Chronic Pain Rehabilitation Program Research Articles

Variability in the Relationship Between Sleep and Pain in Patients Undergoing Interdisciplinary Rehabilitation for Chronic Pain

Chronic pain and sleep disturbance frequently coexist and often complicate the course of treatment. Despite the well-established comorbidity, there are no studies that have investigated concurrent changes in sleep and pain among patients participating in an interdisciplinary chronic pain rehabilitation program (ICPRP). The goal of this study was to investigate the daily changes in sleep and pain among patients participating in an ICPRP. Multilevel modeling techniques were used to evaluate the daily changes in total sleep time (TST) and pain among a sample of 50 patients with chronic noncancer pain participating in the ICPRP. Increases in TST were predictive of less pain the following treatment day, although daily pain ratings were not predictive of that night's TST. Time in treatment was a significant predictor of both TST and pain reduction, even while controlling for age, gender, anxiety, and depression. Additional analyses revealed significant individual variability in the relationship between TST and next day pain. Individuals with stronger associations between previous night's TST and next day pain were found to experience the greatest treatment benefits overall, in terms of pain reduction and TST. Our results provide compelling support for individual variability of the pain-sleep relationship in patients with intractable pain conditions participating in an ICPRP. Importantly, these findings suggest that when pain and sleep are comorbid, both must be addressed to reap the maximum response to treatment programs such as an ICPRP. This study demonstrates the utility of treating sleep problems in patients participating in an interdisciplinary chronic pain rehabilitation program. Results highlight the benefits of accounting for individual variability in the pain-sleep relationship in a clinical setting and targeting sleep interventions for those individuals whose pain and sleep problems are comorbid.

(556) Chronic pain rehabilitation and alcohol use disorder: promising outcomes in an interdisciplinary treatment program

(556) Chronic pain rehabilitation and alcohol use disorder: promising outcomes in an interdisciplinary treatment program

(530) Suboxone decreases the odds of opioid resumption in patients with opioid addiction following treatment in a chronic pain rehabilitation program including opioid weaning

Patients weaned from opioid within an interdisciplinary chronic pain rehabilitation program (CPRP) show improvements in improve pain and function. Patients with chronic non-cancer pain (CNCP) and comorbid opioid addiction also face potential relapse. Suboxone has been demonstrated to decrease the odds of opioid relapse; however, little research has examined it’s use in a CPRP. This retrospective study compared 12 month treatment outcomes of patients with opioid addiction discharged on Suboxone for with patients with opioid addiction who were opioid weaned. 30 patients were discharged on Suboxone between 2007-2012. Cases were matched in age and gender, resulting in a total n of 60. Participants were predominately married (56.7%, n=34) males (n=39, 65.0%) with a mean age of 42.55 (±12.49). Both groups were equally likely to have a lifetime history of a substance use disorder (63.3%, n=38, χ2=.86, 1, ns) and there was no difference between the two in mean morphine equivalence dosage at admission (M=280.28±300.42). Pain and function ratings were collected at admission, discharge and 12 months post-treatment and opioid resumption at 12 months. Repeated measures MANOVA indicated participants reported improvements in pain (p<.01) and function (p<.01) from admission to discharge and sustained improvement at 12 months (p<.01). There were no between-group differences. At 12 months, opioid resumption data was available for 28 opioid weaned and 24 Suboxone patients. 38.5% of patients had resumed opioid use, with weaned patients more likely to resume (χ2=4.74, 1, p<.05). 50% of weaned patients resumed opioid use: 6 resumed chronic opioid therapy and 8 found opioid cravings unmanageable (4 initiated Suboxone and 4 relapsed). 5 Suboxone patients (20.83%) had used opioids; all had relapsed. Findings show that patients with pain and comorbid addiction benefit from CPRP treatment in terms of pain and function and treatment with Suboxone decreases the odds of resumption of other opioids. Patients weaned from opioid within an interdisciplinary chronic pain rehabilitation program (CPRP) show improvements in improve pain and function. Patients with chronic non-cancer pain (CNCP) and comorbid opioid addiction also face potential relapse. Suboxone has been demonstrated to decrease the odds of opioid relapse; however, little research has examined it’s use in a CPRP. This retrospective study compared 12 month treatment outcomes of patients with opioid addiction discharged on Suboxone for with patients with opioid addiction who were opioid weaned. 30 patients were discharged on Suboxone between 2007-2012. Cases were matched in age and gender, resulting in a total n of 60. Participants were predominately married (56.7%, n=34) males (n=39, 65.0%) with a mean age of 42.55 (±12.49). Both groups were equally likely to have a lifetime history of a substance use disorder (63.3%, n=38, χ2=.86, 1, ns) and there was no difference between the two in mean morphine equivalence dosage at admission (M=280.28±300.42). Pain and function ratings were collected at admission, discharge and 12 months post-treatment and opioid resumption at 12 months. Repeated measures MANOVA indicated participants reported improvements in pain (p<.01) and function (p<.01) from admission to discharge and sustained improvement at 12 months (p<.01). There were no between-group differences. At 12 months, opioid resumption data was available for 28 opioid weaned and 24 Suboxone patients. 38.5% of patients had resumed opioid use, with weaned patients more likely to resume (χ2=4.74, 1, p<.05). 50% of weaned patients resumed opioid use: 6 resumed chronic opioid therapy and 8 found opioid cravings unmanageable (4 initiated Suboxone and 4 relapsed). 5 Suboxone patients (20.83%) had used opioids; all had relapsed. Findings show that patients with pain and comorbid addiction benefit from CPRP treatment in terms of pain and function and treatment with Suboxone decreases the odds of resumption of other opioids.

