Changes In Self-reported Pain Research Articles

Does past/current pain change pain experience? Comparing self-reports and pupillary responses.

For decades, a substantial body of research has confirmed the subjective nature of pain. Subjectivity seems to be integrated into the concept of pain but is often confined to self-reported pain. Although it seems likely that past and current pain experiences would interact and influence subjective pain reports, the influence of these factors has not been investigated in the context of physiological pain. The current study focused on exploring the influence of past/current pain on self-reporting and pupillary responses to pain. Overall, 47 participants were divided into two groups, a 4°C-10°C group (experiencing major pain first) and a 10°C-4°C group (experiencing minor pain first), and performed cold pressor tasks (CPT) twice for 30 s each. During the two rounds of CPT, participants reported their pain intensity, and their pupillary responses were measured. Subsequently, they reappraised their pain ratings in the first CPT session. Self-reported pain showed a significant difference (4°C-10°C: p = 0.045; 10°C-4°C: p < 0.001) in the rating of cold pain stimuli in both groups, and this gap was higher in the 10°C-4°C group than in the 4°C-10°C group. In terms of pupillary response, the 4°C-10°C group exhibited a significant difference in pupil diameter, whereas this was marginally significant in the 10°C-4°C group (4°C-10°C: p < 0.001; 10°C-4°C: p = 0.062). There were no significant changes in self-reported pain after reappraisal in either group. The findings of the current study confirmed that subjective and physiological responses to pain can be altered by previous experiences of pain.

Patellofemoral pain over time: Protocol for a prospective, longitudinal study investigating physical and non-physical features.

This is a protocol for a prospective longitudinal study that aims to investigate: (1) group-by-time changes over a minimum of 15 months follow-up in patellofemoral pain (PFP) symptoms, biomechanical, muscle function, pain processing, and psychological features; (2) the extent to which changes in biomechanical, muscle function, pain processing, and psychological features are associated with changes in self-reported pain, physical performance measures, self-reported function, health-related quality of life (HRQOL), and physical activity level. Individuals with PFP (n = 144) and control individuals (n = 85) without PFP were assessed at baseline. Outcomes assessed included: 3D kinematics and kinetics during single leg squat, step-down and single leg hop; maximal torque and rate of torque development of hip abductors and knee extensors/flexors; force steadiness of hip abductors and knee extensors; anterior and lateral trunk endurance; pressure pain thresholds at the center of patella and contralateral shoulder; kinesiophobia (Tampa Scale for Kinesiophobia); pain catastrophizing (Pain Catastrophizing Scale); worst self-reported pain (Visual Analogue Scale); physical performance measures (Single Leg Hop Test and Forward Step-Down Test); self-reported function (Anterior Knee Pain Scale); HRQOL (Medical Outcome Short-Form 36), and physical activity level (Baecke's Questionnaire). Follow-up assessments will be identical to the baseline and will be performed after a minimum of 15 months. Generalized linear mixed model (GLMM) will be used to investigate group-by-time differences. Linear regression models will be used to determine the extent to which changes in biomechanical, muscle function, pain processing, and psychological features are associated with changes in self-reported pain, physical performance measures, self-reported function, HRQOL, and physical activity level. Physical and non-physical features have been previously associated with PFP. However, the present study will be the first to investigate their integrated evolution as part of the natural history of PFP and its progression. In doing so, we will be able to determine their behavior in the long-term, as well as how they prospectively associate with each other and with clinical outcomes. Ultimately, this will provide a greater understanding of predictors of long-term outcome and possible targets for interventions.

Comparing exercise and patient education with usual care in the treatment of hip dysplasia: a protocol for a randomised controlled trial with 6-month follow-up (MovetheHip trial)

IntroductionSurgery is not a viable treatment for all patients with hip dysplasia. Currently, usual care for these patients is limited to a consultation on self-management. We have shown that an...

The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial

BackgroundAdherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks.ObjectiveAssess the influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups.MethodsThis was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs.ResultsOf 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132; P = 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention.ConclusionFactors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process.Trial Registrationclinicaltrials.gov NCT02777983.

Immediate Improvements in Patellofemoral Pain Are Associated With Sagittal Plane Movement Training to Improve Use of Gluteus Maximus Muscle During Single Limb Landing.

