method of concept analysis to establish the attributes, antecedents, and consequences of pain disability.

RESULTS

Two major attributes of pain disability are discussed, including (1) physical and/or psychological responses leading to a functional loss; and (2) the degree of ability to fulfill role expectations. The antecedent to the development of pain disability is a painful trigger. Three leading consequences are identified as suffering, pain reactivity, and secondary loss.

CONCLUSIONS

Pain disability is a fluid concept that is characterized by the subjective experiences of the individual. A new conceptualization of pain disability is offered as the inability to maintain role expectations due to the result of a painful trigger and subsequent physical and/or psychosocial dysfunction.

Preliminary assessment of a neuropathic pain treatment and referral algorithm for patients with cancer

CONTEXT

The purpose of this case series study was to pilot test an evidence-based neuropathic pain (NP) treatment and referral algorithm for use by oncology nurses when managing cancer-related NP.

OBJECTIVES

The primary study objective was to assess patient-reported outcomes (pain severity, changes in activities of daily living, and satisfaction) resulting from algorithm use.

METHODS

Outpatients (n=20) with cancer-related NP scores ≥4 on a 0-10 numeric rating scale participated in the study. NP assessment, treatment, and referral to ancillary providers were guided by an evidence-based NP algorithm that was implemented by oncology nurse practitioners. Based on efficacy evidenced through randomized clinical trials published at the time of study implementation, the following drugs were included in the algorithm: lidocaine patch, gabapentin, oxycodone, tramadol, morphine, methadone, duloxetine, pregabalin, and nortriptyline. Recommendations for starting dose, dose escalation, drug combinations, treatment duration, and contraindications were included for first-tier drugs. Patient-reported outcomes (pain severity, functional capacity, and satisfaction) were assessed monthly over 12 weeks.

RESULTS

Average NP severity (P=0.001), general activity (P<0.001), mood (P=0.002), walking ability (P=0.01), ability to perform normal work (P=0.002), relationships (P=0.002), sleep (P=0.01), life enjoyment (P<0.001), and patient satisfaction (P=0.003) all improved by 12 weeks.

CONCLUSION

Evidence from this pilot study suggests that NP evidence-based treatment may result in improved symptoms, function, and patient satisfaction. A randomized controlled trial is needed to further assess algorithm efficacy.

ISSLS prize winner: Smudging the motor brain in young adults with recurrent low back pain

STUDY DESIGN

Cross-sectional design.

OBJECTIVE

To investigate whether recurrent low back pain (LBP) is associated with changes in motor cortical representation of different paraspinal muscle fascicles.

SUMMARY OF BACKGROUND DATA

Fascicles of the lumbar paraspinal muscles are differentially activated during function. Human studies indicate this may be associated with a spatially separate array of neuronal networks at the motor cortex. Loss of discrete control of paraspinal muscle fascicles in LBP may be because of changes in cortical organization.

METHODS

Data were collected from 9 individuals with recurrent unilateral LBP and compared with 11 healthy participants from an earlier study. Fine-wire electrodes selectively recorded myoelectric activity from short/deep fascicles of deep multifidus (DM) and long/superficial fascicles of longissimus erector spinae (LES), bilaterally. Motor cortical organization was investigated using transcranial magnetic stimulation at different scalp sites to evoke responses in paraspinal muscles. Location of cortical representation (center of gravity; CoG) and motor excitability (map volume) were compared between healthy and LBP groups.

RESULTS

Individuals with LBP had a more posterior location of LES center of gravity, which overlapped with that for DM on both hemispheres. In healthy individuals, LES center of gravity was located separately at a more anterior location to that for DM. Map volume was reduced in LBP compared to healthy individual across muscles.

CONCLUSION

The findings highlight that LBP is associated with a loss of discrete cortical organization of inputs to back muscles. Increased overlap in motor cortical representation of DM and LES may underpin loss of differential activation in this group. The results further unravel the neurophysiological mechanisms of motor changes in recurrent LBP and suggest motor rehabilitation that includes training of differential activation of the paraspinal muscles may be required to restore optimal control in LBP.

Reliability and discriminatory capacity of a clinical scale for assessing abdominal muscle coordination

OBJECTIVE

This study evaluated the reliability and discriminatory capacity of a novel clinical scale for assessing abdominal muscle coordination. We investigated the interrater reliability of this tool in patients with chronic low back pain (LBP) (reliability section); the ability of this tool to discriminate healthy and LBP subjects (discriminatory section); and the association between the score and measures of pain, disability, and kinesiophobia (correlation section).

METHODS

For the reliability section of this study, 14 patients with chronic LBP were included. For the discriminatory section, 10 patients with chronic LBP and 10 pain-free controls were recruited. In the correlation study, data from the 10 chronic LBP patients in the discriminatory section were used. The clinical test was conducted by a blinded examiner while the subjects attempted to independently activate transversus abdominis separate from the rest of the abdominal muscles (hollowing or draw-in maneuver). The intraclass correlation coefficients, receiver operating characteristic curve, and Pearson r correlation coefficients were calculated to assess reliability and validity.