(553) Treatment outcomes of patients with chronic abdominal pain within an interdisciplinary chronic pain rehabilitation program

Studies examining treatment outcomes among patients with chronic noncancer pain treated in interdisciplinary chronic pain rehabilitation programs (CPRP) are abundant, however outcome studies specific to patients with abdominal pain are virtually non-existent. This retrospective study examined the outcomes of patients with abdominal pain treated in the Cleveland Clinic’s CPRP. Outcomes included pain severity, depression, anxiety and pain related functional impairment and were measured at both admission and discharge.

(540) High dose opioid weaning within the context of a chronic pain rehabilitation program

Research supports weaning patients from chronic opioid therapy (COT) in the context of an interdisciplinary chronic pain rehabilitation program (CPRP). The aim of the current study was to examine CPRP outcomes for patients with chronic non-cancer pain (CNCP) weaned off high-dose COT (HD; >100mg morphine equivalency dose-MED). Outcomes for these patients were compared with patients weaned from low-dose COT (LD, 0.01-99.9mg MED) and patients not on COT (ND). Data was available from 1248 patients admitted to a CPRP between 2007-2011.

(545) Treatment outcomes of an interdisciplinary chronic pain rehabilitation program in smokers and nonsmokers

Previous research suggests there is a relationship between pain and smoking, but there is limited research on the treatment outcomes of people with chronic pain who smoke. This is particularly evident in the context of interdisciplinary chronic pain treatment programs because the only such study (Hooten et al., 2009) has not been replicated. Therefore, the current study examined the immediate treatment outcomes in patients who have been through an interdisciplinary chronic pain rehabilitation program. The treatment outcomes that were examined were depression, anxiety, pain intensity, and pain disability. Depression scores were higher both at admission and discharge for smokers when compared to nonsmokers, anxiety scores and pain intensity scores were higher at admission for smokers, but were no longer significantly different from nonsmokers at discharge, and pain disability scores for smokers and nonsmokers were not significantly different at both admission and discharge. In addition, both smokers and nonsmokers improved on all of these measures between admission and discharge. These data support the findings of Hooten et al. (2009) and provide additional evidence that comprehensive chronic pain rehabilitation programs can be effective for both smokers and nonsmokers, specifically regarding pain intensity, anxiety, depression, and pain disability outcomes.

(563) Treatment success of older adults with chronic pain at an interdisciplinary chronic pain rehabilitation program

(563) Treatment success of older adults with chronic pain at an interdisciplinary chronic pain rehabilitation program

(557) Age and education matched comparison of female and male veterans participating in an inpatient chronic pain rehabilitation program

(557) Age and education matched comparison of female and male veterans participating in an inpatient chronic pain rehabilitation program

Insomnia in clients with chronic, work-related musculoskeletal pain in a work recovery rehabilitation program