The authors sought to examine the immediate effects of movement training aimed at improving use of gluteus maximus (GMAX) in the sagittal plane on hip internal rotation and self-reported patellofemoral pain (PFP) during single-limb landing. Seventeen females with PFP participated. Lower extremity kinematics and kinetics, GMAX activation, and self-reported PFP were obtained before and after a single-session movement training program aimed at increasing the use of GMAX. Dependent variables of interest included self-reported PFP, average GMAX activation, average hip extensor moment, and peak hip internal rotation. Post-training changes were evaluated using paired t tests and Wilcoxon signed rank tests. Following movement training, self-reported PFP decreased significantly (mean [standard deviation]) (3.9 [1.1] vs 0.8 [1.3] on a 0-10 scale). Additionally, significant increases were observed for the average hip extensor moment (0.6 [0.3] vs 1.8 [0.4] Nm/kg) and average GMAX activation (41.0% [18.3] vs 51.6% [25.7] maximum voluntary isometric contraction), whereas peak hip internal rotation decreased significantly (8.5 degrees [5.8] vs 6.0 degrees [5.3]). Movement training aimed at improving the use of GMAX in the sagittal plane resulted in clinically relevant changes in self-reported pain, GMAX activation, and hip kinetics and kinematics. Improving the use of GMAX during movement merits consideration when designing rehabilitation programs for females with PFP. The current study highlights the clinical utility of movement training for persons with PFP and provides a biomechanical rationale for its use as a potential intervention in this population.

Isometric hip strength impairments in patients with hip dysplasia are improved but not normalized 1 year after periacetabular osteotomy: a cohort study of 82 patients

Background and purpose — In patients with hip dysplasia, knowledge of hip muscle strength after periacetabular osteotomy is lacking. We investigated isometric hip muscle strength in patients with hip dysplasia, before and 1 year after periacetabular osteotomy, and compared this with healthy volunteers. Furthermore, we investigated whether pre- to post-surgical changes in self-reported pain and sporting function were associated with changes in isometric hip muscle strength. Patients and methods — Isometric hip muscle strength was assessed twice in 82 patients (11 men) with a mean age of 30 (SD 9) years, before and 1 year after surgery, and once in 50 healthy volunteers. Isometric hip muscle strength was assessed with a hand-held dynamometer. Copenhagen Hip and Groin Outcome Score was used to measure self-reported outcome. Results — Despite 1-year improvements in isometric hip flexion (0.1 Nm/kg; 95% CI 0.06–0.2) and abduction (0.1 Nm/kg; CI 0.02–0.2), the patients’ muscle strength was 13–34% lower than the strength of the healthy volunteers both pre- and post-surgery (p < 0.01). Moreover, changes in self-reported pain were associated with changes in hip flexion (13 points per Nm/kg; CI 1–26) and abduction (14 points per Nm/kg; CI 3–25), while changes in self-reported sporting function were associated with changes in hip extension (9 points per Nm/kg; CI 1–18). Interpretation — Isometric hip muscle strength is impaired in symptomatic dysplastic hips measured before periacetabular osteotomy. 1 year after surgery, isometric hip flexion and abduction strength had improved but muscle strength did not reach that of healthy volunteers.

Changes in physical inactivity during supervised educational and exercise therapy in patients with knee osteoarthritis: A prospective cohort study

BackgroundPhysical inactivity is a global problem and patients with knee osteoarthritis (OA) are predisposed to inactivity and its health-related consequences. Current guidelines recommend exercise as primary treatment but whether this affects time spent physically inactive is unknown. The objective was to investigate changes in physical inactivity among individuals with knee OA following an educational and exercise program. MethodsPragmatic prospective cohort study performed in six physical therapy clinics in Denmark offering a nationwide education and exercise program for knee OA. The program consists of physiotherapy guided education and group-based or home exercise sessions, performed biweekly for approximately eight weeks. The exercises target knee and hip joint stability as well as focus on increasing muscle strength. Primary outcome was time spent physically inactive (min/day), measured with a tri-axial accelerometer mounted on the lateral side of the thigh during the entire exercise program duration. OA symptoms were assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). ResultsThirty-two individuals with knee OA were analyzed. From baseline to post-intervention, no changes occurred in average time spent physically inactive (mean change: +16.2 min [95% CI −15.7 to 48.1]; P = 0.31), but statistically significant improvements in KOOS pain (+6.7 points [95% CI 2.3 to 11.0]; P = 0.0032) and KOOS function (+5.8 points [95% CI 1.9 to 9.7]; P = 0.0046) were found. ConclusionsParticipating and completing a widely adopted education and exercise program are not associated with spontaneous improvements in physical inactivity despite changes in self-reported pain and function. Interventions specifically targeting physical inactivity are needed.Registration number: www.clinicaltrials.gov: NCT03125954.

