Pain Fear Avoidance and Pain Acceptance: A Cross-Sectional Study Comparing Their Influence on Adjustment to Chronic Pain Across Three Samples of Patients

Background

Prior studies found that pain fear avoidance and pain acceptance are significantly associated with adjustment to chronic pain.

Purpose

The purpose of this study is to compare the influence of pain fear avoidance and pain acceptance on adjustment to chronic pain across three samples: patients with chronic back pain treated at primary care centres, patients with heterogeneous pain conditions treated at a pain clinic and patients with pain associated with inflammatory bowel disease.

Methods

Structural equation modelling was used to test for differences between groups in the linear relationships between variables.

Results

The model had the best fit for the group of patients with back pain. Three significant relationships were equal across the groups: experiential avoidance on pain fear avoidance, pain intensity on pain fear avoidance, and pain fear avoidance on negative mood.

Conclusions

The associations between both pain fear avoidance and pain acceptance and adjustment to chronic pain vary depending on the pain condition and the type of health care centres where the patients are treated.     

Spinal Morphine in Nonmalignant Chronic Pain: A Retrospective Study in 39 Patients

It was the purpose of this study to retrospectively test the safety and efficacy of the use of intraspinal analgesics in a diverse population of patients with chronic nonmalignant pain. This study was conducted in 39 patients, refractory to conventional therapies for intrathecal therapy. Twenty‐two patients had neuropathic pain and 17 had nociceptive pain. The mean follow‐up of this patient population was 2.2 years with a range of 36 months to 6.5 years. Analgesia with intraspinal morphine, initial and final dose of intraspinal agents used, stability of morphine dose over time, and side effects and complications with or without bupivacaine and/or clonidine was assessed after 6 months of treatment, and at the end of study. After 6 months, three patients discontinued the study for differing reasons, 28 patients (77.8%) reported excellent results, and five patients (14%) reported good results. One patient reported no pain relief with intraspinal morphine and bupivacaine and five patients reported insufficient or no pain relief. At final assessment, 20 patients (55.6%) reported excellent results with no differences based on pain type or pain syndrome and eight patients (22.2%) reported good analgesia. Morphine doses remained stable throughout treatment, with an average dose of 2 mg per patient. Ninety‐one percent of patients were satisfied with the method used and considered it superior to all previous therapeutic techniques tried, improving their quality of life. As for complications, one patient developed a clostridial infection during the immediate postoperative period which required pump removal and one patient developed severe urinary retention requiring system removal. There were three catheter obstructions (two in the same patient) and one catheter disconnection. Other patient‐reported side effects were not considered significant by the authors to be mentioned here. After more than 6 years of experience with spinal infusion of morphine, either alone or admixed with other spinal analgesics, in patients with pain of nonmalignant origin, we consider the technique to be helpful in selected patients not responding to oral treatment or when untoward side effects exist with oral treatment. The advantages, as regards to analgesic efficacy and quality of life, clearly outweigh the drawbacks of the long‐term use of spinal morphine.     

Sonographic Predictors in Patients with Hemiplegic Shoulder Pain: A Cross-Sectional Study

ObjectivesTo evaluate the sonographic findings of soft tissues more comprehensively, to investigate the relationship between sonographic pathologies and clinical features, and to determine the predicted factors that may interfere with the most common sonographic findings in patients with hemplegic shoulder pain (HSP) .MethodsSixty-four consecutive stroke patients with HSP admitted to inpatient clinic were included in this cross-sectional study. Demographic, clinical, and sonographic findings were recorded. Patients were assigned to poor or good motor function groups according to the Brunnstrom motor recovery (BMR) stages.ResultsThere were abnormal sonographic findings in 63 patients (98.4%). A significant reverse correlation was found between the sonographic grading and functional independence measure (p=0.005) and a positive correlation with energy level (p=0.044). The main risk factors were age for acromioclavicular joint degeneration, BMR stage for glenohumeral joint subluxation, subacromial-subdeltoid bursitis for partial-thickness rotator cuff tear, and Pittsburgh Sleep Quality Index for long head of the biceps tenosynovitis.ConclusionAge, motor recovery, subacromial-subdeltoid bursitis, and sleep quality were the strongest predictors of different sonographic findings in HSP patients. Functional capacity and energy level are negatively affected by an increased number of abnormal sonographic findings. Therefore, sonographic evaluation of shoulder soft tissue lesions eventually might provide a more constructive rehabilitation approach to achieve optimal outcomes, particularly in elderly patients with poor motor function and sleep quality.     

