Current Pain Severity Research Articles

Characteristics and outcomes of chronic pain patients referred to hospital pain clinics: a prospective observational study.

Understanding the patient referral patterns and medical profiles of patients attending hospital pain clinics, and the therapies offered to them, can provide a useful starting point for evaluating their effectiveness and identifying areas for improvement. A prospective observational study was carried out. Sociodemographic and clinical data were gathered at twelve centres. The diagnoses and pain treatments provided by the referring doctors were compared with the ones provided by pain clinicians. Pain severity and patients' quality of life were measured prospectively. Descriptive statistics were compared. Two-hundred sixty-nine patients referred to 12 outpatient hospital pain clinics in Catalonia were followed for 3 months. Most were referred by orthopaedists (50.0%) or primary care physicians (20.2%). The mean age and time since pain onset were 59.4 and 4.1 years, respectively. Pain clinicians changed the diagnostic labels of 48.5% of the patients. Nearly all patients (89.2%) were receiving pain medications prior to referral. Treatment was modified in 94.8%. Pain clinicians used more interventional and/or alternative therapies (65.1% of patients), opioids (46.8%) and co-adjuvants (38.2%). Three months after referral, the 24-h worst and current pain severity had decreased by 30.9% and 27.8% on average, respectively. The mean (effect size) improvements in a quality of life (the EuroQol 5 Dimensions index) and pain (visual analogue scale) scores were, respectively, 0.16 (0.73) and 6.7 (0.31). Pain clinicians refined the diagnoses and treatments of patients referred to hospital pain clinics and improved outcomes. Relatively few patients are referred from primary care considering the prevalence of chronic pain in this setting.

MP31-18 UTILIZATION OF NIH PROMIS® TOOL FOR EVALUATION OF PATIENT REPORTED OUTCOMES IN UROLITHIASIS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making III1 Apr 2016MP31-18 UTILIZATION OF NIH PROMIS® TOOL FOR EVALUATION OF PATIENT REPORTED OUTCOMES IN UROLITHIASIS Giulia Lane, Suzanne Neises, and Andrew Portis Giulia LaneGiulia Lane More articles by this author , Suzanne NeisesSuzanne Neises More articles by this author , and Andrew PortisAndrew Portis More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1271AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS®) is a validated system of questionnaires intended to measure patients′ symptoms and health-related quality of life across several domains. This is the first report of PROMIS® utilized through the course of acute stone management. METHODS PROMIS® Pain Intensity Short Form 3a and Pain Interference Short Form 6b were offered to all patients at a subspecialty kidney-stone clinic from 6/1/14-9/1/15. Pain intensity items address current, worst, and average pain severity in the preceding week. Pain interference items address life enjoyment and ability to concentrate and perform daily, recreational, and social activities. PROMIS® survey items consist of 5-point Likert scales, which are translated to normally distributed T-scores using a scoring guide. A T-score of 50 represents the American population mean. RESULTS A total of 1707 patients (age 52.0±16 years, 52% male, mean) completed 3965 surveys. Patients surveyed during acute phases of stone management reported T-scores one standard deviation above the mean (T-score>60) for pain interference more often than for pain intensity. (Table 1) Multivariate logistic regression demonstrates strong impact of phase of acute care relative to patients in long-term follow up. (Figure 1) New and post-operative patients were more likely than follow-up patients to report T-scores >60s for both domains. Whereas male patients and those >65 years old were less likely to report scores >60 in both domains. CONCLUSIONS This is the first report describing PROMIS® pain intensity and interference in urolithiasis. PROMIS® scores for these domains are responsive to the phase of acute care for urolithiasis and are influenced by age and gender. The finding of higher patient reported interference as compared to intensity may be useful in management of patient experience. Future association of PROMIS® pain scores with clinical outcomes may provide a valuable tool for stone management. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e426 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Giulia Lane More articles by this author Suzanne Neises More articles by this author Andrew Portis More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Sleep Quality and Reexperiencing Symptoms of PTSD Are Associated With Current Pain in U.S. OEF/OIF/OND Veterans With and Without mTBIs.