There is a high prevalence of sleep disturbance with people experiencing chronic pain. Although multi-disciplinary rehabilitation programs address many contributing factors for chronic pain, the impact of insomnia on clients is not often measured. Two studies were used to: first explore the experience of insomnia in a group of clients with chronic pain and then, in a group enrolled in a six-week work recovery rehabilitation program, compare measures of sleep disturbance at entry and upon its completion. Sixteen clients participated in focus groups and 29 completed questionnaires; 46% were women and the average age was 43 years. They had a wide range of work-related musculoskeletal injuries and all had chronic pain. First two, semi-structured focus group interviews explored sleep disturbance. Then a different set of participants completed three sleep questionnaires before and after completing a rehabilitation program. Focus group participants described sleep disturbance consistent with clinical insomnia and how it had a considerable impact on their lives. Completed questionnaires confirmed the presence of sleep disturbance at admission into a six-week rehabilitation program and at discharge, most measures were unchanged. Although chronic pain rehabilitation generally includes interdisciplinary approaches, specific attention to insomnia is not part of this chronic pain rehabilitation program and therefore it is not surprising that there was no appreciable change by the end of the program. However, because sleep disturbance is prevalent in the chronic pain population and in this sample, and has such a strong impact on the individual's daytime functioning, effective interventions directed at sleep restriction and stimulus control should complement chronic pain rehabilitation programs.

Opioid Use 12 Months Following Interdisciplinary Pain Rehabilitation with Weaning

To examine the frequency of and factors predicting opioid resumption among patients with chronic non-cancer pain (CNCP) and therapeutic opioid addiction (TOA) treated in an interdisciplinary chronic pain rehabilitation program (CPRP) incorporating opioid weaning. Longitudinal retrospective treatment outcome study. Only those with addiction were counseled to avoid opioids for non-acute pain. Large academic medical center. One hundred twenty patients, 32.5% with TOA. Participants were predominately married (77.5%), females (66.7%). Mean age was 49.5 (±13.7). 29.2% had lifetime histories of non-opioid substance use disorders. TOA was diagnosed using consensus definitions developed by American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine to supplement Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) criteria. Non-opioid substance use disorders were diagnosed using DSM-IV-TR. Data, including pain severity, depression and anxiety, were collected at admission, discharge and 12 months. Opioid use during treatment was based on medical records and use at 12 months was based on self-report. Only 22.5% reported resuming use at 12 months. Neither patients with TOA nor patients with non-opioid substance use disorders were more likely to resume use than those without substance use disorders. Only posttreatment depression increased the probability of resumption. CNCP and co-occurring TOA can be successfully treated within a CPRP. Patients report low rates of resumption regardless of addiction status. This is in marked contrast to reported outcomes of non-medically induced opioid addictions. Prolonged abstinence may depend upon the successful treatment of depression.

Validation of a French version of Roland–Morris questionnaire in chronic low back pain patients

ObjectiveTo validate a French version of the Roland–Morris Disability Questionnaire (RMDQ) in patients with chronic low back pain (LBP). Material and methodsFifty-eight patients due to participate in a functional rehabilitation programme for chronic low back pain were included prospectively. The RMDQ, the Quebec Back Pain Disability Scale (QBPDS) and the “daily activities” subscale of the Dallas Pain Questionnaire (DPQ) were administered. The RMDQ was assessed for internal consistency, reliability, criterion validity and sensitivity to change. ResultsCronbach's alpha for the RMDQ was 0.84. The intraclass correlation coefficient [95% confidence interval] was 0.89 [0.83–0.93]. The RMDQ score was correlated with the QBPDS score (r=0.713) and the DPQ's “daily activities” subscore (r=0.514). The results of assessments before and after functional rehabilitation showed that the French version of the RMDQ had very high sensitivity to change (effect size: 1.49) and was more sensitive than the QBPDS and the DPQ's “daily activities” subscore. ConclusionsOur study validated the French version of the RMDQ in patients suffering from chronic low back pain. Furthermore, we highlighted the questionnaire's very high sensitivity to change.

Retrospective Outcome Analyses for Headaches in a Pain Rehabilitation Interdisciplinary Program

Incapacitating chronic migraine and other severe headaches can have significant impact on peoples' lives, including family and occupational functioning. Although a number of reports have investigated the prevalence and medical treatment of chronic headache, few have reported on the efficacy of treating these disorders within a comprehensive, intensive chronic pain rehabilitation program (CPRP), instead of a headache-specific program. CPRPs provide treatment of headache by focusing not only on physical pain, but also its association with impaired mood and function. We examined the efficacy of CPRP in patients with chronic headache via a retrospective analysis of 123 patients (76.4% female), ages 21 to 85, who completed the CPRP at the Cleveland Clinic between January 2007 and December 2011, and were diagnosed using International Classification of Headache Disorders, 2nd edition and International Classification of Headache Disorders, 2nd edition revision, with migraine or headache as a major complaint. Outcome measures included: pain intensity scores present at the moment of questioning where 10 is the maximal (0-10/10), Depression Anxiety Stress Scale (DASS) scores, (measuring mood), and Pain Disability Index scores (measuring function). Repeated measures t-tests were used. Average pain score on admission was 6.4, and 3.4 upon discharge. Average function on admission was moderately impaired, and normalized on discharge. The average depression score was in the moderate range, and had normalized on discharge. The average anxiety score on admission was in the severe range and was in the mild range on discharge. Results indicate that individuals had statistically and clinically meaningful improvement in pain, mood, and function. Data suggest that an interdisciplinary CPRP approach for patients diagnosed with headache can be effective in helping to decrease pain, as well as normalize mood and function. Thus, CPRPs serve as an alternative treatment to multidisciplinary headache programs, interventional pain techniques, and primary care standard headache care.

