Expectations Of Pain Relief Research Articles

High Preoperative Expectations may not Need to be Feared.

Retrospective. Evaluate correlations between preoperative expectations for pain improvement and 12-month functional outcomes and satisfaction following 1-2 level primary anterior cervical surgery. Limited data exists evaluating correlations between patients' preoperative expectations for pain relief and subsequent functional and satisfaction outcomes following primary anterior cervical surgery. Understanding correlations between expectations and outcomes may help identify patients most likely to benefit from surgery. Patients who underwent 1-2 level primary ACDF or CDA for degenerative disease between 2016-2021 were included. All patients had 12-month NDI data. Preoperative expectations for pain relief were collected at the initial clinic visit using 5-point Likert scales. Preoperative and 12-month postoperative satisfaction were recorded using 7-point Likert scales. Covariates including age, gender, procedure type, smoking status, opioid use, worker's compensation/litigation, BMI, and indication (radiculopathy versus myelopathy). Linear regression models were constructed to assess 12-month NDI change score versus pain relief expectations. Additional regression models assessed expectations versus achievement of MCID at 3- and 12-months and satisfaction at 12-months. 198 ACDF (56.1% female, median age 57) and 52 CDR patients (55.8% female, median age 51) were included. Regression models found no significant correlations between pain relief expectations and degree of NDI score improvement at the 12-month postoperative timepoint or MCID achievement at the 3- and 12-month postoperative timepoints. There was no association between preoperative expectations and 12-month satisfaction. However, greater preoperative dissatisfaction was significantly associated with greater 12-month improvement in NDI score. Preoperative pain relief expectations were not associated with functional outcomes or satisfaction following 1-2 level primary ACDF or CDR at 12-month follow-up. Patients' dissatisfaction with their preoperative spinal condition was significantly associated with greater 12-month NDI improvement. Assessing preoperative satisfaction may help identify those most likely to benefit from surgery.

Social media users’ perspectives of spinal cord stimulation: an analysis of data sourced from social media

ObjectivesTo identify Reddit users’ viewpoints and inquiries about spinal cord stimulation (SCS) for chronic back pain using Reddit databases.MethodsWe performed a qualitative analysis of public, anonymous threads and comments from...

Pain Management in Knee Osteoarthritis: Insights from an Exploratory Online Survey of Italian Patients and Physicians.

In Italy, knee osteoarthritis (KOA) accounts for over 5 million prevalent cases and requires long-term multidisciplinary management. The most frequent KOA symptom is pain. The aim of the survey is to provide a national overview of the current management of moderate-to-severe pain associated with KOA from both clinicians' and patients' perspectives. An exploratory qualitative survey was conducted in Italy between July and October 2023. The survey participants were members of four national scientific societies and two patient associations who were invited to participate via email and given an online questionnaire. Questions included a mix of single and multiple responses and scalar items. In total, 1473 clinicians and 150 patients with KOA completed the questionnaire. Patients rated knee pain as both the most burdensome symptom and the most frequent reason for treatment dissatisfaction and seeking consultation. One in two patients declared that they were unsatisfied/little satisfied with the current prescribed analgesic treatments. The clinicians surveyed preferentially prescribed intra-articular hyaluronic acid, oral non-steroidal anti-inflammatory drugs/paracetamol, non-pharmacological intervention, and intra-articular corticosteroids. The clinicians' selection of analgesic therapy often failed to adequately meet patients' expectations for pain relief. Our findings highlight the current unmet needs of patients with KOA in Italy and call for new approaches to effectively optimize the management of KOA-associated pain.

The Interplay Between Health Disparities and Acceptability of Virtual Reality: A Survey Study.