Pain, a debilitating condition, is frequently reported by U.S. veterans returning from Afghanistan and Iraq. This study investigated how commonly reported clinical factors were associated with pain and whether these associations differed for individuals with a history of chronic pain. From the Boston metropolitan area, 171 veterans enrolled in the Veterans Affairs Center of Excellence were assessed for current posttraumatic stress disorder (PTSD) symptom severity, current mood and anxiety diagnoses, lifetime traumatic brain injury, combat experiences, sleep quality, and alcohol use. Hierarchical regression models were used to determine the association of these conditions with current pain. Average pain for the previous 30 days, assessed with the McGill Pain Questionnaire, was 30.07 out of 100 (SD = 25.43). Sleep quality, PTSD symptom severity, and alcohol use were significantly associated with pain (R(2) = .24), as were reexperiencing symptoms of PTSD (R(2) = .25). For participants with a history of chronic pain (n = 65), only PTSD symptoms were associated with pain (R(2) = .19). Current pain severity was associated with increased PTSD severity (notably, reexperiencing symptoms), poor sleep quality, and increased alcohol use. These data support the hypothesis that PTSD symptoms influence pain, but suggest that problems with sleep and alcohol use may exacerbate the relationship.

One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders

Previous research suggests that Mulligan's Mobilisation-with-Movement (MWM) technique for the shoulder produces an immediate improvement in movement and pain. The aims of this study were to investigate the time course of the effects of a single MWM technique and to ascertain the effects of adding tape following MWM in people with shoulder pain. Twenty-five participants (15 males, 10 females), who responded positively to an initial application of MWM, were randomly assigned to MWM or MWM-with-Tape. Range of movement (ROM), pressure pain threshold (PPT) and current pain severity (PVAS) were measured pre- and post-intervention, 30-min, 24-h and one week follow-up. Following a one-week washout period, participants were crossed over to receive a single session of the opposite intervention with follow-up measures repeated. ROM significantly improved with MWM-with-Tape and was sustained over one week follow-up (p < 0.001; 18.8°, 95% confidence intervals (CI) 7.3–30.4), and in PVAS up to 30-min follow-up (38.4 mm, 95% CI 20.6–56.1 mm). MWM demonstrated an improvement in ROM (11.8°, 95% CI 1.9–21.7) and PVAS (40.4 mm, 95% CI 27.8–53.0 mm), but only up to 30-min follow-up. There was no significant improvement in PPT for either intervention at any time point. MWM-with-Tape significantly improved ROM over the one-week follow-up compared to MWM alone (15.9°, 95% CI 7.4–24.4). Both MWM and MWM-with-Tape provide a short-lasting improvement in pain and ROM, and MWM-with-Tape also provides a sustained improvement in ROM to one-week follow-up, which is superior to MWM alone.

Pain distribution and predictors of widespread pain in the immediate aftermath of motor vehicle collision

Musculoskeletal pain is common after motor vehicle collision (MVC). The study objective was to evaluate distribution of pain and predictors of widespread musculoskeletal pain in the early aftermath (within 48 h) of collision. European American adults aged 18-65 years presenting to the emergency department (ED) after collision who were discharged to home after evaluation were eligible. Evaluation included an assessment of reported pre-collision psychological characteristics, crash characteristics, current pain severity and location, and current psychological symptoms. Adjusted risk ratios were estimated using generalized linear models. Among 890 participants included in the study, 589/890 (66%) had pain in three or more regions, and 192/890 (22%) had widespread musculoskeletal pain (pain in seven or more regions). In adjusted analyses, the presence of widespread pain was strongly associated with depressive and somatic symptoms prior to collision, pain catastrophizing, and acute psychological symptoms, and was not associated with most collision characteristics (road speed limit, extent of vehicle damage, collision type, driver vs. passenger, airbag deployment). The reported number of body regions that struck an object during the collision was associated with both reported pre-collision depressive symptoms and with widespread pain. More than one in five individuals presenting to the ED in the hours after MVC have widespread pain. Widespread pain is strongly associated with patient characteristics known to be modulated by supraspinal mechanisms, suggesting that stress-induced hyperalgesia may influence acute widespread pain after collision.

Examine of Quality of Life of Elderly Indivudals Suffering Pain

This study aims to examine the quality of life of elderly individuals suffering pain. The study was carried out on 84 individuals over the age of 65 resident at a local authority administered nursing home in Izmir who were suffering pain at the time of the interview. The individuals' introduction form, made up of 12 questions, was used to identify the individuals' socio-demographic characteristics, and the McGill Melzack Pain Questionnaire was used to assess the pain, and the WHOQOL-OLD (World health Organization Quality of Life Scale Older Adults Module) was applied. A significant relationship was found between the current pain severity and the quality of life scale's sensory capacity, today's activities and future activities, and relationship sub-fields and the total points (p<0.05). It was established, as well as the elderly individuals' socio-demographic characteristics, sub-sections such as the features, severity and time of pain also had an effect on the quality of life.