AB0672 Articular hyper mobility in chronic lumbar pain : touching 10% of the patients

BackgroundChronic lumbar pain is a relative frequent pain problem, with different etiologies: a great part is of no specific origin. Another part of the problem, is the presence of increased...

Acceptance of Pain: Associations With Depression, Catastrophizing, and Functional Disability Among Children and Adolescents in an Interdisciplinary Chronic Pain Rehabilitation Program

The aims of this study were: (1) investigate relations between pain acceptance, depressive symptoms, catastrophizing, and functional disability in pediatric patients in an interdisciplinary chronic pain rehabilitation program, (2) examine changes in acceptance from pre- to posttreatment, and (3) test if changes in acceptance predict changes in depressive symptoms, catastrophizing, and functional disability from pre- to posttreatment. 112 participants, ages 11-18 years, completed the Chronic Pain Acceptance Questionnaire, Adolescent Version, Center for Epidemiological Studies-Depression-Children's Scale, Pain Catastrophizing Scale for Children, and Functional Disability Inventory on admission to and completion of the program. Significant and strong relations between acceptance, depression, catastrophizing, and functional disability were demonstrated. Participants demonstrated significant increases in acceptance and decreases in depression, catastrophizing, and functional disability. Finally, changes in acceptance significantly predicted changes in depressive symptoms, catastrophizing, and functional disability. Pain acceptance is an important variable in the treatment of pediatric chronic pain.

Treatment outcomes of patients with and without active marijuana use within an interdisciplinary chronic pain rehabilitation program

Treatment outcomes of patients with and without active marijuana use within an interdisciplinary chronic pain rehabilitation program

A Smartphone-Based Intervention With Diaries and Therapist Feedback to Reduce Catastrophizing and Increase Functioning in Women With Chronic Widespread Pain. Part 2: 11-month Follow-up Results of a Randomized Trial

BackgroundInternet-based interventions are increasingly used to support self-management of individuals with chronic illnesses. Web-based interventions may also be effective in enhancing self-management for individuals with chronic pain, but little is known about long-term effects. Research on Web-based interventions to support self-management following participation in pain management programs is limited.ObjectiveThe aim is to examine the long-term effects of a 4-week smartphone-intervention with diaries and therapist-written feedback following an inpatient chronic pain rehabilitation program, previously found to be effective at short-term and 5-month follow-ups.Methods140 women with chronic widespread pain, participating in a 4-week inpatient rehabilitation program, were randomized into two groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of one face-to-face individual session and 4 weeks of written communication via a smartphone, consisting of three diaries daily to elicit pain-related thoughts, feelings, and activities, as well as daily personalized written feedback based on cognitive behavioral principles from a therapist. Both groups were given access to an informational website to promote constructive self-management. Outcomes were measured with self-reported paper-and-pencil format questionnaires with catastrophizing as the primary outcome measure. Secondary outcomes included daily functioning and symptom levels, acceptance of pain, and emotional distress. ResultsBy the 11-month follow-up, the favorable between-group differences previously reported post-intervention and at 5-month follow-up on catastrophizing, acceptance, functioning, and symptom level were no longer evident (P>.10). However, there was more improvement in catastrophizing scores during the follow-up period in the intervention group (M=-2.36, SD 8.41) compared to the control group (M=.40, SD 7.20), P=.045. Also, per protocol within-group analysis showed a small positive effect (Cohen’s d=.33) on catastrophizing in the intervention group (P=.04) and no change in the control group from the smartphone intervention baseline to 11-month follow-up. A positive effect (Cohen’s d=.73) on acceptance was found within the intervention group (P<.001) but not in the control group. Small to large negative effects were found within the control group on functioning and symptom levels, emotional distress, and fatigue (P=.05) from the intervention baseline to the 11-month follow-up.ConclusionThe long-term results of this randomized trial are ambiguous. No significant between-group effect was found on the study variables at 11-month follow-up. However, the within-group analyses, comparing the baseline for the smartphone intervention to the 11-month data, indicated changes in the desired direction in catastrophizing and acceptance in the intervention group but not within the control group. This study provides modest evidence supporting the long-term effect of the intervention.Trial RegistrationClinicaltrials.gov NCT01236209; http://www.clinicaltrials.gov/ct2/show/NCT01236209 (Archived by WebCite at http://www.webcitation.org/6FF7KUXo0)

