Differential changes in functional disability and pain intensity over the course of psychological treatment for children with chronic pain

Patients presenting for treatment of chronic pain often believe that pain reduction must be achieved before returning to normal functioning. However, treatment programs for chronic pain typically take a rehabilitative approach, emphasizing decreasing pain-related disability first with the expectation that pain reduction will follow. This information is routinely provided to patients, yet no studies have systematically examined the actual trajectories of pain and disability in a clinical care setting. In this study of youth with chronic pain (N=94, 8 to 18 years), it was hypothesized that 1) functional disability and pain would decrease over the course of psychological treatment for chronic pain and 2) functional disability would decrease more quickly than pain intensity. Participants received cognitive behavioral therapy (CBT) for pain management (M=5.6 sessions) plus standard medical care. The Functional Disability Inventory and a Numeric Rating Scale of average pain intensity were completed by the child at every CBT session. Hierarchical linear modeling was conducted to examine the longitudinal trajectories of disability and pain. Standardized estimates of the slopes of change were obtained to test differences in rates of change between pain and disability. Results showed an overall significant decline in functional disability over time. Although pain scores reduced slightly from pretreatment to posttreatment, the longitudinal decline over treatment was not statistically significant. As expected, the rate of change of disability was significantly more rapid than pain. Evidence for variability in treatment response was noted, suggesting the need for additional research into individual trajectories of change in pediatric pain treatment.

Choosing the right outcome measurement instruments for patients with low back pain

Choosing the most fit-for-purpose outcome measurement instruments is fundamental because using inappropriate instruments can lead to detection bias and measurement inconsistency. Recent recommendations, consensus procedures and systematic reviews on existing patient-reported outcome measures (PROMs) informed this manuscript, which provides suggestions on which outcome domains and measurement instruments to use in patients with low back pain (LBP). Six domains are identified as highly relevant: (1) physical functioning, (2) pain intensity, (3) health-related quality of life, (4) work, (5) psychological functioning and (6) pain interference. For each domain, one or more PROMs are suggested for clinical research and practice, selecting among those that are most frequently used and recommended, and that have satisfactory measurement properties in patients with LBP. Further research on the measurement properties of these suggested PROMs is needed while also considering other emerging instruments, such as the PROMIS computerised adaptive testing and short forms.

Pain in hospitalized children: Effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes

Hospitalized children frequently receive inadequate pain assessment and management despite substantial evidence to support effective pediatric pain practices. The objective of this study was to determine the effect of a multidimensional knowledge translation intervention, Evidence-based Practice for Improving Quality (EPIQ), on procedural pain practices and clinical outcomes for children hospitalized in medical, surgical and critical care units. A prospective cohort study compared 16 interventions using EPIQ and 16 standard care (SC) units in 8 Canadian pediatric hospitals. Chart reviews at baseline (time 1) and intervention completion (time 2) determined the nature and frequency of painful procedures and of pain assessment and pain management practices. Trained pain experts evaluated pain intensity 6 months post-intervention (time 3) during routine, scheduled painful procedures. Generalized estimating equation models compared changes in outcomes between EPIQ and SC units over time. EPIQ units used significantly more validated pain assessment tools (P<0.001) and had a greater proportion of patients who received analgesics (P=0.03) and physical pain management strategies (P=0.02). Mean pain intensity scores were significantly lower in the EPIQ group (P=0.03). Comparisons of moderate (4-6/10) and severe (7-10/10) pain, controlling for child and unit level factors, indicated that the odds of having severe pain were 51% less for children in the EPIQ group (adjusted OR: 0.49, 95% CI: 0.26-0.83; P=0.009). EPIQ was effective in improving practice and clinical outcomes for hospitalized children. Additional exploration of the influence of contextual factors on research use in hospital settings is required to explain the variability in pain processes and clinical outcomes.

Cardiovascular risk factors associated with the metabolic syndrome are more prevalent in people reporting chronic pain: results from a cross-sectional general population study

