Talking points for the safe and effective alleviation of pain

Effects of modified oropharyngeal exercises on individuals with simple snoring: An online randomized controlled trial

BACKGROUND

Individuals who suffer from simple snoring rarely go to a doctor due to a lack of medical knowledge, but simple snoring can reduce the individual's quality of life and may cause social problems to the bed partner/family members.

OBJECTIVES

The aims of the present study are to explore the effects of online modified oropharyngeal exercises on the individuals with simple snoring and to provide a rehabilitation method for individuals with simple snoring.

METHODS

This study is a double-blinded, two-arm, randomized controlled trial. Participants were enrolled and randomly assigned to the intervention group (n = 33) or the control group (n = 33). The participants in the control group received health education on snoring, while the participants in the intervention group received the modified oropharyngeal exercise besides health education on snoring. The intervention duration was 4 weeks. The primary outcomes included snoring index, snoring loudness, and snoring quantity. The secondary outcomes included self-reported snoring, sleep quality, daytime sleepiness, anxiety symptoms, depression symptoms, and quality of life. All outcomes were measured at baseline, 4 weeks, and 8 weeks.

RESULTS

Generalized estimating equations (GEE) analyses showed significant differences between the intervention group and the control group on snoring index, loudness, and quantity (p < .001). Moreover, modified oropharyngeal exercise had effects on sleep quality, daytime sleepiness, anxiety symptoms, depression symptoms, and quality of life in individuals with simple snoring (p < .001). Self-reported snoring also improved at 8 weeks.

CONCLUSION

The modified oropharyngeal exercises were effective in improving simple snoring. It could also improve sleep quality, daytime sleepiness, anxiety symptoms, depression symptoms, and quality of life.

A multi-disciplinary program for opioid sparse arthroplasty results in reduced long-term opioid consumption: a four year prospective study

INTRODUCTION

The current opioid epidemic poses patient safety and economic burdens to healthcare systems worldwide. Postoperative prescriptions of opioids contribute, with reported opioid prescription rates following arthroplasty as high as 89%. In this multi-centre prospective study, an opioid sparing protocol was implemented for patients undergoing knee or hip arthroplasty. The primary outcome is to report our patient outcomes in the context of this protocol, and to examine the rate of opioid prescription on discharge from our hospitals following joint arthroplasty surgery. This is possibly associated with the efficacy of the newly implemented Arthroplasty Patient Care Protocol.

METHODS

Over three years, patients underwent perioperative education with the expectation to be opioid-free after surgery. Intraoperative regional analgesia, early postoperative mobilisation and multimodal analgesia were mandatory. Long-term opioid medication use was monitored and PROMs (Oxford Knee/Hip Score (OKS/OHS), EQ-5D-5 L) were evaluated pre-operatively, and at 6 weeks, 6 months and 1 year postoperatively. Primary and secondary outcomes were opiate use and PROMs at different time points.

RESULTS

A total of 1,444 patients participated. Two (0.2%) knee patients used opioids to one year. Zero hip patients used opioids postoperatively at any time point after six weeks (p < 0.0001). The OKS and EQ-5D-5 L both improved for knee patients from 16 (12-22) pre-operatively to 35 (27-43) at 1 year postoperatively, and 70 (60-80) preoperatively to 80 (70-90) at 1 year postoperatively (p < 0.0001). The OHS and EQ-5D-5 L both improved for hip patients from 12 (8-19) preoperatively to 44 (36-47) at 1 year postoperatively, and 65 (50-75) preoperatively to 85 (75-90) at 1 year postoperatively (p < 0.0001). Satisfaction improved between all pre- and postoperative time points for both knee and hip patients (p < 0.0001).

CONCLUSIONS

Knee and hip arthroplasty patients receiving a peri-operative education program can effectively and satisfactorily be managed without long-term opioids when coupled with multimodal perioperative management, making this a valuable approach to reduce chronic opioid use.

Preoperative Patient-Reported Data Indicate the Risk of Prolonged Opioid Use After Hand and Upper Extremity Surgeries

PURPOSE

Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery.

