Spinal Cord Stimulation for Loin Pain Hematuria Syndrome: Clinical Report

Loin pain hematuria syndrome (LPHS) is a rare condition characterized by cryptogenic debilitating flank pain and microscopic or macroscopic hematuria. The pathophysiology of LPHS remains poorly understood, and diagnosis is made largely by exclusion of alternate pathology. Management strategies can vary widely and include chronic opioid medication and a variety of invasive procedures, including regional nerve blocks, transcutaneous electrical nerve stimulation, local capsaicin infusion, and surgical renal denervation. Neuromodulation may provide a new paradigm of treatment for LPHS, potentially sparing patients from long‐term complications of opiate therapy and invasive surgery. This report demonstrates the first case of successful symptomatic management of LPHS using spinal cord stimulation.     

Evidence-Based Clinical Practice Guidelines for Interdisciplinary Rehabilitation of Chronic Nonmalignant Pain Syndrome Patients

Abstract:   This is an update to evidence-based practice guidelines for chronic nonmalignant pain syndrome patients first published in 1995 and revised in 1999. The current guidelines recommend interdisciplinary-focused rehabilitation, which is goal-directed and time-limited. Emphasis is placed on educating patients in active self-management techniques that stress maximizing function. Integrated treatment involving medical, psychological/behavioral, physical/occupational therapy, and disability/vocational interventions are recommended on an outpatient basis whenever clinically possible. Patient selection criteria are delineated. Updated references providing evidence-based support for the recommendations are provided, including the use of opioids and sedative-hypnotic medications, injection and block procedures, acupuncture, implantable spinal infusion and stimulation devices, and other invasive spinal surgery procedures such as intradiscal electrothermal therapy. Guideline integration and early detection and intervention with chronic pain syndrome patients are encouraged.     

Complex Regional Pain Syndrome in Children: a Multidisciplinary Approach and Invasive Techniques for the Management of Nonresponders

Complex regional pain syndrome (CRPS) is multifactorial condition with complex pathogenesis characterized by spontaneous or stimulus‐induced pain that is disproportionate to the inciting event. It is also commonly accompanied by a myriad of autonomic and motor disturbances in highly variable combinations. This condition has been underreported in children until recently. Consequently, the management of CRPS in the pediatric population presents an even greater challenge than in adults, partly because there is a lack of clinical data concerning the efficacy of the diverse treatment methods available, and partly because successful treatment of CRPS involves a multidisciplinary approach. In this retrospective case series, a multidisciplinary management plan is presented in 10 children for whom the standard noninvasive treatment was unsuccessful. Within this management plan, novel drugs were included such as the capsaicin 8% patch, in addition to invasive techniques in patients who did not respond to noninvasive therapies.     

Persistent Back Pain after Multiple Operations: Case Presentation From Israel With Commentaries From Austria and The Netherlands

ABSTRACT

A case of chronic back pain following multiples spine surgeries is presented as an example of postlaminectomy (failed back surgery) syndrome. The roles of physical modalities and spine rehabilitation rather than additional surgery and pharmacotherapy are described. In the commentaries the potential usefulness of adjunctive pharmacotherapy with opioids and tricyclic antidepressants is mentioned, as is the potential future need for more invasive procedures.     

Bilateral dorsal foot pain in a young tennis player managed by neurodynamic treatment techniques

Exercise-related lower limb pain represents one of the most common presentations in sports medicine practice. This is usually caused by musculoskeletal overuse injuries but not uncommonly, a neuropathic cause may be suspected. A review of the literature revealed that peripheral neuropathic pain has never been documented in a child. It is possible that peripheral neuropathic pain of spinal origin may be more prevalent in children than previously recognized. This case report describes the presentation of a 12 year old tennis player with bilateral dorsal foot pain, who presented with positive findings of peripheral nerve sensitization which was successfully managed using neurodynamic treatment techniques. Differential diagnoses are considered and treatment and management described. A discussion of the clinical reasoning which led to the patient’s diagnosis is included. This case report suggests the effectiveness of neurodynamic treatment in a child with bilateral foot pain who fulfilled published criteria for peripheral nerve sensitization. However, the single case methodology employed in this study limits generalization of its findings. Further studies are warranted to investigate the role of neurodynamics in musculoskeletal pain disorders in children.     