To explore whether chronic pain is associated with cardiovascular risk factors and identify whether increased distribution or intensity of pain is associated with cardiovascular risk, participants in Generation Scotland: The Scottish Family Health study completed pain questionnaires recording the following: presence of chronic pain, distribution of pain, and intensity of chronic pain. Blood pressure, lipids, blood glucose, smoking history, waist-hip ratio, and body mass index were recorded; Framingham 10-year coronary heart disease (CHD) risk scores were calculated and a diagnosis of metabolic syndrome derived. Associations between chronic pain and cardiovascular risk were explored. Of 13,328 participants, 1100 (8.3%) had high CHD risk. Chronic pain was reported by 5209 (39%), 1294 (9.7%) reported widespread chronic pain, and 707 (5.3%) reported high-intensity chronic pain. In age- and gender-adjusted analyses, chronic pain was associated with elevated CHD risk scores (odds ratio 1.11, 95% confidence interval 1.01-1.23) and the metabolic syndrome (odds ratio 1.42, 95% confidence interval 1.24-1.62). Multivariate analyses identified dyslipidaemia, age, gender, smoking, obesity, and high waist-hip ratio as independently associated with chronic pain. Within the chronic pain subgroup, widespread pain did not confer any additional cardiovascular disease risk. However, cardiovascular disease risk factors contributing to metabolic syndrome were more prevalent in those reporting high-intensity chronic pain. This large population-based study has demonstrated that chronic pain, and in particular high-intensity chronic pain, is associated with an increased prevalence of cardiovascular risk factors and metabolic syndrome. The 10-year CHD risk score and metabolic syndrome correlate well with increased pain intensity, but not with widespread pain.

The Temporal Relationship between Pain Intensity and Pain Interference and Incident Dementia

BACKGROUND

Chronic pain is common among older adults and is associated with cognitive dysfunction based on cross-sectional studies. However, the longitudinal association between chronic pain and incident dementia in community-based samples is unknown.

OBJECTIVE

We aimed to evaluate the association of pain intensity and pain interference with incident dementia in a community-based sample of older adults.

METHODS

Participants were 1,114 individuals 70 years of age or older from Einstein Aging Study (EAS), a longitudinal cohort study of community-dwelling older adults in the Bronx County, NY. The primary outcome measure was incident dementia, diagnosed using DSM-IV criteria. Pain intensity and interference in the month prior to first annual visit were measured using items from the SF-36 questionnaire. Pain intensity and pain interference were assessed as predictors of time to incident dementia using Cox proportionate hazards models while controlling for potential confounders.

RESULTS

Among participants, 114 individuals developed dementia over an average 4.4 years (SD=3.1) of follow-up. Models showed that pain intensity had no significant effect on time to developing dementia, whereas higher levels of pain interference were associated with a higher risk of dementia. In the model that included both pain intensity and interference as predictors of incident dementia, pain interference had a significant effect on incident dementia, and pain intensity remained non-significant.

CONCLUSION

As a potential remediable risk factor, the mechanisms linking pain interference to cognitive decline merit further exploration.

Cut points for mild, moderate, and severe pain on the VAS for children and adolescents: what can be learned from 10 million ANOVAs?

Cut points that classify pain intensity into mild, moderate, and severe levels are widely used in pain research and clinical practice. At present, there are no agreed-upon cut points for the visual analog scale (VAS) in pediatric samples. We applied a method based on Serlin and colleagues' procedure (Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. PAIN(®) 1995;61:277-84) that was previously only used for the 0 to 10 numerical rating scale to empirically establish optimal cut points (OCs) for the VAS and used bootstrapping to estimate the variability of these thresholds. We analyzed data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study and defined OCs both for parental ratings of their children's pain and adolescents' self-ratings of pain intensity. Data from 2276 children (3 to 10 years; 54% female) and 2982 adolescents (11 to 17 years; 61% female) were analyzed. OCs were determined in a by-millimeter analysis that tested all possible 4851 OC combinations, and a truncated analysis were OCs were spaced 5 mm apart, resulting in 171 OC combinations. The OC method identified 2 different OCs for parental ratings and self-report, both in the by-millimeter and truncated analyses. When we estimated the variability of the by-millimeter analysis, we found that the specific OCs were only found in 11% of the samples. The truncated analysis revealed, however, that cut points of 35:60 are identified as optimal in both samples and are a viable alternative to separate cut points. We found a set of cut points that can be used both parental ratings of their children's pain and self-reports for adolescents. Adopting these cut points greatly enhances the comparability of trials. We call for more systematic assessment of diagnostic procedures in pain research.

The utility and validity of pain intensity rating scales for use in developing countries

Introduction:

Pain intensity is the domain most often assessed in pain research. Although the Numerical Rating Scale is recommended for use in western countries, the utility and validity of this scale, relative to others, has not been established in non–western developing countries, such as Nepal.

Objectives:

Here, we sought to (1) identify which of 4 commonly used pain scales is most preferred by Nepalese, (2) compare error rates, (3) determine whether preference and error rates are influenced by age or education level, and (4) evaluate construct validity of each scale using factor analysis.

Methods:

Two hundred two adults with musculoskeletal pain from Nepal rated their worst and average pain intensity using all 4 scales and selected their most preferred scale.