Pilot study: rapidly cycling hypobaric pressure improves pain after 5 days in adiposis dolorosa

Adiposis dolorosa (AD) is a rare disorder of painful nodular subcutaneous fat accompanied by fatigue, difficulty with weight loss, inflammation, increased fluid in adipose tissue (lipedema and lymphedema), and hyperalgesia. Sequential compression relieves lymphedema pain; we therefore hypothesized that whole body cyclic pneumatic hypobaric compression may relieve pain in AD. To avoid exacerbating hyperalgesia, we utilized a touch-free method, which is delivered via a high-performance altitude simulator, the Cyclic Variations in Altitude Conditioning™ (CVAC™) process. As a pilot study, 10 participants with AD completed pain and quality of life questionnaires before and after 20–40 minutes of CVAC process daily for 5 days. Participants lost weight (195.5 ± 17.6–193.8 ± 17.3 lb; P = 0.03), and bioimpedance significantly decreased (510 ± 36–490 ± 38 ohm; P = 0.01). There was a significant decrease in scores on the Pain Catastrophizing Scale (P = 0.039), in average (P = 0.002), highest (P = 0.029), lowest (P = 0.04), and current pain severity (P = 0.02) on the Visual Analogue Scale, but there was no change in pain quality by the McGill Pain Questionnaire. There were no significant changes in total and physical SF-36 scores, but the mental score improved significantly (P = 0.049). There were no changes in the Pain Disability Index or Pittsburgh Sleep Quality Index. These data present a potential, new, noninvasive means of treating pain in AD by whole body pneumatic compression as part of the CVAC process. Although randomized, controlled trials are needed to confirm these data, the CVAC process could potentially help in treating AD pain and other chronic pain disorders.

Toward characterization and definition of fibromyalgia severity

BackgroundThere are no standard criteria for defining or assessing severity of fibromyalgia (FM) as a condition as fibromyalgia is associated with multiple symptom domains. The objective of this study was to evaluate whether patient self-reported severity of FM is associated with severity of pain and sleep interference and the presence of core co-morbidities.MethodsWe recruited individuals ≥ 18 years of age with a clinician-confirmed diagnosis of FM ≥ 3 months and a current pain rating >2 on a 0-10 numeric rating scale (NRS). Patients completed a questionnaire by mail in which they self-rated their FM severity (very mild, mild, moderate, and severe), their current pain severity and extent of sleep interference (NRS; mild, 0-3; moderate, 4-6, severe, 7-10), and provided information (yes/no) on the presence of core comorbidities (symptoms of depression, anxiety, sleep problems, back pain, neck pain) and medication use for FM. The core symptoms of FM were stratified to assist with patient characterization. Analysis of variance (ANOVA) was used to explore the relationship between self-reported FM severity and continuous variables (pain severity and sleep interference), and Mantel-Haenszel chi-square analysis was used to evaluate the trend in the proportions of patients reporting use of medications and core symptoms of FM by severity of FM. To complement patient-reported FM severity and to understand physicians' perspectives, a survey was performed among 28 physician specialists (rheumatology, neurology, anesthesiology/pain management, family practice, internal medicine, and psychiatry) to determine what they assessed when evaluating FM severity in clinical practice.ResultsThe population (N = 129) of FM patients was predominantly female (89.1%), with a mean age of 49.4 ± 11.0 years, and 81.4% reported duration ≥ 2 years. Self-reported FM severity was moderate/severe in 86.0% of patients; mean current pain score was 6.40 ± 2.19 (moderate), and mean sleep interference score was 7.28 ± 2.23 (severe). Greater FM severity was significantly associated with higher levels of current pain and sleep interference (p < 0.0001), the proportion of patients reporting FM medication use (p = 0.0001), and the presence of core comorbidities (p < 0.05). Pain, functional disability, and fatigue severity were ranked as the top three criteria by the highest proportion of physicians when evaluating FM severity.ConclusionWith higher self-reported FM severity, patients have greater pain and sleep interference as well as increased frequency of core comorbidities. Further investigation into understanding FM severity is warranted.

