This article offers a critical review of the literature examining spouse responses to the pain behaviour of chronic pain patients. An overview is given of 27 studies that have explored patient - spouse interactions in chronic pain, together with a summary of the various findings. It is concluded that the body of research is broadly supportive of the operant behavioural paradigm on which it has developed. Patients' coping with chronic pain is significantly influenced by the ways in which those closest to them respond to their expressions of discomfort. However, it is argued that the behavioural model alone is insufficient when accounting for the complexity of pain couples' interactions. The impact of the spouse's response is mediated by a range of cognitive and affective variables that have yet to be fully recognized in the research literature. It is also argued that the operationalization of the construct of solicitousness, which is central to research on chronic pain couples, is flawed. A number of suggestions for future theoretical and empirical developments in this area are made.
Objective: To develop a scale for estimating the severity of patellofemoral pain syndrome (PFPS) and to determine its reliability and validity. Design: The PFPS Severity Scale (PSS) was developed following a literature search, input from clinicians, and pilot testing in people with PFPS. The final version of the instrument encompasses 10 statements regarding PFPS pain in a visual analogue format. Reliability and validity of the new scale were determined in a PFPS population. Setting: All testing was performed at the Canadian Forces Base Kingston, Physiotherapy Department. Subjects: Twenty-nine military subjects (7 female) between the ages of 20 and 48 (32 years9/8.9) with subjective and objective findings consistent with PFPS were recruited. Twenty-four of the participants (6 female, 31.8 years 9/9.4) participated in the reliability phase of the study. Methods: Reliability of the PSS was determined by comparing the scores obtained on two test days (24 hours apart). Convergent validity of the PSS was determined by comparing data from the PSS with two established knee scales: the WOMAC (Western Ontario and McMaster Universities) Osteoarthritis Index and the Hughston Foundation subjective knee scale. Results: Test-retest reliability was excellent (Spearman's rho=0.95, p<0.0001). The correlations between the PSS and the WOMAC and Hughston scales were strong (rho=0.72 and 0.83, p<0.001 respectively). Conclusions: The PSS is reliable and has demonstrated convergent validity making it a useful tool for monitoring rehabilitative or surgical outcomes in clients with PFPS.
The McGill Pain Questionnaire (MPQ) is a verbal pain assessment tool allowing for the quantification of the intensity and quality of pain. However, describing dental pain ( including both acute and chronic orofacial conditions causing pain) in single numbers may mask differential response patterns. That is, calculating Pain Rating Indices brings along the implicit assumption that the conditions under investigation are homogeneous with respect to words used to describe the pain. In the present study, a review of available literature was performed to assess the status of the MPQ in dental pain research. Forty-five studies were identified and examined, leading to the following conclusions. The MPQ's assumption that dental pain is one homogeneous condition is rejected. That is, dental pain may imply a variety of painful sensations. Using a statistical technique that incorporates all information regarding response patterns facilitates successful differentiation, and painful dental conditions being studied need to be as homogeneous as possible. Otherwise, describing dental pain in numbers masks differential response patterns.
The endogenous cannabinoid system is widespread and responsible for a number of modulatory functions, including analgesia. Akin to the endogenous opioid system, the analgesic actions of cannabinoids are mediated by the neuronal receptor ( CB1) and immune cell- expressed receptor ( CB2). Animal data have shown cannabinoids to be effective in many models of inflammatory and neuropathic pain. Less evidence is available from human studies, although investigation is under way. Ultimately, an effective cannabinoid analgesic should aim to be therapeutic but without the 'high' of unwanted central side effects.
INTRODUCTION:The effective management of pain requires a multidisciplinary approach. Previous studies have suggested that around 8% of cancer patients will require interventional techniques from an anaesthetist with special interest in pain management to maximize pain control, although this percentage may increase in the cohort of patients with difficult pain syndromes under the care of specialist palliative care services. We wished to determine the experiences and views of other palliative care physicians with regard to input from specialists in pain management.METHOD:A postal questionnaire was sent to the consultant members of the Association of Palliative Medicine.RESULTS:Most respondents had access to 'as-required' anaesthetist consultations with 72% of respondents feeling that the frequency of consultation was adequate. However, over half of the respondents had used the services of a pain management specialist less than four times in the past year and a quarter of respondents had not been involved in a joint consultation with an anaesthetist in the past year. All respondents felt that the pain management specialist's role included advice on technical procedures but less than 25% felt that their role should extend to advice on prescribing analgesics.DISCUSSION:There are likely to be several reasons for this apparent underutilization of specialist anaesthetist/pain management services. This survey has identified possible factors including lack of formal arrangements, lack of suitable experience and the attitudes of palliative medicine consultants.
