The Clinical journal of pain
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Despite the growing use of opioids for persisting noncancer pain, evidence for their effectiveness is limited, especially in relation to functional outcomes. Guidelines have been developed for prescribers, but their utility is untested. This review examines the use of opioids in this population from a biopsychosocial perspective and makes a number of recommendations. ⋯ The available evidence indicates that by themselves, oral opioids generally achieve only modest reductions in pain levels in patients with chronic noncancer pain. Functional outcomes are inconsistent across studies. There are questions about the timing of their use and patient selection. There are risks in trials of opioids only after other conservative interventions have been tried unsuccessfully. Also, in some patients, ongoing use of opioids risks repeated over-doing of pain-generating activities and reinforcing escape/avoidance responses that promote disability. These risks may be lessened by assessment of current use of pain self-management strategies among potential candidates for opioids. This offers advantages in promoting collaborative management of persisting pain as well as better pain and functional outcomes. In this view, opioids may be considered as one possible element of a management plan rather than the primary treatment.
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Multicenter Study Clinical Trial
Treatment of chronic plantar fasciitis with Botulinum toxin A: preliminary clinical results.
Based on recent results in chronic lateral epicondylitis we decided to investigate the efficacy of Botulinum toxin A (BTX-A) for treatment of chronic therapy resistant plantar fasciitis. Nine patients with an average duration of symptoms of 14 months and at least two prior conservative treatments received a one injection of 200 units of BTX-A (Dysport) subfascially into the painful area. The patients documented pain at rest and during weight-bearing after 2, 6, 10 and 14 weeks by a visual analogue scale. ⋯ The effect was still present at the latest follow-up of 14 weeks. Similarly, the pain at rest was reduced to less than half of the initial value at any follow-up. All patients were satisfied and did not require further treatment.
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The purposes of this study were to investigate the association among measures of fear-avoidance beliefs, pain intensity, and lumbar flexion and to determine if changes in these measures were predictive of treatment outcome following physical therapy for acute low back pain. It was hypothesized that items of the Fear-Avoidance Beliefs Questionnaire would be correlated with concurrent measures of pain intensity and lumbar flexion. In addition, it was hypothesized that changes in fear-avoidance beliefs would be predictive of changes in self-report of pain intensity and disability. ⋯ These results suggest that fear-avoidance beliefs have a similar association with pain intensity, physical impairment, and disability for patients with acute and chronic low back pain. This study provides preliminary support for the use of the Fear-Avoidance Beliefs Questionnaire as an outcome measure for patients with acute low back pain.
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Understanding the psychological processes that underlie the development of a chronic pain problem is important to improve prevention and treatment. The aim of this study was to test whether distinct profiles of variables within the fear-avoidance model could be identified and could be related to disability in a meaningful way. ⋯ Distinct profiles of psychological functioning could be extracted and meaningfully related to future disability. These profiles give support to the fear-avoidance model and underscore the need to address the psychological aspects of the pain experience early on.
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Comparative Study Clinical Trial
Direct comparison of placebo effects on clinical and experimental pain.
Placebo effects have been suggested to be more potent on clinical than experimental pain. However, this proposition is based on the comparison of the magnitude of placebo analgesia between studies using different methodologies or between different groups of subjects within the same study. The authors sought to provide a more direct test of this hypothesis using a within-subject design and to investigate the potential mediating effect of expectancy. ⋯ The important reduction in placebo analgesia in low back pain after the single pre-exposure to the ineffective control treatment suggests the additional involvement of highly flexible mechanisms that may counteract the pro-analgesic effects of expectations.