Results:

The results indicate that the Faces Pain Scale-Revised is the most preferred scale, followed by a Verbal Rating Scale. The Numerical Rating Scale and Visual Analogue Scale were both least preferred and had higher rates of incorrect responses, especially among the older participants. However, all the scales demonstrated adequate construct validity as measures of pain intensity among those participants who could accurately use all 4 scales.

Conclusion:

The findings indicate that the Faces Pain Scale-Revised should be the first choice for assessing pain intensity in Nepalese adults. Research is needed to determine whether these findings replicate in other non–western and developing countries, to identify the pain intensity measure that would be the best choice for use in cross-cultural pain research.

Cervical proprioception and its relationship with neck pain intensity in subjects with cervical spondylosis

Background

Cervical proprioception is critical in the maintenance of posture and movements, so its assessment in different cervical conditions has gained importance in recent clinical practice. Studies reporting this assessment in subjects with cervical spondylosis (CS) have not previously been investigated. The goals of the study are (1) comparison of joint position error (JPE) in subjects with CS to healthy control group. (2) Correlation of neck pain intensity to cervical proprioception in patients with CS.

Methods

In a Cross-sectional study, 132 subjects with CS and 132 healthy age-matched control subjects were evaluated for cervical JPE with the cervical range of motion device. The subjects were blindfolded and repositioned their heads to a target position, which was determined by the examiner previously and their repositioning accuracy (absolute error in degrees) was measured in the frontal (flexion and extension) and transverse planes (left rotation and right rotation). The CS subjects resting neck pain intensity was assessed using visual analog scale (VAS).

Results

CS subjects showed statistically significantly larger JPEs compared to healthy control subjects in all the directions tested (flexion - 95% CI = 2.38–3.55, p < 0.001, extension - 95% CI =3.26–4.33, p < 0.001, left rotation - 95% CI = 2.64 - 3.83, p < 0.001, right rotation − 95% CI = 3.77–4.76, p < 0.001). The mean JPE errors in the CS group ranged from 6.27° to 8.28° and in the control group ranged from 2.36° to 4.48°. Pearson’s correlation coefficient showed a significant and positive relationship between neck pain intensity and cervical proprioception (p ≤ 0.001).

Conclusions

Proprioception is impaired in subjects with CS when compared to healthy control group. Higher pain intensity was associated with greater cervical JPE in patients with CS.

Development and testing of painometer: a smartphone app to assess pain intensity

Electronic and information technologies are increasingly being used to assess pain. This study aims to 1) introduce Painometer, a smartphone app that helps users to assess pain intensity, and 2) report on its usability (ie, user performance and satisfaction) and acceptability (ie, the willingness to use it) when it is made available to health care professionals and nonprofessionals. Painometer includes 4 well-known pain intensity scales: the Faces Pain Scale-Revised, the numerical rating scale-11, the Coloured Analogue Scale, and the visual analog scale. Scores reported with these scales, when used in their traditional format, have shown to be valid and reliable. The app was tested in a sample of 24 health care professionals and 30 nonprofessionals. Two iterative usability cycles were conducted with a qualitative usability testing approach and a semistructured interview. The participants had an average of 10 years' experience in using computers. The domains measured were ease of use, errors in usage, most popular characteristics, suggested changes, and acceptability. Adding instructions and changing format and layout details solved the usability problems reported in cycle 1. No further problems were reported in cycle 2. Painometer has been found to be a useful, user-friendly app that may help to improve the accuracy of pain intensity assessment.

PERSPECTIVE

Painometer, a smartphone app to assess pain intensity, shows good usability and acceptability properties when used by health care professionals and nonprofessionals.

Translation, cross-cultural adaptation and psychometric properties of the Nepali versions of numerical pain rating scale and global rating of change

Background

Pain intensity and patients’ impression of global improvement are widely used patient-reported outcome measures (PROMs) in clinical practice and research. They are commonly assessed using the Numerical Pain Rating Scale (NPRS) and Global Rating of Change (GROC) questionnaires. The GROC is essential as an anchor for evaluating the psychometric properties of PROMs. Both of these PROMs are translated to many languages and have shown excellent psychometric properties. Their availability in Nepali would facilitate pain research and cross-cultural comparison of research findings. Therefore, the objectives of this study were to translate and cross-culturally adapt the NPRS and GROC into Nepali and to assess the psychometric properties of the Nepali version of the NPRS (NPRS-NP).

Methods

After translating and cross-culturally adapting the NPRS and GROC into Nepali using recommended guidelines, NPRS-NP was administered to 104 individuals with musculoskeletal pain twice. The Nepali version of the GROC (GROC-NP) was administered at the follow-up for anchor-based assessment. (1) Test-retest reliability and minimum detectable change (MDC) among the stable group, (2) construct validity (by single sample t-test within the improved group and independent sample t-test between groups), and (3) concurrent validity were assessed. Receiver operating characteristic (ROC) curves were plotted to determine the responsiveness of the NPRS-NP using the area under the curve (AUC), and minimum important changes (MIC) for small, medium and large improvements.

