Pain
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Painful musculoskeletal conditions are common in older adults; however, pain identification, assessment, and management are reported to be suboptimal for people with dementia. Adequate pain management is an integral aspect of care for people with dementia to prevent or delay negative outcomes, such as behavioural and psychological changes, emergency department attendance, and premature nursing home admission. This study aims to examine musculoskeletal consultations and analgesic prescriptions for people with dementia compared with those for people without dementia. ⋯ People with dementia had a consistently (over time) lower prevalence and odds of musculoskeletal consultation and analgesic prescription compared with people without dementia. The evidence suggests that pain management may be suboptimal for people with dementia. These results highlight the need to increase awareness of pain and use better methods of pain assessment, evaluation of treatment response, and acceptable and effective management for people with dementia, in primary care.
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Randomized Controlled Trial
An implantable restorative-neurostimulator for refractory mechanical chronic low back pain: a randomized sham-controlled clinical trial.
Chronic low back pain can be caused by impaired control and degeneration of the multifidus muscles and consequent functional instability of the lumbar spine. Available treatment options have limited effectiveness and prognosis is unfavorable. We conducted an international randomized, double-blind, sham-controlled trial at 26 multidisciplinary centers to determine safety and efficacy of an implantable, restorative neurostimulator designed to restore multifidus neuromuscular control and facilitate relief of symptoms (clinicaltrials.gov identifier: NCT02577354). ⋯ Prespecified secondary outcomes and analyses were consistent with a modest but clinically meaningful treatment benefit at 120 days. Improvements from baseline, which continued to accrue in all outcome measures after conclusion of the double-blind phase, were clinically important at 1 year. The incidence of serious procedure- or device-related adverse events (3.9%) compared favorably with other neuromodulation therapies for chronic pain.
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Migraine is one of the most common neurological disorders characterized by recurrent attacks of typically throbbing and unilateral headaches, affecting up to 20% of the population worldwide. Despite the high prevalence and severity of this primary headache disorder, it remains to be a challenge to fully understand and treat migraine headaches. By characterizing and validating a mouse migraine model, this study aimed to investigate the functional contribution of protein kinase C (PKC) isoforms in migraine. ⋯ In response to repeated administration of NTG, ongoing spontaneous pain was not developed in mice lacking the specific PKC isoform. This study identified the presence of ongoing pain in mice treated with NTG, a known human migraine trigger that closely resembles the common manifestation of spontaneous migraine attacks in humans. These findings demonstrated a critical regulatory role of PKCδ in migraine pathophysiology, which may offer new pharmacological targets for antimigraine treatment.
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Damage to thinly myelinated and unmyelinated nerve fibers causes small fiber pathology, which is increasingly found in pain syndromes such as small fiber neuropathy (SFN) and fibromyalgia syndrome (FMS). The peripheral nerve endings of the small nerve fibers terminate within the epidermis, where they are surrounded by keratinocytes that may act as primary nociceptive transducers. We performed RNA sequencing of keratinocytes obtained from patients with SFN, FMS, and healthy controls. ⋯ Further analysis revealed enriched inflammatory pathways. Validation of selected candidates in an independent cohort confirmed higher expression of the proinflammatory mediators interleukin-8, C-X-C motif chemokine 3, endothelin receptor type A, and the voltage-gated sodium channel 1.7 in SFN compared with patients with FMS. We provide a diverse keratinocyte transcriptome signature between patients with SFN and patients with FMS, which may hint toward distinct pathomechanisms of small fiber sensitization in both entities and lay the basis for advanced diagnostics.
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We assessed the effect of back problems on healthcare utilization and costs in a population-based sample of adults from a single-payer health system in Ontario. We conducted a population-based cohort study of Ontario respondents aged ≥18 years of the Canadian Community Health Survey (CCHS) from 2003 to 2012. The CCHS data were individually linked to health administrative data to measure healthcare utilization and costs up to 2018. ⋯ Incremental annual per-person costs were higher in adults with back problems than those without back problems (women: $395, 95% CI $281-$509; men: $196, 95% CI $94-$300). This corresponded to $532 million for women and $227 million for men (adjusted to 2018 Canadian dollars) annually in Ontario given the high prevalence of back problems. Given the high health system burden, new strategies to effectively prevent and treat back problems and thus potentially reduce the long-term costs are warranted.