Virtual reality (VR) has emerged as a nonpharmacological adjuvant to manage acute and chronic pain symptoms. The goal of this survey study was to determine the acceptability of VR among chronic pain participants hailing from distressed and prosperous neighborhoods in the state of Maryland. We hypothesized that pain severity and interference vary in groups experiencing health disparities, potentially influencing VR's acceptability. From March 11 to March 15, 2020, we surveyed a cohort of clinically phenotyped participants suffering from chronic orofacial pain. Participants were asked to express their willingness to participate in a longitudinal VR study and their expectation of pain relief from using VR. Seventy out of 350 participants with chronic pain completed the survey (response rate: 20%). There was no difference in the likelihood of responding to the survey based on their neighborhood distress. Among survey respondents and nonrespondents, similar proportions of participants were from distressed neighborhoods. Among the respondents, 63 (90%) and 59 (84.3%) were willing to participate and expected to experience pain relief from the VR intervention, respectively. Age, sex, race, neighborhood distress, severity of pain, and prior VR experience did not influence willingness to participate in the VR trial or the expectations of VR-induced improvement. These findings suggest that VR as an adjuvant intervention is potentially accepted by chronic pain participants, irrespective of neighborhood-level social determinants of health.

Neural circuit basis of placebo pain relief.

Placebo effects are notable demonstrations of mind-body interactions1,2. During pain perception, in the absence of any treatment, an expectation of pain relief can reduce the experience of pain-a phenomenon known as placebo analgesia3-6. However, despite the strength of placebo effects and their impact on everyday human experience and the failure of clinical trials for new therapeutics7, the neural circuit basis of placebo effects has remained unclear. Here we show that analgesia from the expectation of pain relief is mediated by rostral anterior cingulate cortex (rACC) neurons that project to the pontine nucleus (rACC→Pn)-a precerebellar nucleus with no established function in pain. We created a behavioural assay that generates placebo-like anticipatory pain relief in mice. In vivo calcium imaging of neural activity and electrophysiological recordings in brain slices showed that expectations of pain relief boost the activity of rACC→Pn neurons and potentiate neurotransmission in this pathway. Transcriptomic studies of Pn neurons revealed an abundance of opioid receptors, further suggesting a role in pain modulation. Inhibition of the rACC→Pn pathway disrupted placebo analgesia and decreased pain thresholds, whereas activation elicited analgesia in the absence of placebo conditioning. Finally, Purkinje cells exhibited activity patterns resembling those of rACC→Pn neurons during pain-relief expectation, providing cellular-level evidence for a role of the cerebellum in cognitive pain modulation. These findings open the possibility of targeting this prefrontal cortico-ponto-cerebellar pathway with drugs or neurostimulation to treat pain.

Temporal Summation but Not Expectations of Pain Relief Predict Response to Acupuncture Treatment in Fibromyalgia

Fibromyalgia (FM) is a common chronic pain condition for which acupuncture treatment is increasingly utilized. However, there is no universally accepted measure to predict whether a specific patient will benefit from acupuncture. This is a single-center, single-blind, sham-controlled, randomized, noncrossover, longitudinal trial of 76 subjects with FM, assigned to either electroacupuncture (EA) or a placebo control, mock laser (ML) acupuncture. Outcome measures included clinical pain severity (Brief Pain Inventory [BPI]), degree of nociplastic pain (Fibromyalgia Survey Questionnaire), and pressure pain tolerance (PPtol). Baseline measures of temporal summation of pain and expectations for treatment relief were used as predictors. Individuals in both treatment groups experienced significant reductions in BPI (EA: P < .001, ML: P = .018) and Fibromyalgia Survey Questionnaire (EA: P = .032, ML: P = .002) after treatment; however, neither group showed a significant increase in PPtol. Lower temporal summation at baseline was correlated with greater post-treatment improvement in BPI in the EA group (rho = .389, P = .025) but not in the ML group (rho = −.272, P = .109). Lower-baseline temporal summation was correlated with greater decreases in PPtol following EA (rho = .400, P = .040), whereas the opposite was seen for ML (rho = −.562, P = .001). Treatment expectancy at baseline was not correlated with any outcome after EA or ML treatments. Our results support using a quantitative sensory testing metric, temporal summation of pain, but not expectations, to predict analgesia following acupuncture treatment for pain. PerspectiveA randomized study of acupuncture in FM found baseline temporal summation, but not expectations of pain relief, to be predictive of treatment response. Clinical Trial RegistrationRegistered under ClinicalTrials.gov identifier NCT02064296.

Attentional Bias for Opioids in Taiwanese Heavy Smokers with Chronic Noncancer Pain.

