Mechanisms-based classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back (± leg) pain

As a mechanisms-based classification of pain 'nociceptive pain' (NP) refers to pain attributable to the activation of the peripheral receptive terminals of primary afferent neurones in response to noxious chemical, mechanical or thermal stimuli. The symptoms and signs associated with clinical classifications of NP have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of NP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol after which their pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist indicating the presence/absence of various symptoms and signs. A regression analysis identified a cluster of seven clinical criteria predictive of NP, including: 'Pain localised to the area of injury/dysfunction', 'Clear, proportionate mechanical/anatomical nature to aggravating and easing factors', 'Usually intermittent and sharp with movement/mechanical provocation; may be a more constant dull ache or throb at rest', and the absence of 'Pain in association with other dysesthesias', 'Night pain/disturbed sleep', 'Antalgic postures/movement patterns' and 'Pain variously described as burning, shooting, sharp or electric-shock-like'. This cluster was found to have high levels of classification accuracy (sensitivity 90.9%, 95% CI: 86.6-94.1; specificity 91.0%, 95% CI: 86.1-94.6). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of NP mechanisms in patients with low back pain disorders.     

Self-reports of pain intensity and direct observations of pain behavior: when are they correlated?

Meta-analytic techniques were utilized to investigate the relationship between self-reports of pain intensity and direct observations of pain behavior. Estimation of the overall effect size from 29 studies and 85 effect sizes yielded a moderately positive association, z=0.26. High variability across studies permitted a random-effects moderator analysis that determined chronicity of pain, the timing of the pain assessment, the use of global measures of pain behavior, and pain site significantly moderate the relationship between self-reports of pain intensity and direct observations of pain behavior. These findings indicate that self-reports of pain intensity and direct observations of pain behavior are more likely to be significantly related to each other when the individual being studied has acute pain (z=0.35), when the self-report of pain intensity data are collected soon after the observation of pain behavior (z=0.40), when global composite measures are used to quantify pain behavior (z=0.37), and when the person being observed suffers from chronic low back pain (z=0.30). Other factors not found to be significant moderators include: extent of observer training, relevance of the pain-inducing task, and pain behavior observation measure used. The implications of the findings for the assessment of pain are discussed.     

“Governed by the pain”: narratives of fibromyalgia

Purpose: Fibromyalgia (FM) is a chronic syndrome characterized by pain and fatigue. The aim of this study was to explore how individuals with FM make sense of the illness experience and integrate it into their personal biographies. Method: Ten women from a pain management service in the north west of England were interviewed for the study. A chronological summary of each life story was produced and narrative features such as plot, tone, imagery and metaphors were identified and compared. Results: Findings are presented in the form of a meta-narrative incorporating all 10 narratives over five phases: (1) making sense of FM: when I was younger, I didn’t have any problems at all; (2) onset and diagnosis: you just feel like you’re constantly complaining; (3) invasion of FM: you’re just trapped; trapped in this body; (4) coping with FM: you try to do things in a pattern it will obey and (5) ongoing struggle: I refuse to give in to it. Conclusions: The narrative is characterized by a lack of movement and resolution, with participants engaged in an enduring struggle against the challenges of FM. Psychological approaches that facilitate this ongoing adjustment process may prove beneficial in FM treatment and rehabilitation.

Implications for Rehabilitation

• Fibromyalgia (FM) is a chronic syndrome characterized by pain and fatigue.

• This study shows women with FM are engaged in an enduring struggle against the challenges this presents.

• Psychological approaches which acknowledge and facilitate the adjustment process may prove beneficial in terms of assisting rehabilitation for this client group.

     

Prophylaxis of phantom pain: is regional analgesia ineffective?