Outcomes Associated With Infection of Chronic Pain Spinal Implantable Electronic Devices: Insights From a Nationwide Inpatient Sample Study

ObjectivesChronic pain spinal implantable electronic devices (CPSIEDs) include devices that provide spinal cord stimulation and intrathecal drug therapy. In this study, we sought to evaluate the trends of CPSIED infections, related complications, and outcomes following the treatment of infection.Materials and MethodsThe Nationwide Inpatient Sample database contains data from 48 states, and the District of Columbia was used to identify patients with a primary diagnosis of CPSIED infection during the years 2005–2014. Patients with intrathecal pumps for the treatment of spasticity were excluded to limit the study population to patients with chronic pain disorders. Treatments were categorized as: 1) without device removal, 2) pulse generator or pump only removal, 3) intrathecal pump system removal, and 4) spinal cord stimulation system removal. Complications associated with CPSIED infections were identified using administrative billing codes.ResultsDuring the study period 2005–2014, a total of 11,041 patients were admitted to the hospital with CPSIED infections. The majority of the patients were treated without surgical intervention (56%), and a smaller proportion underwent complete system explantation (22.7%). In-hospital mortality or permanent disability due to paralysis after CPSIED infection was around 1.83% and 2.77%, respectively. Infectious complications such as meningitis, abscess formation, and osteomyelitis occurred in 4.93%, 5.08%, and 1.5%, respectively. The median cost of hospitalization was around US $14,118.00, and the median length of stay was approximately six days (interquartile range = 4–13 days).ConclusionsThe complications of CPSIED infection were higher among patients that did not undergo device removal.     

Pain and Interoceptive Awareness Outcomes of Chronic Pain Patients With Spinal Cord Stimulation

ObjectivesMeditation has been shown to improve outcomes for chronic pain by increasing patients’ awareness of their own bodies. Some patients have an innate ability to leverage their mind–body connection, and this interoceptive awareness may aid them in garnering pain relief. We explored whether spinal cord stimulation (SCS) patients with greater innate awareness had better outcomes.Materials and MethodsWe contacted 30 thoracic SCS patients with baseline and postoperative pain, psychological, and disability outcomes to complete the Multidimensional Assessment of Interoceptive Awareness (MAIA) survey. MAIA distinguishes between beneficial and maladaptive aspects of the perception of body sensations via six positive subscales (noticing, attention regulation, emotional awareness, self-regulation, body listening, and trusting) and two negative subscales (not distracting, not worrying). MAIA subscales and positive/negative groups were correlated with percentage change in Numerical Rating Scale (NRS), Oswestry Disability Index (ODI), Beck’s Depression Inventory (BDI), Pain Catastrophizing Scale (PCS), and McGill Pain Questionnaire (MPQ).ResultsPatients included 14 males/16 females with a mean age of 58. At a mean follow-up of 14.13 months (range 6–26), NRS, ODI, BDI, PCS, and MPQ showed improvements. Positive traits correlated with improvements in pain (MAIA-self regulation with NRS-worst [p = 0.018], NRS-least [p = 0.042], NRS-average [p = 0.006], NRS-current [p = 0.001]; MAIA-body listening with MPQ-total [p = 0.016] and MPQ-sensory [p = 0.026]). Improvement in PCS-total was associated with higher scores in noticing (p = 0.002), attention regulation (p = 0.017), emotional awareness (p = 0.039), and trusting (p = 0.047). PCS-rumination correlated with MAIA-positive total (p = 0.012). In contrast, better attention regulation signified less improvement in ODI (p = 0.043) and MPQ affective (p = 0.026).ConclusionsHigher interoceptive awareness in SCS patients correlated with greater improvement following the procedure, particularly with regards to pain relief and pain catastrophizing. These findings suggest that patients with better mind–body connections may achieve greater pain relief following SCS in this patient population, thereby aiding providers in determining who may benefit from this intervention.     

Spinal Cord Stimulation for the Treatment of Chronic Pain in Patients with Lumbar Spinal Stenosis

Objective: Chronic back and leg pain associated with lumbar spinal stenosis (LSS) is common in the elderly. Surgical decompression is usually performed when conservative treatments fail. We present an evaluation of the long‐term outcome of patients suffering from symptomatic LSS treated with spinal cord stimulation (SCS). Materials and Methods: Data were collected prospectively in three independent registries in three European centers. Pooled data were analyzed retrospectively. Changes in pain intensity, functional status, and analgesic medication were compared at baseline and at the last available follow‐up. Demographic data as well as details regarding the implantation procedure and any adverse events were systematically recorded. Results: Data were recorded in 69 patients with a mean follow‐up period of 27 months. All patients showed clinically and statistically significant improvement in pain relief, the visual analog scale decreasing from 7.4 ± 2.3 to 2.8 ± 2.4 (p < 0.05). The use of analgesic medication decreased and the functional status improved. Conclusion: Spinal cord stimulation seems to be effective in the treatment of patients suffering from chronic pain associated with LSS. Being less invasive and reversible, SCS should be considered before surgical decompression, particularly in patients with increased risks associated with back surgery.     

A New Spinal Cord Stimulation System Effectively Relieves Chronic,Intractable Pain: A Multicenter Prospective Clinical Study

Objectives. A prospective, open label, multicenter clinical trial confirmed the functionality of a new spinal cord stimulation (SCS) system for the treatment of chronic, intractable pain of the trunk and/or limbs. Materials and Methods. Sixty‐five subjects tested a rechargeable 16‐channel SCS system with individual current control of each contact on one or two percutaneous eight‐contact epidural leads. After baseline measurements, subjects were tracked on pain ratings and complication rates for up to 18 months. Results. After a trial period, 75% of subjects underwent permanent implantation of the entire SCS system. More than one‐half the implanted subjects experienced 50% or greater relief of pain after permanent implantation; some subjects reported relief of 90% or more of their pain. The most common complications after permanent implantation were lead migration, uncomfortable stimulation, and component failure; most resolved after reprogramming or device replacement. Conclusions. The new SCS system provided good pain relief to a majority of subjects, and the results confirm a favorable safety and efficacy profile for the SCS system.     