Background and Objectives: Attentional bias (AB) for addictive substances is a feature of attention found in individuals with substance misuse or diagnosed with substance use disorders. When AB exists, the attention of the addicted individual may be quickly oriented to cues related to the addictive substance or be maintained on these cues for a longer time. AB toward opioids was found in Western samples of smokers with chronic noncancer pain. The level of AB was dose-responsive. However, similar studies in the Taiwanese population are lacking. This study compared the patterns of AB for opioid analgesics in Taiwanese participants with chronic noncancer pain to that of individuals without pain. This study aimed to investigate if AB toward opioids is presented in Taiwanese heavy smokers who are on long-term opioid therapy for pain control. Materials and Methods: Participants were grouped into chronic noncancer pain smokers, chronic pain nonsmokers, and smokers without pain, according to smoking habits and whether or not on long-term opioid therapy for pain control. Each participant completed demographic questionnaires, mood scales, and the opioid-related visual probe task. Differences in AB among the groups were compared using a three-way analysis of covariance controlling for daily cigarette consumption. Results: Chronic noncancer pain smokers (n = 17) and chronic pain nonsmokers (n = 16) displayed more severe levels of depression, anxiety, and pain, compared to smokers without pain (n = 28). Only did chronic pain nonsmokers show significant AB for opioid cues that were displayed for a short time. Analysis on reaction time found that smokers without pain consistently responded faster to the tasks. No difference in reaction time was found between the pain groups. Conclusions: The current study did not fully replicate findings from studies that were based in Western countries. Formulary availability and regulatory limitations might have affected patient's perception of prescription opioids in Taiwan. However, chronic pain nonsmokers exhibited initial orientation toward opioid-related cues when daily cigarette consumption was accounted for. According to previous research, this AB for shortly displayed opioid cues can be associated with the expectation of pain relief. The current finding also indicated general psychomotor retardation in individuals who were on long-term use of opioids.

Preoperative Rank of Expectations for Shoulder Surgery (PRESS): a novel survey

Patient expectations for orthopedic surgeries, and elective shoulder surgery in particular, have been shown to be important for patient outcomes and satisfaction. Current surveys assessing patient expectations lack clinical applicability and allow patients to list multiple expectations at the highest level of importance. The purpose of this study was to develop and evaluate the use of a novel, rank-based survey assessing the relative importance of patient expectations for shoulder surgery. The Preoperative Rank of Expectations for Shoulder Surgery (PRESS) survey was developed by polling 100 patients regarding their expectations for surgery. The PRESS survey consisted of 8 common expectations for elective shoulder surgery by importance and a 0%-100% scale of expected pain relief and range of motion improvement. After initial development of the PRESS survey, it was administered preoperatively to 316 patients undergoing surgery for shoulder arthritis, rotator cuff tear, subacromial pain syndrome, or glenohumeral instability between August 2020 and April 2021. Patients also completed preoperative outcome measures such as the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Physical Function 7a version 1.0 (PROMIS PF), and PROMIS Pain Interference short form 8a version 2.0 (PROMIS PI) surveys. Patient-reported outcome measure (PROM) surveys were administered 6 months postoperatively. Improvement in range of motion was the expectation most often ranked first for the entire study group (18%), arthritis subgroup (23%), and rotator cuff tear subgroup (19%). Subacromial pain syndrome patients most often ranked improving ability to complete activities of daily living and relieving daytime pain first (19%). Shoulder instability patients most often ranked improving ability to participate in sports first (31%). Patients who ranked improving range of motion or sports highly had better PROMs. Those who ranked relieving pain highly had worse PROMs. Patients with high (>90%) expectations of pain relief had better PROMIS PI scores. Patients with high pain relief expectations in the arthritis and subacromial pain syndrome groups had better PROMs, whereas patients with instability were less satisfied. The novel PRESS survey assesses patient expectations for shoulder surgery in a new, more clinically applicable rank-based format. The responses provided by patients provide actionable information to clinicians and are related to postoperative outcomes. Therefore, the PRESS survey represents a useful tool for guiding discussions between patients and surgeons, as well as aiding in overall patient-centered clinical decision making.

Clinical Significance of Arthroscopic Debridement, Trapeziectomy, and Joint Replacement for Basilar Thumb Joint Arthritis: A Meta-analysis of Pain Score Improvements.