AIM: A recently published randomized study failed to show a significant reduction of phantom limb pain after perioperative epidural analgesia EDA [9]. Since these findings were not supported by previous studies,we conducted an analysis of factors contributing to the results of phantom limb pain prophylaxis. We calculated the efficacy of perioperative EDA as "Number Needed to Treat" (NNT). METHODS: Included studies were retrieved by a medline-search from 1966 to 1999 and published articles on phantom limb pain prophylaxis. First,we analyzed the influence of patient data, type of intervention and study design on the results. Then,we stratified studies in comparable groups and outcome measures. The efficacy of perioperative EDA in phantom limb pain prophylaxis was calculated using NNT's. The outcome criterion in this analysis was "free of phantom limb pain < or = 3 on an analogue scale from 0 ( no pain) to 10 (worst pain) 12 months after amputation". RESULTS: Variations in preoperative pain, start and duration of regional analgesia and the definition of phantom limb pain were associated with different results. After stratifying the results by the above mentioned definition of phantom pain intensity, only time and duration of regional analgesia showed effects on the study results. Pre-, intra- and postoperative EDA was associated with a significant reduction of phantom limb pain 12 months after amputation, NNT = 5,8 (95%-CI 3,2-28,6). However, a reduction of phantom limb pain by postoperative EDA alone could not be confirmed on the basis of the analysed data. CONCLUSIONS: Perioperative EDA has been shown to be an effective prophylaxis of phantom limb pain. The most important differences between studies were the definition of phantom limb pain by intensity ratings. Thus, perioperative EDA does not completely abolish phantom limb pain, but increases the number of patients with a mild form of phantom pain.     

The International Classification of Headache Disorders: accurate diagnosis of orofacial pain?

The aim was to apply diagnostic criteria, as published by the International Headache Society (IHS), to the diagnosis of orofacial pain. A total of 328 consecutive patients with orofacial pain were collected over a period of 2 years. The orofacial pain clinic routinely employs criteria published by the IHS, the American Academy of Orofacial Pain (AAOP) and the Research Diagnostic Criteria for Temporomandibular Disorders (RDCTMD). Employing IHS criteria, 184 patients were successfully diagnosed (56%), including 34 with persistent idiopathic facial pain. In the remaining 144 we applied AAOP/RDCTMD criteria and diagnosed 120 as masticatory myofascial pain (MMP) resulting in a diagnostic efficiency of 92.7% (304/328) when applying the three classifications (IHS, AAOP, RDCTMD). Employing further published criteria, 23 patients were diagnosed as neurovascular orofacial pain (NVOP, facial migraine) and one as a neuropathy secondary to connective tissue disease. All the patients were therefore allocated to predefined diagnoses. MMP is clearly defined by AAOP and the RDCTMD. However, NVOP is not defined by any of the above classification systems. The features of MMP and NVOP are presented and analysed with calculations for positive (PPV) and negative predictive values (NPV). In MMP the combination of facial pain aggravated by jaw movement, and the presence of three or more tender muscles resulted in a PPV = 0.82 and a NPV = 0.86. For NVOP the combination of facial pain, throbbing quality, autonomic and/or systemic features and attack duration of > 60 min gave a PPV = 0.71 and a NPV = 0.95. Expansion of the IHS system is needed so as to integrate more orofacial pain syndromes.     

Mechanisms-based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of central sensitisation in patients with low back (± leg) pain

As a mechanisms-based classification of pain 'central sensitisation pain' (CSP) refers to pain arising from a dominance of neurophysiological dysfunction within the central nervous system. Symptoms and signs associated with an assumed dominance of CSP in patients attending for physiotherapy have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of CSP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol. Patients' pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist specifying the presence or absence of various clinical criteria. A binary logistic regression analysis with Bayesian model averaging identified a cluster of three symptoms and one sign predictive of CSP, including: 'Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors', 'Pain disproportionate to the nature and extent of injury or pathology', 'Strong association with maladaptive psychosocial factors (e.g. negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviours)' and 'Diffuse/non-anatomic areas of pain/tenderness on palpation'. This cluster was found to have high levels of classification accuracy (sensitivity 91.8%, 95% confidence interval (CI): 84.5-96.4; specificity 97.7%, 95% CI: 95.6-99.0). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of CSP in patients with low back pain disorders in a way that might usefully inform their management.     