Results

Significant cultural adaptations were required to obtain relevant Nepali versions of both the NPRS and GROC. The NPRS-NP showed excellent test-retest reliability and a MDC of 1.13 points. NPRS-NP demonstrated a good construct validity by significant within-group difference in mean of NPRS score- t(63)= 7.57, P < 0.001 and statistically significant difference of mean score- t(98)= -4.24, P < .001 between the stable and improved groups. It demonstrated moderate concurrent correlation with the GROC-NP; r = 0.43, P < 0.01. Responsiveness of the NPRS-NP was shown at three levels with AUC = 0.68–0.82, and MIC = 1.17–1.33.

Conclusions

The NPRS and GROC were successfully translated and culturally adapted into Nepali. The NPRS-NP demonstrated good reliability, validity and responsiveness in assessing musculoskeletal pain intensity in a Nepali population.

Electronic supplementary material

The online version of this article (10.1186/s12955-017-0812-8) contains supplementary material, which is available to authorized users.

Pain intensity and smoking behavior among treatment seeking smokers

Empirical evidence supporting the interplay between pain intensity and tobacco smoking has been growing. The current investigation advances this work in three important ways: (1) controlling for negative affectivity and gender; (2) examining pain intensity in smokers from a community sample, rather than specialized pain treatment centers; and, (3) studying smokers who are highly motivated to quit. Participants were adult smokers (N=112; 35% female; Mage=41.4, SD=13.1) participating in a larger study examining barriers to cessation during a self-guided quit attempt. At baseline, participants completed self-report measures on pain intensity and smoking severity outcomes. As hypothesized, more intense pain was significantly associated with all four smoking severity variables: years as a daily smoker, current cigarettes per day, cigarettes per day during the heaviest lifetime smoking period, and current level of nicotine dependence. These associations remained when taking into account the variance accounted for by gender and negative affectivity. These data provide evidence that more intense pain is related to more severe smoking behavior and nicotine dependence. Pain reduction could be an important target in regard to smokers with chronic pain.

Pain in children and adolescents with cerebral palsy - a cross-sectional register study of 3545 individuals

Background

Pain is a common problem for individuals with cerebral palsy (CP). In Sweden, 95% of children and adolescents with CP are followed in a national follow-up programme (CPUP), which includes data on pain. The purpose of this study was to investigate the prevalence of pain based on age, sex, gross motor function and source of report (self or proxy). Pain intensity, pain site, and how much pain disturbed sleep and daily activities were also studied.

Methods

This was a cross-sectional register study based on all participants in CPUP, 4–18-years of age, with data reported in 2017–2018. Gross motor function was classified using the Gross Motor Function Classification System (GMFCS). Logistic regression was used to analyse prevalence of pain and how much pain had disturbed sleep and daily activities in the last four weeks.

Results

In total, 3545 participants (2065 boys) were included. The overall prevalence of pain was 44%. Older age and female sex were associated with higher risk of pain with odds ratios of 1.07 (95% confidence interval (CI) 1.06–1.09) and 1.28 (CI 1.12–1.47), respectively. Pain was most common in the lower extremities. There was no statistically significant difference in prevalence of pain related to source of report. Pain intensity was higher at older ages and higher GMFCS-levels. Hip/thigh pain and abdominal pain were associated with the most intense pain.

Of those who reported pain, pain disturbed sleep for 36% and daily activities for 61%.

Conclusions

Both pain frequency and pain intensity were higher at higher age. Pain intensity increased with increasing GMFCS-level. Two-thirds of all children and adolescents with CP reported that their pain disturbed their daily activities, and one-third reported that pain disturbed their sleep.

Insomnia in a chronic musculoskeletal pain with disability population is independent of pain and depression

BACKGROUND CONTEXT

Insomnia is frequently experienced by patients suffering from chronic musculoskeletal disorders but is often seen as simply a symptom of pain or depression and not as an independent disorder. Compared with those who experience only chronic pain, patients with both chronic pain and insomnia report higher pain intensity, more depressive symptoms, and greater distress. However, insomnia has not yet been systematically studied in a chronic musculoskeletal pain with disability population.

PURPOSES

This study assessed the prevalence and severity of patient-reported insomnia, as well as the relationship among insomnia, pain intensity, and depressive symptoms, in a chronic musculoskeletal pain with disability population.

STUDY DESIGN/SETTING

This was a retrospective study of prospectively captured data.

