Management Of Chronic Musculoskeletal Pain Research Articles

Ageing well with chronic musculoskeletal pain: protocol for a systematic review of non-pharmacological interventions aimed at reducing pain in an ageing population

Background: Chronic musculoskeletal pain in the elderly is highly prevalent, with osteoarthritis, low back pain, neck pain and other musculoskeletal disorders as the leading contributors to pain chronicity and disability. Previous reviews identifying effective components of non-pharmacological interventions for treating chronic pain have either few studies or the included studies examine outcome over a limited time span. This systematic review will investigate the effectiveness and components of interventions associated with management of chronic musculoskeletal pain in older adults (≥65 years).Methods/Design: This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Randomised controlled trials of non-pharmacological interventions aimed at reducing pain in older adults with chronic musculoskeletal pain will be included. Articles will be identified through a comprehensive search of the following databases: Ovid MEDLINE, Embase, CINAHL, AMED, Scopus, Web of Science and PEDro. Two review authors will independently screen articles retrieved from the search for eligibility, and extract relevant data on methodological issues. A narrative synthesis will be completed if there are insufficient data for a meta-analysis. The narrative synthesis will summarise the current state of knowledge, interventions, study designs and robustness of evidence.Discussion: Findings of the study will inform support programs and interventions to assist people aging with pain, carers and other supporters and practitioners.Systematic review registration: PROSPERO 2017:CRD42017074173.

Chronic musculoskeletal pain and function improve with a plant-based diet

BackgroundChronic musculoskeletal pain, often debilitating, affects all genders, ethnicities, and age groups. Research suggests consumption of a plant-based diet may improve the status of persons with chronic pain. A diet rich in fruits, vegetables and whole grains has been shown to reduce chronic pain and disability associated with musculoskeletal conditions. ObjectiveThe purpose of this study was to examine the value of a plant-based diet in the management of chronic musculoskeletal pain and functional limitations. MethodFourteen subjects participated in the eight-week study. Baseline evaluation included anthropometric measurements and completion of two self-reported outcome measures: Numeric Pain Rating Scale (NPRS) and the Short Form Health Survey (SF-36). A registered dietitian nutritionist provided a sample menu cycle and education on a plant-based diet. Subjects utilized a phone app to log food intake and receive support from the dietitian. Post data collection included a repeat of the baseline measures and the Patient Global Impression of Change Scale. The sample was small. Twenty subjects began, 14 completed. No comparison group was used. Results should be considered with caution. ResultsThe diet intervention resulted in decreased pain and improvement in quality of life. Diet adherence by ten of fourteen subjects was 89% based on completion of food intake records and adherence to allowed foods. ConclusionConsumption of a plant-based diet produced positive improvements in chronic pain and function. Interprofessional collaboration between physical therapists and registered dietitian nutritionists, along with other healthcare practitioners, can encourage and promote diet interventions that positively affect chronic pain.

A Research Agenda for Advancing Non-pharmacological Management of Chronic Musculoskeletal Pain: Findings from a VHA State-of-the-art Conference.

Chronic pain is widely prevalent among Veterans and can have serious negative consequences for functional status and quality of life among other domains. The Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of non-pharmacological management of chronic musculoskeletal pain. In this perspective article, we present the methods and consensus recommendations for research priorities emanating from the SOTA. In the months leading up to the SOTA, a core group of researchers defined four areas of focus: psychological/behavioral therapies; exercise/movement therapies; manual therapies; and models for delivering multi-modal pain care and divided into workgroups. Each workgroup, in their respective areas of focus, identified seminal studies capturing the state of the evidence. Herein, we present consensus recommendations ranging from efficacy to effectiveness to implementation/dissemination research depending on the state of the evidence as assessed by participants, including commentary on common elements across workgroups and future areas of innovation in study design, measurement, and outcome ascertainment.

Chronic musculoskeletal pain in European older adults: Cross-national and gender differences.