Further evaluation of the pain stages of change questionnaire: is the transtheoretical model of change useful for patients with chronic pain?

Patient readiness to adopt new beliefs and coping responses to pain may predict response to multidisciplinary or cognitive-behavioral pain treatments that emphasize changes in beliefs and coping behaviors. According to the transtheoretical model of change, individuals go through specific stages in the process of changing maladaptive behaviors. Based on this model, Kerns et al. (1997) (Kerns RD, Rosenberg R, Jamison RN, Caudill MA, Haythornthwaite J. Readiness to adopt a self-management approach to chronic pain: the Pain Stages of Change Questionnaire (PSOCQ). Pain 1997;72:227-234) developed a measure of readiness to adopt a self-management approach to pain problems (the Pain Stages of Change Questionnaire; PSOCQ) and provided preliminary data supporting the validity of the measure. The current study sought to further evaluate the PSOCQ by determining the generalizability of these preliminary findings and the ability of the PSOCQ to classify persons with chronic pain into specific stages of readiness to self-manage pain. One hundred ten patients with diverse chronic pain problems, and 119 patients with fibromyalgia completed the PSOCQ and two measures of pain-related beliefs and coping prior to entry into two separate multidisciplinary pain programs. The internal consistency and concurrent validity of the PSOCQ subscales were largely replicated, supporting the validity of the subscales as measures of readiness to self-manage pain. However, the PSOCQ demonstrated less utility as a tool for classifying individuals into one of four specific stages of readiness to adopt a self-management approach. This result may be due to the classification procedure used in the current study, the characteristics of the samples in the study, specific limitations of the measure, and/or limitations in the applicability of the transtheoretical model of change to patients with chronic pain.     

A systematic review of pain drawing literature: should pain drawings be used for psychologic screening?

OBJECTIVES: The use of pain drawings to identify the psychologic "state" of patients has been advocated. They are used for psychologic screening before considering treatments, such as surgery. For pain drawings to be clinically useful as a psychologic screen they need good positive and negative predictive values. We systematically reviewed the literature that directly compared pain drawing scoring systems with measures of psychologic state. METHOD: We searched 12 medical and social science databases, using key words and their derivatives. Nineteen articles were suitable for analysis. The majority focused on low back pain (79%) in secondary or tertiary care (90%). Pain drawings were evaluated against psychologic tools testing: somatization, depression, anxiety, and distress. RESULTS: Three studies concluded that the association between pain drawings and psychologic state was sufficient for clinical use; of these only 1 showed reasonable sensitivity and specificity data. Six reported a statistical association and 10/19 studies reported inconclusive results and weak association. The pooled median sensitivity score was 56% (range 24% to 93%), specificity 79.5% (range 44% to 91%), positive predictive value 71.5% (range 28% to 94%), and negative predictive value 88% (range 35% to 100%). The predictive data were too low, wide-ranging, and inconsistent to accept the pain drawing as a clinical diagnostic tool to predict psychologic state. CONCLUSIONS: We conclude that the available data do not support the assumption that unusual pain drawings or extensive marking indicate disturbed psychologic state. There is no high quality evidence to support pain-drawing use as a psychologic assessment tool; therefore, pain drawings are not recommended for this purpose.     

Does gender affect appraisal of pain and pain coping strategies?

