What does the chronic pain grade questionnaire measure?

This study explored the ability of the Chronic Pain Grade Questionnaire (CPG) to operationalise the WHO’s model of health outcomes, namely the International Classification of Functioning, Disability and Health (ICF). Twelve expert judges used the method of discriminant content validation to allocate the seven items of the CPG to one or more ICF outcome, namely, impairment, activity limitations and participation restrictions. One-sample t-tests classified each item as measuring impairment, activity limitations or participation restrictions, or a combination thereof. The results indicated that the CPG contains items able to measure each of the three ICF outcomes. However, the pain grade classification system used in the CPG conflates the ICF outcomes. The implication of this conflation of outcome for the assessment of interventions is discussed.     

What are the marital problems of patients with chronic pain?

Throughout the past two decades, researchers have studied the close relationships of patients to understand the role that these relationships play in the maintenance and alleviation of pain and the role that pain plays in affecting relationships. In this article, a brief review of the evidence is provided, showing a link between marital functioning and pain, and the marital problems reported by patients with chronic pain in our studies also are described. We provide information about several promising couples pain management and couples therapy approaches that appear to help couples manage pain together. Recommendations for clinical and research directions also are offered.     

What do the numbers mean? Normative data in chronic pain measures

Although self-reported measures play a central role in the assessment of pain and its treatment, it has long been recognized that interpretation of these measures is severely limited by the absence of normative data. Despite that, relatively few of the measures used in pain clinics or research studies have normative data for reference. Using a pain centre sample (n=6124), this paper describes the development of a normative dataset on a number of commonly used pain-related measures. The measures cover many of the key dimensions in pain assessment, including pain severity/quality, disability (physical functioning), and mood (emotional functioning). Measures of different cognitive and coping constructs are also included. Mean scores are reported for each measure according to age group, gender, pain site, as well as percentiles for different scores for patients with chronic low back pain. The potential uses for datasets of this type include the assessment and evaluation of individual cases, as well as the interpretation of published clinical trials. It is also argued that future systematic reviews of pain treatments should include consideration of such patient characteristics as pain levels, disability and mood in the studies reviewed rather than pain site and chronicity alone.     

Does spinal manipulative therapy help people with chronic low back pain?

A systematic review of randomised clinical trials was conducted to assess the effect of spinal manipulative therapy on clinically relevant outcomes in patients with chronic low back pain. Databases searched included EMBASE, CINAHL, MEDLINE and PEDro. Methodological assessment of the trials was performed using the PEDro scale. Where there was sufficient homogeneity, a meta-analysis was conducted. Nine trials of mostly moderate quality were included in the review. Two trials were pooled comparing spinal manipulative therapy and placebo treatment, and two other trials were pooled comparing spinal manipulative therapy and non-steroidal anti-inflammatory drugs (NSAIDs). Spinal manipulative therapy reduced pain by 7mm on a 100mm visual analogue scale (95% CI 1 to 14) at one month follow-up when compared with placebo treatment, and by 14mm (95% CI -11 to 40) when compared with NSAIDs. Spinal manipulative therapy reduced disability by 6 points (95% CI 1 to 12) on a 100-point disability questionnaire when compared with NSAIDs. It is concluded that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain.     

How does pain work? A qualitative analysis of how young adults with chronic pain conceptualize the biology of pain

Background

Pain science education (PSE) is commonly integrated into treatments for childhood-onset chronic pain. A core component of PSE is learning about, and often reconceptualizing, the biology of chronic pain. Yet, few interventions have been developed specifically for young adults and little is known about how young adults conceptualize the biology of pain. This study used a qualitative methodology to examine how young adults with childhood-onset chronic pain understand the biology of pain, and the language they use in this meaning-making process, which may inform future interventions tailored to this age group.

Methods

We identified a cohort of young adults with childhood onset chronic pain, and a subset of 17 young adults with continuing chronic pain completed individual, semi-structured interviews. Telephone interviews were audio-recorded, transcribed verbatim and analysed using reflexive thematic analysis.