Treatment history, patient satisfaction, and expectations: preliminary observations from a comprehensive patient registry

The Center for Pain Relief implemented a comprehensive registry (MyPainProfile, MPP) that captures patient (1) demographics, (2) history of the painful disorder, (3) history of medication and modalities prescribed. Although 1-3 are commonly obtained, MPP also assesses (4) current pain severity, location, and characteristics, (5) emotional and physical functioning, (6) substance use/misuse, and (7) perspectives on current and future treatments. In this study we focus on treatments. A consecutive sample of 564 patients had a mean age of 47 years (SD =14.8), mean pain duration of 7.6 years (SD = 8.7), and an average pain rating of 5.5 (SD = 2.2).

Ethnic Shifts Raise Issues in Elder Care

BABY BOOMERS MAY SEEM LIKE A thundering herd about to trample the US health care system with a raft of age-related chronic illnesses. But these soon-to-be seniors will challenge health professionals in ways that go beyond their sheer numbers. Theleadingedgeofboomerswhoreach age65yearsin2011willusherinthemost diversepopulationofseniors inthecountry’shistory.By2030, theUSCensusBureauprojectsthattheproportionofwhites aged65yearsorolderwilldeclineby11% whiletheolderblackpopulationincreases by25%.ThepercentagesofHispanicand Asianelderlyareexpectedtonearlydouble (http://www.census.gov/prod/2006pubs /p23-209.pdf). These seismic demographic shifts will require a greater understanding of the different ways in which chronic illnesses and their complications affect diverse elderly populations, said experts at the recent Gerontological Society of America’s annual scientific meeting. Carmen Green, MD, of the University of Michigan, Ann Arbor, said chronic pain severe enough to interfere with daily activities is a “silent epidemic” that affects one-third to half of older US adults. But Green’s work has zeroed in on an area not previously studied: whether the prevalence and severity of chronic cancer-related pain differ between older black and white cancer survivors. She presented preliminary findings fromasampleof400blackandwhitepatients aged 53 to 77 years who survived multiple myeloma or breast, colorectal, lung,orprostatecancer.Overall,17%had painat the timeof thestudyand32%had pain at some point since their diagnosis. The prevalence of pain did not differ between blacks and whites, but blacks reported more severe pain than whites. On a scale of 0 (no pain) to 10 (worst pain imaginable), blacks rated their most severe pain at 6.5 compared with 3.5 for whites. Blacks scored their least severe pain at 2.5 compared with 0.9 for whites. At the time the survey was taken, blacks reported their current pain severity was 4.0 compared with 1.5 for whites. The data did not account for differences in treatment among cancer survivors.

The Minimum Clinically Significant Difference in Visual Analogue Scale Pain Score in a Local Emergency Setting

ObjectivesTo determine whether the minimum clinically significant difference (MCSD) in visual analogue scale (VAS) pain score varies with age, gender, education level and cause of pain (trauma versus non‐trauma) in Chinese patients.MethodsThis was a prospective descriptive study of local Chinese patients 15 years of age or older who presented with pain to the accident &amp; emergency department. On presentation, patients were asked to indicate their current pain severity with a single mark through a standard 100–mm visual analogue scale. Then they would be offered an analgesic for pain‐relief. After 30–45 minutes, the patients were asked to give a verbal categorical rating of their pain as ‘a lot better’, ‘a little better’, ‘much the same’, ‘a little worse’, or ‘much worse’ and to mark the level of pain on a VAS of the same type as used previously. The MCSD in VAS pain score was defined as the mean difference between the current and preceding scores when the subject reported ‘a little worse’ or ‘a little better’ in pain. Data were compared based on gender, age, education level, and traumatic versus non‐traumatic causes of pain.Results186 patients were enrolled in the study, yielding 77 evaluable comparisons where pain was rated as ‘a little better’ or ‘a little worse’. Overall, the MCSD in VAS pain score in the group was 17 mm (95%CI 13.6 mm to 20.6 mm). There were statistically significant differences between the MCSD in VAS pain score between genders and causes of pain (trauma versus non‐trauma).ConclusionsThe MCSD in VAS pain scores was found to be 17 mm. There was significant differences in MCSD in VAS pain score in different genders and between trauma and non‐trauma cases.