PATIENT SAMPLE

A consecutive cohort of 326 chronic musculoskeletal pain with disability patients (85% with spinal injuries) entered a functional restoration treatment program. All patients signed a consent form to participate in this protocol.

OUTCOME MEASURES

Insomnia was assessed with the Insomnia Severity Index, a validated patient-report measure of insomnia symptoms. Four patient groups were formed: no clinically significant insomnia (score, 0-7); subthreshold insomnia (score, 8-14); moderate clinical insomnia (score, 15-21); and severe clinical insomnia (score, 22-28). Three patterns of sleep disturbance were also evaluated: early, middle, and late insomnia. Additional validated psychosocial patient-reported data were collected, including the Pain Visual Analog Scale, the Beck Depression Inventory, the Oswestry Disability Index, and the Pain Disability Questionnaire.

METHODS

Patients completed a standard psychosocial assessment battery on admission to the functional restoration program. The program included a quantitatively directed exercise process in conjunction with a multimodal disability management approach. The four insomnia groups were compared on demographic and psychosocial variables. The shared variances among insomnia, depression, and pain were determined by partial correlational analyses.

RESULTS

The presence of no clinically significant insomnia, subthreshold insomnia, moderate clinical insomnia, and severe clinical insomnia was found in 5.5%, 21.2%, 39.6%, and 33.7% of the cohort, respectively. More than 70% of patients reported moderate to severe insomnia symptoms, which is a considerably higher prevalence than that found in most patient cohorts studied previously. A stepwise pattern was found, in which severe clinical insomnia patients reported the highest pain, the most severe depressive symptoms, and the greatest disability. The severe clinical insomnia patients also reported a higher number of sleep disturbance types (early, middle, and late insomnia) than the other three groups. In fact, 62.9% of them reported all three disturbance types. Although correlations were found between insomnia and depressive symptoms and between insomnia and pain, the shared variances were small (12.9% and 3.6%, respectively), indicating that depression and pain are separate constructs from insomnia.

CONCLUSION

This research indicates that insomnia is a significant and pervasive problem in a chronic musculoskeletal pain with disability population. Most importantly, although insomnia has traditionally been assumed to be simply a symptom of pain or depression, the findings of the present study reveal that it is a construct relatively independent from both pain and depression. Specific insomnia assessment and treatment is therefore recommended for this chronic musculoskeletal pain with disability population.

Pain experience during initial alignment with three types of nickel-titanium archwires: a prospective clinical trial

OBJECTIVE

To clinically evaluate the pain intensity during the week following initial placement of three different orthodontic aligning archwires.

MATERIALS AND METHODS

A consecutive sample of 75 patients requiring upper and lower fixed orthodontic appliances were alternately allocated into three different archwires (0.014-inch superelastic NiTi, 0.014-inch thermoelastic NiTi or 0.014-inch conventional NiTi). Assessments of pain/discomfort were made on a daily basis over the first 7-day period after bonding by means of visual analog scale and consumption of analgesics. The maximum pain score was recorded. The possible associations between age, gender, degree of crowding, and teeth irregularity and the pain intensity were also examined. Demographic and clinical differences between the three groups were compared with chi-square test or analysis of variance (ANOVA) test.

RESULTS

No statistically significant differences were found in the pain intensity when the three aligning NiTi archwires were compared (P  =  .63). No significant differences in pain perception were found in terms of gender, age, lower arch crowding, and incisor irregularity. The intake of analgesics was the least in the superelastic NiTi group.

CONCLUSION

The three forms of NiTi wires were similar in terms of pain intensity during the initial aligning stage of orthodontic fixed appliance therapy. Gender, age, and the degree of crowding have no effect on the perceived discomfort experienced by patients undergoing fixed orthodontic treatment.

Do patient perceptions of provider communication relate to experiences of physical pain?

OBJECTIVES

Patient-provider communication is an important component of the medical interaction yet little research has examined the relationships between perceptions of communication and health outcomes or the mechanisms by which communication may ameliorate the pain experience. This is the first study to examine the relationships between patients' perceptions of provider communication, pain intensity and self-efficacy for managing chronic disease.

METHODS

The total sample contained 1027 (85.8% male) Veteran patients. Patients responded to surveys about their experiences and outcomes of care, including measures of patient-provider communication, self-efficacy and pain outcomes including pain intensity and pain interference.

RESULTS

Results showed more positive perceptions of provider communication were related to lower levels of pain intensity and pain interference and that this relationship was significantly mediated by higher levels of self-efficacy for managing chronic disease.