A meta-analysis was conducted comparing the impact of Arthroscopic debridement (AD), trapeziectomy (TRAP), and joint replacement (JR) on the change in pain scores on patients with Basilar thumb joint arthritis (BTJA). Four databases were searched for studies presenting pain outcomes following surgical intervention for BTJA. Pain scores were reported using the Visual Analog Scale (VAS) and compared against the pre-established threshold for Minimal Clinically Important Difference (MCID) of 1.65. Eighteen studies with 763 patients treated with AD(n=102, 13%), TRAP(n=428, 56%), and JR(n=233, 31%) between 2010 and 2023 with a mean follow-up period of 38 ± 28 months were included. There were 25 groups including 4 AD, 14 TRAP, and 7 JR. The mean difference between pre- and post-operative VAS pain was 4.9 ± 2 for all groups. Meta-analysis demonstrated a mean delta VAS of 3.6 (95%CI 1.79-5.38, for AD, 5.1(95%CI, 4.20-6.02) for TRAP and 6.8(95%CI, 5.93-7.97) for JR. ANOVA showed a significant difference between groups (P=0.016). Post-Hoc testing showed a significant difference between AD and JR (P=0.014). A significant improvement in pain scores, surpassing the MCID threshold, was obtained in all surgical interventions. Change in pain score was 2.6 times MCID for AD, 2.9 times for TRAP, and 3.6 times for JR. All interventions showed significant improvement in pain. Variability in treatment options and improvement depends on patient selection and surgeon's preference. This data can be used to counsel patients regarding the expected pain relief. However, longevity, and long-term outcomes warrant further study.

How side effects can improve treatment efficacy: a randomized trial.

While treatment side effects may adversely impact patients, they could also potentially function as indicators for effective treatment. In this study, we investigated whether and how side effects can trigger positive treatment expectations and enhance treatment outcomes. In this pre-registered trial (DRKS00026648), 77 healthy participants were made to believe that they will receive fentanyl nasal sprays before receiving thermal pain in a controlled experimental setting. However, nasal sprays did not contain fentanyl, rather they either contained capsaicin to induce a side effect (mild burning sensation) or saline (inert). After the first session, participants were randomized to two groups and underwent functional MRI. One group continued to believe that the nasal sprays could contain fentanyl while the other group was explicitly informed that no fentanyl was included. This allowed for the independent manipulation of the side effects and the expectation of pain relief. Our results revealed that nasal sprays with a side effect lead to lower pain than inert nasal sprays without side effects. The influence of side effects on pain was dependent on individual beliefs about how side effects are related to treatment outcome, as well as on expectations about received treatment. Functional MRI data indicated an involvement of the descending pain modulatory system including the anterior cingulate cortex and the periaqueductal gray during pain after experiencing a nasal spray with side effects. In summary, our data show that mild side effects can serve as a signal for effective treatment thereby influencing treatment expectations and outcomes, which is mediated by the descending pain modulatory system. Using these mechanisms in clinical practice could provide an efficient way to optimize treatment outcome. In addition, our results indicate an important confound in clinical trials, where a treatment (with potential side effects) is compared to placebo.

Train in Pain: A Review of Exercise Benefits and Application for Individuals With Musculoskeletal Pain

ABSTRACT Exercise is a safe and recommended treatment for individuals experiencing chronic musculoskeletal pain. After receiving medical clearance, strength and conditioning practitioners and clinicians may prescribe exercise for clients with comorbid pain conditions, representing a unique challenge in determining the appropriate exercise prescription. Although exercise is a recommended intervention for pain, pain can also act as a key barrier to exercise participation because of associated increases in pain intensity or location during activity. In addition, biopsychosocial factors integral to the pain experience may affect response to exercise and should be considered when developing an exercise plan of care for this population. Strength and conditioning professionals may also consider the role of contextual factors in the delivery of exercise, such as expectations for pain relief and therapeutic alliance. This narrative review provides an overview of the current evidence regarding exercise for individuals with musculoskeletal pain.

Exploratory evaluation of spinal cord stimulation with dynamic pulse patterns: a promising approach to improve stimulation sensation, coverage of pain areas, and expected pain relief.

