Methylprednisolone worsening neuropathic pain in non‐traumatic thoracic myelopathy

Methylprednisolone (MP) is the only neuroprotective medication currently in widespread use for the treatment of spinal cord injury. Increasingly, published studies challenge its clinical effects in view of its serious side‐effects including wound infection, pneumonia, sepsis and steroid myopathy. Most cases with spontaneous spinal epidural haematoma (SSEH) need emergency evacuation, and typically show good neurologic recovery. Some patients with SSEH given preoperative or postoperative MP within hours of the onset of symptoms, and have had good motor recovery, although no mention was made of sensory function. Severe, intractable neuropathic pain has not been reported in patients with SSEH. We present a case of SSEH treated with a high‐dose MP 16 h after onset of symptoms. Surgical decompression was performed 1 h after MP treatment. Motor recovery was good; however, intractable neuropathic pain developed 5 weeks postoperatively. We discuss the factors contributing to intractable pain. We speculate that the severe, intractable pain might be due to misuse of large‐dose steroids in this case of non‐traumatic spinal myelopathy, and not because of the injury per se.     

Referral practices in patients suffering from non‐malignant chronic pain

This paper presents the results of a prospective observational cohort study investigating referral practices to six specialized pain centres (SPCs) in 303 patients with headache (HD), low back pain (LBP), and neuropathic pain (NP). The study was divided into three parts. Part 1: The pain health care history (contacts with general practitioners and specialists, further referrals, time spans, therapies) before first contact with the SPC. Part 2: Reality of pain therapy and management in the SPC (patients’ attrition, interdisciplinarity of therapy and novel therapeutic strategies instigated). Part 3: Follow‐up and assessment of pain levels (NRS, SES), disability scores (PDI), QoL scores (SF 12), and anxiety and depression scores (HADS) at 0, 6 and 12 months. Using an ordinal linear regression model, factors predicting a good treatment outcome were identified. On average it took 3 years of pain symptoms before first consultation with GP. The median time period from the first pain sensations until the appointment in the SPC was 12 years. Nearly half of the referrals to specialists or SPCs were initiated by a non‐professional. In the SPC the medication was changed in 71% of cases. Care was interdisciplinary in only 32%. At 6 and 12 months after the first contact with the SPC, only 20% of the patients had improved with respect to levels of pain and psychometric data. A high degree of chronicity, a history of pain‐associated surgeries and low social support were negative predictors for treatment outcome.     

Asians differ from non‐Hispanic Whites in experimental pain sensitivity

This study examined differences between Asians and non‐Hispanic Whites (Whites) in pain sensitivity, and its relationship to mean arterial pressure (MAP) and heart rate (HR). In 30 Whites (50% female) and 30 Asians (50% female), experimental pain sensitivity was assessed with a hand cold pressor task, yielding measures of pain threshold, tolerance, intensity, and unpleasantness. Mean arterial pressure and HR measurements taken at rest and in response to speech stress were assessed. Perceived stress, anxiety, perfectionism, parental criticism, parental expectations and depressive symptoms were also measured. The results indicated that for the cold pain test, Asians demonstrated significantly lower pain threshold and tolerance levels than Whites. Although no ethnic differences were seen for MAP or HR responses to stress, for Whites higher stress MAP levels were correlated with reduced pain sensitivity, while for Asians higher baseline and stress HR levels were correlated with reduced pain sensitivity. Asians reported higher parental expectations and greater parental criticism than Whites. For Asians only, higher levels of perfectionism were related to more depressive symptoms, anxiety and perceived stress. These results indicate that Asian Americans are more sensitive to experimental pain than Whites and suggest ethnic differences in endogenous pain regulatory mechanisms (e.g. MAP and HR). The results may also have implications for understanding ethnic differences in clinical pain.     

Effects of patients’ anxiety,previous pain experience and non‐drug interventions on the pain experience during colonoscopy

Aims. This paper is a report of a study evaluating anxiety in patients prior to colonoscopy and identifying correlations between that anxiety, previous pain experience, non‐drug interventions and pain intensity during colonoscopy. Background. Waiting for forthcoming procedures, such as colonoscopy, is stressful. However, a few studies have evaluated the influence of patients’ anxiety, previous pain experience and non‐drug interventions during colonoscopy. Design. A quantitative cross‐sectional survey design was used. The data were collected from colonoscopy patients by using the Spielberger State Trait Anxiety Inventory and a questionnaire developed for the study. Methods. We assigned one hundred and thirty patients scheduled for diagnostic colonoscopy in a Finnish university hospital during 2006. Patients completed the State Trait Anxiety Inventory before and a questionnaire developed for the study after colonoscopy. Results. Most of the patients suffered from pain but they considered it to be tolerable. Women were more anxious before colonoscopy and experienced more pain and discomfort than men. Previous pain experiences and high state anxiety level decreased patients’ perceptions of colonoscopy. Non‐drug interventions, such as peaceful talk, explanation of the reason for pain and guidance helped both anxious and non‐anxious patients to ease the pain. Conclusion. Awareness and understanding of previous pain experiences and anxiety levels in patients are essential and must be taken into account. Relevance to clinical practice. Colonoscopy patients’ clinical education should be developed so as to be more individual. Furthermore, nurses should be better aware of the positive effects of non‐drug interventions and should use them as an element of pain management for colonoscopy patients.     

