A prognostic approach to defining chronic pain: application to knee pain in older adults

A prognostic approach to defining chronic pain has been proposed as an alternative to traditional definitions based on retrospective duration of pain. While this new approach performs well in low back pain (LBP), headache and orofacial pain, it is not known whether it translates to regional pain syndromes with an underlying pathological component, such as osteoarthritis (OA). We investigated the performance of this approach in a population-based cohort of older adults reporting knee pain, with a spectrum of radiographic knee OA. 676 adults (50 years+) attended a research clinic and were followed up at 18 months and 3 years. Risk scores were calculated using pain intensity, pain duration, pain-related activity, number of pain sites and depressive symptoms, measured at baseline and at 18 months. These scores were used to determine the probability of future clinically significant knee pain, defined as Chronic Pain Grade II-IV, at 18 months and at 3 years using logistic regression. Cut-points on the risk score were applied to determine groups at intermediate (probability >or=0.2), possible (>or=0.5) and probable (>or=0.8) risk of clinically significant knee pain. Discriminative ability of the risk scores, determined by area under the ROC curve, was high (0.78-0.82), varied little by radiographic severity and was superior to pain duration alone. The derived cut-points suggested a lower threshold for each of the risk groups than the previous LBP work. This prognostic approach to defining chronic pain appears to translate well to knee pain. Different cut-points for defining risk groups may be needed for different pain syndromes.     

The use of pain neuroscience education in older adults with chronic back and/or lower extremity pain

Introduction: Chronic pain due to musculoskeletal disorders is the leading cause of disability among older adults and is associated with a lower quality of life, reduced function, and increased risk of institutionalization. Pain Neuroscience Education (PNE) has demonstrated effectiveness in reducing pain and improving pain self-efficacy in individuals under 60 years of age, but there is a paucity of research examining its use with older adults. If PNE has similar effects in older adults, it has the potential to be a useful non-pharmacological intervention for this population. Methods: This quasi-experimental feasibility study included 25 subjects over the age of 65 with a 3 month or greater history of lower back and/or lower extremity pain. Subjects participated in two semi-standardized one-on-one PNE sessions and were asked to read a booklet (Why Do I Hurt, Louw, International Spine and Pain Institute, USA) in between sessions. Subjects’ perception of PNE was measured after the second session and gait speed, pain disability, and fear of movement were measured pre- and post-PNE. Results: Subjects consistently reported a positive experience with PNE. There were statically significant positive improvements in gait speed, pain disability, and fear of movement after the intervention. Conclusion: PNE is a feasible and potentially efficacious treatment for older adults with chronic pain.     

Self-management intervention for chronic pain in older adults: A randomised controlled trial

This study compared an outpatient pain self-management (PSM) program, using cognitive-behavioural therapy and exercises, with 2 control conditions in 141 chronic pain patients aged > 65 years. Results immediately posttreatment indicated that relative to the Exercise-Attention Control (EAC) group, the PSM group was significantly improved on measures of pain distress, disability, mood, unhelpful pain beliefs, and functional reach. The mean effect size for these gains was 0.52 (range: 0.44–0.68). By 1-month follow-up, relative to the EAC group, the PSM group remained better on most measures. At the 1-month follow-up, relative to a Waiting List (usual care) (WL) group, the PSM group was significantly improved on measures of pain distress, disability, and unhelpful pain beliefs. The mean effect size for these variables was 0.69 (range: 0.56–0.83). Relative to the WL group, the EAC group made no significant gains on any of the measured variables. At 1-month follow-up, the mean proportion of reliably improved cases (across outcome variables) was 41% (range: 16–60%) for the PSM group, twice that of those who met this criterion in the 2 control conditions (and this difference was statistically significant). Similarly, significantly more (44%) of the PSM group (vs 22% and 20% for the control groups) achieved a clinically significant improvement on pain disability. In the short term at least, cognitive-behavioural therapy-based PSM was more effective than exercises and usual care.     