The societal burden of chronic pain and the contribution-in-part to the opioid crisis, is a strong motivation to improve and expand non-addictive treatments, including spinal cord stimulation (SCS). For several decades standard SCS has consisted in delivery of tonic pulses with static parameter settings in frequency, pulse width, and amplitude. These static parameters have limited ability to personalize the quality of paresthesia, the dermatomal coverage, and thus may affect SCS efficacy. Further, static settings may contribute to the build-up of tolerance or loss of efficacy of the therapy over time in some patients. We conducted an acute exploratory study to evaluate the effects of SCS using time-dynamic pulses as compared to time-static (conventional tonic) stimulation pulses, with the hypotheses that dynamic pulse SCS may enable beneficial tailoring of the sensation and the patient's expectation for better pain relief with SCS. During a single clinic visit, consented subjects undergoing a standard SCS trial had their implanted leads temporarily connected to an investigational external stimulator capable of delivering time-static and six categories of time-dynamic pulse sequences, each characterized by continuously varying a stimulation parameter. Study subjects provided several assessments while blinded to the stimulation pattern, including: drawing of paresthesia maps, descriptions of sensation, and ratings for comfort and helpfulness to pain relief. Even without optimization of the field location, a majority of subjects rated sensations from dynamic stimulation as better or equal to that of static stimulation for comfortableness and for helpfulness to pain relief. The initial data showed a gender and/or pain dermatomal location related preference to a stimulation pattern. In particular, female subjects and subjects with pain at higher dermatomes tended to rank the sensation from dynamic stimulation better. Dynamic stimulation produced greater pain coverage without optimization; in 70% (9/13) of subjects, maximal pain coverage was achieved with a dynamic stimulation pattern. There was also greater variety in the words used by patients to describe stimulation sensation in the free text and free form verbal descriptions associated with dynamic stimulation. With the same electrode configuration and comparable parameter settings, acute SCS using dynamic pulses produced more positive ratings, expanded paresthesia coverage, and greater variation in sensation as compared to SCS using static pulses, suggesting that dynamic stimulation has the potential to improve capabilities of SCS for the treatment of chronic pain. Further study is warranted. This study was registered at ClinicalTrials.gov under ID NCT02988713, November 2016 (URL: https://clinicaltrials.gov/ct2/show/NCT02988713).

Patient Values and Preferences for Managing Acute Dental Pain Elicited through Online Deliberation.

Patient values and preferences (PVP) are among multiple sources of information panelists synthesize when developing clinical practice guidelines (CPG). Patient and public involvement (PPI) can be critical for learning PVP; however, the methodology for engaging patients in CPG development is lacking. Deliberative engagement is effective for obtaining public views on complex topics that require people to consider ethics, values, and competing perspectives. Elicit comprehensive understanding of PVP concerning oral analgesics for managing acute dental pain consecutive to toothache and simple and surgical dental extractions, with consideration of associated outcomes, both desirable and undesirable. Multistage engagement involving 2 electronic surveys and a 90-min online small group deliberative engagement. Adults who have experienced acute dental pain deliberated about 3 hypothetical scenarios stratified according to expected pain intensity, completed a postdeliberation survey, and validated a PVP statement developed by researchers based on review of qualitative data from deliberations and quantitative data from surveys. Participants affirmed the PVP statement reflected their small group deliberations and their individual views. Most indicated that pain relief is critical to deciding which pain relief medicine they would want regardless of expected pain level. Most also identify as critical concerns about substance abuse or misuse, although many believe it unlikely that they will experience these outcomes over the brief prescription timeframe for acute dental pain. Participants identified agency in decision-making, consultation including "better communication" of options, and treatment actions tailored to life circumstances as key values. Participants preferred nonprescription and nonopioid pain relief options. As expected pain levels increased, more participants expressed willingness to accept opioids, but more also mentioned rescue analgesia as a third outcome critical to decision-making. Online deliberative method provided opportunities for obtaining informed perspectives. Guideline developers and policymakers may find online deliberations useful for eliciting PVP related to health outcomes. Study results informed the US Food and Drug Administration-funded clinical practice guideline on the management of acute dental pain. Findings may be a resource for clinicians in decision-making conversations with patients regarding expectations for pain relief and positive and negative outcomes of differing pain relief medications. Further research should pursue applicability of online deliberative engagement as a method to elicit patient values and preferences.