Chronic pain and the interpersonal theory of suicide.

Chronic pain is a known risk factor for suicide. To date, however, few studies of people with chronic pain have tested specific predictions about suicidal ideation that are derived from theory. The interpersonal theory of suicide proposes that the psychological constructs of thwarted belongingness and perceived burdensomeness are unique and independent precursors to suicidal ideation. We tested this hypothesis in a clinical sample of patients with chronic pain. A total of 303 patients of a chronic pain rehabilitation program completed measures of pain severity, duration, and disability; cognitive-affective measures of depression and catastrophizing; and interpersonal measures of relationship distress and self-perceived burden to others. The latter measures were included as indices of the belongingness and burdensomeness constructs. Participants also rated two items pertaining to suicidal ideation. In a multiple regression analysis, both distress in interpersonal relations (β = 0.12, p = .037) and self-perceived burden to others (β = 0.25, p < .001) were significant predictors of suicidal ideation, even after adjusting statistically for demographic characteristics, pain severity and duration, functional limitations, catastrophizing, and depression. These findings suggest that the interpersonal theory is relevant to understanding elevated rates of suicidal ideation among people with chronic pain, and may have broader applicability to other populations with chronic illness or disability.

A Smartphone-Based Intervention With Diaries and Therapist-Feedback to Reduce Catastrophizing and Increase Functioning in Women With Chronic Widespread Pain: Randomized Controlled Trial

BackgroundInternet-based interventions using cognitive behavioral approaches can be effective in promoting self-management of chronic pain conditions. Web-based programs delivered via smartphones are increasingly used to support the self-management of various health disorders, but research on smartphone interventions for persons with chronic pain is limited.ObjectiveThe aim of this trial was to study the efficacy of a 4-week smartphone-delivered intervention with written diaries and therapist feedback following an inpatient chronic pain rehabilitation program.MethodsA total of 140 women with chronic widespread pain who participated in a 4-week inpatient rehabilitation program were randomized into 2 groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of 1 face-to-face session and 4 weeks of written communication via a smartphone. Participants received 3 smartphone diary entries daily to support their awareness of and reflection on pain-related thoughts, feelings, and activities. The registered diaries were immediately available to a therapist who submitted personalized written feedback daily based on cognitive behavioral principles. Both groups were given access to a noninteractive website after discharge to promote constructive self-management. Outcomes were measured with self-reported questionnaires. The primary outcome measure of catastrophizing was determined using the pain catastrophizing scale (score range 0-52). Secondary outcomes included acceptance of pain, emotional distress, functioning, and symptom levels.ResultsOf the 140 participants, 112 completed the study: 48 in the intervention group and 64 in the control group. Immediately after the intervention period, the intervention group reported less catastrophizing (mean 9.20, SD 5.85) than the control group (mean 15.71, SD 9.11, P<.001), yielding a large effect size (Cohen’s d=0.87) for study completers. At 5-month follow-up, the between-group effect sizes remained moderate for catastrophizing (Cohen’s d=0.74, P=.003), acceptance of pain (Cohen’s d=0.54, P=.02), and functioning and symptom levels (Cohen’s d=0.75, P=.001).ConclusionsThe results suggest that a smartphone-delivered intervention with diaries and personalized feedback can reduce catastrophizing and prevent increases in functional impairment and symptom levels in women with chronic widespread pain following inpatient rehabilitation.Trial RegistrationClinicaltrials.gov NCT01236209; http://www.clinicaltrials.gov/ct2/show/NCT01236209 (Archived by WebCite at http://www.webcitation.org/6DUejLpPY)

Interdisciplinary treatment of patients with multiple sclerosis and chronic pain: a descriptive study.