In an ageing Europe, chronic pain is a major public health problem, but robust epidemiological data are scarce. This study aimed to analyse the prevalence of and factors associated with chronic musculoskeletal pain by gender in older adults of 14 European countries. A cross-sectional study was performed from wave 5 of the Survey of Health, Ageing and Retirement in Europe (SHARE). The study included people ≥50 years residing in Austria, Belgium, Czech Republic, Denmark, Estonia, France, Germany, Italy, Luxembourg, the Netherlands, Slovenia, Spain, Sweden and Switzerland. Chronic pain was defined as being bothered by joint and/or back pain for the previous 6months. Multivariable Poisson regression models with robust variance were performed to analyse prevalence ratio by covariates, stratified by sex. A total of 61,157 participants were included. Overall prevalence of chronic musculoskeletal pain was 35.7% (28.8-31.7), ranging from 18.6% (17.1-20.1) for Switzerland to 45.6% (43.3-47.8) for France. Prevalence was higher in women than in men: 41.3% (40.2-42.4) versus 29.1% (28.0-30.3). Chronic musculoskeletal pain was lower in men aged >75 years (PR=0.82; 0.72-0.92) than the younger (50-59) group. Separated/divorced status presented opposite effects among men (PR=0.85; 0.76-0.96) and women (PR=1.12; 1.03-1.21) compared with married, and unemployment was a significant factor in men (PR=1.21; 95% CI 1.02-1.43) compared with employed. Musculoskeletal pain in older European adults is very frequent, especially in women, with large differences depending on the country of residence. Health policy makers should prioritize strategies aimed at improving the prevention and management of chronic musculoskeletal pain in Europe. This study provides epidemiological data of chronic musculoskeletal pain in older adults. Reported differences contribute to highlight the relevance of considering a gender perspective in chronic musculoskeletal pain research. Cross-national comparison also offers a map of differences that improves the knowledge of this chronic condition in Europe.

Responsibility of the doctor who prescribes serotonin and noradrenaline reuptake inhibitors for patients with chronic musculoskeletal pain

Duloxetine, a serotonin and noradrenaline reuptake inhibitor (SNRI), is indicated for the management of chronic musculoskeletal pain, as it helps inhibit pain signals by activating descending pain inhibitory pathways.1 Thus, duloxetine is increasingly being prescribed by many doctors who are not familiar with psychopharmacology. We conducted a questionnaire survey on Japanese physicians’ recognition of the severe side-effects of duloxetine. We surveyed 69 physicians who had prescribed duloxetine for chronic musculoskeletal pain and 52 (75.4%) responded. The main specialties of the responders were psychosomatic medicine (n = 26, 50.0%), orthopedics (n = 14, 26.9%), anesthesiology and pain (n = 6, 11.5%), and general internal medicine (n = 6, 11.5%). The average age of the 52 responders was 52.4 years. Seventeen responders reported side-effects in their patients due to duloxetine, as follows: falls (n = 12, 23.1%), hyponatremia (n = 2, 3.8%), and discontinuation syndrome (n = 3, 5.8%). Of the 52 responders, 24 (46.2%) considered falls and syncope as a side-effect, 13 (25.0%) recognized hyponatremia as a serious complication, and only 11 (21.2%) knew about discontinuation syndrome. These results suggest that many prescription doctors are unaware or ignore these side-effects of SNRI. Of the 52 responders, 26 (50.0%) considered duloxetine as an analgesic drug, and 26 (50.0%) recognized it as an SNRI. Duloxetine has some severe side-effects at the same level as other SNRI. Syncope and orthostatic hypotension can occur at any time during treatment, particularly after dose increases. SNRI, as well as selective serotonin reuptake inhibitors (SSRI), are well known to have side-effects, including the syndrome of inappropriate antidiuretic hormone secretion, which results in hyponatremia, the most commonly encountered electrolyte abnormality in clinical practice. Following the abrupt discontinuation of SNRI, discontinuation symptoms, such as dizziness, headache, irritability, insomnia, and fatigue, may occur. Moreover, the majority of patients with chronic musculoskeletal pain are elderly and tend to have a higher underlying risk for falls, such as use of multiple medications and medical comorbidities. In Japan, after the introduction of SSRI and SNRI for depression, pharmaceutical companies initiated educational campaigns. Due to these marketing practices, SSRI and SNRI sales have achieved a tremendous increase, resulting in an increase in severe side-effects.2 We can learn a great deal from this experience with the aggressive marketing of these drugs as a kind of disease mongering. Now, the same risk exists with duloxetine for chronic musculoskeletal pain. The doctor who prescribes SNRI must weigh the benefits against the side-effects. When prescribing an SNRI for chronic musculoskeletal pain, patients should be carefully monitored against side-effects. Discontinuation should be considered in patients who experience side-effects during SNRI therapy. Even then, a gradual reduction in the dose rather than abrupt cessation is recommended, whenever possible, to prevent discontinuation syndrome. The author declares no conflicts of interest.

