Military workers experience different types of lower back pain (LBP), but there is little evidence concerning the incidence of LBP in this group, especially in Asian countries. Increasing rate of LBP in this group is not considered and there is not a source to distinguish the different types of LBP. One of the most common forms of LBP is discogenic low back pain (DLBP) which is a consequence of internal disc disruption accounting for approximately 40% of LBP cases. This cross-sectional study aimed to determine the incidence of non-specific low back pain (LBP), discogenic LBP, and other forms of LBP in military office workers in Iran. 564 military office workers (303 men and 261 women, age: 20-50 years), who had worked in this setting for at least two years, were randomly selected from one military office. The Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was used as the primary screening tool. Participants who reported severe and mild LBP (graded low, mild, and severe) received a detailed physical examination including radiological magnetic resonance imaging. Based on the results of the physical examination, in conjunction with individual history, and medical opinion, mild-to-severe LBP was evident in 39% (n=220) of the participants. Of these, non-specific LBP accounted for 60%, discogenic LBP accounted for 31%, and other forms of LBP accounted for the remaining 9% of the sample. We found that LBP is highly incident in military office workers, with non-specific LBP being the most incident form. Considering these high incidence rates, a strategy for preventive health screening and exercise intervention should be considered in this population to help reduce absenteeism and increase workforce productivity.
OBJECTIVE:In the context of the opioid epidemic, there is value in examining the use of opioids in specific cancer patient cohorts. We analyzed opioid use in patients undergoing adjuvant therapy for oral cavity cancer to define the incidence of new persistent use beyond 3 months.STUDY DESIGN:Retrospective.SETTING:Comprehensive academic cancer center.SUBJECTS AND METHODS:We performed a retrospective IRB-approved analysis of opioid use in patients who received adjuvant radiotherapy with or with concurrent systemic therapy for surgically resected oral cavity cancer between 2003 and 2016. Factors associated with opioid use were evaluated by Chi-square test and one-way ANOVA. The Kaplan-Meier method was used to estimate overall survival.RESULTS:Of 77 identified patients, 10 (13%) patients received opioid prescriptions at 3 months or greater following completion of radiotherapy. Patients who were opioid naive prior to surgery required significantly fewer opioid prescriptions than intermittent or chronic opioid users. No specific factors were associated with new persistent opioid use.CONCLUSIONS:Patients undergoing surgery and adjuvant radiotherapy for oral cavity cancer who required opioids for cancer treatment related pain are at minimal risk for new dependency. Judicious pain management should be applied for patients with a history of prior opioid use. Larger patient cohorts will be needed to identify patient, disease, and treatment characteristics associated with new persistent use given its limited incidence.
The purpose of this study was to characterize emergency department (ED) physicians' beliefs and current practices regarding the use of haloperidol for the management of acute and acute on chronic pain.METHODS:A survey regarding haloperidol use was distributed by email to attending physicians, resident physicians, nurse practitioners, and physician assistants at emergency medicine departments in the Indiana University Health System and at St Joseph Mercy Ann Arbor.RESULTS:Of the 129 responses received, the majority (89.1%) of providers had used haloperidol for control of pain in the ED. The most common reason that respondents used haloperidol to treat pain was that they did not want to use an opioid or other agent (91.3%). The majority of providers (73.9%) believed that haloperidol was effective because there is a psychiatric component to pain, while over half of respondents (58.3%) chose haloperidol as they believed it to have analgesic properties. When haloperidol was used as a first line medication, providers felt that it was effective in controlling pain about 69.0% of the time without the need for further medication. The most common presentations for use were for unspecified abdominal pain, headache, and gastroparesis.CONCLUSION:ED providers reported using haloperidol most often as a second line treatment to manage both acute and acute on chronic pain. When haloperidol was used as a first line agent, providers claimed that additional medicines were not usually required. Haloperidol may provide an effective alternative to opioids in treatment of acute pain and acute exacerbations of chronic pain in the ED.