Analgesic Techniques in Minor Painful Procedures in Neonatal Units: A Survey in Northern Italy

Introduction: The aim of this survey was to evaluate the current practice regarding pain assessment and pain management strategies adopted in commonly performed minor painful procedures in Northern Italian Neonatal Intensive Care Units (NICUs). Methods: A multicenter survey was conducted between 2008 and 2009 in 35 NICUs. The first part of the survey form covered pain assessment tools, the timing of analgesics, and the availability of written guidelines. A second section evaluated the analgesic strategies adopted in commonly performed painful procedures. The listed analgesic procedures were as follows: oral sweet solutions alone, non‐nutritive sucking (NNS) alone, a combination of sweet solutions and NNS, breast‐feeding where available, and topical anesthetics. Results: Completed questionnaires were returned from 30 neonatal units (85.7% response rate). Ten of the 30 NICUs reported using pain assessment tools for minor invasive procedures. Neonatal Infant Pain Scale was the most frequently used pain scale (60%). Twenty neonatal units had written guidelines directing pain management practices. The most frequently used procedures were pacifiers alone (69%), followed by sweet‐tasting solutions (58%). A 5% glucose solution was the most frequently utilized sweet‐tasting solution (76.7%). A minority of NICUs (16.7%) administered 12% sucrose solutions for analgesia and the application of topical anesthetics was found in 27% of NICUs while breast‐feeding was performed in 7% of NICUs. Discussion: This study found a low adherence to national and international guidelines for analgesia in minor procedures: the underuse of neonatal pain scales (33%), sucrose solution administration before heel lance (23.3%), topical anesthetics before venipuncture, or other analgesic techniques. The presence of written pain control guidelines in these regions of Northern Italy increased in recent years (from 25% to 66%).     

Intrathecal Drug Administration in Chronic Pain Syndromes

Chronic pain may recur after initial response to strong opioids in both patients with cancer and patients without cancer or therapy may be complicated by intolerable side effects. When minimally invasive interventional pain management techniques also fail to provide satisfactory pain relief, continuous intrathecal analgesic administration may be considered. Only 3 products have been officially approved for long‐term intrathecal administration: morphine, baclofen, and ziconotide. The efficacy of intrathecal ziconotide for the management of patients with severe chronic refractory noncancer pain was illustrated in 3 placebo‐controlled trials. A randomized study showed this treatment option to be effective over a short follow‐up period for patients with pain due to cancer or AIDS. The efficacy of intrathecal opioid administration for the management of chronic noncancer pain is mainly derived from prospective and retrospective noncontrolled trials. The effect of intrathecal morphine administration in patients with pain due to cancer was compared with oral or transdermal treatment in a randomized controlled trial, which found better pain control and fewer side effects with intrathecal opioids. Other evidence is derived from cohort studies. Side effects of chronic intrathecal therapy may either be technical (catheter or pump malfunction) or biological (infection). The most troublesome complication is, however, the possibility of granuloma formation at the catheter tip that may induce neurological damage. Given limited studies, the evidence for intrathecal drug administration in patients suffering from cancer‐related pain is more compelling than that of chronic noncancer pain.     

Low Back Pain: From Algorithm to Cost‐Effectiveness?

Abstract:   Low back pain is one of the most important burdens for the patient, the health-care provider, and society. Treatment selection should target the appropriate use of the available health-care resources with the highest probability of success. When conventional treatment fails to provide satisfactory pain reduction and improvement of the quality of life, more interventional techniques can be envisioned. The degree of invasiveness of the different treatment modalities varies as well as the costs. A stepwise approach to chronic low back pain may reduce the economic burden with optimal use of the less invasive treatments. In this review, we discuss the treatment algorithm with special attention to the interventional pain management techniques. We also describe the results of a cost evaluation for the management of low back pain in Belgium compared with that in the Netherlands, two neighboring countries with different social security systems.     

Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis

Emerging research suggests that pain may persist longer-term for many children after major surgery, with significant effects on their health outcomes. This systematic review identified the prevalence of chronic postsurgical pain (CPSP) in children after surgery, and determined presurgical biomedical and psychosocial risk factors associated with CPSP prevalence or severity. Prospective studies assessing CPSP 3 to 12 months after surgery in children 6 to 18 years of age published in English in MedLine, EMBASE, PsycINFO, and Cochrane Database of Systematic Reviews since 1996 were eligible for inclusion. Of 16,084 abstracts yielded by the search, 123 full articles were assessed for eligibility, and 12 studies were included in the review. Overall quality of included studies assessed using the Quality in Prognostic Studies tool was low. On the basis of 4 studies with a total of 628 participants across all surgery types, median prevalence of CPSP across studies was 20% (25th percentile = 14.5%, 75th percentile = 38%) at 12 months after surgery. Presurgical pain intensity, child anxiety, child pain coping efficacy, and parental pain catastrophizing were the only presurgical factors identified as predictive of CPSP. Biological and medical factors assessed were not associated with CPSP in any study. Well designed studies examining prevalence and predictors of CPSP are critically needed in children.

Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Low Back Pain: Two Clinical Case Reports of Sustained Pain Relief

As the leading cause of disability among U.S. adults, chronic low back pain (LBP) is one of the most prevalent and challenging musculoskeletal conditions. Neuromodulation provides an opportunity to reduce or eliminate the use of opioids to treat chronic LBP, but the cost and invasiveness of existing methods have limited its broad adoption, especially earlier in the treatment continuum. The present case report details the results of a novel method of short‐term percutaneous peripheral nerve stimulation (PNS) in 2 subjects with chronic LBP. At the end of the 1‐month therapy, stimulation was discontinued and the leads were withdrawn. PNS produced clinically significant improvements in pain (62% average reduction in Brief Pain Inventory Question #5, average pain), and functional outcomes (73% reduction in disability, Oswestry Disability Index; 83% reduction in pain interference, Brief Pain Inventory). Both subjects reduced nonopioid analgesic use by 83%, on average, and the one subject taking opioids ceased using all opioids. The only adverse event was minor skin irritation caused by a topical dressing. The clinically significant improvements were sustained at least 4 months after start of therapy (79% average reduction in pain; both reported minimal disability; 100% reduction in opioids; 74% reduction nonopioids). The results reveal the utility of this novel, short‐term approach and its potential as a minimally invasive neuromodulation therapy for use earlier in the treatment continuum to produce sustained pain relief and reduce or eliminate the need for analgesic medications, including opioids, as well as more expensive and invasive surgical or therapeutic alternatives.     

Topical anaesthesia in haemodialysis: Evaluation of topical anaesthesia with lidocaine during vascular access in children undergoing long-term haemodialysis for chronic renal failure

Türkmen M, Kavukçu S, Soylu A, Ay N, Sevinç N, Sersan R. International Journal of Nursing Practice 1997; 3: 79–83
Topical anaesthesia in haemodialysis: Evaluation of topical anaesthesia with lidocaine during vascular access in children undergoing long-term haemodialysis for chronic renal failure
Children with chronic renal failure are frequently exposed to painful invasive procedures. Ointments containing lignocaine-prilocaine, when used before intravenous punctures, have been reported to lessen the pain sensation. The aim of this study was to interpret the effectiveness of lidocaine 2.5% ointment in preventing pain when used before venous and arterial punctures in children undergoing a haemodialysis programme for chronic renal failure. Eight children were included in this study. The pain level was identified by the patients using a linear analogue scale. When topical anaesthetic and placebo were compared, there was no statistical difference in interpretation of pain during arterial ( P >0.4), venous ( P >0.375) or both ( P >0.4) procedures. We conclude that lidocaine 2.5% ointment is not effective in preventing pain in children undergoing long-term haemodialysis. In these patients some other factors, like psychological factors, puncture technique and needle size must be taken into consideration for the prevention of pain.     