CONCLUSION

More positive provider communication was related to higher levels of self-efficacy, which in turn was related to lower levels of pain intensity and pain interference. Findings suggest that providers may be able to elicit higher levels of self-efficacy in their patients by providing patient-centered communication, which in turn will reduce pain intensity and interference in their patient's lives.

Efficient conditioned pain modulation despite pain persistence in painful diabetic neuropathy

Despite persistent clinical pain in patients with painful diabetic neuropathy, longer pain duration was associated with more efficient CPM.

Introduction:

Alleviation of pain, by either medical or surgical therapy, is accompanied by transition from less efficient, or pro-nociceptive, to efficient conditioned pain modulation (CPM). Spontaneous decrease or resolution of pain with disease progression is reported for some patients with painful diabetic neuropathy (PDN).

Objectives:

To explore whether CPM changes similarly in parallel to spontaneous resolution of pain in PDN patients.

Methods:

In this cross-sectional study, thirty-three patients with PDN underwent psychophysical assessment of pain modulation on the forearm, remote from the clinical pain.

Results:

Pain duration was not correlated with neuropathic pain intensity, yet, it correlated with CPM efficiency; patients with longer pain duration had same pain level, but more efficient CPM than those with short-pain duration (ρ = −0.417; P = 0.025, Spearman correlation). Patients with pain more than 2 years (median split) expressed efficient CPM that was not different from that of healthy controls. These patients also had lower temporal summation of pain than the short-pain duration patients group (P < 0.05). The 2 patient groups did not differ in clinical pain characteristics or use of analgesics.

Conclusion:

Pro-nociception, expressed by less efficient CPM and high temporal summation that usually accompanies clinical painful conditions, seems to “normalize” with chronicity of the pain syndrome. This is despite continuing pain, suggesting that pro-nociceptivity in pain syndromes is multifactorial. Because the pain modulation profile affects success of therapy, this suggests that different drugs might express different efficacy pending on duration of the pain in patients with PDN.

Altered Structural and Functional Connectivity of Salience Network in Patients with Classic Trigeminal Neuralgia

Classic trigeminal neuralgia (CTN) is a neuropathic pain disorder displaying spontaneously stabbing or electric shock-like paroxysms in the face. Previous research suggests structural and functional abnormalities in brain regions related to sensory and cognitive-affective dimensions of pain contribute to the pathophysiology of CTN. However, few studies to date have investigated how changes in whole-brain functional networks and white matter connectivity are related to CTN. We performed an independent component analysis to examine abnormalities in resting state functional connectivity of large-scale networks in 48 patients with CTN compared to 46 matched healthy participants. Then, diffusion tensor tractography was performed to test whether these alterations of functional connectivity in intrinsic networks were associated with impairment of the white matter tracts connecting them. Distinct patterns of functional connectivity were detected within default mode network, somatosensory network, and salience network (SN) in the CTN group when compared with healthy controls. Furthermore, abnormality of SN was negatively correlated with pain severity. In support of aberrant functional connectivity within SN, structural disintegration was observed in the white matter tract from left anterior insula (aIns) to left anterior cingulate cortex (ACC) in CTN. These results suggest that altered structural and functional connectivity between aIns and ACC may underpin the aberrant SN in patients with CTN and provide an alternative target for clinical interventions. PERSPECTIVE: This article presents distinctive abnormalities of functional and structural connectivity from aIns to ACC in the patients with CTN, which is associated with pain ratings. This measure could potentially provide an alternative target for clinicians to alleviate this type of intermittent and refractory pain.

Consistent effects of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: additional findings from the randomized, sham-controlled, double-blind PRESTO trial

BACKGROUND

Non-invasive vagus nerve stimulation (nVNS) has been shown to be practical, safe, and well tolerated for treating primary headache disorders. The recent multicenter, randomized, double-blind, sham-controlled PRESTO trial provided Class I evidence that for patients with episodic migraine, nVNS significantly increases the probability of having mild pain or being pain-free 2 h post stimulation. We report additional pre-defined secondary and other end points from PRESTO that demonstrate the consistency and durability of nVNS efficacy across a broad range of outcomes.

METHODS

After a 4-week observation period, 248 patients with episodic migraine with/without aura were randomly assigned to acute treatment of migraine attacks with nVNS (n = 122) or a sham device (n = 126) during a double-blind period lasting 4 weeks (or until the patient had treated 5 attacks). All patients received nVNS therapy during the subsequent 4-week/5-attack open-label period.