Body maps have long been used to assess pain location in adult and pediatric chronic pain patients. Assessing agreement between parent and child reports of pain location using such maps may help establish a unified picture of children's pain experience. However, few studies have examined the extent of agreement between mothers and children on the location of the child's pain. Using kappa coefficients and other determinants of the magnitude of kappa we assessed mother-child concordance in pain location using body maps with 21 standardized areas in 41 children with chronic pain (65.9% female, mean age = 14.60) and their mothers. The highest level of agreement was found for the abdominal region; agreement for the head region was moderate and not superior to the other body areas. Approximately half of the body map areas yielded poor to fair mother-child agreement, while the other half yielded moderate or better agreement. There was more agreement between mothers and sons than between mothers and daughters on the total number of body areas considered painful, but there were no effects of pubertal status, race, and ethnicity on agreement. Our results are consistent with previous studies indicating that parent assessments of children's pain do not necessarily mimic their child's report. Future research should test additional psychosocial factors that may contribute to parent-child discordance regarding the location of the child's pain.
Pain in children can become chronic and disabling, associated with high degrees of social isolation from schooling absences, physical limitations that prevent participation in social settings, and difficulties forming self-identity. This lack of social support network impairs social coping skills and can lead to worsening pain symptoms.OBJECTIVE:In this case study, we describe a new program to disrupt the cycle of social isolation and chronic pain by emphasizing social coping skills via peer mentorship. The program aimed to utilize peers who have learned to self-manage their own chronic pain to assist patients with social coping skills to reduce isolation caused by chronic pain conditions.STUDY GROUP:Children and adolescents with chronic pain.METHODS:This case describes the experience of a 17 year-old, African American boy with diffuse chronic body pain as a participant ("the mentee") in the program; his mentor was a 19 year-old girl with chronic pain associated with rheumatoid arthritis. The mentor received six hours of training and she mentored the patient in 10 weekly sessions.RESULTS:The mentee connected very well with his mentor through sharing similar pain experiences. He demonstrated improvements in positive affect, sleep, social coping, and perception of bodily pain on a variety of quantitative measures. Qualitative data from interviews also suggested that the mentee learned important social coping skills through peer mentorship.CONCLUSIONS:A peer mentoring approach to chronic pain may help alleviate social isolation in adolescents and result in improvements in a number of associated symptoms.
BACKGROUND Pain is a common problem among persons living with HIV. In this population, pain often co-occurs with psychological symptoms, as well as illicit drug abuse. Recently, the misuse of prescription drugs, including the misuse of opioid medications for pain relief, has emerged as a significant public health problem. The purpose of this article is to review the literature on the associations among pain, illicit drug use, and symptoms of depression and anxiety in the misuse of prescription medications in HIV disease. RESULTS AND CONCLUSIONS Although relatively little attention has centered on the management of pain, psychological symptoms and other distressing, yet treatable symptoms in HIV, the fact that drug abuse behaviors now constitute a primary risk factor for HIV infection requires a shift in focus for clinicians and researchers alike. There is currently little agreement regarding the medical provision of opioids to persons with a history of illicit drug use. Thus, additional research is required to ensure adequate treatment of pain and psychological symptoms in persons living with HIV while minimizing the risk of prescription drug misuse.
To determine which of the previously proposed functional interference cluster models is most appropriate in patients with bone metastases and to determine if the cluster structures identified at baseline differed between responders and non-responders following palliative radiotherapy. METHODS: The confirmatory test data set consists of breast and prostate cancer patients treated with palliative radiotherapy between May 2003 to January 2007. Worst pain and functional interference scores were assessed using Brief Pain Inventory at baseline, 4, 8 and 12 weeks post radiation treatment. The baseline cluster structure of the confirmatory dataset was compared to each of the previously proposed baseline cluster models. Maximum likelihood CFA was used to account for possible correlation amongst the factor components. A MIMIC model was used to determine the invariance of the cluster models between responders and non-responders during follow-up. RESULTS: A total of 169 eligible patients were analysed. There were 91 male and 78 female patients with a median age of 68 years. The median KPS was 70. A single 8 Gy and 20 Gy in 5 fractions were used in 97% of all analysed patients. The RTOG model, in which relationships with others and sleep comprised the mood-related interference cluster and walking ability and normal work comprised the physical-interference cluster, provides the best fit for the sample data. The follow-up cluster structure is not similar across the responder groups indicating that cluster structures shift following radiation treatment, as evidenced by pain response. CONCLUSION: Although differing slightly this analysis confirms pretreatment symptom clusters exist for patients with bone metastases from breast or prostate cancer based on the RTOG 9714 data. This could help formulate symptom management interventions at initial diagnosis. Symptom clusters dissolve or change after treatment which may be a function of the treatment or population and requires further study.