METHODS

We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve.

RESULTS

We included 2,114 patients. In our final model on the 2018-2019 electronic health records and PRD data (n = 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit.

CONCLUSIONS

We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

People Have Mixed Reactions to Both Physiological and Psychological Explanations of Disproportionate Pain

BACKGROUND

There are two general frameworks that conceptualize pain that is more intense or persistent than expected based on measurable pathologic findings: the psychological (unhelpful thoughts and emotions) and the physiological (purported nervous system dysfunction, such as central sensitization). Some clinicians believe people will be more receptive to a physiological conceptualization. Prior quantitative research demonstrated that carefully crafted psychological explanations are rated similarly to crafted physiological explanations, with relatively mixed reactions. This qualitative study was undertaken in parallel with that quantitative study to help develop effective communication and treatment strategies by identifying specific thoughts and feelings (themes) regarding the physiological and psychological conceptualizations of disproportionate pain that make people more or less comfortable considering comprehensive, biopsychosocial treatment approaches.

QUESTION/PURPOSE

What themes arise in patient thoughts and feelings regarding physiological and psychological conceptualizations of pain that is more intense or persistent than expected?

METHODS

We sought to understand the experience of considering pain as a biopsychosocial experience (phenomenology approach) by studying the thoughts and feelings that arise as people seeking care for arm and back pain engage with physiological and psychological conceptualizations of pain that is more intense or persistent than one would expect based on the pathology. We recruited 29 patients presenting for upper extremity or back pain specialty care at one of two urban offices, intentionally recruiting people of various ages, genders, backgrounds, socioeconomic status, as well as type and duration of pain (purposive sampling). The 29 patients included 18 women and 11 men (16 married, 15 non-White, 20 with arm pain) with a median (interquartile range) age of 62 years (42 to 67). The interviews were conducted by a trained woman orthopaedic surgeon interviewer using a semistructured interview guide soliciting participants' thoughts and feelings about a physiological explanation (nerves in the central nervous system stuck in the on position can make pain more intense) and a psychological explanation (unhelpful thoughts and feelings of distress can make pain more intense) for pain more intense or persistent than expected. The interviews were transcribed and themes were identified as the data were collected. Based on current experimental evidence, including what is known about the physiological effects of thoughts, feelings, and context (placebo/nocebo effects), we assumed an underlying physiological basis for pain that is variably experienced and expressed (mixed postpositive/interpretive approach). Themes were identified in the interview transcripts systematically by two coders and then discussed with the entire research team to arrive at consensus. We stopped enrolling patients when the authors agreed that additional themes did not arise in five consecutive interviews.

RESULTS

The following themes and interpretations were derived from the analysis: Neither the physiological nor the psychological explanation for disproportionate pain (1) avoided the stigma associated with mental health, (2) was consistently understood, (3) provided a consistent sense of control, (4) consistently provided hope, and (5) represented the stress and emotion of disproportionate or persistent pain. The physiological explanation also generated mixed reactions regarding whether or not it: (1) was a useful point of conversation, (2) was reassuring or frightening, and (3) supported physiological or psychological treatments. The psychological explanation made some people feel worse.

CONCLUSION

People have mixed reactions to both physiological and psychological explanations of disproportionate pain. As such, without direction on content, communication might be most effective by focusing on relational aspects, such as emotional connection and trust.

CLINICAL RELEVANCE

Although there is room to improve the content of strategies for explaining more pain than expected to patients, our findings extend the discoveries of others in highlighting the need for tailored relational communication strategies that prioritize feeling heard, validated, and accompanied.

Geographic variation in the frequency and potency of postoperative opioid prescriptions for extremity fracture surgery. A retrospective cohort study

INTRODUCTION

There is increasing evidence that the prescription opioid crisis is spreading internationally. However, there is scarce literature comparing contemporary prescribing practices between units in different countries, particularly in the context of this evolving international problem. We sought to determine the patterns of postoperative opioid prescribing in three hospitals from geographically distinct regions.