Roelien H Enting and Wendy H Oldenmenger Department of Neuro-oncology, Daniel den Hoed Cancer Center, University Hospital Rotterdam, Rotterdam, Carin CD van der Rijt Department of Medical Oncology/ Palliative Care Unit, Daniel den Hoed Cancer Center, University Hospital Rotterdam, Rotterdam, Peter Koper Department of Radiotherapy, Daniel den Hoed Cancer Center, University Hospital Rotterdam, Rotterdam, Paul J Lieverse Department of Anesthesiology, Daniel den Hoed Cancer Center, University Hospital Rotterdam, Rotterdam and Peter AE Sillevis Smitt Department of Neuro-oncology, Daniel den Hoed Cancer Center, University Hospital Rotterdam, Rotterdam
This article reviews classic conditioning, operant conditioning and cognitive(- behavioural) approaches to the understanding and treatment of chronic low back pain. In- vivo exposure, which combines classic and cognitive- behavioural principles, is also detailed. A central tenet of classic conditioning is the pain tension - pain cycle. Empirical evidence is scarce for electromyographic biofeedback and progressive muscle relaxation aimed at breaking this cycle. The central hallmark of the operant conditioning model of chronic pain is the reinforcement of pain behaviour and the extinction of well behaviour. Operant conditioning treatment is generally quite effective for increasing activity levels and exercise tolerance, and decreasing pain medication intake. The effects on pain, however, are usually more modest. Cognitive-behavioural treatments are loosely defined in the literature but are generally effective. Exposure in- vivo, embedded in a cognitive- behavioural treatment, has yielded preliminary evidence of effectiveness. Compared with graded activity, graded exposure substantially decreases levels of pain- related fear, pain catastrophizing, pain disability and pain vigilance, and increases physical activity. Generalization of the effects of exposure in- vivo treatment can be enhanced by adapting lengthy exposures to a full variety of contexts and natural settings in which fear has been experienced. Cognitive- behavioural exposure in vivo appears to be a promising treatment for fearful pain patients. However, the application of exposure in vivo in low back pain patients and other pain syndromes should be further investigated using more sophisticated research designs such as randomized clinical trials. Future research should aim to elucidate further the mechanisms involved in the development and maintenance of ( chronic) pain.
The study objective was to determine whether switching patients from morphine to transdermal fentanyl resulted in a reduction of morphine-associated side effects, and an improvement in cognitive function and patients' well being while maintaining adequate pain and symptom control. Nineteen patients aged 42– 86 with terminal cancer, maintained on morphine for pain and distressed as a result of morphine toxicity, were given the dose of fentanyl corresponding to their current morphine dose. Pain control was then maintained (mostly fentanyl 50– 100 μg/h) over the 14-day study period. Throughout the study, patients' global assessment of well being (primary efficacy variable) was statistically significantly improved. Sleepiness and drowsiness were significantly less of a problem. There was a trend towards improvement in attention span/ concentration, and in the power and quality of concentration. Cognitive function tests also revealed a significant improvement in working (short term) and speed of memory although not in secondary (long term) memory. Patients did not experience hallucinations or delusions and there was no change in levels of anxiety or depression (Hospital Anxiety Depression Scale). The incidence of dizziness was significantly reduced, and there was a nonsignificant decrease in number of patients who suffered myoclonus and in the severity of this condition over the 14 days. The investigator's overall impression of treatment with transdermal fentanyl was ‘fair’, which was not in agreement with the positive impression expressed by patients (score 74, range: 0 worst, 100 best). Further work is required to determine if the improvement in patients' well being and cognitive function is achieved in larger study populations.
Neuropathic pain is a very difficult problem with which the neurosurgeon frequently must deal. The neurosurgical methods to be considered are: (1) modulative, by using neurostimulation or implanted drug delivery systems, and (2) ablative, by making selective therapeutic lesions in well-defined and identified targets proven to sustain pain mechanisms (especially DREZotomy).
Objective: To evaluate the effect of conservative interventions on clinically relevant outcome measures for patients with subacute low back pain. This is particularly important because effective treatment for subacute low back pain will prevent the transition to chronic low back pain, a condition that is largely responsible for the high health care costs of low back pain. Design: Systematic review of randomized controlled trials. Main outcome measures: Methodological quality of each trial was assessed. Effect sizes and 95% confidence intervals were calculated for pain and disability and risk ratios for return to work. Results: Thirteen trials were located, evaluating the following interventions: manipulation, back school, exercise, advice, transcutaneous electrical nerve stimulation (TENS), hydrotherapy, massage, corset, cognitive behavioural treatment and co-ordination of primary health care. Most studies were of low quality and did not show a statistically significant effect of intervention. For the strict duration of low back pain (six weeks to three months), no evidence of high internal validity was found but when other methodological criteria were considered, evidence was found for the efficacy of advice. Furthermore, there is evidence that when a broader view is taken of the duration of subacute low back pain (seven days to six months), other treatments (e.g. manipulation, exercise, TENS) may be effective. Conclusions: Our review identified a major gap in the evidence for interventions that are currently recommended in clinical practice guidelines for the treatment of subacute low back pain. Lack of a uniform definition of subacute low back pain further limited current evidence.