Little is known about how sociodemographic factors relate to children's chronic pain. This paper describes the pain, health, and sociodemographic characteristics of a cohort of children presenting to an urban tertiary chronic pain clinic and documents the role of age, sex and minority status on pain-related characteristics. A multidisciplinary, tertiary clinic specializing in pediatric chronic pain. Two hundred and nineteen patients and their parents were given questionnaire packets to fill out prior to their intake appointment which included demographic information, clinical information, Child Health Questionnaire - Parent Report, Functional Disability Index - Parent Report, Child Somatization Index - Parent Report, and a Pain Intensity Scale. Additional clinical information was obtained from patients' medical records via chart review. This clinical sample exhibited compromised functioning in a number of domains, including school attendance, bodily pain, and health compared to normative data. Patients also exhibited high levels of functional disability. Minority children evidenced decreased sleep, increased somatization, higher levels of functional disability, and increased pain intensity compared to Caucasians. Caucasians were more likely to endorse headaches than minorities, and girls were more likely than boys to present with fibromyalgia. Younger children reported better functioning than did teens. The results indicate that sociodemographic factors are significantly associated with several pain-related characteristics in children with chronic pain. Further research must address potential mechanisms of these relationships and applications for treatment.
Medically unexplained symptoms (MUS) confound physicians, and the incidence and prevalence of these conditions is poorly documented. This is not least due to the complex nature of MUS and mimicry of morbidity with conditions that have common clinical assessment and treatment modalities, e.g. migraine headaches which stress headaches commonly are misdiagnosed as. Effective treatment modalities for MUS have been more or less non-existent. In the following we present a modality for the assessment, diagnosis and treatment of MUS that in our experience leads to cure, at least in better than half of these cases measured in terms of allowing the individual back to work. These results are at least twice as high as those described hitherto (see below), and yet, our treatment modality is beset with many obstacles, not the least of which is the intrasigence of a system that will not and/or can not understand why this modality is so much better than what they are able to offer. The most importance obstacle is financing, as this modality requires long term and committed financing to work. The economic implications of not dealing with these issues are described.
There is limited evidence to date of the effectiveness of minimally-invasive brain stimulation in controlling postoperative pain. Two studies have provided preliminary evidence that transcranial magnetic stimulation (TMS) can significantly reduce post-operative pain, and no studies have been published on the effects of transcranial direct current stimulation (tDCS) on postoperative pain. The evidence supporting the role of brain stimulation in producing general anesthetic effects is also limited but there is a possibility that appropriately targeted electrical stimulation might have a role in the future if the technology permits such stimulation in a non-invasive manner. The present article provides a brief overview of the available evidence supporting the role of minimally invasive brain stimulation technology in perioperative medicine. More studies and well-controlled trials are needed to establish a clear role for minimally-invasive brain stimulation technologies in the perioperative arena.
Fibromyalgia is a poorly understood disorder that likely involves central nervous system sensory hypersensitivity. There are a host of genetic, neuroendocrine and environmental abnormalities associated with the disease, and recent research findings suggest enhanced sensory processing, and abnormalities in central monoamines and cytokines expression in patients with fibromyalgia. The morbidity and financial costs associated with fibromyalgia are quite high despite conventional treatments with antidepressants, anticonvulsants, low-impact aerobic exercise and psychotherapy. Noninvasive brain stimulation techniques, such as transcranial direct current stimulation, transcranial magnetic stimulation, and electroconvulsive therapy are beginning to be studied as possible treatments for fibromyalgia pain. Early studies appear promising but more work is needed. Future directions in clinical care may include innovative combinations of noninvasive brain stimulation, pharmacological augmentation, and behavior therapies.