Patient's expectations of surgery for lumbar degenerative spondylolisthesis: analysis by type of surgery and patient factors from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUND CONTEXTPreoperative expectations influence postoperative outcomes. Patients with lumbar degenerative spondylolisthesis have especially high expectations of pain relief and overall functional well-being compared to patients with lumbar stenosis. PURPOSEThe primary objective was to analyze preoperative expectations of lumbar DS patients with respect to the type of surgery proposed (decompression vs decompression and fusion). Secondarily, we aimed to assess the associations between preoperative expectations and patient and clinical factors as well as postoperative expectations fulfillment. STUDY DESIGN/SETTINGPatients were prospectively enrolled in a multicenter, prospective cohort study evaluating the assessment and management of degenerative spondylolisthesis utilizing the infrastructure of the Canadian Spine Outcomes and Research Network (CSORN) surgical registry. PATIENT SAMPLEPatients with a diagnosis of degenerative spondylolisthesis with symptoms of neurogenic claudication or radiculopathy with or without back pain, unresponsive to nonoperative management over at least 3 months were included. Patients who underwent decompression, decompression and posterolateral fusion or decompression and interbody fusion at Canadian spine centers between January 2015 and September 2021 were included. OUTCOME MEASURESThe North American Spine Society Lumbar Spine Questionnaire was utilized for expectations measurement. The expectation questionnaire was completed following consent and before surgery and at 1 year. METHODSExpectations for pain relief and improvements in overall functional well-being were rated on a scale of 0 to 100. Preoperative expectation in terms of pain relief and functional well-being score were calculated. Multivariate linear regression was used to evaluate the association between expected preoperative patient factors and pain relief and functional well-being. The factors associated with the most important expectation were evaluated using multivariable multinomial logistic regression. RESULTSThree hundred fifty-two patients were included with 100 patients undergoing decompression and 252 patients also undergoing fusion. The seven items of preoperative expectations did not differ between the procedure groups nor did expected change. The mean pain relief and overall functional well-being expectation scores did not significantly differ between procedures.Higher expectations were associated with having more comorbidities [β=-2.0 (SE 0.8), p=.020], being physically active [β=8.4 (SE 3.2), p=.010] and having more leg pain [β=1.6 (SE 0.7), p=.015]. Better perceived physical health measured by SF12 PCS was associated with lower expectation of pain relief [β= -0.4 (SE 0.2), p=.039] and functional well-being [β=-0.84 (SE 0.2), p=.001]. Better perceived mental health measured by SF12 MCS was associated with lower expectation of functional well-being [β=-0.8 (SE 0.2), p=.001].Postoperative expectations fulfillment did not differ between procedures. CONCLUSIONPreoperative expectations in terms of pain relief and functional well-being were similar between the two most common procedures performed, decompression ± fusion. Secondarily, higher preoperative expectations were associated with greater pain, disability and being physically active. Expectations fulfillment did not differ between procedures.

Mechanisms of chiropractic spinal manipulative therapy for patients with chronic primary low back pain: protocol for a mechanistic randomised placebo-controlled trial

IntroductionChronic low back pain (CLBP) is a highly prevalent and disabling condition. Identifying subgroups of patients afflicted with CLBP is a current research priority, for which a classification system based...

Efficacy of Cannabidiol Versus Ibuprofen in the Relief of Menstrual Pain in Females Living with Primary Dysmenorrhea A phase II, Non-Inferiority trial