Using oral morphine-equivalent values to track the analgesic effect of treatments in clinical trials.

e14075 Background: Patient reported pain is subjective, requiring individuals to grade the feeling of pain as “high” or “low”, typically using a numeric scale. As a supplement to self-reported pain, monitoring the dosage and type of treatment needed to keep pain at a tolerable or comfortable level has been suggested. However, differences in treatments can complicate the ability to compare analgesic effects. One approach to this problem uses a 30 mg oral dose of morphine as a standard to quantify the relative analgesic strength of different pain medications. Methods: For use in clinical research, we developed an application on a handheld device for logging opioid consumption and supporting automated determination of oral morphine equivalents (OME) for commonly prescribed analgesics. We reviewed the literature to prepare a comprehensive database of OMEs for more than 450 commonly prescribed pain medications. From treatment logs (time, dose, and route of administration), the application determines a daily “OME Score” in standardized units of mg of oral morphine. Results: As prescriptions change, the daily OME Score gives a comparable measure to track the utilization of diverse analgesic medications. OME Scores can be categorized using the Analgesic Quantification Algorithm (AQA scale) developed by Chung (1). The AQA scale has eight categories and provides 5 gradations for patients in advanced pain who receive strong opioids, each gradation reflecting adoubling in the daily OME Score. The impact of a therapy on pain may be considered clinically significant depending on the changes in self-reported pain and AQA scores related to the treatment. Conclusions: We have developed a method and associated application for easily logging the time, dose, and route of administration of analgesic treatments. This information can be used to compute the daily OME Score for a wide variety of analgesics. The daily OME score can then be tracked and used to report the AQA score alongside self-reported pain for evaluating pain relief in clinical studies. Reference: 1) Chung KC, Barlev A, Braun AH, Qian Y, Zagari M. Pain Medicine 2014; 15:225-232.

Effects of Covertly Measured Home Exercise Adherence on Patient Outcomes Among Older Adults With Chronic Knee Pain.

Assessment of home exercise adherence and the degree to which adherence influences changes in patient outcomes is limited by the use of self-reported measures. To determine the relationship between adherence to a home strengthening program, covertly measured by accelerometers in ankle cuff weights, and changes in self-reported pain, physical function, and knee extensor strength among people with chronic knee pain. This is a secondary analysis of data from a clinical measurement study in 54 adults, aged 45 years or older, with chronic knee pain who completed a 12-week, home-based quadriceps-strengthening program. A triaxial accelerometer was concealed in the ankle cuff weight used for exercises to assess exercise adherence. Associations between exercise adherence and changes in pain and function (measured using the Western Ontario and McMaster Universities Osteoarthritis Index) and peak isometric knee extensor strength were examined using mixed-effects and linear regression models and fractional polynomials. Exercise adherence declined from a median of 90% (interquartile range, 70%-100%) in weeks 0 to 2 to 65% (interquartile range, 25%-90%) in weeks 10 to 12. Significant improvements were observed in knee pain (mean change, -3.2 units; 95% confidence interval [CI]: -2.4, -3.9 units), function (mean change, -10.1 units; 95% CI: -7.8, -12.4 units), and knee extensor strength (mean change, 0.34 Nm/kg; 95% CI: 0.26, 0.42 Nm/kg) across the group over the same period. Exercise adherence was not associated with changes in pain, function, and knee extensor strength over 2-week periods or over the entire 12 weeks. Covertly measured adherence to a home strengthening program was not associated with changes in patient outcomes. These findings challenge the notion that greater exercise adherence leads to greater improvement in patient outcomes during a short-term intervention. J Orthop Sports Phys Ther 2019;49(7):548-556. doi:10.2519/jospt.2019.8843.

Changes in physical inactivity during supervised educational and exercise therapy in patients with knee osteoarthritis: a prospective cohort study