Although sex differences in anxiety sensitivity or the specific tendency to fear anxiety-related sensations have been reported in adults with clinical pain, there is a dearth of relevant research among children. This study examined sex differences in anxiety sensitivity across unselected samples of 187 children with chronic pain (71.7% girls; mean age = 14.5) and 202 non-clinical children (52% girls; mean age = 13.6). Girls in the chronic pain and non-clinical samples reported elevated anxiety sensitivity relative to boys irrespective of clinical status. Girls with chronic pain also reported heightened fears of the physical consequences of anxiety compared to non-clinical girls but there were no such differences for psychological or social concerns. Among boys, anxiety sensitivity did not differ between the chronic pain and non-clinical groups. Future longitudinal research may examine whether specific fears of anxiety-related somatic sensations constitutes a sex-based vulnerability factor in the development of chronic pain.
Fibromyalgia has been recognized as a central pain disorder with evidence of neuroanatomic and neurophysiologic alterations. Previous studies with techniques of noninvasive brain stimulation--transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS)--have shown that these methods are associated with a significant alleviation of fibromyalgia-associated pain and sleep dysfunction. Here we sought to determine whether a longer treatment protocol involving 10 sessions of 2 mA, 20 min tDCS of the left primary motor (M1) or dorsolateral prefrontal cortex (DLPFC) could offer additional, more long-lasting clinical benefits in the management of pain from fibromyalgia. METHODS: Forty-one women with chronic, medically refractory fibromyalgia were randomized to receive 10 daily sessions of M1, DLPFC, or sham tDCS. RESULTS: Our results show that M1 and DLPFC stimulation both display improvements in pain scores (VAS) and quality of life (FIQ) at the end of the treatment protocol, but only M1 stimulation resulted in long-lasting clinical benefits as assessed at 30 and 60 days after the end of treatment. CONCLUSIONS: This study demonstrates the importance of the duration of the treatment period, suggesting that 10 daily sessions of tDCS result in more long lasting outcomes than only five sessions. Furthermore, this study supports the findings of a similarly designed rTMS trial as both induce pain reductions that are equally long-lasting.
Methods of cortical stimulation including epidural motor cortex stimulation (MCS), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) are emerging as alternatives in the management of pain in patients with chronic medically-refractory pain disorders. Here we consider the three methods of brain stimulation that have been investigated for the treatment of central pain: MCS, rTMS, and tDCS. While all three treatment modalities appear to induce significant clinical gains in patients with chronic pain, tDCS is revealed as the most cost-effective approach (compared to rTMS and MCS) when considering a single year of treatment. However, if a 5-year treatment is considered, MCS is revealed as the most cost-effective modality (as compared to rTMS and tDCS) for the neuromodulatory treatment of chronic pain. We discuss the theory behind the application of each modality as well as efficacy, cost, safety, and practical considerations.
This study examined the relationship between race, laboratory-based coping strategies and anticipatory anxiety and pain intensity for cold, thermal (heat) and pressure experimental pain tasks. Participants were 123 healthy children and adolescents, including 33 African Americans (51% female; mean age =13.9 years) and 90 Caucasians (50% female; mean age = 12.6 years). Coping in response to the cold task was assessed with the Lab Coping Style interview; based on their interview responses, participants were categorized as 'attenders' (i.e., those who focused on the task) vs. 'distractors' (i.e., those who distracted themselves during the task). Analysis of covariance (ANCOVA) revealed significant interactions between race (African-American vs. Caucasian) and lab-based coping style after controlling for sex, age and socioeconomic status. African-American children classified as attenders reported less anticipatory anxiety for the cold task and lower pain intensity for the cold, heat and pressure tasks compared to those categorized as distractors. For these pain outcomes, Caucasian children classified as distractors reported less anticipatory anxiety and lower pain intensity relative to those categorized as attenders. The findings point to the moderating effect of coping in the relationship between race and experimental pain sensitivity.