OBJECTIVE: To investigate the impact of gender and a set of pain characteristics on the threat or challenge appraisal of pain and the impact of these appraisals on the coping strategies used to manage the pain. DESIGN: This study used a community telephone survey to examine these relationships for a troublesome pain experienced by respondents in the 2 weeks preceding the interview. STUDY RESPONDENTS: The sampling frame consisted of 1,430 households randomly selected from the Halifax-Dartmouth-Bedford community. Of the 390 respondents with a troublesome pain in the 2 weeks preceding the interview, 309 respondents agreed to participate (79% response rate). RESULTS: Women tended to report more pain located in the head and more somatic problems. They reported significantly more intense pain. For women and men, the most important impact on threat appraisal of pain was overall interference of pain and emotional upset due to pain. These two variables accounted for 48% of the variance in threat appraisal for women and 37% of the variance for men. There was no gender difference in emotional upset due to pain or in the impact of emotional upset on threat appraisal. There was no gender difference in challenge appraisal. Threat appraisal was associated with increased catastrophizing whereas challenge appraisal was associated with positive self-statements. Women reported significantly more problem solving, social support, positive self-statements, and palliative behaviors than did men. CONCLUSIONS: Interference of pain has a greater impact on threat appraisal of pain for women. Increasing threat appraisal is associated with health care utilization for women, but women's more frequent use of several coping strategies is unrelated to their appraisal of pain. Appraisal of pain may have important implications on coping and overall well-being of women and men.     

Prediction of postoperative pain - beneficial to perioperative pain management?

Pain treatment of surgical patients is still a deficient area, even if there are evidence-based possibilities of pain management. The aim of this study is to identify patients with a higher risk of severe postoperative pain at an early stage and improve nurses' pain management by identifying pain predictors whilst including them in analgesic treatment. In addition to the identification of predictors by a literature review, a cross-sectional study with 84 surgical patients of a convenience sample was undertaken to find possible predictors. The enquiry was conducted by means of a questionnaire which the patient had to fill in prior surgery. The intensity of pain was surveyed in a personal interview on the first post-operative day. Correlation analysis was applied to verify the statistical significance of patient characteristics as well as surgical variables. Out of the 14 variables preoperative pain was found to increase the risk of postoperative pain. Comparison with other studies showed inconsistent results for pain predictors, and therefore nursing pain management based on pain predictors seems questionable.     

Contemporary therapy: aromatherapy in the management of acute pain?

Recent surveys indicate that people are increasingly using complementary therapies as an adjunct or alternative to conventional treatment options as well as for general health and well being. Whilst complementary therapies such as aromatherapy have been utilised in clinical settings as diverse as long term care facilities and palliative care, its application to the acute care setting has not been explored in depth. The changes in contemporary health care practices such as post-operative pain management and length of hospital admissions have provided nurses with the challenge of examining the range of therapeutic interventions that can be applied to their practice. The purpose of this paper is to examine critically the potential uses of aromatherapy in the management of acute post-operative pain. The concept of aromatherapy will be explored in relation to its effects on the pain pathways, methods of administration and therapeutic effects. Specific reference will be made to Lavender (Lavandula angustifolia) and its use in aromatherapy. A review of the literature points to gaps in the knowledge related to the clinical application of aromatherapy in relation to issues of dosage, methods of administration and therapeutic effects. The relatively small number of studies that have looked at aromatherapy in the acute care setting supports the literature reviewed. Issues such as small sample sizes and the difficulty in replicating these studies make it difficult to generalize the findings. In order to achieve best practice, further research is necessary to explore the use of aromatherapy in the management of acute post-operative pain.     

Observation of therapeutic effect of MSKD in treating late pain from cancer with grade method of pain intensity

SinceAugust１９９８toAugust１９９９，ourhospitalhastreated１２０patientswithlatepainfromcarcinoma．Inthesepatients，６０acceptedtreatmentwithMSKD（controlledreleasetabletofmorphinesulfate），theotherpatientsappliedtherapywithpethidine．Twomethodswerecompared，andtheresultswereshowedasfollowing：１Subjectandmethod１．１SubjectAcohortof２９patients（aged２４to７６averaged５４，９４maleand２６female）wasinvolved．Allpatientshavebeendiagnosedascarcinomainmildorlatestagedefinitely，including２…