The objective of this study was to examine the efficacy of an interdisciplinary pain rehabilitation program in a multiple sclerosis (MS) population by evaluating changes in mood, pain, and functioning. This descriptive study examined 20 patients with chronic pain and MS who were admitted to the Cleveland Clinic's Chronic Pain Rehabilitation Program (CPRP) between 2000 and 2009. At both admission to and discharge from the CPRP, measures of pain, depression, and functioning were obtained using a pain visual analogue scale (VAS), the Beck Depression Inventory (BDI), the Depression Anxiety Stress Scale (DASS), and the Pain Disability Index (PDI). Outcomes for the MS patients were compared with those of patients without MS who had participated in the same program. The results showed that MS patients who completed the CPRP reported dramatic decreases in pain and depression and an increase in daily functioning. The benefits received by MS patients from the program were similar to those received by patients without MS. Thus programs like the CPRP can result in significant improvements in pain, depression, and functioning among people with MS.

Editorial

As we close out another busy year in caring for patients with multiple sclerosis (MS), the current issue of IJMSC offers another set of articles covering a broad range of topics relevant to MS clinicians and researchers.One important article deals with the initial diagnosis of MS, which is a critical step in defining subsequent treatment approaches, whether these are pharmacologic, rehabilitative, or a mixture of the two. Dr. Lalan and colleagues of the University of Mississippi Medical Center in Jackson contribute to our understanding of how to differentiate neuromyelitis optica (NMO) from MS using magnetic resonance imaging. Given that NMO is treated differently than more standard forms of MS, and that NMO patients may even worsen if given standard disease-modifying agents used in MS, this differentiation between the two entities is critical. The authors offer guidelines that are helpful to all MS clinicians, but especially to those who may not have seen this rarer form of demyelinating disease on a regular basis.Once the diagnosis of MS is established, the next step for an MS clinician is generally to consider whether a disease-modifying agent is appropriate and, if so, which one. An important subsequent step is to make sure that the patient is compliant with this agent. Dr. Dhib-Jalbut of the UMDNJ–Robert Wood Johnson Medical School in New Brunswick, New Jersey, and colleagues describe the effect of a focused training and education program using specialized nurses on compliance with interferon beta-1b in patients with early-onset MS. The program seemed to be effective in increasing patients' adherence to disease-modifying therapy.We have two contributions on specific areas of symptom management in this issue, one being a discussion of the use of a comprehensive pain management program in MS, and the other being a listing of poster presentations at a recent symposium on gait and balance in MS. While some clinicians continue to believe that MS does not cause pain, MS patients clearly experience pain from the disease as well as from multiple other causes, and most MS clinicians feel ill-equipped to effectively help patients with their pain. Dr. Sullivan and colleagues at the Cleveland Clinic in Cleveland, Ohio, describe the experience of MS patients who have chronic pain and have been enrolled in a comprehensive chronic pain rehabilitation program at the Cleveland Clinic. The authors demonstrate that MS patients can have significant improvements in pain, depression, and functioning, with results similar to those experienced by non-MS patients. Dr. Zackowski of the Johns Hopkins University School of Medicine in Baltimore, Maryland, and colleagues have organized a symposium on gait and balance in MS for a couple of years now, and we have the pleasure of including a list of the poster abstract titles from the most recent conference in the print issue, with the full abstracts published in our online edition at IJMSC.org. We are glad to help achieve a wider audience for their excellent work on this important topic.We are particularly pleased to have a contribution from a colleague in Jordan, Dr. Hamed of the University of Jordan in Amman, which discusses the real-life experience of MS patients and how environmental factors hinder their attempts to integrate into the wider community. Dr. Hamed also discusses the potential role for occupational therapists as well as others in planning intervention programs for patients with MS. Although the study involved Jordanian MS patients, the findings are equally applicable to other countries.Closing out this issue are two helpful contributions regarding caregivers of people with MS. Ms. Gupta of Kantar Health in Princeton, New Jersey, along with colleagues at EMD Serono and Pfizer, compares the reported burden of caregiving for MS patients and Alzheimer's disease patients, finding that MS caregivers have a much heavier load in some areas. This interesting study has important implications for policymaking as well as raising our awareness of caregiving issues. Ms. Preissner and colleagues of the University of Illinois at Chicago discuss the difficulty of doing research involving MS caregivers and how to get around these issues in order to advance such research and then develop educational programs to assist the caregivers, who are so crucial to the lives of our MS patients.We also want to remind you that the deadline for submitting abstracts for the Fifth Cooperative Meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis, to be held in the spring of 2013, is December 31, 2012. Enjoy the rest of 2012, and we at IJMSC wish you all a very happy New Year!