The association between displacement of sedentary time and chronic musculoskeletal pain: an isotemporal substitution analysis

ObjectivesPhysical activity is an effective intervention for the prevention and management of chronic musculoskeletal pain (CMP). However, there is a lack of research to inform the intensity of physical activity that should be recommended. The aim of this study was to investigate the association between substituting 10minutes of sedentary time with either 10minutes of light physical activity (LPA) or moderate-to-vigorous physical activity (MVPA) and the CMP prevalence ratio. DesignSecondary Analysis (November 2015) of data from the Health Survey for England (2008). Participants2313 adults (≥16years). Main outcome measuresSedentary time, LPA and MVPA were measured using accelerometry. We used isotemporal models to quantify the prevalence ratio for CMP of replacing 10minutes of sedentary time with 10minutes of LPA or MVPA. ResultsThe prevalence of CMP in this sample was 17%. The unadjusted prevalence ratio was 0.99 (95% CI: 0.97 to 1.01) for LPA and 0.76 (0.70 to 0.84) for MVPA. The fully adjusted prevalence ratio was 1.01 (95% CI: 0.99 to 1.02) for LPA and 0.89 (0.82 to 0.96) for MVPA. ConclusionsSubstituting 10minutes of sedentary time with an equivalent period of LPA was not associated with a reduction in the prevalence ratio for CMP, whereas the equivalent replacement with MVPA showed a small protective relationship. Regarding CMP prevalence, physical activity intensity appears to be important, with MVPA rather than LPA showing a protective relationship. Prospective studies are needed to investigate causality.

The association between displacement of sedentary time and chronic musculoskeletal pain: an isotemporal substitution analysis

Relevance: A number of systematic reviews have consistently identified a small but positive protective effect of physical activity for the prevention and management of chronic musculoskeletal pain (CMP). However, there is a lack of research to inform the intensity of physical activity that should be recommended.

Does a two-day postgraduate course on the management of chronic musculo-skeletal pain increases the physiotherapists' pain neurophysiology knowledge?

Does a two-day postgraduate course on the management of chronic musculo-skeletal pain increases the physiotherapists' pain neurophysiology knowledge?

Clinical practice guidelines for the management of chronic musculoskeletal pain in primary health care: A systematic review

Background Up-to-date, high quality, evidence-based clinical practice guidelines (CPGs) that are applicable for primary healthcare are vital to optimize services for the population with chronic musculoskeletal pain (CMSP). The study aimed to systematically identify and appraise the available evidence-based CPGs for the management of CMSP in adults presenting in primary healthcare settings.

The role of contextual factors in the management of chronic musculoskeletal pain in primary health care settings

The role of contextual factors in the management of chronic musculoskeletal pain in primary health care settings

Characterization of the Percutaneous Absorption of Ketoprofen Using the Franz Skin Finite Dose Model

ABSTRACTObjectives: Ketoprofen is an analgesic, anti-inflammatory agent commonly used in the management of chronic musculoskeletal pain. The aim of this study is to characterize the percutaneous absorption of 2 ketoprofen formulations (ketoprofen 10% in Pluronic Lecithin Organogel (PLO) and ketoprofen 10% in Lipoderm, referred to as phospholipid base), when applied to the human cadaver trunk skin, in vitro, using the Franz skin finite dose model. PLO and phospholipid base are vehicles used to facilitate the delivery of drugs into and through the skin following topical applications.Methods: The percutaneous absorption of ketoprofen was evaluated using human cadaver trunk skin from 3 donors. The skin was cut into small sections and cultured within Franz diffusion cells. A variable finite dose of each formulation was then applied to 3 replicate skin sections per donor and receptor solutions were collected at predetermined time points (0, 4, 8, 12, 24, 32, and 48 hr). After the last receptor sample was collected, skin surfaces were washed and split into epidermis and dermis. Collected samples were analyzed using HPLC.Results: Both PLO and phospholipid base were capable of facilitating the absorption of ketoprofen across human cadaver trunk skin. However, ketoprofen, when in phospholipid base, showed higher mean total absorption (p = 0.022) and faster rate of absorption (p < 0.05 at 2, 6, 10, and 18 hr) than when in PLO.Conclusion: Chronic musculoskeletal pain can be a major burden for most patients, affecting their lifestyle and reducing overall quality of life. When compared to PLO, phospholipid base has the ability to potentially deliver higher concentrations of ketoprofen to underlying soft tissues and at a more rapid rate. With more ketoprofen at the site of injury, the analgesic and anti-inflammatory effects will likely be enhanced, potentially reducing pain and improving quality of life.