Abstract Background Physical inactivity is a global problem and patients with knee osteoarthritis (OA) are predisposed to inactivity and its health-related consequences. Current guidelines recommend exercise as primary treatment but whether this affects time spent physically inactive is unknown. The objective was to investigate changes in physical inactivity among individuals with knee OA following an educational and exercise program. Methods Pragmatic prospective cohort study performed in six physical therapy clinics in Denmark offering a nationwide education and exercise program for knee OA. The program consists of physiotherapy guided education and group-based or home exercise sessions, performed biweekly for approximately eight weeks. The exercises target knee and hip joint stability as well as focus on increasing muscle strength. Primary outcome was time spent physically inactive (min/day), measured with a tri-axial accelerometer mounted on the lateral side of the thigh during the entire exercise program duration. OA symptoms were assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). Results Thirty-two individuals with knee OA were analyzed. From baseline to post-intervention, no changes occurred in average time spent physically inactive (mean change: + 16.2 min [95% CI − 15.7 to 48.1]; P = 0.31), but statistically significant improvements in KOOS pain (+ 6.7 points [95% CI 2.3 to 11.0]; P = 0.0032) and KOOS function (+ 5.8 points [95% CI 1.9 to 9.7]; P = 0.0046) were found. Conclusions Participating and completing a widely adopted education and exercise program are not associated with spontaneous improvements in physical inactivity despite changes in self-reported pain and function. Interventions specifically targeting physical inactivity are needed. Registration number: www.clinicaltrials.gov : NCT03125954 .

Response to Conservative Treatment for Thumb Carpometacarpal Osteoarthritis Is Associated With Conversion to Surgery: A Prospective Cohort Study.

BackgroundThe current guidelines for treatment of carpometacarpal osteoarthritis recommend starting with conservative treatment before a surgical procedure is considered.ObjectiveThe objective was to investigate how response to conservative treatment, in terms of pain and hand function, influences the hazard that patients convert to surgical treatment.DesignThis was a multicenter, prospective cohort study.MethodsParticipants comprised 701 patients who received 3 months of hand therapy and an orthosis. Pain and function were measured with the Michigan Hand Questionnaire (MHQ) at baseline and at 6 weeks and 3 months follow-up. Conversion to surgical treatment was recorded from clinical records. Joint modeling (a statistical method of combining prediction models) was used to perform the analysis and to calculate hazard ratios (HRs).ResultsThe joint analytical model showed that both MHQ pain score at a certain point (HR = 0.93; 95% confidence interval [CI] = 0.92–0.94) and change in MHQ pain score (HR = 1.07; 95% CI = 1.06–1.09) during conservative treatment was significantly associated with conversion to surgical treatment. The joint analytical model between functional outcome and conversion to surgical treatment showed only a significant association between MHQ function at a certain point (HR = 0.97; 95% CI = 0.95–0.99), and no significant association between the change in MHQ score for function (HR = 1.0; 95% CI = 1.0–1.0) and conversion to surgical treatment.LimitationsMissing data might have resulted in biased estimates.ConclusionsSelf-reported pain and function, as well as change in self-reported pain during treatment, were associated with the hazard of conversion to surgical treatment, whereas change in self-reported functioning was not associated with conversion. Because a reduction in pain during conservative treatment appears to decrease the rate of conversion to surgical treatment, it is advised to structurally monitor pain levels during treatment. Listen to the author interview at https://academic.oup.com/ptj/pages/podcasts

Myofascial Massage for Chronic Pain and Decreased Upper Extremity Mobility After Breast Cancer Surgery

Chronic localized pain and decreased upper extremity mobility commonly occur following breast cancer surgery and may persist despite use of pain medication and physical therapy. We sought to determine the value of myofascial massage to address these pain and mobility limitations. The study took place at a clinical massage spa in the U.S. Midwest. The research was overseen by MetroHealth Medical Center's Institutional Review Board and Case Center for Reducing Health Disparities research staff. 21 women with persistent pain and mobility limitations 3-18 months following breast surgery. We conducted a pilot randomized controlled trial where intervention patients received myofascial massages and control patients received relaxation massages. Intervention participants received 16 myofascial massage sessions over eight weeks that focused on the affected breast, chest, and shoulder areas. Control participants received 16 relaxation massage sessions over eight weeks that avoided the affected breast, chest, and shoulder areas. Participants completed a validated questionnaire at the beginning and end of the study that asked about pain, mobility, and quality of life. Outcome measures include change in self-reported pain, self-reported mobility, and three quality-of-life questions. At baseline, intervention and control participants were similar in demographic and medical characteristics, pain and mobility ratings, and quality of life. Compared to control participants, intervention participants had more favorable changes in pain (-10.7 vs. +0.4, p < .001), mobility (-14.5 vs. -0.8, p < .001), and general health (+29.5 vs. -2.5, p = .002) after eight weeks. All intervention and control participants reported that receiving massage treatments was a positive experience. Myofascial massage is a promising treatment to address chronic pain and mobility limitations following breast cancer surgery. Further work in several areas is needed to confirm and expand on our study findings.

Prognostic Value of Diagnostic Sonography in Patients With Plantar Fasciitis.