RESULTS

An intraclass correlation coefficient((2,1)) of 0.72 (95% confidence interval, 0.33-0.90) was recorded for interrater reliability. The tool correctly identified the subject condition in 97% of the cases. The score did not correlate substantially with any clinical measures, with Pearson r ranging from 0.122 (P = .737) to 0.493 (P = .148).

CONCLUSIONS

This study showed that the proposed scale is a reliable tool and may be useful in discriminating patients with chronic LBP from pain-free controls. The poor correlation between the score and clinical measures may be due to the multidimensional nature of chronic LBP.

The Relationship between Temperament and Anxiety

This study of 509 (340 female) undergraduate university students in southern Appalachia who completed the Adult Temperament Questionnaire (ATQ) and the State-Trait Anxiety Inventory (STAI), is the first phase in the development of a model to predict risk for stress-related health problems. Results indicate that high negative affect strongly predicted individuals with above average anxiety (OR = 3.7, 95% CI 2.43, 5.64), while high positive affect, effortful control, and sociability predicted that individuals would be low in reported anxiety (OR = .33 [95% CI .25, .44], .29 [95% CI .19, .45], and .69 [95% CI .56, .86], respectively).

Driving plasticity in the motor cortex in recurrent low back pain

The sensory and motor systems can reorganise following injury and learning of new motor skills. Recently we observed adaptive changes in motor cortical organisation in patients with recurrent low back pain (LBP), which are linked to altered motor coordination. Although changes in motor coordination can be trained and are associated with improved symptoms and function, it remains unclear whether these training-induced changes are related to reorganisation of the motor cortex. This was investigated using the model of a delay in postural activation of the deep abdominal muscle, transversus abdominis (TrA) in 20 individuals with recurrent LBP. Subjects were allocated to either motor skill training that involved isolated voluntary contractions of TrA, or a control intervention of self-paced walking exercise for 2 weeks. Electromyographic (EMG) activity was recorded from TrA bilaterally using intramuscular fine-wire electrodes. Motor cortical organisation using transcranial magnetic stimulation (TMS) and postural activation associated with single rapid arm movements were investigated before and after training. Motor skill training induced an anterior and medial shift in motor cortical representation of TrA, towards that observed in healthy individuals from our previous study. This shift was associated with earlier postural activation of TrA. Changes were not observed following unskilled walking exercise. This is the first observation that motor training can reverse reorganisation of neuronal networks of the motor cortex in people with recurrent pain. The observed relationship between cortical reorganisation and changes in motor coordination following motor training provides unique insight into potential mechanisms that underlie recovery.

Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain

This study investigated long-term effects of training on postural control using the model of deficits in activation of transversus abdominis (TrA) in people with recurrent low back pain (LBP). Nine volunteers with LBP attended four sessions for assessment and/or training (initial, two weeks, four weeks and six months). Training of repeated isolated voluntary TrA contractions were performed at the initial and two-week session with feedback from real-time ultrasound imaging. Home program involved training twice daily for four weeks. Electromyographic activity (EMG) of trunk and deltoid muscles was recorded with surface and fine-wire electrodes. Rapid arm movement and walking were performed at each session, and immediately after training on the first two sessions. Onset of trunk muscle activation relative to prime mover deltoid during arm movements, and the coefficient of variation (CV) of EMG during averaged gait cycle were calculated. Over four weeks of training, onset of TrA EMG was earlier during arm movements and CV of TrA EMG was reduced (consistent with more sustained EMG activity). Changes were retained at six months follow-up (p<0.05). These results show persistence of motor control changes following training and demonstrate that this training approach leads to motor learning of automatic postural control strategies.

Music versus distraction for procedural pain and anxiety in patients with cancer

PURPOSE/OBJECTIVES

To test the hypotheses that the effects of a music intervention are greater than those of simple distraction and that either intervention is better at controlling procedural pain and anxiety than treatment as usual.

DESIGN

Randomized, controlled experiment.

SETTING

A midwestern comprehensive cancer center.

SAMPLE

60 people with cancer having noxious medical procedures such as tissue biopsy or port placement or removal; 58 provided usable data.

METHODS

Participants completed measures of pain and anxiety before and after their medical procedures and provided a rating of perceived control over pain and anxiety after the procedure.

MAIN RESEARCH VARIABLES

Procedural pain, state anxiety, and perceived control over pain and anxiety.

FINDINGS

Contrary to hypotheses, outcomes achieved with music did not differ from those achieved with simple distraction. Moreover, outcomes achieved under treatment as usual were not significantly different from those obtained with music or distraction interventions. Some patients found that the interventions were bothersome and reported that they wanted to attend to the activities of the surgeon and the medical procedure itself.

CONCLUSIONS

The effects of music, distraction, and treatment as usual are equivocal. In addition, patients have individual preferences for use of distraction during painful or anxiety-provoking procedures.

IMPLICATIONS FOR NURSING

Patients having noxious medical procedures should be asked about their desire to be distracted before and during the procedure and offered a strategy that is consistent with their preferences.