Pragmatic Model for Integrating Complementary and Alternative Medicine in Primary Care Management of Chronic Musculoskeletal Pain

Background: Integration of complementary and alternative medicine (CAM) into conventional care is driven by patients’ needs for holistic care. This study aimed to develop a model for integration of CAM into primary healthcare in close collaboration with patients suffering from chronic musculoskeletal pain (CMP). Methods: The study had a qualitative inductive approach following the principles of Grounded Theory, where data were collected and generated via several data sources and steps; individual and focus group interviews and meetings with patients, general practitioners (GPs), CAM practitioners, health insurers and other key informants. Results: Consensus was reached on a model in which shared decision making was introduced to facilitate discussions on CAM between patients and GPs. Guided by evidence and best-practices, GPs refer patients to one of five selected and reimbursed CAM therapies (acupuncture, homeopathy, naturopathy, osteopathy or Tai Chi) and respective practitioner within their integrative network. CAM practitioners report treatment outcome back to the GP who follows-up on the patient for further evaluation. Conclusions: In conclusion, it was feasible to develop a model for integration of CAM into primary healthcare management of CMP that was driven by patients’ needs and obtained consensus of all stakeholders. The model is the first in the Netherlands to provide for integrative health services in primary care. It needs to be tested in a study setting before further implementation is recommended.

Decision Support Preferences Among Hispanic and Non-Hispanic White Older Adults With Chronic Musculoskeletal Pain.

Despite broad recognition that social networks play a key role in the management of chronic musculoskeletal pain (CMP), little is known about when and why older adults with CMP choose to involve others in treatment decisions. This study investigates the types (i.e., informational, emotional, and instrumental) and sources (i.e., formal and informal) of support Hispanic and non-Hispanic White CMP patients desire and receive when making decisions about their pain care. Semi-structured interviews were conducted with Hispanic and non-Hispanic White older adults with CMP (N = 63) recruited from one medical center and one senior center in New York City. Interviews were transcribed and then analyzed using content analysis. CMP patients sought network members who supported their emotional well-being throughout the decision-making process. When considering high-stakes treatment decisions, participants selectively involved individuals who had similar pain conditions or first-hand experience with the procedure. Participants' perceptions of the decision-making process were contingent upon the congruence between the decision they made and the support they received for it. For Spanish-speaking participants, positive perceptions were linked with satisfactory language competence by their providers. On the other hand, lack of language competence among providers hindered Spanish speakers' ability to obtain adequate informational support. Results reveal the importance of empathic patient-provider exchanges across diverse patient populations and cultural sensitivity for Spanish-speaking patients. Findings suggest that social networks beyond the patient-provider dyad influence patients' decision-making satisfaction.

Direct and Indirect Benefits Reported by Users of Transcutaneous Electrical Nerve Stimulation for Chronic Musculoskeletal Pain: Qualitative Exploration Using Patient Interviews.

There is no consensus regarding the effectiveness of transcutaneous electrical nerve stimulation (TENS) for management of chronic musculoskeletal pain or chronic low back pain. A recent review of previous trial methodology identified significant problems with low treatment fidelity. There is little information available to guide selection of patient-reported outcome measures appropriate for TENS evaluation. The purpose of this study was to explore the experiences of patients at a secondary care pain clinic who successfully used TENS to help manage chronic musculoskeletal pain. These key informants were selected because they had the potential to generate knowledge that could inform research design and clinical practice. A qualitative method using individual semistructured interviews with open questions was selected for its capacity to generate rich data. A mini focus group informed the development of a discussion guide for semistructured interviews with 9 patients (6 women, 3 men). Thematic analysis was used as the primary data analysis method, and this analysis was enhanced by a case-level analysis of the context and processes of TENS use of each individual. Data analysis indicated that distraction from pain and a reduction in the sensations associated with muscle tension or spasm should be considered as separate outcomes from pain relief. These direct benefits led to a wide range of indirect benefits dependent on patient decision making, including medication reduction, enhanced function, psychological benefits, and enhanced ability to rest. The findings indicate that evaluating TENS using a unidimensional pain scale is likely to overlook potential benefits. The complex pattern of TENS usage, as well as multiple direct and indirect outcomes, indicates that TENS could be considered as a complex intervention.

Clinical experience with duloxetine in the management of chronic musculoskeletal pain. A focus on osteoarthritis of the knee.

Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SNRI) with central nervous system activity. Its analgesic efficacy in central pain is putatively related to its influence on descending inhibitory pain pathways. The analgesic efficacy of duloxetine has been demonstrated in four distinct chronic pain conditions. These include neuropathic pain associated with diabetic peripheral neuropathy, fibromyalgia, chronic low back pain, and osteoarthritis knee pain (OAKP). The purpose of this review is to examine the clinical efficacy and safety of duloxetine in the management of chronic OAKP. Three separate randomized, double-blind placebo-controlled trials have demonstrated that (1) a clinically meaningful decrease in pain severity occurs at about 4 weeks relative to placebo, (2) patients receiving duloxetine report better improvements in physical functioning relative to placebo, (3) duloxetine is safe and effective when used adjunctively with nonsteroidal anti-inflammatory drugs, and (4) that there are no new safety signals beyond what has been observed in other indications.

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Med Check

Duloxetine in the management of chronic musculoskeletal pain

Chronic musculoskeletal pain is among the most frequent painful complaints that healthcare providers address. The bulk of these complaints are chronic low back pain and chronic osteoarthritis. Osteoarthritis is the most common form of arthritis in the United States. It is a chronic degenerative disorder characterized by a loss of cartilage, and occurs most often in older persons. The management of osteoarthritis and chronic low back pain may involve both nonpharmacologic (eg, weight loss, resistive and aerobic exercise, patient education, cognitive behavioral therapy) and pharmacologic approaches. Older adults with severe osteoarthritis pain are more likely to take analgesics than those with less severe pain. The pharmacologic approaches to painful osteoarthritis remain controversial, but may include topical as well as oral nonsteroidal antiinflammatory drugs, acetaminophen, duloxetine, and opioids. The role of duloxetine for musculoskeletal conditions is still evolving.

Primary Care Clinician Adherence to Guidelines for the Management of Chronic Musculoskeletal Pain: Results from the Study of the Effectiveness of a Collaborative Approach to Pain

We assessed primary care clinician-provided guideline-concordant care as documented in patients' medical records, predictors of documented guideline-concordant care, and its association with pain-related functioning. Patients were participants in a randomized trial of collaborative care for chronic musculoskeletal pain. The intervention featured patient and primary care clinician education, symptom monitoring and feedback to clinicians by the intervention team. To assess concordance with the evidence-based treatment guidelines upon which our intervention was based, we developed an 8-item chart review tool, the Pain Process Checklist (PPC). We then reviewed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months. Intervention status, demographic, and clinical variables were tested as predictors of PPC scores using generalized estimating equations (GEE). GEE was also used to test whether PPC scores predicted treatment response (≥30% decrease in Roland-Morris Disability Questionnaire score). Rates of documented guideline-concordant care varied widely among PPC items, from 94% of patients having pain addressed to 17% of patients on opioids having side effects addressed. Intervention status was unrelated to item scores, and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients (61.2%, standard error [SE] = 3.3% vs 55.2%, SE = 2.6%, P = 0.15). In a multivariate model, higher PPC-7 scores were associated with receiving a prescription for opioids (odds ratio [OR] = 1.07, P = 0.007) and lower PPC-7 scores with patient age (10-year difference OR = 0.97, P = 0.004). Finally, intervention patients who received quantitative pain and depression assessments were less likely to respond to treatment (assessed vs not: 18% vs 33%, P = 0.008, and 13% vs 28%, P = 0.001, respectively). As measured by medical record review, additional training and clinician feedback did not increase provision of documented guideline-concordant pain care, and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain.

Nurse Practitioner Management of Chronic Musculoskeletal Pain

This study explored NPs' management of chronic musculoskeletal pain via a record review of 50 uninsured patients. The findings include a summary of the utilization of services and treatments along with demographic data. Recommendations for education, practice, and further research are discussed.

Evaluation of Duloxetine for Chronic Pain Conditions

SummaryDuloxetine hydrochloride (duloxetine) is used as a nonopioid analgesic for the treatment of certain chronic pain conditions. It is a serotonin and norepinephrine reuptake inhibitor and has been approved in the USA for the management of both diabetic peripheral neuropathic pain and fibromyalgia. In addition, based on several studies demonstrating that duloxetine was efficacious in the management of chronic low back pain and chronic pain caused by osteoarthritis, duloxetine was approved for the management of chronic musculoskeletal pain. Effect sizes in studies of each of the aforementioned chronic pain conditions are comparable with other commonly used pain medications. Treatment-emergent adverse events are generally mild to moderate in severity, and tend to occur early and transiently.