Pain
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The STarT Back approach comprises subgrouping patients with low back pain (LBP) according to the risk of persistent LBP-related disability, with appropriate matched treatments. In a 12-month clinical trial and implementation study, this stratified care approach was clinically and cost-effective compared with usual, nonstratified care. Despite the chronic nature of LBP and associated economic burden, model-based economic evaluations in LBP are rare and have shortcomings. ⋯ Sensitivity analyses indicate the approach is likely to be cost-effective in all scenarios and cost saving in most. It is likely this stratified care model will help reduce unnecessary healthcare usage while improving the patient's quality of life. Although decision-analytic modelling is used in many conditions, its use has been underexplored in LBP, and this study also addresses associated methodological challenges.
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Spatial acuity measured by 2-point discrimination (2PD) threshold and spatial summation of pain (SSp) are useful paradigms to probe the pain system in humans. Whether the results of these paradigms are influenced by different stimulus modalities and intensities is unclear. The aim of this study was to test 2PD controlling the stimulus modality and the intensity and to investigate the effect of modality on SSp. ⋯ Higher pain intensities were reported when a larger area was stimulated (SSp), independent of the modality. Furthermore, reported pain intensities were higher when the distance between 2 stimulated areas was increased from 2 to 6 cm (P < 0.001), 8 cm (P < 0.01), and 14 cm (P < 0.01). 2PDs determined by mechanical and electrocutaneous stimuli were significantly correlated within both stimulus intensities, ie, innocuous (r = 0.34, P < 0.05) and noxious (r = 0.35, P < 0.05). The current results show 3 novel findings: (1) the precision of the pain system might be higher than in the innocuous (tactile) system when mechanical and electrocutaneous modalities are used, (2) the pattern of distance-based and area-based SSp seems to be comparable irrespective of the modality applied (mechanical and electrocutaneous), and (3) both modalities are moderately correlated.
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One in 3 patients with lumbar spinal stenosis undergoing decompressive laminectomy (DL) to alleviate neurogenic claudication do not experience substantial improvement. This prospective cohort study conducted in 193 Veterans aimed to identify key spinal and extraspinal factors that may contribute to a favorable DL outcome. Biopsychosocial factors evaluated pre-DL and 1 year post-DL were hip osteoarthritis, imaging-rated severity of spinal stenosis, scoliosis/kyphosis, leg length discrepancy, comorbidity, fibromyalgia, depression, anxiety, pain coping, social support, pain self-efficacy, sleep, opioid and nonopioid pain medications, smoking, and other substance use. ⋯ Using opioids was associated with lower odds of significant functional improvement (OR 0.46 [0.23-0.93]). All P < 0.05. Key modifiable factors associated with DL success-self-efficacy, apparent leg length inequality, and opioids-require further investigation and evaluation of the impact of their treatment on DL outcomes.
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Randomized Controlled Trial
Effect of a brief scenario-tailored educational program on parents' risk knowledge, perceptions and decisions to administer prescribed opioids: a randomized controlled trial.
This randomized, controlled trial evaluated whether a brief educational program (ie, Scenario-Tailored Opioid Messaging Program [STOMP]) would improve parental opioid risk knowledge, perceptions, and analgesic efficacy; ensure safe opioid use decisions; and impact prescription opioid use after surgery. Parent-child dyads (n = 604) who were prescribed an opioid for short-term use were randomized to routine instruction (Control) or routine plus STOMP administered preoperatively. Baseline and follow-up surveys assessed parents' awareness and perceived seriousness of adverse opioid effects, and their analgesic efficacy. ⋯ Instead, parents' analgesic efficacy and pain-relief preferences explained 7%, whereas child and surgical factors explained 22% of the variance in opioid doses. Scenario-tailored education enhanced parents' opioid risk knowledge, perceptions, and scenario-based decision-making. Although this may inform later situation-specific decision-making, our research did not demonstrate an impact on total opioid dosing, which was primarily driven by surgical and child-related factors.