Results

We generated four themes that capture participants' conceptualizations of the biology of pain: (1) Something is wrong with the body, (2) An injury has not healed, (3) Nerves fire when they should not, (4) An overactive stress system.

Conclusion

These conceptualizations, and the language used by young adults with childhood-onset chronic pain to describe them are discussed. Recommendations are provided for how PSE interventions can be tailored for young adults.

Significance

This study provides new qualitative insights reflecting a variety of ways that young adults with childhood-onset chronic pain conceptualize pain. Some conceptualizations of pain align with modern pain science principles (altered function of nervous and endocrine systems) while others conflict (unhealed injury). Health professionals can use these findings to tailor their pain education interventions by leveraging concepts that ‘stick’ for youth, being aware of, and interrogating, common misconceptions, and offering language and metaphors familiar to youth.     

What is the quality of the implemented meta-analytic procedures in chronic pain treatment meta-analyses?

OBJECTIVE: Meta-analysis (MA) is the application of quantitative techniques for the purposes of summarizing data from individual studies. This type of review has many advantages over traditional reviews. However, different investigators performing MAs on the same data set have reached different conclusions. These reliability problems have been attributed to differences in the quality of the implemented meta-analytic procedures. We, therefore, examined the chronic pain treatment meta-analytic literature for MA procedure quality and for the consistency of conclusions. DESIGN, SETTING, PARTICIPANTS, OUTCOME MEASURES: Chronic pain treatment MAs were isolated according to inclusion/exclusion criteria. Data from these MAs were abstracted into structured tables. Table format reflected eight meta-analytic procedures identified previously as being important to MA implementation quality. These were: adequacy of retrieval, publication bias, inclusion/exclusion criteria, abstraction of data, quality, homogeneity/heterogeneity, independence, and statistical versus clinical interpretation. Each meta-analytic procedure was then independently rated by two raters. Rating results were then analyzed by procedure for each individual MA for percentage scores out of 100%, and mean scores. For MAs addressing the same topic area (pain facility treatment, antidepressant treatment, manipulation treatment) direction of effect size was noted. Mean effect sizes were calculated for these subgroups. RESULTS: Sixteen chronic pain treatment MAs fulfilled inclusion/exclusion criteria. Mean procedure ratings indicated that four procedures may not be implemented adequately. These were publication bias, abstraction of data, quality, and homogeneity/heterogeneity. There was wide MA implementation score variability, with 37.5% scoring less than 50%. The effect sizes of the MA subgroups demonstrated replicate nonvariability. CONCLUSIONS: Some meta-analytic procedures could be interpreted to be implemented inadequately in some chronic pain treatment MAs. There is wide variability between individual chronic pain treatment MAs on adequacy of implementation of these procedures. However, the effect sizes of the different MA subgroups demonstrated consistency. This finding indicates that for these MA subgroups, MA results are consistent between authors. In addition, chronic pain MAs, as compared with other groups of MAs, appear to address some of the procedures in a more adequate fashion. Future chronic pain MAs should concentrate on improving the quality of their methods with particular emphasis on the above four procedures. Because of potential validity problems with these results, these data cannot and should not be used to make administrative decisions about previous MAs.     

What do we know about the state of chronic pain?

Chronic pain syndromes are characterized by altered neuronal excitability in the pain matrix. The ability to rapidly acquire and store memory of aversive events is one of the basic principles of nervous systems throughout the animal kingdom. These neuroplastic changes take place e. g. in the spinal cord, in thalamic nuclei and cortical and subcortical (limbic) areas integrating pain threshold, intensity and affective components. Chronic inflammation or injury of peripheral nerves evokes the reorganisation of cortical sensory maps. Neurons conveying nociceptive information are controlled by various sets of inhibitory interneurons. The discharge activity of these interneurons counteracts long-term changes in the pain matrix following nociceptor activation, i. e. it prevents the transition of acute pain signaling to chronic pain states. Our most recent research suggests that pain states may be sensitive to novel families of agents and therapeutic measures not predicted by traditional preclinical pain models as well as human pain states. The endogenous cannabinoid system plays a central role in the extinction of aversive memories. We propose that endocannabinoids facilitate extinction of aversive memories via their selective inhibitory effects on GABAergic networks in the amygdala.     