The Use of Electromyography to Predict Functional Outcome Following Transforaminal Epidural Spinal Injections for Lumbar Radiculopathy

This study aimed to determine if electromyographic (EMG) diagnostic evaluation can predict functional outcome in patients undergoing transforaminal lumbar spine epidural injections. In this retrospective study, functional outcome by Oswestry Disability Index (ODI) and verbal rating scale (VRS) for current pain severity was evaluated in 39 patients undergoing lumbar transforaminal epidural spinal injections (ESI). Subjects with low back pain (mean age, 60 +/- 12.5 years) were evaluated for functional improvement post EMG and ESI. Of 39 patients tested with EMG before injection, 18 patients were positive for radiculopathy and 21 had a normal or negative examination. The patients were followed postinjection on average of 10.8 (SD +/- 3.9) weeks. Pretreatment ODI scores were not significantly different between groups showing positive (72.3 SD +/- 12.7) and negative (65.9 SD +/- 18.6, P > .05) EMG findings. There was significantly greater improvement of ODI for EMG positive radiculopathy (7.11 SD +/- 9.5) compared with negative EMG (3.2 SD +/- 17.4, P < .05). Positive radiculopathy subjects complained of more pain by VRS before ESI than subjects with negative EMG findings, 8.1 SD +/- 1.0 and 7.3 SD +/- 0.8, respectively, which was not significant (P > .05). VRS mean improvement was not significantly different in the positive EMG group (1.8 SD +/- 1.2) compared with a negative EMG (1.2 SD +/- 1.2, P > .05). The results appear to show that patients undergoing transforaminal ESI, who have a positive radiculopathy by EMG before injection, will have significant improvement in functional outcome by ODI but not with current pain intensity by VRS. This study suggests the importance and diagnostic value of ordering electromyography studies for lumbar radiculopathy evaluation, which may lead to prediction of outcome with lumbar transforaminal epidural spinal procedures. Furthermore, the current study highlights the difficulty of pain evaluation outcome by VRS.

Safety and effectiveness of topiramate for the management of painful diabetic peripheral neuropathy in an open-label extension study

The aim of this study was to further assess the long-term safety and effectiveness of open-label topiramate therapy in subjects with moderately to severely painful diabetic peripheral neuropathy (DPN). Adults aged 18 to 75 years received open-label topiramate (25-600 mg/d for 26 weeks) in an extension of a previously published randomized, double-blind trial comparing topiramate with placebo. Safety analyses included adverse event (AE) reports and clinical laboratory tests. Metabolic end points included body weight and glycosylated hemoglobin (HbA(1c)). Effectiveness analyses included a 100-mm pain visual analog (PVA) scale, worst and current pain severity, and sleep disruption. Two hundred five subjects participated in this open-label extension study (118 formerly treated with topiramate and 87 who formerly received placebo). The groups did not differ in baseline demographics or disease characteristics. One hundred twenty-four (60.5%) subjects (68.6% of former topiramate recipients and 49.4% of former placebo recipients) completed the extension study; the most common reason for discontinuation was an AE (27.3% of subjects). AEs among subjects who received > or =1 dose of topiramate (n = 298) included upper respiratory tract infection (16.1%), anorexia (15.1%), diarrhea (12.8%), nausea (12.8%), paresthesia (10.7%), and headache (10.1%). Baseline pain scores were lower in those formerly treated with topiramate (n = 117) than in the former placebo group (n = 86) (PVA: 43.3 vs 52.5, P = 0.014; worst pain: 1.9 vs 2.5, P < 0.001; current pain: 1.6 vs 1.9, P = 0.026; sleep disruption: 3.6 vs 4.6, P = 0.021). At the final visit, PVA, current pain, and sleep disruption scores were not significantly different between the former topiramate and former placebo groups, but worst pain differed significantly (1.4 vs 1.8; P = 0.025). Mean weight loss from the start of topiramate therapy was 5.2 and 5.3 kg in the former topiramate and former placebo groups, respectively (P < 0.001 vs baseline). Mean HbA(1c) values before and after topiramate treatment were 7.7% and 7.4%, respectively, in the former topiramate group (P = 0.004 vs baseline), and 7.6% and 7.1%, respectively, in the former placebo group (P < 0.001 vs baseline). Although 39.5% of subjects discontinued, most often due to AEs, the results of this 26-week, open-label extension study with topiramate (up to 600 mg/d) in subjects with moderately to severely painful DPN suggest that pain relief was effective and durable.