RESULTS

The intent-to-treat population consisted of 243 patients. The nVNS group (n = 120) had a significantly greater percentage of attacks treated during the double-blind period that were pain-free at 60 (P = 0.005) and 120 min (P = 0.026) than the sham group (n = 123) did. Similar results were seen for attacks with pain relief at 60 (P = 0.025) and 120 min (P = 0.018). For the first attack and all attacks, the nVNS group had significantly greater decreases (vs sham) in pain score from baseline to 60 min (P = 0.029); the decrease was also significantly greater for nVNS at 120 min for the first attack (P = 0.011). Results during the open-label period were consistent with those of the nVNS group during the double-blind period. The incidence of adverse events (AEs) and adverse device effects was low across all study periods, and no serious AEs occurred.

CONCLUSIONS

These results further demonstrate that nVNS is an effective and reliable acute treatment for multiple migraine attacks, which can be used safely while preserving the patient's option to use traditional acute medications as rescue therapy, possibly decreasing the risk of medication overuse. Together with its practicality and optimal tolerability profile, these findings suggest nVNS has value as a front-line option for acute treatment of migraine.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02686034 .

Rotator cuff tear with concomitant long head of biceps tendon (LHBT) degeneration: what is the preferred choice? Open subpectoral versus arthroscopic intraarticular tenodesis

BACKGROUND

Lesions associated with the biceps tendon are commonly detected during arthroscopic repair of rotator cuff tears. Acquiring a preferable technique to repair both cuff and long head of biceps tendon (LHBT) lesions was the aim of several recent studies. This study aimed to compare clinical and functional outcomes of open subpectoral versus arthroscopic intraarticular tenodesis in patients with repairable rotator cuff tear associated with LHBT degeneration.

PATIENTS AND METHODS

In this randomized clinical trial, 60 eligible candidates for arthroscopic rotator cuff repair (mean age 55.7 ± 6.9 years) were allocated to a control group (open subpectoral, SP) or intervention group (intraarticular, IA). In the IA group, an anchor suture was used for both rotator cuff repair and LHBT tenodesis. In the SP group, after arthroscopic repair of the rotator cuff, subpectoral tenodesis of LHBT was performed using an interference screw. Patients were evaluated for 2 years follow-up regarding pain intensity using the visual analogue scale (VAS) and shoulder function using the Constant Score and Simple Shoulder Test.

RESULTS

The two groups were similar with regard to demographic characteristics and preoperative evaluations (all P > 0.05). The functional status of both groups was improved, but not significantly differently so between the two groups (P = 0.1 and P = 0.4, respectively). Pain intensity decreased during the 2-year follow-up period, similarly so in the two groups. Patient satisfaction was also similar in the two groups.

CONCLUSION

Large and massive rotator cuff tears (tears > 3 cm) associated with LHBT pathologies benefited from intraarticular or subpectoral tenodesis similarly, with no differences in short- or mid-term results between these two techniques.

LEVEL OF EVIDENCE

II.

Factors Associated with Greater Pain Intensity

The intensity of pain reported for a given nociception is highly variable. Variation in pain intensity is best accounted for by stress, distress, and ineffective coping strategies. Among orthopedic surgery patients, greater intake of opioids is associated with greater pain intensity and decreased satisfaction with pain control, no matter the pathophysiology or nociception. The single most effective pain reliever is self-efficacy (the sense that one can manage and that everything will be okay).

Association of pain intensity, pain-related disability, and depression with hypothalamus-pituitary-adrenal axis function in female patients with chronic temporomandibular disorders

Patients with temporomandibular disorders (TMD) commonly experience myofascial and joint pain, pain-related disability, and other pain conditions including depression. The present study was carried out to explore the function of the hypothalamus-pituitary-adrenal (HPA) axis in relation to variables of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis II and comorbid depression in female patients with TMD. Cortisol and dehydroepiandrosterone (DHEA) levels were determined in saliva samples that had been collected at various periods after waking (0, 30, and 60min) and at nighttime (2100-2200h) from 52 female patients with chronic TMD pain and age- and gender-matched controls (n=54, 20-40 years old). There were no significant differences in the levels and diurnal patterns of cortisol and DHEA secretion between groups of patients with TMD and controls. In patients, the cortisol awakening response (CAR) or diurnal cortisol rhythm were not associated with any variables of the RDC/TMD Axis II or the Beck Depression Inventory (BDI)-II total scores. However, the ratio of overall cortisol secretion within the first hour after waking (CARauc) to overall DHEA secretion during the post-waking period (Daucawk), defined as CARauc/Daucawk, was significantly associated with pain-related RDC/TMD variables (pain intensity and pain-related disability) and BDI-II total scores. Pain intensity and pain-related disability scores were also significantly associated with BDI-II total scores. These results indicated that an increase in molar cortisol/DHEA ratio due to the dissociation between cortisol and DHEA secretion was associated with pain intensity, pain-related disability, and depression in female patients with TMD.