The primary objective of this study was to determine whether the sonographic appearance of the plantar fascia is predictive of the treatment (ie, pain) response in patients receiving supportive therapy for proximal plantar fasciitis. This study was a secondary analysis of data obtained from a randomized controlled trial of ambulatory adults, which examined the efficacy of 3 different foot supports for plantar fasciitis. Participants underwent diagnostic sonographic examinations of their heel at baseline and again at 3 months by a single experienced foot and ankle surgeon. Quantitative (eg, thickness) and qualitative (eg, biconvexity) characteristics of the fascia were recorded according to a standard protocol. Logistic regression models were used to identify predictors of the pain response. Seventy patients completed a baseline evaluation, and 63 patients completed a 3-month follow-up assessment. The pain response was not associated with the type of foot support (P> .05). The only significant indicator of an unfavorable response in the univariate and multivariate analyses was biconvexity of the plantar fascia on sonography at presentation (multivariate odds ratio, 4.76 [95% confidence interval, 1.16-19.5; P= .030). Furthermore, changes in self-reported pain over the 3-month study period were not accompanied by alterations in plantar fascia thickness over this time (r = .056; P = .671). We conclude that patients who present with biconvexity of the plantar fascia may be less responsive to tier 1 treatment regimens that center around mechanical support of the plantar fascia. Furthermore, follow-up measurements of the fascia in this population should not weigh heavily in decisions such as return to play.

Effects of testosterone replacement in men with opioid-induced androgen deficiency: a randomized controlled trial.

Symptomatic androgen deficiency is common in patients taking opioid analgesics, as these drugs potently suppress the hypothalamic-pituitary-gonadal axis. However, the efficacy of testosterone replacement in this setting remains unclear. The objective of this trial was to evaluate the efficacy of testosterone replacement on pain perception and other androgen-dependent outcomes in men with opioid-induced androgen deficiency. We conducted a randomized, double-blind, parallel placebo-controlled trial at an outpatient academic research center. Participants were men aged 18 to 64 years on opioid analgesics for chronic noncancer pain, and total testosterone levels were <350 ng/dL. Participants were randomly assigned to 14 weeks of daily transdermal gel that contained 5 g of testosterone or placebo. Primary outcomes were changes in self-reported clinical pain and objectively assessed pain sensitivity. Sexual function, quality of life, and body composition were also assessed. The mean age was 49 years. The median total and free testosterone levels at baseline were 243 ng/dL and 47 pg/mL and 251 ng/dL and 43 pg/mL in the testosterone and placebo arm, respectively. Of the 84 randomized participants, 65 had follow-up data on efficacy outcomes. Compared with men assigned to the placebo arm, those assigned to testosterone replacement experienced greater improvements in pressure and mechanical hyperalgesia, sexual desire, and role limitation due to emotional problems. Testosterone administration was also associated with an improvement in body composition. There were no between-group differences in changes in self-reported pain. In conclusion, in men with opioid-induced androgen deficiency, testosterone administration improved pain sensitivity, sexual desire, body composition, and aspects of quality of life.

(555) Psychological functioning improves during intensive interdisciplinary pediatric pain rehabilitation