Modes of Remembering in Patients With Chronic Pain

The objective of our study was to assess the relation of current pain ratings to observer versus field modes of memory retrieval in patients with chronic pain. Memories from an observer perspective involve seeing oneself in the original event as if from an external point of view; memories from a field perspective involve recalling the event as if viewing it through one's own eyes. Sixty-one patients with chronic pain were asked to (1) recall a painful memory, (2) indicate whether they saw themselves in the memory (observer mode) or re-experienced events of the memory from the first-person perspective (field mode), and (3) rate various phenomenologic properties of the memory. Twenty of these pain patients were also given two frontal lobe tests to examine potential neuropsychologic correlates of memory retrieval preferences. Memory retrieval in the field mode was associated with (a) significantly higher self-reported pain scores on the McGill Pain Questionnaire, (b) nonright-handedness, and (c) poorer performance on the tests of frontal function. Patients with chronic pain who adopt the field mode of memory retrieval when recalling painful memories experience greater current pain severity than chronic pain patients who adopt observer retrieval strategies. Those adopting field retrieval strategies may also evidence frontal system neuropsychologic anomalies.

Poster 107: Gabapentin’s effect on functional outcome after epidural spinal injections for lumbar radiculopathy.

Objective: To determine whether the addition of gabapentin can influence functional outcome in patients undergoing lumbar spinal injections for chronic pain. Design: Retrospective study of functional outcome in patients undergoing lumbar epidural spinal injections (ESIs) with and without the addition of gabapentin. Setting: Clinic. Participants: Subjects with chronic low back and radicular pain in the lower extremity were evaluated for functional improvement after ESI. The addition of gabapentin use was factored into the assessment. Interventions: Fluoroscopic guidance of ESI done at the clinically suspected level in the lumbar region. Main Outcome Measures: Oswestry Disability Index (ODI) and verbal rating scale (VRS) for current pain severity. Results: 75 patients with a radiculopathy were evaluated for an ESI. 29 were on gabapentin and 46 were not. The mean gabapentin use ± SD prior to injections was 1662±950mg. The patients were followed postinjection on average for 10.8±3.9 weeks. Posttreatment ODI score (61.9±16.2) was significantly improved ( P<.001) in all cases compared with pretreatment ODI score (66.8±17.3). Pretreatment ODI and VRS scores did not differ significantly between groups showing positive (66.2±17.7, 7.2±1.9) and negative (67.1±17.2, 7.8±1.0) gabapentin use ( P<.05). ODI improvement and VRS postinjection did not differ significantly for positive gabapentin use (6.6±10.8, 6.2±1.6) compared with negative use (3.7±15.3, 6.2±1.4) ( P<.05). Conclusions: Subjects undergoing ESI for chronic radicular pain, who were using gabapentin prior to injection, did not show significant improvement in functional outcome as measured by the ODI or in current pain intensity as measured by the VRS. This study did not demonstrate that gabapentin use prior to spinal procedures has any benefit on the outcome of spinal injections in patients with chronic pain. The limitation of the study was the lack of patients on gabapentin and low functional improvement after ESI. The timing of gabapentin use and the dose of maximal therapeutic benefit were not evaluated by this study.

Abstract 13: Use of electromyography to predict functional outcome after epidural spinal injections for lumbar radiculopathy.