METHODS

This is a retrospective cohort study involving patients from three hospitals: XXX, Maine, USA; XXX, Scotland; and XXX, Australia. The health records, surgical details, and frequency and potency of discharge prescriptions were analyzed for 350 patients receiving surgery for isolated wrist or ankle fractures. Regression analysis was used to identify independent predictors of prescription opioid provision.

RESULTS

Following ankle fracture surgery, Aberdeen patients (OR 6.0, 95% CI 3.0-11.5) and Adelaide patients (11.8, 95% CI 4.1-39.6) were significantly more likely to receive a prescription for opioids than those in Augusta (p < 0.001). For distal radius fractures, this was also the case (Aberdeen OR 21.2, 95% CI 7.2-79.3, Adelaide OR 21.6, 95% CI 7.3-81.3). For both fracture groups, the potency of prescription provided (measured in morphine milligram equivalents) was not significantly different. When opioids were included in the discharge prescription, Adelaide prescribers favored strong opioids, Aberdeen prescribers selected weak opioids, and prescribers in Augusta chose an even distribution of both types (p < 0.001). Multivariate analysis demonstrated that the odds of receiving prescription opioids were significantly influenced by geographic location and decreased by advancing patient age.

CONCLUSIONS

Geographic location is a key factor influencing the provision of postoperative opioids. We found no association with fracture type, patient demographic factors or intra-operative practices. Prescriber culture is likely an influential determinant of postoperative opioid provision. Emphasis on patient and prescriber education regarding the risks of prescription opioids and their potential long-term sequelae is key if we wish to change modifiable prescriber behavior.

Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland—Tradition Prevails

The American ‘opioid crisis’ is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional ‘standard practice’. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.

Chronic pain with neuropathic characteristics after surgery for major trauma to the lower limb: prevalence, predictors, and association with pain severity, disability, and quality of life in the UK WHiST trial

AIMS

To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury.

METHODS

Secondary analysis of a UK multicentre randomized controlled trial (Wound Healing in Surgery for Trauma; WHiST) dataset including adults aged 16 years or over following surgery for lower limb major trauma. The trial recruited 1,547 participants from 24 trauma centres. Neuropathic pain was measured at three and six months using the Doleur Neuropathique Questionnaire (DN4); 701 participants provided a DN4 score at three months and 781 at six months. Overall, 933 participants provided DN4 for at least one time point. Physical disability (Disability Rating Index (DRI) 0 to 100) and health-related quality-of-life (EuroQol five-dimension five-level; EQ-5D-5L) were measured. Candidate predictors of neuropathic pain included sex, age, BMI, injury mechanism, concurrent injury, diabetes, smoking, alcohol, analgaesia use pre-injury, index surgery location, fixation type, Injury Severity Score, open injury, and wound care.

RESULTS

The median age of the participants was 51 years (interquartile range 35 to 64). At three and six months post-injury respectively, 32% (222/702) and 30% (234/787) had neuropathic pain, 56% (396/702) and 53% (413/787) had chronic pain without neuropathic characteristics, and the remainder were pain-free. Pain severity was higher among those with neuropathic pain. Linear regression analyses found that those with neuropathic pain at six months post-injury had more physical disability (DRI adjusted mean difference 11.49 (95% confidence interval (CI) 7.84 to 15.14; p < 0.001) and poorer quality of life (EQ-5D utility -0.15 (95% CI -0.19 to -0.11); p < 0.001) compared to those without neuropathic characteristics. Logistic regression identified that prognostic factors of younger age, current smoker, below knee fracture, concurrent injuries, and regular analgaesia pre-injury were associated with higher odds of post-injury neuropathic pain.

CONCLUSION

Pain with neuropathic characteristics is common after lower limb fracture surgery and persists to six months post-injury. Persistent neuropathic pain is associated with substantially poorer recovery. Further attention to identify neuropathic pain post-lower limb injury, predicting patients at risk, and targeting interventions, is indicated. Cite this article: Bone Joint J 2021;103-B(6):1047-1054.