Intensive interdisciplinary pediatric pain rehabilitation programs seek to return children and adolescents who are disabled by pain to normal physical, social, and academic functioning. Psychological outcomes represent an important domain of functioning for these teens as they tend to show high levels of catastrophizing, have increased depressive symptoms, and tend to make avoidance of pain a priority over the pursuit of other goals and values. However, no study has specifically investigated the longitudinal pattern of change in these variables over the course of intensive treatment. Adolescents in our interdisciplinary pediatric pain rehabilitation program engage in physical therapy and occupational therapy, and each week also participate in 4.5 hours of yoga, 1 hour of self-regulation training, 2-3 hours of individual and 2-3 hours of group behavioral health intervention, and one hour each of group-based music and art therapy. Parents also attend 2-3 hours per week of group behavioral health intervention and occasional individual family sessions. For this investigation of initial outcomes, 22 participants completed measures (PROMIS anxiety and depression, PRCQ-catastrophizing, Pain Acceptance Questionnaire for Adolescents, and VAS pain ratings) at program baseline, the end of each week, and 19 completed one-month follow-up. Statistically-significant improvements in depression, anxiety, catastrophizing, and pain acceptance (all p’s<.01), but not pain, were observed during the program. Self-reported pain improved significantly between the end of the program and follow-up (t=3.14, p<.01), and pain acceptance showed further improvement between program-end and follow-up (t=3.17, p=.001). Heirarchical linear modeling analysis supports consistent improvement in psychological variables across the program and follow-up (all p’s<.001). Data also suggest that psychological variables change prior to changes in pain. These results suggest that interdisciplinary pediatric pain rehabilitation leads to steady improvements in psychological factors relevant to adolescents’ return to normal activities, and that changes in psychological functioning precede changes in self-reported pain. Intensive interdisciplinary pediatric pain rehabilitation programs seek to return children and adolescents who are disabled by pain to normal physical, social, and academic functioning. Psychological outcomes represent an important domain of functioning for these teens as they tend to show high levels of catastrophizing, have increased depressive symptoms, and tend to make avoidance of pain a priority over the pursuit of other goals and values. However, no study has specifically investigated the longitudinal pattern of change in these variables over the course of intensive treatment. Adolescents in our interdisciplinary pediatric pain rehabilitation program engage in physical therapy and occupational therapy, and each week also participate in 4.5 hours of yoga, 1 hour of self-regulation training, 2-3 hours of individual and 2-3 hours of group behavioral health intervention, and one hour each of group-based music and art therapy. Parents also attend 2-3 hours per week of group behavioral health intervention and occasional individual family sessions. For this investigation of initial outcomes, 22 participants completed measures (PROMIS anxiety and depression, PRCQ-catastrophizing, Pain Acceptance Questionnaire for Adolescents, and VAS pain ratings) at program baseline, the end of each week, and 19 completed one-month follow-up. Statistically-significant improvements in depression, anxiety, catastrophizing, and pain acceptance (all p’s<.01), but not pain, were observed during the program. Self-reported pain improved significantly between the end of the program and follow-up (t=3.14, p<.01), and pain acceptance showed further improvement between program-end and follow-up (t=3.17, p=.001). Heirarchical linear modeling analysis supports consistent improvement in psychological variables across the program and follow-up (all p’s<.001). Data also suggest that psychological variables change prior to changes in pain. These results suggest that interdisciplinary pediatric pain rehabilitation leads to steady improvements in psychological factors relevant to adolescents’ return to normal activities, and that changes in psychological functioning precede changes in self-reported pain.

Hypertonic Saline as a Therapy for Pediatric Concussive Pain

Three-percent hypertonic saline (HTS) is a hyperosmotic therapy used in pediatric traumatic brain injury to treat increased intracranial pressure and cerebral edema. It also promotes plasma volume expansion and cerebral perfusion pressure, immunomodulation, and anti-inflammatory response. We hypothesized that HTS will improve concussive symptoms of mild traumatic brain injury. The study was a prospective, double-blind, randomized controlled trial. Children, 4 to 7 years of age with a Glasgow Coma Scale score greater than 13, were enrolled from a pediatric emergency department following closed-head injury upon meeting Acute Concussion Evaluation criteria with head pain. Patients were randomized to receive 10 mL/kg of HTS or normal saline (NS) over 1 hour. Self-reported pain values were obtained using the Wong-Baker FACES Pain Rating Scale initially, immediately following fluids, and at 2 to 3 days of discharge. The primary outcome measure was change in self-reported pain following fluid administration. Secondary outcome measures were a change in pain and postconcussive symptoms within 2 to 3 days of fluid administration. We used an intention-to-treat analysis. Forty-four patients, ranging from 7 to 16 years of age with comparable characteristics, were enrolled in the study; 23 patients (52%) received HTS, and 21 (48%) received NS. There was a significant difference (P < 0.001) identified in the self-reported improvement of pain following fluid administration between the HTS group (mean improvement = 3.5) and the NS group (mean improvement = 1.1). There was a significant difference (P = 0.01) identified in the self-reported improvement of pain at 2 to 3 days after treatment between the HTS group (mean improvement = 4.6) and the NS group (mean improvement = 3.0). We were unable to determine a difference in other postconcussive symptoms following discharge. Three-percent HTS is more effective than NS in acutely reducing concussion pain in children.