The Performance and Safety of an Implantable Spinal Cord Stimulation System in Patients with Chronic Pain: A 5‐Year Study

Reliability and ease of use of the Itrel 3 System (Medtronic Inc., Minneapolis, MN) were prospectively assessed over 5 years in patients with a range of pain syndromes (mainly low back and/or leg pain, or ischemic pain due to peripheral vascular disease). The longevity of the implantable pulse generator (IPG) battery, the frequency with which system settings were changed, and the ease of use of the EZ patient programmer were assessed. Data on adverse events, pain relief, and patient satisfaction with therapy were also collected. Following a screening procedure, 85 systems were implanted in 84 patients. Twenty‐four patients were withdrawn prematurely and, in an additional 32 cases, end of battery life was reached before the end of the study. The survival curve for the IPG batteries showed that approximately 50% are expected to last up to the sixth year. No device failures or unanticipated device‐related adverse events were reported. At least 90% of patients considered the EZ patient programmer easy to use. System settings were stable over time. The intensity and duration of pain were reduced significantly and patient satisfaction with therapy was high. We conclude that the Itrel 3 System performed well over 5 years and was easy to use. Its safety and effectiveness for the relief of chronic intractable pain of the trunk or limbs were also confirmed.     

Integration of Pharmacological and Psychological Treatment of Chronic Pain Patients: A Preliminary Study

Two types of psychological treatment, applied relaxation and applied relaxation plus an operant package, were compared to either flupentixol 0.5 mg or placebo. The data indicated that flupentixol in general had a better effect than placebo, and that combining flupentixol and applied relaxation resulted in the best reductions of subjective pain, while flupentixol combined with applied relaxation plus operant treatment led to the best improvements in activity. Since the number of subjects in this study was small, these results are of a preliminary nature.     

Cervical Spinal Cord Stimulation for Pain: A Report on 41 Patients

The objectives of this study were to assess the effectiveness of cervical spinal cord stimulation in the management of intractable pain syndromes affecting the upper limb and face and to assess the reliability of a specific electrode system in this mobile environment. Forty‐one patients, aged 26–76 years (median 48) with neuropathic or ischemic pain underwent the cervical epidural implantation of identical dual two‐contact paddle (four contacts per system) laminectomy electrodes. Follow‐up (from 5 months to 11 years, 3 months; median 4 years, 7 months) was by multiple consultations carried out by the surgeon and/or in a nurse‐led specialist clinic. Overall, 68% obtained sustained pain relief, rated as significant in 51% of the total. Facial pain did not respond. Ischemic syndromes responded well. Lead fracture rate was 15% of the original (11% of the total including replacements) and only 7% (5%) became dislodged.We conclude that the electrode system described provides reliable and sustained cervical cord stimulation. The outcomes are comparable with thoracic cord stimulation for neuropathic and ischemic syndromes.     

Triangular Stimulation Method Utilizing Combination Spinal Cord Stimulation With Peripheral Subcutaneous Field Stimulation for Chronic Pain Patients: A Retrospective Study

Objectives: This retrospective data collection study aims to evaluate the responses of patients who have been implanted with a neuromodulation system using a combination of spinal cord stimulation (SCS) and peripheral subcutaneous field stimulation (PSFS) leads for chronic intractable pain. Materials and Methods: Forty patients with chronic, intractable pain implanted with both SCS and PSFS leads were enrolled in a retrospective data collection study. Pre‐implant data (demographics, pain levels, pain location, and medication use) and post‐implant data (pain levels, medication use, and device programming reports) were compared to measure short‐ and long‐term improvements in pain for a period of approximately six months. Device system use and parameter data were collected. Results: The majority of patients experienced immediate and short‐term pain relief and reduction in oral pain medications as a result of combination SCS/PSFS therapy. The improvements were maintained for some, but not all patients by six months. Patients cycled through multiple programs over follow‐up; the use of triangular stimulation was consistent over time, and by six months, patients preferred this program over others. Limitations of the retrospective chart review included missing data and variable follow‐up times, and may have made determinations of long‐term efficacy difficult. Conclusions: This study demonstrates that combination SCS and PSFS therapy is potentially a beneficial treatment option for reducing pain levels and oral pain medication compared with baseline in previously resistive chronic pain patients. There is a need for further study of this therapy in a greater number of subjects and in a prospective, controlled setting. In the author's general experience, triangular stimulation is very effective for treating isolated low back pain, because it covers larger topographic areas of the lower back than flow or field stimulation. An investigational device exemption study will be necessary for subcutaneous field stimulation indicated for focal isolated pain to be adequately investigated and utilized by physicians in the future.