The use of hydromorphone is increasing but little is known about its effects during painful episodes in adolescents with sickle cell disease. This pilot study examined the intensity, location, and quality of pain and evaluated the amount of relief and side effects from PCA hydromorphone during acute painful episodes in five adolescents with sickle cell disease. Data suggest that hydromorphone may provide a better alternative than morphine, the most commonly prescribed opioid in patients with sickle cell disease. Hydromorphone may provide improved pain control and recovery from acute painful episodes in patients with sickle cell disease.
Morphine given by Patient Controlled Analgesia (PCA) is widely used in hospital settings to manage severe pain during acute painful episodes. Wide variations in prescription patterns occur and some patients are often self-administering sub- or low- therapeutic doses. In this preliminary study, a descriptive design with repeated measures was used to examine the effects of different PCA morphine regimens on the intensity, location and quality of pain as well as on the perceived amount of relief and side effects in patients with sickle cell disease (N=13; mean age 13.7 years; eight males; five females). The preliminary data showed that a regimen with a high background infusion rate and low intermittent push dose (Regimen B) may provide better response to PCA morphine. The difference in trends between the worst and least pain intensity ratings were narrower in this regimen, suggesting that pain peaks and troughs were not occurring as in a regimen with an around the clock nurse administered dosing schedule (Regimen C). The amount of morphine that was administered per day was not significantly different (p > 0.05) among the three morphine regimens. The combination of a high background infusion rate and low intermittent push dose (as in Regimen B) within the first 24 hours of admission, may provide improved response and possibly shorter recovery from the painful episode than the regimen that would routinely be prescribed with lower background infusion rate and high intermittent push dose (as in regimen A).
Chronic or recurrent pain is a widespread health issue that affects a large proportion of the population, including adults and children. Family factors in the development of pain have received increasing attention of late as research has shown that pain tends to run in families, A burgeoning literature has also demonstrated the influence of parental factors in children's responses to chronic and laboratory pain. This review attempts to integrate: first,) the literature documenting an association between parent and child pain both within the clinical chronic pain and laboratory pain literatures; and second,) research accounting for likely mechanisms explaining the parent-child pain association. To this end, we present a conceptual model that incorporates a number of parent and child specific characteristics, such as parental responses, coping and gender role socialization as well as broader socio-demographic factors such as parent and child age and sex, family functioning, socioeconomic status, and race/ethnicity. It is anticipated that consideration of such variables will lead to needed research exploring the mechanisms of parent-child pain relationships, and to interventions designed to prevent and ameliorate child pain sensitivity when it correlates with poor adaptation to pain.
This paper uses a mixed-methods approach to examine the impact of pain-associated functioning limitations on children's lives and the strategies they develop to try to continue functioning. Forty-five children ages 10-18 completed standardized questionnaires and participated in semistructured interviews prior to intake at a university-based tertiary clinic specializing in the treatment of pediatric chronic pain. All the children reported that pain limited their functioning in everyday activities and that these limitations caused them frustration and distress. Qualitative analysis identified three distinct functioning patterns or groups, which were designated as Adaptive, Passive, and Stressed. The groups did not differ significantly in demographics or clinical pain characteristics. Adaptive children continued to participate in many activities and were more likely to realize that focusing on pain would heighten their perception of pain. Children in this group reported more effective use of distraction and of other independently developed strategies to continue functioning. Passive children had given up most activities, tended to use passive distraction when in pain, and were more likely to feel isolated and different from peers. Stressed children described themselves as continuing to function, but were highly focused on their pain and the difficulties of living with it. The qualitative groupings were supported by quantitative findings that Stressed children reported a higher degree of social anxiety than did Passive children and were more likely than the other groups to report experiencing pain throughout the day. Finally, Adaptive children were rated by their parents as having better overall health compared to Passive children.