Introduction: Pain is the cardinal symptom in women living with primary dysmenorrhea (PDM), resulting in a relentless negative effect on their quality of life.&nbsp; Women with PDM have higher levels of prostaglandin in their endometrial fluid, which correlates with the degree of pain. The standard of care treatment for pain associated with PDM starts with nonsteroidal anti-inflammatory drugs (NSAIDs) that block prostaglandin-triggering enzymes. Although NSAIDs present as a feasible option, they are also associated with a significant risk of side effects. Around 20 to 25% of patients will experience pain refractory to NSAIDs and will then seek alternative therapies. Cannabidiol (CBD) is a well-tolerated potential therapy for several chronic diseases, including pain, and acts by blocking prostaglandin-triggering enzymes, similarly to NSAIDs. The safety of CBD is well established, with the advantage of it acting via central and peripheral mechanisms. To date, no previous trials assessing CBD alone for dysmenorrhea have been conducted. Objective: To evaluate the effect of CBD alone in the reduction of acute menstrual pain compared to ibuprofen, as assessed by the total pain relief (TOTPAR) scale. Design: Randomized (with random block sizes), triple-blinded, multicenter, parallel-group, non-inferiority clinical trial. Setting: St. George, Scarborough, and Mississauga campuses at the University of Toronto, Ontario, Canada. Participants: PDM patients aged 18 to 40 years, regular menstrual cycles (ranging from 21 to 35 days), and a visual analog scale (VAS) score of ≥ 5. Intervention: 108 patients will be randomized with an allocation ratio of 1:1 to either CBD 200 mg/day or ibuprofen 800mg/day. The sample size is based on a mean expected pain relief for ibuprofen of 16.49 and CBD of 14.02, as assessed by the TOTPAR scale and on a 30% estimated dropout rate. Main Outcome Measures: The primary outcome will be the mean difference in the TOTPAR scale (range, 0-4) after taking the study drugs over four menstrual cycles. TOTPAR will be assessed after 1, 2, 3, 4, 5, and 6 hours after taking the study drugs. Secondary outcomes include pain VAS, adverse events, the need for breakthrough medications, and quality of life (QoL). Discussion: NSAIDs may cause troubling side effects, and CBD is well tolerated in clinical trials, with acceptable adverse event profiles. Numerous randomized clinical trials have demonstrated the safety and efficacy of CBD in alleviating central and peripheral pain of other disorders. The results of this trial aim to provide much-needed evidence that oral CBD alone is an alternative for the treatment of menstrual pain in women with PDM. CBD presents as an important promise for women with PDM who do not respond or who have contraindications to NSAIDs. Keywords: Cannabidiol, CBD, menstrual pain, ibuprofen, pain relief, non-inferiority, dysmenorrhea

Exploring the Feasibility of Virtually Delivered Auricular Point Acupressure in Self-Managing Chronic Pain: Qualitative Study.

Background Chronic pain remains highly prevalent. Current pharmacological and non-pharmacological strategies have not adequately managed chronic pain which has contributed to disability and high healthcare costs. With existing challenges in providing adequate pain care and access, we tested vAPA, a virtually delivered, self-management intervention using Auricular Point Acupressure (APA) by mobile app and virtual consultations (telehealth). Our key purpose was to evaluate the feasibility of the vAPA in self-managing chronic pain in preparation for a future randomized controlled trial. Methods We conducted a descriptive, qualitative study evaluating our 4-week vAPA intervention among 18 participants. We used directed qualitative content analysis. Results and Conclusion. Participants perceived that vAPA was feasible (acceptable, useable, practical, and beneficial). In addition, the following themes were gathered: better control of pain, less use of pain medications, self-management and motivation in pain, and expectations for pain relief. Refinements were recommended for the app, content, and delivery to improve study interventions. Findings are relevant in moving forward to a future randomized controlled trial and for wider implementation in a pragmatic clinical trial.

Patient Expectations About Palliative Treatment for Symptomatic Spinal Metastases: A Qualitative Study

ObjectivesPatients with spinal metastases often receive palliative surgery or radiation therapy to maintain or improve health-related quality of life. Patients with unrealistic expectations regarding treatment outcomes have been shown to be less satisfied with their post-treatment health status. This study evaluated expectations of patients with spinal metastases scheduled for surgery and/or radiation therapy. MethodsIndividual semistructured interviews were conducted with patients with symptomatic spinal metastases before and 6 weeks after surgery and/or radiation therapy. Expectations regarding treatment outcomes were discussed before treatment, and level of fulfillment of these pretreatment expectations was discussed after treatment. Interviews were recorded, transcribed and analyzed according to the thematic analysis method to identify themes. ResultsBefore treatment, patients thought they were not, or minimally, informed about (expected) treatment outcomes, but they felt well informed about treatment procedures and possible complications. Although patients expected pain relief and improvement in daily functioning, they found it difficult to describe any recovery timeline or the impact of these expected improvements on their daily life. Patients generally understood that treatment was not curative, but lacked insight into the impact of treatment on life expectancy given that this was hardly discussed by their surgeon and/or radiation oncologist. Pretreatment expectations regarding pain and daily functioning were only partially met in most patients post-treatment. ConclusionsPatients thought they were not, or only minimally, informed about expected outcomes after surgery and/or radiation therapy for symptomatic spinal metastases. Improvements in patient-physician communication and counseling could help guide patients toward realistic pretreatment expectations.