Relaxation for the relief of chronic pain: a systematic review

The effectiveness of relaxation techniques in the management of chronic pain was determined in this systematic review of published randomized controlled trials. Reports were sought by searching MEDLINE, psycLIT, CINAHL, EMBASE and the Oxford Pain Relief Database. Studies were included in this review if they were randomized controlled trials of relaxation techniques in chronic pain. Studies which investigated the effects of relaxation in combination with other interventions were not considered. Nine studies involving 414 patients met the predefined inclusion criteria and are critically appraised in this review. Meta-analysis was not possible, due to lack of quantitative data in the primary studies. Studies involved patients with a range of chronic pain conditions. The McGill Pain Questionnaire was the most common pain outcome used. Whilst four studies were able to show a significant difference for the pain outcomes in favour of relaxation for the pre- and post-treatment assessments, few statistically significant differences were reported in favour of relaxation when between treatment comparisons were used. Only three studies reported statistically significant differences in favour of relaxation (judged as a significant difference for at least 1 of the pain outcomes) compared to the other treatment groups. In rheumatoid arthritis the McGill Pain Questionnaire scores were significantly lower for patients receiving relaxation compared to those who were in the routine treatment control group. In ulcerative colitis significant differences were reported for six of seven different pain outcome measures in favour of progressive muscle relaxation compared to patients in the waiting list control group. In one of the two cancer pain studies, relaxation taught by nurses produced significantly lower pain sensation scores compared to the control group. Two studies reported significant differences in favour of the experimental control groups rather than for relaxation. There is insufficient evidence to confirm that relaxation can reduce chronic pain. Many of the studies both positive and negative suffer methodological inadequacies. Recommendations for future research into the effectiveness of relaxation techniques for chronic pain are made.     

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

Purpose. To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.

Methods. Study design: exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8 - 21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.

Results. Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.

Conclusion. The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.     

The Effect of Parental Presence on Pain Levels of Children During Invasive Procedures: A Systematic Review

AimThis systematic review was conducted to determine the effect of parental presence on the child's pain intensity during invasive procedures.DesignA systematic review.MethodThe systematic review was conducted in July 2019 and updated in December 2020 to include the latest research published during the publication process by scanning the articles in English. Scopus, Pubmed, Cochrane, Science Direct, MedLine databases were used for scanning. The keywords “parental presence”, “family presence”, “parent involvement”, “invasive procedures”, “venipuncture”, “painful procedures”, “child”, “children”, “pediatric” were used in the scanning. Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol was followed to prepare the study and the report, and the systematic review was created according to the patient, intervention, comparison, outcomes (PICOS) strategy.ResultsA total of 248 articles were reached, and the full texts of 18 articles were evaluated for eligibility. After the articles excluded by the full-text search were eliminated, six studies, involving 730 children with a sample aged between 0-12 years, were included in the analysis. In 4 studies, it was determined that having a parent with the child during the invasive procedure significantly decreased the pain level, and in 2 studies, there was no statistically significant decrease in the pain level of the children.ConclusionsParental presence and parental involvement during invasive procedures effectively reduced the children's pain levels. Since the number of studies with a high level of evidence regarding the effect of family participation on pain level is limited, it is recommended to conduct more randomized controlled studies.     

Pet Ownership and Prophylaxis of Headache and Chronic Pain

SYNOPSIS
The belief that having household pets promotes good health is ubiquitous among Americans. Recent studies support this belief where certain medical conditions are concerned. To investigate the advantages of pet ownership in the prophylaxis of headache and other chronic pain conditions, we queried 62 patients suffering from such diseases about whether they owned pets and whether children and other adults shared their households. We similarly queried a control group of 38 patients with various conditions not involving headache or chronic pain. We found that statistically, the experimental group and the control group were not significantly different in their household compositions. In fact, those with headaches and chronic pain, on average, owned slightly more pets and had slightly more children and other adults sharing their households than did those without headache or chronic pain conditions. Thus, contrary to our expectations, pet ownership apparently conferred no analgesic benefits, nor did the presence of children or of other adults in the household confer any benefit to headache and other chronic pain sufferers.     

Intraspinal opioid therapy for chronic nonmalignant pain: Current practice and clinical guidelines

The multidimensional nature of chronic nonmalignant pain lends itself to numerous treatment options, which vary in cost and invasiveness. Based on the principle that use invasive and less costly interventions for pain treatment should be attempted first, a continuum of interventions for chronic pain states is presented. Although intraspinal opioid therapy is a relatively invasive and costly modality for pain treatment, it has a rational place in the treatment continuum for some chronic nonmalignant pain patients. A through review of the literature, supplemented by clinical experience, provides a foundation for the development of management guidelines.     