Assessing pain in cognitively impaired older adults

BACKGROUND: Accurate assessments of pain help healthcare professionals to identify its source and manage it appropriately. Pain in cognitively impaired older adults is difficult to assess and this can result in poor management and outcomes. In response to the vulnerability of this patient group, researchers have produced a variety of tools for pain assessment in cognitively impaired older adults. CONCLUSION: Replication research is recommended to validate further and generalize results, although there is enough evidence to support the use of direct observation of behaviour in identifying pain in this group of patients.     

Recognising pain in older adults living in sheltered accommodation: the views of nurses and older adults

Sixty-six randomly selected older adults and their contact nurses participated in interviews based on standardised assessments of pain and open-ended questions focusing how pain was expressed and recognised. The sample included older adults with normal as well as cognitively impaired function. Seventy-nine percent of older adults with normal cognition were often in pain. Contact nurses assessed pain in 57% of cognitively impaired older adults. The content in the statements showed that pain recognition was a communicative interactive process based on verbal and non-verbal expressions. The process comprised attempts to understand the cause and intention of the expression and to verify the presence of pain. Changes in mood, facial expressions and physiological responses were described less often by older adults than by their nurses. Contact nurses of cognitively impaired older adults judged immobility as the source of pain, that it was possible to see when the person was in pain and that pain was expressed by paralinguistic and body language more often than contact nurses of cognitively healthy older adults. Characteristics of nurses and older adults could facilitate or hinder pain recognition. The findings indicate a need for reflective discussions in the staff group focusing on how to perform systematic assessments of verbal and non-verbal expressions and of hindrances and facilitators for recognising pain in older adults.     

Correlates of recovery among older adults after major abdominal surgery

BACKGROUND: Little research has examined the recovery patterns of older adults who have had major abdominal surgery. OBJECTIVE: To determine whether pain, depression, and fatigue are significant factors in the return of older adults who had major abdominal surgery to functional status and self-perception of recovery in the first 3 months after discharge from the hospital. METHODS: A correlational predictive study involved adults 60 years of age or older who had undergone major abdominal surgery. Data were collected during hospitalization (n = 192), then 3 to 5 days (n = 141), 1 month (n = 132), and 3 months after discharge to home (n = 126) using the Brief Pain Inventory, the Geriatric Depression Scale-Short Form, the Modified Fatigue Symptom Checklist, the Enforced Social Dependency Scale, and the Self-Perception of Recovery Scale. RESULTS: Multiple regression analysis indicated that pain, depression, and fatigue are significantly related to patients' self-perception of recovery and functional status. Pain, depression, and fatigue explain 13.4% of the variation in functional status at 3 to 5 days, 30.8% at 1 month, and 29.1% at 3 months after discharge. These three factors also explain 5.6% of the variation in self-perception of recovery during hospitalization, 12.3% at 3 to 5 days, 33.2% at 1 month, and 16.1% at 3 months after discharge. CONCLUSIONS: Pain, depression, and fatigue are important factors to consider in the provision of care to abdominal surgery patients with a relatively uncomplicated postoperative course. Specific interventions to reduce pain, depression, and fatigue need to be evaluated for their impact on the postoperative recovery of older adults.     

Sex differences in musculoskeletal pain in older adults

Little is known about sex differences in musculoskeletal pain in older persons. There were 682 women and 380 men aged 72 years and older who participated in the 22nd biennial exam of the Framingham Study (1992-1993). Participants were asked to identify pain locations on a homunculus showing all regions of the body. Pain was categorized according to number of regions, with the most disseminated pain classified as widespread pain (back pain and upper and lower extremity pain with bilaterality). Among the women, 63% reported pain in one or more regions, compared to 52% of men. Widespread pain was more prevalent among women than men (15 versus 5%, respectively). In both men and women, pain was associated with fair or poor self-rated health, history of back pain before age 65, and disability. Factors associated with pain only in women included body mass index, systolic blood pressure, and depressive symptoms. In men but not women, pain was associated with polyarticular radiographic osteoarthritis. In conclusion, musculoskeletal pain was more prevalent and more widespread in older women than older men. Men and women differ in the factors associated with musculoskeletal pain in older ages. Further research is needed to understand sex differences in musculoskeletal pain the older population.