Music-Induced Analgesia in Healthy Participants Is Associated With Expected Pain Levels but Not Opioid or Dopamine-Dependent Mechanisms.

Music interventions accommodate the profound need for non-pharmacological pain treatment. The analgesic effect of listening to music has been widely demonstrated across studies. Yet, the specific mechanisms of action have still to be elucidated. Although the endogenous opioid and dopamine systems have been suggested to play an important role, a direct link has not been established. In addition, the involvement of placebo mechanisms is likely while largely unexplored. We examined the analgesic effect of music in healthy participants (n = 48) using a 3 × 3 within-subjects design with pharmacological manipulations and a matched, auditory control for music. Participants were exposed to thermal pain stimuli while listening to three auditory excerpts: music (active condition), nature sound (matched, auditory contextual condition), and noise (neutral control condition). The participants rated their expected and perceived pain levels in relation to each of the auditory excerpts. To investigate the involvement of the endogenous opioid and dopamine systems, the test session was performed three times on separate days featuring a double-blind randomized oral administration of naltrexone (opioid antagonist), haloperidol (dopamine antagonist), and an inactive agent (control). Our results support an analgesic effect of music. Contrary to current hypotheses, neither of the antagonists attenuated the effect of music. Yet, the participants' expectations for pain relief predicted their perceived pain levels during the auditory excerpts—even when controlling for a gradual learning effect. In conclusion, we demonstrate that the analgesic effect of music is at least partially mediated by expectations of an analgesic effect—a core mechanism in placebo effects—but not by opioid and dopamine-dependent mechanisms.Clinical Trial Registrationwww.clinicaltrials.gov, identifier: NCT03410563.

Why patients fail to achieve a Patient Acceptable Symptom State (PASS) after total shoulder arthroplasty?

BackgroundThe purpose of this study was to compare patient-reported outcomes (PROs) and range of motion (ROM) measurements between patients achieving and failing to achieve a Patient Acceptable Symptom State (PASS) after anatomic total shoulder arthroplasty (TSA) to determine which PRO questions and ROM measurements were the primary drivers of poor outcomes.MethodsA retrospective review of a multicenter database identified 301 patients who had undergone primary TSA between 2015 and 2018 with ROM and PRO data recorded preoperatively and at a minimum of two years postoperatively. The primary outcome was the difference in active ROM between patients achieving and failing to achieve the PASS threshold for the American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. The secondary outcome was the difference in self-reported pain levels between those achieving and failing to achieve a PASS.ResultsBased on the ASES PASS threshold, 87% (261/301) of patients achieved a PASS after TSA, whereas 13% did not. Based on the SANE PASS threshold, 69% (208/301) of patients achieved a PASS after TSA, whereas 31% did not. Patients who failed to achieve a PASS after TSA were younger and had lower short form-12 mental health scores than those who did. There was a significant difference in pain between those who achieved and failed to achieve a PASS after TSA (ASES PASS current shoulder pain 16.5% vs. 95%, P < .001, SANE PASS current shoulder pain 13% vs. 58.1%, P < .001). Those failing to reach a PASS had significantly higher pain levels (ASES PASS Visual Analog Scale pain scores [4.2 vs. 0.4, P < .001] and SANE PASS Visual Analog Scale pain scores [2.0 vs. 0.4, P < .001]) and worse function in nearly all domains of the ASES and Western Ontario Osteoarthritis of the Shoulder index after surgery. There was little difference in ROM between those reaching and failing to reach a PASS (no difference in active external rotation with the arm adducted, active internal rotation at the nearest spinal level, or active internal rotation with the shoulder abducted to 90 degrees for ASES and SANE PASS).ConclusionThere is variability in the percentage of patients who achieve a PASS after TSA, ranging from 69% to 87% depending on the PRO used to define the threshold. Patients who did not achieve a PASS after TSA were significantly more likely to have pain, whereas there were very few differences in ROM, indicating pain as the primary driver of failing to achieve a PASS. Setting realistic postoperative expectations for pain relief may be important for improving patient-reported results after TSA.