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Background

Complex regional pain syndrome (CRPS; formerly known as Morbus Sudeck/reflex dystrophy) is diagnosed in children and adolescents, but the clinical presentation is often atypical. Unfortunately, potentially harmful, invasive treatments are used in pediatric patients.

Patients and methods

A retrospective chart study of pediatric chronic pain patients with CRPS was performed.

Results

Over the course of 6?years, 37 (35?girls) children and adolescents took part in a multidisciplinary chronic pain inpatient program. At admission, patients took on average 4.4 (range 1–10) different medications and 29?different pharmaceuticals were used overall. Prior to admission, invasive pain treatments were performed without success in 16 of the children (43%). At least 13?children received two or more invasive treatments. Although sympathetic blocks were most prevalent, operations and regional anesthesia were also used.

Conclusion

Despite a lack of evidence for invasive procedures, these continue to be used in children and adolescents with CRPS, who later respond positively to conventional treatment. The English full-text version of this article is available at SpringerLink (under “Supplemental”).     

Systematic Review of Family Functioning in Families of Children and Adolescents With Chronic Pain

Disturbances in family functioning have been identified in youth with chronic pain and are associated with worse child physical and psychological functioning. Assessment measures of family functioning used in research and clinical settings vary. This systematic review summarizes studies investigating relationships among family functioning, pain, and pain-related disability in youth with chronic pain. Sixteen articles were reviewed. All studies were cross-sectional; 7 utilized between-group comparisons (chronic pain versus healthy/control) and 12 examined within-group associations among family functioning, pain, and/or pain-related disability. Studies represented youth with various pain conditions (eg, headache, abdominal pain, fibromyalgia) ages 6 to 20 years. Findings revealed group differences in family functioning between children with chronic pain and healthy control subjects in 5 of 7 studies. Significant associations emerged among family variables and pain-related disability in 6 of 9 studies with worse family functioning associated with greater child disability; relationships between family functioning and children's pain were less consistent. Different patterns of results emerged depending on family functioning measure used. Overall, findings showed that families of children with chronic pain generally have poorer family functioning than healthy populations and that pain-related disability is more consistently related to family functioning than pain intensity.     

Effectiveness of massage therapy for chronic, non-malignant pain: a review

Previous reviews of massage therapy for chronic, non-malignant pain have focused on discrete pain conditions. This article aims to provide a broad overview of the literature on the effectiveness of massage for a variety of chronic, non-malignant pain complaints to identify gaps in the research and to inform future clinical trials. Computerized databases were searched for relevant studies including prior reviews and primary trials of massage therapy for chronic, non-malignant pain. Existing research provides fairly robust support for the analgesic effects of massage for non-specific low back pain, but only moderate support for such effects on shoulder pain and headache pain. There is only modest, preliminary support for massage in the treatment of fibromyalgia, mixed chronic pain conditions, neck pain and carpal tunnel syndrome. Thus, research to date provides varying levels of evidence for the benefits of massage therapy for different chronic pain conditions. Future studies should employ rigorous study designs and include follow-up assessments for additional quantification of the longer-term effects of massage on chronic pain.     

Cognitive Biases in Children and Adolescents With Chronic Pain: A Review of Findings and a Call for Developmental Research

Cognitive biases that emphasize bodily harm, injury, and illness could play a role in the maintenance of chronic pain by facilitating fear and avoidance. Whereas extensive research has established attention, interpretation, and memory biases in adults with chronic pain, far less is known about these same biases in children and adolescents with pain. Studying cognitive biases in attention, interpretation, and memory in relation to pain occurring in youth is important because youth is a time when pain can first become chronic, and when relationships between cognitive biases and pain outcomes emerge and stabilize. Thus, youth potentially offers a time window for the prevention of chronic pain problems. In this article, we summarize the growing corpus of data that have measured cognitive biases in relation to pediatric pain. We conclude that although biases in attention, interpretation, and memory characterize children and adolescents with varying pain experiences, questions regarding the direction, magnitude, nature, and role of these biases remain. We call for independent extension of cognitive bias research in children and adolescents, using well powered longitudinal studies with wide age ranges and psychometrically sound experimental measures to clarify these findings and any developmental trends in the links between cognitive biases and pain outcomes.