The journal of pain : official journal of the American Pain Society
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Multicenter Study
Neuropathic aspects of persistent postsurgical pain: a French multicenter survey with a 6-month prospective follow-up.
To investigate the role of peripheral neuropathy in the development of neuropathic postsurgical persistent pain (N-PSPP) after surgery, this French multicentric prospective cohort study recruited 3,112 patients prior to elective cesarean, inguinal herniorrhaphy (open mesh/laparoscopic), breast cancer surgery, cholecystectomy, saphenectomy, sternotomy, thoracotomy, or knee arthroscopy. Besides perioperative data collection, postoperative postal questionnaires built to assess the existence, intensity, and neuropathic features (with the Douleur Neuropathique 4 Questions [DN4]) of pain at the site of surgery were sent at the third and sixth months after surgery. In the 2,397 patients who completed follow-up, the cumulative risk of N-PSPP within the 6 months ranged from 3.2% (laparoscopic herniorrhaphy) to 37.1% (breast cancer surgery). Pain intensity was greater if DN4 was positive and decreased with time since surgery; it depended on the type of surgery. In pain-reporting patients, the response to the DN4 changed from time to time in about 1:4 of the cases. Older age and a low anxiety score were independent protective factors of N-PSPP, whereas a recent negative event, a low preoperative quality of life, and previous history of peripheral neuropathy were risk factors. The type of anesthesia had no influence on the occurrence of N-PSPP.
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Pain is a serious consequence of spinal cord injury (SCI). Our aim was to investigate the temporal aspects of different types of pain following traumatic SCI and to determine possible predictors of neuropathic pain. Prospective data on 90 patients were collected at 1, 6, and 12 months after traumatic SCI. The patients completed questionnaires on pain severity, descriptors, and impact and underwent clinical examination with bedside sensory testing. Eighty-eight patients completed the 12-month follow-up. Approximately 80% of patients reported any type of pain at all 3 time points. Neuropathic pain related to SCI increased over time, and musculoskeletal pain decreased slightly, with both being present in 59% of patients at 12 months; other neuropathic pain not related to SCI and visceral pain were present in 1 to 3%. At-level neuropathic pain present at 1 month resolved in 45% and below-level pain resolved in 33%. Early (1 month) sensory hypersensitivity (particularly cold-evoked dysesthesia) was a predictor for the development of below-level, but not at-level, SCI pain at 12 months. In conclusion, the present study demonstrates phenotypical differences between at-level and below-level SCI pain, which is important for future studies aiming to uncover underlying pain mechanisms. ⋯ The finding that early sensory hypersensitivity predicts later onset of below-level central neuropathic pain may help to identify patients at risk of developing neuropathic pain conditions after traumatic spinal cord injury. Information about onset of pain may help to identify different phenotypes in neuropathic pain conditions.
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There is an emerging body of evidence regarding interdisciplinary acceptance and commitment therapy in the rehabilitative treatment of chronic pain. This study evaluated the reliability and clinical significance of change following an open trial that was briefer than that examined in previous work. In addition, the possible mediating effect of psychological flexibility, which is theorized to underlie the acceptance and commitment therapy model, was examined. Participants included 117 completers of an interdisciplinary program of rehabilitation for chronic pain. Assessment took place at treatment onset and conclusion, and at a 3-month follow-up when 78 patients (66.7%) provided data. At the 3-month follow-up, 46.2% of patients achieved clinically significant change, and 58.9% achieved reliable change, in at least 1 key measure of functioning (depression, pain anxiety, and disability). Changes in measures of psychological flexibility significantly mediated changes in disability, depression, pain-related anxiety, number of medical visits, and the number of classes of prescribed analgesics. These results add to the growing body of evidence supporting interdisciplinary acceptance and commitment therapy for chronic pain, particularly with regard to the clinical significance of an abbreviated course of treatment. Further, improvements appear to be mediated by changes in the processes specified within the theoretical model. ⋯ Outcomes of an abbreviated interdisciplinary treatment for chronic pain based on a particular theoretical model are presented. Analyses indicated that improvements at follow-up mediated change in the theorized treatment process. Clinically significant change was indicated in just under half of participants. These data may be helpful to clinicians and researchers interested in intervention approaches and mechanisms of change.
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Review Meta Analysis
Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis.
This systematic review evaluated evidence from randomized controlled trials investigating interventions available over the counter and advice that could be provided to people with acute low back pain. Searches were conducted on MEDLINE, Embase, Cochrane Database of Systematic Reviews, AMED, CENTRAL, and PsycINFO for eligible randomized controlled trials. The primary outcome measure was pain. Eligible controls included placebo, no treatment, or usual care. Two reviewers extracted data and rated study quality. A random effects model was used to pool trial effects with the overall strength of evidence described using the GRADE criteria. Thirteen randomized controlled trials (2,847 participants) evaluating advice, bed rest, simple analgesics (paracetamol, nonsteroidal anti-inflammatory drugs), heat application, and a topical rubefacient were included. There was low-quality evidence that bed rest is ineffective and very-low-quality evidence that advice is ineffective in the short, intermediate, and long terms. There was very-low-quality evidence that nonsteroidal anti-inflammatory drugs (ibuprofen and diclofenac "when required" dosing) provide an immediate analgesic effect (mean differences -10.9 [95% confidence interval = -17.6 to -4.2] and -11.3 [95% confidence interval = -17.8 to -4.9], respectively). There is very-low-quality evidence that heat wrap and a capsicum-based rubefacient provide an immediate analgesic effect (mean differences -13.5 [95% confidence interval = -21.3 to -5.7] and 17.5, P < .001, respectively), but there was no information on longer-term outcomes. ⋯ There is limited evidence that nonsteroidal anti-inflammatory drugs, heat wrap, and rubefacients provide immediate pain relief for acute back pain and that bed rest and advice are both ineffective. Future research is needed to provide evidence to support rational use of over-the-counter remedies and advice for people with acute low back pain.
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Multicenter Study Comparative Study
Comparisons of patient and physician assessment of pain-related domains in cancer pain classification: results from a large international multicenter study.
The aim of the present study is to compare physician clinical assessment with patient-rated evaluations in the classification of cancer pain patients into groups with different pain levels, according to the presence of incident/breakthrough pain, neuropathic pain, and psychological distress. Average pain in the previous 24 hours was used as the dependent variable in multivariate linear regression models, and incident/breakthrough pain, neuropathic pain, and psychological distress were tested as regressors; in the assessment of regressors, physicians used the Edmonton Classification System for Cancer Pain, whereas patients used structured self-assessment questionnaires. The amount of variability in pain intensity scores explained by the 2 sets of regressors, physician and patient rated, was compared using R(2) values. When tested in 2 separate models, patient ratings explained 20.3% of variability (95% confidence interval [CI] = 15.2-25.3%), whereas physician ratings explained 6.1% (95% CI = 2.2-9.8%). The higher discriminative capability of patient ratings was still maintained when both regressor sets were introduced in the same model, with R(2) indices of 17.6% (95% CI = 13.0-22.2%) for patient ratings vs 3.4% (95% CI = .9-5.9%) for physician ratings. Patients' self-assessment of subjective symptoms should be integrated in future cancer pain classification systems. ⋯ Our results indicate that patient-structured assessment of incident/breakthrough pain, neuropathic pain, and psychological distress significantly contributes to the discrimination of cancer patients with different pain levels. The integration of patient self-assessment tools with more objective clinician assessments can improve the classification of cancer pain.