Lumbopelvic manipulation in patients with patellofemoral pain syndrome

Objectives: A recent clinical prediction rule (CPR) identified characteristics that may predict an immediate reduction in pain following lumbopelvic manipulation in patients with patellofemoral pain syndrome. The purpose of this single-arm cohort study was to replicate the proposed CPR in a different population and investigate changes in self-reported pain, hip range of motion, strength, and function immediately following lumbopelvic manipulation.Methods: Forty-four subjects (63·6% female; mean age 27·4 years) met inclusion criteria. Hip internal rotation range of motion, lower extremity strength using a handheld dynamometer, and single/triple hop tests were assessed prior to and immediately following a spinal manipulation. A global rating of change questionnaire was administered after testing and telephonically at 1 week. Paired t-tests compared pre- and post-manipulation range of motion, strength, and hop test limb symmetry indices (α = 0·05).Results: Fifty-seven percent of subjects had a successful outcome measured by the numerical pain rating scale immediately following manipulation. Twenty-five of subjects experienced a successful outcome as measured by the global rating of change questionnaire at 1 week. No single individual or combination of predictor variables predicted a positive outcome immediately following the lumbopelvic manipulation (+likelihood ratio 0·7 with three of five predictor variables present). Statistically significant differences (P<0·05) were found in hip extension and abduction strength and hip internal rotation symmetry post-manipulation, but do not appear to be clinically meaningful.Discussion: The previously identified CPR was not able to be replicated and no clinically meaningful changes in range of motion, strength, or function were apparent. Future research should focus on a comprehensive impairment-based treatment approach in patients with patellofemoral pain syndrome.

Peak knee adduction moment and impulse are not related to changes in self-reported pain or physical function over 12 months in individuals with medial knee osteoarthritis

Purpose: Dynamic joint loading is thought to be a major contributing factor to the development and progression of knee joint structural changes. The external knee adduction moment (KAM) during walking is a valid and reliable proxy for the load on the medial tibiofemoral compartment of the knee and is related to radiographic knee OA severity and risk of structural disease progression. However, no study has longitudinally examined the relationship between baseline KAM and changes in pain or physical function in a cohort with knee OA. The purpose of this study was to examine the relationship between peak KAM and KAM impulse with changes in self-reported pain and self-reported physical function over a 12-month period. Methods: Data from 141 individuals with medial knee OA (80 females, 61 males, age: 64.5±8.0yrs, BMI: 28.6±4.5m/kg2) who participated in a clinical trial were analyzed. The clinical trial showed no significant effect of lateral wedge insoles on pain or function compared to control insoles, thus data from treatment groups were pooled for this analysis. All participants underwent baseline three-dimensional gait analysis, and completed baseline and follow-up self-report measures of pain and function. Peak KAM and the KAM impulse were determined via gait analysis (8-camera VICON, 3 AMTI force plates). Pain and physical function at baseline and at 12 months were evaluated using a) The Western Ontario and McMaster Universities Arthritis Index (WOMAC) and b) numeric rating scales (NRS) to rate average overall weekly pain, average weekly pain when walking and average restriction to daily activities. Paired t-tests were used to examine changes in pain and function over 12-months in the whole cohort. Initially, unadjusted linear regression models were performed to examine the relationships between peak KAM (independent variable and change in self-reported pain and function (dependent variables). Models were repeated adjusting for a) age, sex, and body mass index and b) with the additional covariate of treatment group. All analyses were repeated using KAM impulse as the independent variable. Results: Baseline and follow-up self-reported pain and function scores are reported in Table 1. The cohort showed a small but significant improvement in WOMAC pain and function scores (Table 1). Neither peak KAM nor KAM impulse were associated with changes in self-reported WOMAC pain or function (Table 2). Similar to WOMAC scores, the NRS scores also significantly improved over time (Table 1). However, these improvements were less than the minimal clinically important differences. Neither peak KAM nor KAM impulse were associated with changes in self-report NRS pain or activity restrictions (Table 2). Conclusions: We found no relationship between parameters of the KAM and change in self-reported pain and function over 12-months in our cohort. Future research targeting those who exhibit worsening of pain and function over time, longer follow-up duration and incorporating performance-based measures of physical function is warranted.Table 1Baseline and follow-up self-reported pain and function scoresBaselineFollow-upMean Difference (95%CI)p-valueWOMAC Pain (0-20)7.2 (2.9)6.3 (3.3)0.9 (0.4, 1.4)0.001WOMAC Function (0-68)23.7 (11.1)20.2 (12.2)3.5 (1.8, 5.1)<0.001Average weekly pain when walking (0-10)4.3 (2.1)3.1 (2.4)1.2(0.8, 1.5)<0.001Average weekly pain (0-10)4.2 (1.9)3.1(2.2)1.1(0.7, 1.4)<0.001Average weekly restriction to activities (0-10)3.8 (2.3)3.1 (2.5)0.7 (0.4, 1.1)<0.001Lower scores indicate less pain/better function Open table in a new tab Table 2Relationship between KAM and changes in self-reported pain and functionUnivariate analysisMultivariate analysis*Multivariate analysis**Regression coefficient (95% CI)p-valueRegression coefficient (95% CI)p-valueRegression coefficient (95% CI)p-valueWOMAC PainPeak Knee Adduction Moment (Nm/BW*ht%)Knee Adduction Moment Impulse (Nm.s/BW*ht)-0.11 (-0.62, 0.41)-0.51 (-1.85, 0.83)0.680.45-0.08 (-0.62, 0.47)-0.55 (-1.93, 0.82)0.780.43-0.06 (-0.61, 0.48)-0.53 (-1.92, 0.85)0.810.45WOMAC FunctionPeak Knee Adduction Moment (Nm/BW*ht%)Knee Adduction Moment Impulse (Nm.s/BW*ht)0.53 (-1.14, 2.20)0.79 (-3.57, 5.15)0.530.720.48 (-1.29, 2.25)1.02 (-3.47, 5.51)0.590.650.50 (-1.29, 2.28)1.06 (-3.46, 5.58)0.580.64Average weekly pain when walkingPeak Knee Adduction Moment (Nm/BW*ht%)Knee Adduction Moment Impulse (Nm.s/BW*ht)0.22 (-0.17, 0.61)0.51 (-0.52, 1.53)0.270.330.24 (-0.18, 0.65)0.58 (-0.47, 1.63)0.260.290.24 (-0.17, 0.66)0.60 (-0.46, 1.65)0.250.26Average weekly painPeak Knee Adduction Moment (Nm/BW*ht%)Knee Adduction Moment Impulse (Nm.s/BW*ht)0.07 (-0.32, 0.45)0.07 (-0.83, 1.06)0.740.890.13 (-0.27, 0.54)0.18 (-0.83, 1.20)0.520.720.15 (-0.26, 0.55)0.21 (-0.81, 1.23)0.480.68Average weekly restriction to activitiesPeak Knee Adduction Moment (Nm/BW*ht%)Knee Adduction Moment Impulse (Nm.s/BW*ht)0.17 (-0.20, 0.54)0.21 (-1.18, 0.76)0.270.330.22 (-0.17, 0.61)0.33 (-0.66, 1.33)0.260.510.23 (-0.16, 0.62)0.35 (0.65, 1.35)0.250.49* adjusted for age, gender, body mass index** adjusted for age, gender, body mass index, treatment group Open table in a new tab