Objective: To determine if electromyographic diagnostic evaluation can predict functional outcome in patients undergoing lumbar spinal injections. Design: Retrospective study of functional outcome in patients undergoing lumbar interforaminal epidural spinal injections (ESIs) after electromyographic testing. Setting: Clinic. Participants: 39 subjects with low back pain with radicular symptoms into the lower extremity were evaluated for functional improvement after electromyography and ESI. Interventions: Fluoroscopic guidance of interforaminal ESI in the lumbar region was performed where positive clinical or electromyographic levels were suspected. Main Outcome Measures: Oswestry Disability Index (ODI) and Verbal Rating Scale (VRS) for current pain severity. Results: Electromyography diagnosed 18 patients with a radiculopathy; 21 had a normal or negative examination. Patients were followed postinjection on average for 10.8±3.9 weeks. Pretreatment ODI scores ± SD did not differ significantly between groups showing positive radiculopathy (72.3±12.7) or negative electromyographic findings (65.9±18.6) ( P>.05). There was significantly greater improvement of ODI rating for electromyography positive radiculopathy (7.11±9.5) compared with negative electromyography (3.2±17.4) ( P<.05). Positive radiculopathy subjects complained of more pain as measured on the VRS before ESI (8.1±1.0) than subjects with negative electromyographic findings (7.3±0.8) ( P>.05). The VRS mean improvement did not differ significantly between the positive electromyography group (1.8±1.2) and the negative electromyography group (1.2±1.2) ( P>.05). Conclusions: Subjects undergoing interforaminal ESI, who had a positive radiculopathy by electromyography prior to injection, showed significant improvement in functional outcome as measured by the ODI but not as measured by current pain intensity on the VRS. This study showed the importance and diagnostic value of electromyography for radiculopathy evaluation prior to spinal procedures and the difficulty of pain evaluation outcome by using the VRS.

Validation of 2 pain scales for use in the pediatric emergency department.

To determine the construct, content, and convergent validity of 2 self-report pain scales for use in the untrained child in the emergency department (ED). A prospective study was conducted of all children who presented to an urban ED between 5 and 16 years of age inclusive after written informed consent was obtained. Children were excluded if they were intoxicated, had altered sensorium, were clinically unstable, did not speak English, or had developmental delays. Children marked their current pain severity on a standardized Color Analog Scale (CAS) and a 7-point Faces Pain Scale (FPS). They were then asked whether their pain was mild, moderate, or severe. Children were then administered an analgesic at the discretion of the attending physician and asked to repeat these measurements. For assessing content validity, the scales were also administered to age- and gender-matched children in the ED for nonpainful conditions. Convergent validity was assessed by determining the Spearman correlation coefficient between the 2 pain scales. A total of 60 children were enrolled, 30 with pain and 30 without, with a mean age of 9.3 +/- 3.3 years. Boys accounted for 38 of the enrollees (63.3%). The median score before analgesic administration was 6.0 cm (interquartile range [IQR]: 4.0-8.0) on the CAS and 3.0 faces (IQR: 2.0-5.0) on the FPS; after analgesic administration, the median scores decreased to 3.1 cm (IQR: 1.1-4.3) and 2.0 faces (IQR: 1.0-3.0), respectively. As the reported pain intensity increased, so did the scores on the 2 pain scales. The 30 children with no pain had a median score on the CAS of 0.0 (IQR: 0.0-1.0) and on the FPS of 0.0 (IQR: 0.0-1.0), whereas the 13 children with severe pain had a median CAS of 7.0 (IQR: 6.0-8.0) and a median FPS of 5.0 (IQR: 4.0-6.0). The Spearman correlation coefficient between the CAS and the FPS was positive and strong (r = 0.894). The CAS and the FPS exhibit construct, content, and convergent validity in the measurement of acute pain in children in the ED.

Reliability and validity of a visual analog scale for acute abdominal pain in the ED

The objective of the study was to assess the validity and reliability of the visual analog scale (VAS) in the measurement of acute abdominal pain, and to identify the minimum clinically significant difference in VAS scores among patients with acute abdominal pain. The study was undertaken in preparation for a randomized clinical trial of opioid use in acute abdominal pain. A prospective, observational cohort study of a convenience sample of patients presenting to 2 urban EDs with the chief complaint of acute abdominal pain was conducted. At time 0 and 1 minute later each subject indicated pain severity on a 100mm VAS. This was repeated every 30 minutes for 2 hours. Patients were also asked to contrast their current pain severity with their pain in the preceding 30 minutes using one of 5 graded verbal descriptors: “much less pain,” “little less pain,” “the same pain,” “little more pain,” and “much more pain.” Validity was assessed by performing an analysis of variance for linear trend on the association between the 5 categorical pain descriptors and change in VAS scores. Reliability was assessed using the intra-class correlation coefficient (ICC) between VAS scores taken 1 minute apart, supplemented by a Bland-Altman analysis. The minimum clinically significant difference in pain was defined as the mean difference between sequential VAS scores obtained 30 minutes apart when the patient noted a “little less” or “little more” pain. Differences in VAS scores increased linearly as pain descriptors escalated from “much less” to “much more” pain (P <.001). Reliability was high, ICC = 0.99 [95%CI 0.989 to 0.992] for 0 and 1 minute VAS scores. The minimum clinically significant difference in acute abdominal pain was 16 mm (95% CI 13, 18 mm). VAS measures of acute abdominal pain are valid and reliable. The 95% CI surrounding the minimum clinically significant difference of approximately 16mm overlaps with the 95% CI of minimum clinically significant difference of approximately 13mm reported previously in traumatic and other types of acute pain. We conclude that the VAS is a methodologically sound instrument for quantitative assessment of acute abdominal pain and for detecting clinically important changes in such pain. (Am J Emerg Med 2002;20:287-290. Copyright 2002, Elsevier Science (USA). All rights reserved.)