Respiratory characteristics of individuals with non‐specific low back pain: A cross‐sectional study

Non‐specific low back pain (NS‐LBP) is known to cause respiratory dysfunction. In this study, we investigated alterations in breathing, respiratory strength and endurance, core stability, diaphragm mobility, and chest expansion among patients with NS‐LBP and healthy individuals. The specific aim of the study was to correlate between respiratory function and other variables among NS‐LBP patients. Thirty four patients with NS‐LBP were matched with 34 healthy participants before undergoing total faulty breathing scale, spirometer, respiratory pressure meter, chest expansion, ultrasound, and pressure biofeedback measurements. There were signs of faulty breathing in the NS‐LBP patients when compared to the healthy participants. Diaphragmatic mobility and respiratory muscle endurance were lower in the NS‐LBP group. Chest expansion exhibited a significant decrease at the level of the fourth intercostal space in the NS‐LBP group, but respiratory muscle strength and core stability were not significant between the two groups. Positive correlations were found to be fairly significant regarding respiratory muscle strength. The findings of this study indicated altered respiratory characteristics in the NS‐LBP patients, and suggested that they would improve through respiratory exercises.     

Tapering off long‐term opioid therapy in chronic non‐cancer pain patients: A randomized clinical trial

Background

The indications for initiating long‐term opioid treatment (L‐TOT) for chronic non‐cancer pain (CNCP) are often unclear and associated with problematic use. This study aimed at evaluating the efficacy of stabilizing opioid therapy followed by a sequential opioid tapering off program in CNCP patients.

Methods

A randomized clinical trial with a medications stabilization period (Phase 1) was followed by an opioid tapering off program (Phase 2). In Phase 2, patients were randomized to Control Group (stable treatment) or Taper off Group (sequential opioid dose reduction) and assessed at baseline, after stabilization and up to 6 months. Primary outcomes: measures of cognitive function; secondary outcomes: pain, sleep, rest, quality of life, depression, anxiety, opioid misuse and opioid withdrawal symptoms.

Results

In all, 274 patients were screened; 75 were included, out of which 40 dropped out before Phase 2. Those who succeeded Phase 1 (n = 35) had weak/moderate improvements of psychomotor function (p = 0.020), sleeping hours (p = 0.031), opioid withdrawal symptoms (p = 0.019), measures of quality of life (p ≤ 0.043) and opioid misuse scores (p = 0.003). In Phase 2, patients in Taper off Group (n = 15) experienced stable pain intensity and felt significantly more rested at third assessment than the Control Group (n = 20).

Conclusions

The opioid tapering off program was not successful due to the vast number of dropouts. Phase 1 was associated with weak to moderate improvements on psychomotor function, sleeping, opioid withdrawal symptoms, quality of life and reduced risk of opioid misuse. In the intervention group of Phase 2, pain intensity was stable and patients felt more rested.

Significance

This trial showed that sequential tapering off L‐TOT in CNCP patients may be an unfeasible approach. However, improvements after opioid treatment stabilization were achieved and stable pain intensity in those tapered off may encourage the development of more refined programs.     

Clinical effects and brain metabolic correlates in non‐invasive cortical neuromodulation for visceral pain

Background and aims: Chronic visceral pain is frequent, extremely debilitating, and generally resistant to pharmacological treatment. It has been shown that chronic visceral inflammation, through altered afferent visceral sensory input, leads to plastic changes in the central nervous system that ultimately sustain pain. Therefore approaches aiming at modulation of brain activity are attractive candidates to control visceral pain. Methods: Here we report findings of a phase II, sham‐controlled clinical trial assessing the clinical effects and brain metabolic correlates of a 10‐day course of daily sessions of slow‐frequency, repetitive transcranial magnetic stimulation (rTMS) targeting the right secondary somatosensory cortex (SII) in patients with chronic pancreatitis and severe visceral pain. Results: Our results show a significant reduction in pain after real rTMS that lasted for at least 3weeks following treatment. These clinical changes were correlated with increases in glutamate and N‐acetyl aspartate (NAA) levels – neurometabolites associated with cortical activity and brain damage – as measured by in vivo single‐voxel proton magnetic resonance spectroscopy (1H‐MRS). Adverse effects in the real rTMS group were mild and short‐lasting. Conclusions: Our results support preliminary findings showing that modulation of right SII with rTMS is associated with a significant analgesic effect and that this effect is correlated with an increase in excitatory neurotransmitter levels such as glutamate and NAA.