A randomised non-inferiority controlled trial of a single versus a four intradermal sterile water injection technique for relief of continuous lower back pain during labour

BackgroundAlmost one third of women suffer continuous lower back pain during labour. Evidence from three systematic reviews demonstrates that sterile water injections (SWI) provide statistically and clinically significant pain relief in women experiencing continuous lower back pain during labour. The most effective technique to administer SWI is yet to be determined. Therefore, the aim of this study is to determine if the single injection SWI technique is no less effective than the routinely used four injection SWI method in reducing continuous lower back pain during labour.Methods/designThe trial protocol was developed in consultation with an interdisciplinary team of clinical researchers. We aim to recruit 319 women presenting at term, seeking analgesia for continuous severe lower back pain during labour. Participants will be recruited from two major maternity hospitals in Australia. Randomised participants are allocated to receive a four or single intradermal needle SWI technique. The primary outcome is the change in self-reported pain measured by visual analogue scale at baseline and thirty minutes post intervention. Secondary outcomes include VAS change scores at 10, 60, 90 and 120 min, analgesia use, mode of birth and maternal satisfaction.Statistical analysisSample size was calculated to achieve 90% power at an alpha of 0.025 to detect a non-inferiority margin of ≤ 1 cm on the VAS, using a one-sided, two-sample t-test. Baseline demographic and clinical characteristics will be analysed for comparability between groups. Differences in primary (VAS pain score) and secondary outcomes between groups will be analysed by intention to treat and per protocol analysis using Student's t-test and ANOVA.ConclusionThis study will determine if a single intradermal SWI technique is no less effective than the routinely used four injection technique for lower back pain during labour. The findings will allow midwives to offer women requesting SWI during labour an evidence-based alternative technique more easily administered by staff and accepted by labouring women.Trial RegistrationACTRN12609000964213

Progression of hand osteoarthritis over 2 years: a clinical and radiological follow-up study

Objectives:To investigate the course of hand osteoarthritis over 2 years by currently available outcome measures.Methods:189 participants of the Genetics, Arthrosis and Progression (GARP) study with hand osteoarthritis were followed for...