How much change in pain score does really matter to patients?

ObjectiveThe goal of this study was to determine the minimal change in pain score recognized by patients as meaningful known as minimal clinically important difference (MCID).MethodsPain was recorded upon admission, 30 and 60 min later and patients were asked to describe the extent of pain change on a 5-point Likert scale ranging from “much better” to “much worse”. Patients reported their pain by two common pain scales comprising numeric rating scale (NRS) and visual analog scale (VAS). We used receiver operating characteristic curve to assess the accuracy of pain scales. We then calculated the mean change in pain scores among patients who reported their pain change as “a little better” or “a little worse” and also analyzed regression to evaluate the MCID.ResultsA total of 150 patients and 253 pain changes were recruited. The MCID ± SD (95% CI) was 1.65 ± 1.58 (1.32–1.97) for NRS and 16.55 ± 17.53 (12.96–20.15) for VAS. The area under the curve by NRS and VAS were 0.86 and 0.89. For linear regression, the line slope and the y-intercept were 17.56 and 1.88, for VAS; these values were 1.73 and 0.31 for NRS, respectively.ConclusionsRecognizing the extent of change in pain score that really matters to patients is crucial for the evaluation of treatment effect. Patients perceived a change of 1.65 points on NRS and 16.55 on VAS in their pain severity as meaningful. This value was not different whether the pain was perceived alleviated or aggravated.     

Personalized pain management: Is it time for process-based therapy for particular people with chronic pain?

Background and Objective

Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling and distressing pain. At the same time, improvements in the effectiveness of these treatments appear to be at a standstill. This may be due to an inherent lack of generalizability from aggregated group data to the individual, limited utility of our current schemes for categorizing people with pain conditions, faced with their inherent heterogeneity, our relatively coarse categories of treatment types and focus on treatment packages rather than individual methods, and our current failures to find adequate predictors of outcome, or to assign people their best-suited treatment methods, based on group data. In this review, it is argued that the development and examination of truly personalized treatment is a next logical step to create progress and improve the results people achieve.

Methods

Key research studies pertaining to psychological treatments, treatment outcome, heterogeneity in chronic pain, prediction of treatment outcome, subtyping and treatment tailoring are reviewed.

Results and Conclusion

It is suggested that development of future treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, based on contextually sensitive ongoing assessment. Knowledge and practical solutions needed to make process-based therapy for chronic pain happen are discussed.

Significance

Psychological approaches to chronic pain have been highly successful in the past but improvement in the effectiveness of these over time is slow to nonexistent. It is argued here that this has happened due to a failure to adequately consider the individual. Future psychological treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, grounded in ongoing contextually sensitive assessment.     

What does participation mean? An insider perspective from people with disabilities

PURPOSE: Although participation is an important construct and valued goal, how it is conceptualized, defined and measured varies widely. This qualitative, multi-site study sought to gain an insider perspective from people with disabilities in grounding what participation means, how to characterize it, and the barriers and supports to participation. METHOD: Sixty-three people self-identifying with diverse disabilities participated in qualitative focus groups across sites. RESULTS: Participants conceptualized participation as a cluster of values that included active and meaningful engagement/being a part of, choice and control, access and opportunity/enfranchisement, personal and societal responsibilities, having an impact and supporting others, and social connection, inclusion and membership. CONCLUSIONS: No gold standard for ideal or optimal participation emerged; no one defined set or frequency of activities accounted for 'full' participation. Participants described needing to be free to define and pursue participation on their own terms rather than meeting predetermined societal norms. Participation was viewed as both a right and a responsibility, influenced by and ascribed to the person and to the society. Participation does not occur in a vacuum; the environment dynamically influences participation. Implications of this conceptual framing for assessment, research and systems level change to support participation of people with disabilities are discussed.     

What does participation mean? An insider perspective from people with disabilities

Purpose. Although participation is an important construct and valued goal, how it is conceptualized, defined and measured varies widely. This qualitative, multi-site study sought to gain an insider perspective from people with disabilities in grounding what participation means, how to characterize it, and the barriers and supports to participation.