Effective management of procedural and postoperative pain in neonates is required to minimize acute physiological and behavioral distress and may also improve acute and long-term outcomes. Painful stimuli activate nociceptive pathways, from the periphery to the cortex, in neonates and behavioral responses form the basis for validated pain assessment tools. However, there is an increasing awareness of the need to not only reduce acute behavioral responses to pain in neonates, but also to protect the developing nervous system from persistent sensitization of pain pathways and potential damaging effects of altered neural activity on central nervous system development. Analgesic requirements are influenced by age-related changes in both pharmacokinetic and pharmacodynamic response, and increasing data are available to guide safe and effective dosing with opioids and paracetamol. Regional analgesic techniques provide effective perioperative analgesia, but higher complication rates in neonates emphasize the importance of monitoring and choice of the most appropriate drug and dose. There have been significant improvements in the understanding and management of neonatal pain, but additional research evidence will further reduce the need to extrapolate data from older age groups. Translation into improved clinical care will continue to depend on an integrated approach to implementation that encompasses assessment and titration against individual response, education and training, and audit and feedback.
Objective: To evaluate the effect of conservative interventions on clinically relevant outcome measures for patients with subacute low back pain. This is particularly important because effective treatment for subacute low back pain will prevent the transition to chronic low back pain, a condition that is largely responsible for the high health care costs of low back pain. Design: Systematic review of randomized controlled trials. Main outcome measures: Methodological quality of each trial was assessed. Effect sizes and 95% confidence intervals were calculated for pain and disability and risk ratios for return to work. Results: Thirteen trials were located, evaluating the following interventions: manipulation, back school, exercise, advice, transcutaneous electrical nerve stimulation (TENS), hydrotherapy, massage, corset, cognitive behavioural treatment and co-ordination of primary health care. Most studies were of low quality and did not show a statistically significant effect of intervention. For the strict duration of low back pain (six weeks to three months), no evidence of high internal validity was found but when other methodological criteria were considered, evidence was found for the efficacy of advice. Furthermore, there is evidence that when a broader view is taken of the duration of subacute low back pain (seven days to six months), other treatments (e.g. manipulation, exercise, TENS) may be effective. Conclusions: Our review identified a major gap in the evidence for interventions that are currently recommended in clinical practice guidelines for the treatment of subacute low back pain. Lack of a uniform definition of subacute low back pain further limited current evidence.
Objective: To evaluate the cumulative effect of repeated transcutaneous electrical nerve stimulation (TENS) on chronic osteoarthritic (OA) knee pain over a four-week treatment period, comparing it to that of placebo stimulation and exercise training given alone or in combination with TENS. Design: Sixty-two patients, aged 50–75, were stratified according to age, gender and body mass ratio before being randomly assigned to four groups. Interventions: Patients received either (1) 60 minutes of TENS, (2) 60 minutes of placebo stimulation, (3) isometric exercise training, or (4) TENS and exercise (TENS & Ex) five days a week for four weeks. Main outcome measures: Visual analogue scale (VAS) was used to measure knee pain intensity before and after each treatment session over a four-week period, and at the four-week follow-up session. Results: Repeated measures ANOVA showed a significant cumulative reduction in the VAS scores across the four treatment sessions (session 1, 10, 20 and the follow-up) in the TENS group (45.9% by session 20, p < 0.001) and the placebo group (43.3% by session 20, p = 0.034). However, linear regression of the daily recordings of the VAS indicated that the slope in the TENS group (slope = -2.415, r = 0.943) was similar to the exercise group (slope = -2.625, r = 0.935), which were steeper than the other two groups. Note that the reduction of OA knee pain was maintained in the TENS group and the TENS & Ex group at the four-week follow-up session, but not in the other two groups. Conclusions: The four treatment protocols did not show significant between-group difference over the study period. It was interesting to note that isometric exercise training of the quadriceps alone also reduced knee pain towards the end of the treatment period.