Psychological Factors Associated With Painful Versus Non-Painful HIV-Associated Sensory Neuropathy

HIV-associated sensory neuropathy (HIV-SN) is a common, and frequently painful complication of HIV, but factors that determine the presence of pain are unresolved. We investigated: (i) if psychological factors associated with painful (n = 125) versus non-painful HIV-SN (n = 72), and (ii) if pain and psychological factors affected quality of life (QoL). We assessed anxiety and depression using the Hopkins Symptoms Checklist-25. Pain catastrophizing and QoL were assessed using the Pain Catastrophizing Scale and Euroqol-5D, respectively. Presence of neuropathy was detected using the Brief Neuropathy Screening Tool, and pain was characterised using the Wisconsin Brief Pain Questionnaire. Overall, there was a high burden of pain, depression and anxiety in the cohort. None of the psychological variables associated with having painful HIV-SN. Greater depressive symptoms and presence of pain were independently associated with lower QoL. In those participants with painful HIV-SN, greater depressive symptom scores were associated with increased pain intensity. In conclusion, in a cohort with high background levels of psychological dysfunction, psychological factors do not predict the presence of pain, but both depression and presence of pain are associated with poor quality of life.

Incidence and factors influencing tourniquet pain

PURPOSE

The use of tourniquet in orthopedic surgery facilitates operation by establishing a bloodless surgical field. However, many complications following the use of tourniquets have been reported. Tourniquet pain is the most common complication. This study aimed to find the actual incidence of pain associated with tourniquet use in orthopedic surgery and the various factors.

METHODS

It is a prospective observational study conducted on 132 consecutive cases. Patients aged 18-70 years with musculoskeletal problems of the forearm and leg requiring surgery were included in the study. Patients with open injuries or contraindications such as diabetes mellitus, compromised circulatory states, neurological deficit, compartment syndrome and unable to give informed consent were excluded. The parameters assessed included duration of tourniquet use, tourniquet pressure, type of anesthesia, any interval release of the tourniquet and reapplication after a reperfusion period, whether upper or lower limb surgery, severity of tourniquet pain, timing of tourniquet release and complications. Chi-square and non-parametric Mann-Whitney U test were used for data analysis.

RESULTS

In upper limb surgeries, if duration of surgery was less than 60 min, 14 (51.8%) cases experienced tourniquet pain and 13 (48.1%) had no pain, and if duration of surgery was more than 60 min, 24 (60.0%) had pain and 16 (40.0%) experienced no pain. In lower limb surgeries if duration of surgery was less than 60 min, 2 (7.7%) experienced pain and 24 (92.3%) had no pain, and if duration of surgery was more than 60 min, 14 (35.8%) experienced pain and 25 (64.8%) had no pain. Degree of tourniquet pain increases with the duration of surgery. Statistically, there was significant association between tourniquet inflation time and tourniquet pain in both upper and lower limbs (p = 0.034 and 0.024, respectively) CONCLUSION: Incidence of tourniquet pain was in direct proportion to the duration of tourniquet use and was higher in cases with regional anesthesia. Other risk factors assessed including tourniquet pressure, upper or lower limb surgery, tourniquet release time and interval had no significant contribution to the incidence or severity of tourniquet pain.

Injectable platelet-rich fibrin as treatment for temporomandibular joint osteoarthritis: A randomized controlled clinical trial

The purpose of this study was to assess the treatment outcomes of intraarticular injection of injectable platelet-rich fibrin (i-PRF) after arthrocentesis in patients with temporomandibular joint osteoarthritis (TMJ-OA). Patients were randomly assigned to one of two treatment groups: those who received intraarticular injection of i-PRF after arthrocentesis procedure - the i-PRF group; and those who underwent the arthrocentesis procedure alone - the control group. The primary outcome variable was pain, the level of which was measured preoperatively and at 1, 2, 3, 6, and 12 months postoperatively. The secondary outcome variables included maximum mouth opening (MMO), and lateral and protrusive movements. Of the total of 36 patients, 18 were analyzed in the i-PRF group and 18 in the control group. There were significant differences between the groups in terms of pain levels and measurements of MMO, lateral movement, and protrusive movement over the 12 months of follow-up (p < 0.001). Significant increases in pain levels and decreases in measurements of MMO, lateral movement, and protrusive movement were observed in the control group from the 6th to 12th month postoperatively (p < 0.001). In contrast, no significant differences were found in both pain levels and measurements of MMO, lateral, and protrusive movements for the i-PRF group from the 2nd to the 12th month postoperatively. Within the limitations of the study it seems that intraarticular injection of i-PRF after arthrocentesis should be preferred whenever appropriate because when reducing pain intensity and improving functional jaw movement is the priority.