Method. Sixty-three people self-identifying with diverse disabilities participated in qualitative focus groups across sites.

Results. Participants conceptualized participation as a cluster of values that included active and meaningful engagement/being a part of, choice and control, access and opportunity/enfranchisement, personal and societal responsibilities, having an impact and supporting others, and social connection, inclusion and membership.

Conclusions. No gold standard for ideal or optimal participation emerged; no one defined set or frequency of activities accounted for ‘full’ participation. Participants described needing to be free to define and pursue participation on their own terms rather than meeting predetermined societal norms. Participation was viewed as both a right and a responsibility, influenced by and ascribed to the person and to the society. Participation does not occur in a vacuum; the environment dynamically influences participation. Implications of this conceptual framing for assessment, research and systems level change to support participation of people with disabilities are discussed.     

Does pain mediate the pain interference with sleep problem in chronic pain? Findings from studies for management of diabetic peripheral neuropathic pain with duloxetine

Although sleep problems are common in patients with chronic pain, it is unclear whether pain mediates (causes) impaired sleep. The relationship between pain and sleep has been difficult to investigate because of the potential confounds of depression and somnolence. This report used clinical trials data for duloxetine in the management of diabetic peripheral neuropathic pain (DPNP) to investigate the direction of this association. Data were pooled from three double-blind, randomized, placebo-controlled, 12-week trials of patients with DPNP without mood disorder (n = 1,139). DPNP patients reporting somnolence and those who were receiving sedating concomitant medications were removed from the analyses (n = 93). Efficacy measures included weekly mean scores for average daily pain severity, night pain severity, and pain interference with sleep. Duloxetine at 60 and 120 mg per day separated from placebo for average pain and night pain improvement as early as one week after treatment began, whereas sleep interference improvement separated from placebo at the three visits it was assessed (Weeks 4, 8, and 12). Change in sleep interference was moderately to strongly correlated (P < 0.001) with changes in average pain (r = 0.46) and nighttime pain severity (r = 0.53). These results confirm the association between the improvement in daily pain and nighttime pain, and improvement in sleep interference for a large population without depression or somnolence. Although this association cannot establish causality, these results provide some evidence for the possibility that pain may mediate the sleep problem associated with DPNP and perhaps chronic pain in general.     

Where does it hurt? Small area estimates and inequality in the prevalence of chronic pain

Background

Chronic pain affects up to half of UK adults, impacting quality of life and demand on local health services. Whilst local health planning is currently based on subnational prevalence estimates, associations between pain and sociodemographic characteristics suggest that inequalities in the prevalence of chronic and high-impact chronic pain between neighbourhoods within local authorities are likely. We aimed to derive lower super output area (LSOA) estimates of the prevalence of chronic and high-impact chronic pain.

Methods

Presence of self-reported chronic and high-impact chronic pain were measured in adults aged 35+ in North Staffordshire and modelled using multilevel regression as a function of demographic and geographic predictors. Multilevel model predictions were post-stratified using the North Staffordshire age-sex population structure and LSOA demographic characteristics to estimate the prevalence of chronic and high-impact chronic pain in 298 LSOAs, corrected for ethnic diversity underrepresented in the data. Confidence intervals were generated for high-impact chronic pain using bootstrapping.

Results

Data were analysed from 4162 survey respondents (2358 women, 1804 men). The estimated prevalence of chronic and high-impact chronic pain in North Staffordshire LSOAs ranged from 18.6% to 50.1% and 6.18 [1.71, 16.0]% to 33.09 [13.3, 44.7]%, respectively.

Conclusions

Prevalence of chronic and high-impact chronic pain in adults aged 35+ varies substantially between neighbourhoods within local authorities. Further insight into small-area level variation will help target resources to improve the management and prevention of chronic and high-impact chronic pain to reduce the impact on individuals, communities, workplaces, services and the economy.

Significance

Post-stratified multilevel model predictions can produce small-area estimates of pain prevalence and impact. The evidence of substantial variation indicates a need to collect local-level data on pain and its impact to understand health needs and to guide interventions.