Objective: To develop a scale for estimating the severity of patellofemoral pain syndrome (PFPS) and to determine its reliability and validity.Design: The PFPS Severity Scale (PSS) was developed following a literature search, input from clinicians, and pilot testing in people with PFPS. The final version of the instrument encompasses 10 statements regarding PFPS pain in a visual analogue format. Reliability and validity of the new scale were determined in a PFPS population.Setting: All testing was performed at the Canadian Forces Base Kingston, Physiotherapy Department.Subjects: Twenty-nine military subjects (7 female) between the ages of 20 and 48 (32 years +/- 8.9) with subjective and objective findings consistent with PFPS were recruited. Twenty-four of the participants (6 female, 31.8 years +/- 9.4) participated in the reliability phase of the study.Methods: Reliability of the PSS was determined by comparing the scores obtained on two test days (24 hours apart). Convergent validity of the PSS was determined by comparing data from the PSS with two established knee scales: the WOMAC (Western Ontario and McMaster Universities) Osteoarthritis Index and the Hughston Foundation subjective knee scale.Results: Test-retest reliability was excellent (Spearman's rho = 0.95, p < 0.0001). The correlations between the PSS and the WOMAC and Hughston scales were strong (rho = 0.72 and 0.83, p < 0.001 respectively).Conclusions: The PSS is reliable and has demonstrated convergent validity making it a useful tool for monitoring rehabilitative or surgical outcomes in clients with PFPS.
Introduction: The effective management of pain requires a multidisciplinary approach. Previous studies have suggested that around 8% of cancer patients will require interventional techniques from an anaesthetist with special interest in pain management to maximize pain control, although this percentage may increase in the cohort of patients with difficult pain syndromes under the care of specialist palliative care services. We wished to determine the experiences and views of other palliative care physicians with regard to input from specialists in pain management. Method: A postal questionnaire was sent to the consultant members of the Association of Palliative Medicine. Results: Most respondents had access to 'as-required' anaesthetist consultations with 72% of respondents feeling that the frequency of consultation was adequate. However, over half of the respondents had used the services of a pain management specialist less than four times in the past year and a quarter of respondents had not been involved in a joint consultation with an anaesthetist in the past year. All respondents felt that the pain management specialist's role included advice on technical procedures but less than 25% felt that their role should extend to advice on prescribing analgesics. Discussion: There are likely to be several reasons for this apparent underutilization of specialist anaesthetist/pain management services. This survey has identified possible factors including lack of formal arrangements, lack of suitable experience and the attitudes of palliative medicine consultants.
Facet joint injections have become a common treatment for chronic low back pain in Pain Clinics throughout the UK. They are used to relieve back pain that is thought to arise primarily from the zygapophyseal or facet joints, a condition sometimes referred to as 'facet joint syndrome'. In this review, the evidence for the existence of facet joint syndrome in patients with chronic low back pain will be reviewed. The efficacy of facet joint injections in the management of chronic low back pain will be discussed, using an evidence-based approach. Future areas for research will be recommended.
A review of textbooks concerning pain, arthritis, medicine, endocrinology and orthopaedics reveals a paucity of information on Charcot's neuroarthropathy despite its relatively common prevalence, the severity of the disease, the complexities associated with its diagnosis, and the academic potential for dissecting the pathological basis of this condition. Early diagnosis and prompt action can have a major clinical influence on symptoms and prognosis and therefore self- education is essential. Early neuropathic arthritis can present to many specialties within the hospital sector, including casualty, internal medicine, endocrinology, rheumatology, orthopaedics, pain clinics, neurology, paediatrics and infectious diseases, and we believe that a deeper understanding of the aetiopathogenesis of this condition would be of interest to a wide audience.
The term 'transcutaneous electrical nerve stimulation' (TENS) is synonymous with a standard TENS device. Increasingly, nonstandard TENS-like devices are being marketed to health care professionals for pain relief. These include: interferential current therapy, microcurrent electrical therapy, high-voltage pulsed (galvanic) currents, TENS-pens, transcranial electrical stimulation and Limoge currents, Codetron, transcutaneous spinal electroanalgesia, action potential simulation, and H-wave therapy. This review evaluates the effectiveness of TENS and TENS-like devices for pain relief, to inform health care professionals about device selection. The results from systematic reviews suggest that TENS is not effective for postoperative pain and labour pain, although volatile evaluation models may partly explain the findings. Evidence is inconclusive for chronic pain. Health care professionals should not dismiss the use of TENS for any condition until the issues in clinical trial design and review methodology have been resolved. There is limited experimental evidence available for most TENS-like devices. Claims by manufacturers about the specificity and extent of effects produced using TENS-like devices are overstated and could probably be achieved by using a standard TENS device or a microcurrent electrical therapy device. When making decisions about device selection, health care professionals should consider the physiological intention of currents and whether this can be achieved by using particular devices. Clinical trials that examine the relative effectiveness of TENS-like devices with a standard TENS device are desperately needed.