Assessment of Clinically Significant Changes in Acute Pain in Children

Objective: To quantify, using two pain assessment scales, the amount of change in pain severity required to achieve a clinically significant improvement in pain in children presenting to a pediatric emergency department (ED) with pain. Methods: Prospective, descriptive study involving all children presenting to a pediatric ED between 5 and 16 years of age inclusive with acute pain. Children were excluded if they 1) were intoxicated or had altered sensorium, 2) were clinically unstable, 3) were non‐English‐speaking, or 4) were developmentally delayed. Written informed consent was obtained. Children were asked to mark their current pain severity on the standardized Color Analogue Scale (CAS) and Faces Pain Scale (FPS). After each pain control intervention the child was asked to repeat these measurements and to describe whether his or her pain was “much less,”“a little less,”“about the same,”“a little worse,” or “much worse” compared with before. This process was repeated until the child was discharged from the ED or had a score of zero. The main outcome measure was the smallest change on the CAS or FPS necessary to cause the child to describe his or her pain as a “little less.” This was defined as the clinically significant change in pain. The “ideal” change in pain was defined as the amount of change necessary for the child to describe the pain as “much less” or at which point the child thought he or she no longer required any medicine to help the pain go away. Results: One hundred twenty‐one children were enrolled with a mean age of 9.8 years (SD ± 3.15). Males accounted for 56%. Pain was traumatic in 65% and nontraumatic in 35%. A total of 153 pain comparisons were made using the CAS and 154 using the FPS. Only three children complained that their pain got worse (two a little worse and one much worse). Pain was described as “the same” in 20. Of the 60 pain comparisons judged to be a “little less,” the CAS score changed by a median of 2.0 cm [interquartile ratio (IQR) 1‐3], and the FPS by 1.0 face (IQR 1‐2). In the 71 children who judged their pain to be “much less,” the CAS decreased by a median of 4.0 cm (IQR 2‐5) and the FPS by 2.0 faces (IQR 2‐3). Conclusions: The assessment and treatment of pain in children are an important component of pediatric practice, especially in the ED. This study provides health care professionals and clinical investigators the information necessary to assess whether their method of pain control in children is clinically relevant.

Pain expectancy and work disability in patients with acute and chronic pain: A test of the fear avoidance hypothesis

According to the fear avoidance model, prolonged disability among patients with chronic nonmalignant pain is due, in part, to an exaggerated fear of pain. At issue in the present study was an attempt to refine the fear-avoidance hypothesis by eliciting estimates of anticipated pain as well as anticipated injury. Along with scores on the Fear Avoidance Beliefs Questionnaire-Work (FABQ-W), a validated measure of fear avoidance, pain and injury expectancies were used as predictors of work disability in a hierarchical regression model. We also examined the possibility that fear avoidance might be confined to patients with chronic pain and thus fail to account for work impairment after the onset of acute injury or illness. Samples of patients with acute (N = 47) and chronic (N = 56) pain completed a battery of psychological tests. Pain and injury expectancies collectively explained 40% to 35% of the variance in work disability compared with 12% to 10% explained by the FABQ-W for the acute and chronic samples, respectively. After controlling for pain duration, depression, somatization, and current pain severity, pain expectancy alone accounted for 16% of the variance in patients in the chronic group (P < .001) and 33% of the variance in patients in the acute group (P < .001). Both pain and injury expectancies were associated equally with work disability for patients in the acute group (P < .001), but only pain expectancy accounted for variance in the chronic group (P < .001). Fear-avoidance beliefs, in the form of cognitive expectancies, may have as much influence on the duration of disability in patients with acute pain as they do in patients with chronic pain. © 2001 by the American Pain Society