Higher Average Pain Research Articles

Neuropathic pain is a feature in patients with symptomatic femoral acetabular impingement

Femoral acetabular impingement syndrome (FAIS) is a cause of hip pain thought to be nociceptive, although pain phenotypes e.g., burning, pain attacks, prickling, numbness etc., are reported, mimicking neuropathic pain. Although no lesion to the somatosensory system is identified, neuropathic pain (NeP) may explain why nociceptive-focussed treatments are not always successful. ObjectiveTo identify NeP in patients with FAIS and investigate if related to poorer outcomes. DesignA secondary analysis of the Femoral Acetabular Impingement Trial (FAIT). Outcome of interest: PainDETECT questionnaire; secondary outcomes of interest; International Hip Outcome Tool (iHOT33), Hospital Anxiety and Depression Scale (HADS) and VAS ‘average pain over a month’, at baseline and 8 months follow-up. Intervention (surgery or physiotherapy) were pooled. Results173 data sets at baseline; 123 at 8 months follow-up. Baseline painDETECT identified three groups: 69% nociceptive, 19% unclear and 12% neuropathic pain phenotypes. Baseline, median scores were higher for the neuropathic group compared to the nociceptive group demonstrating borderline anxiety (9.5(5.3 to 14.2), 5(3 to 8), higher normal values for depression (7.5(2.3 to 11.8), (4(2 to 9), higher average pain (7 (6 to 8), 5(4 to 6) and lower iHOT33 14.2(9 to 21.1), 38.4(26.2 to 55.7). Post treatment, there was a median change in the neuropathic score in both iHOT33 (40.8 (25 to 76.5) with a median difference of 24.13 (CI 95% 10.46 to 45.92) and average pain 4.5(1.5 to 7) with a median difference of 2 (CI 95% 1 to 5) but to a lesser amount than the nociceptive group, iHOT33 (64(38.2 to 86.6) with a median difference of 15.50 (CI 95% 6.41 to 21.82) and average pain 3(1 to 5.7) with a median difference of 1 (CI 95% 0.5 to 1). ConclusionNeP exists in symptomatic FAIS patients and is associated with increased average pain, and functional limitations. Nociceptive-targeted treatment improves hip function and pain but with less improvement in the NeP group when compared to the nociceptive group.Pain phenotyping before intervention may improve outcomes. Contribution of paper•Neuropathic pain is a feature in patients with Femoral Acetabular Impingement Syndrome (FAIS).•Neuropathic pain is related to borderline levels of anxiety, higher average pain and poorer hip function.•Nociceptive focused treatment improves hip function and average pain in patients with neuropathic pain but to a lesser extent than patients with nociceptive pain.

ПСИХО-ЕМОЦІЙНІ АСПЕКТИ ФОРМУВАННЯ ХАРАКТЕРИСТИК БОЛЬОВИХ СИНДРОМІВ У ХВОРИХ НА РОЗСІЯНИЙ СКЛЕРОЗ

Introduction: Pain syndromes, anxiety, and depression are common syndromes in multiple sclerosis (MS). Comorbidity of pain and depression or pain and anxiety exists in up to one-third of MS patients. Based on the biopsychosocial model of pain, given the high prevalence of these symptoms and their frequent combination in MS, which is significantly higher than in the general population, we can hypothesize the relationship between the characteristics of pain and anxiety and depression in patients with MS. Objectives: To assess the prevalence of anxiety and depression among MS patients with pain syndromes and analyze the relationship between anxiety and depression with pain syndromes' characteristics in patients with MS. Methods: Data were collected prospectively at Lviv Regional Multiple Sclerosis Center. 120 randomly selected patients with a confirmed diagnosis of multiple sclerosis were examined. 104 of them had pain syndromes during the last month. Complaints and medical history, analysis of medical records, neurological and general medical examination of the patients were collected. Depressive symptoms and anxiety were assessed in all patients using the Hospital Anxiety and Depression Scale (HADS) questionnaire. In patients with pain syndromes, the Visual analogue scale (VAS), Short-form McGill Pain Questionnaire 2 (SF-MPQ-2), Pain Detect were used to assess pain characteristics. Results: The levels of anxiety and depression were higher in the group of MS patients with pain. The level of anxiety was 9.0 [6,0; 12,75] in the group with pain and 7.0 [4,0; 9,25] in the group without pain (p=0.04). The level of depression was 7.0 [4,0; 10,0] in the group with pain and 4.0 [1,75; 6,0] in the group without pain (p<0,01). It was found that part of MS patients with pain syndromes with anxiety was 36.5%, and 29.8% had a subclinical level of anxiety; part of MS patients with pain syndromes with depression was 19.23%. The proportion of patients with anxiety was highest in patients with neuropathic pain: 56.3% ± 8.8% vs. 22.4% ± 6.0% with nociceptive, p<0.01. A similar situation is observed in patients with depression. The share of patients with depression was higher in the group with neuropathic pain 37.5% ± 8.6%, compared to 14.3% ± 5.0% with nociceptive, p=0.02. The proportion of patients with MS without signs of anxiety and depression is significantly higher among patients with nociceptive pain (p<0,05). Also, the correlational relationship between the level of anxiety and depression with the level of the neuropathic type of pain manifestation was found (r=0,40; p<0,01 and r=0,30; p<0,01). Levels of anxiety and depression correlated with the average pain intensity per month (r = 0,21; p=0,03) and did not have a statistically significant relationship with pain intensity at the time of examination and the strongest pain for the last month. The anxiety and depression had correlations with all components of the structure of pain syndromes (according to sfMPQ-2), but the most pronounced direct correlation was found between anxiety and the affective component of pain (r=0,57; p<0,01). It was also found that the level of anxiety was proved to be higher in patients who have 2-3 pain syndromes, than in patients with one pain syndrome: 12.0 [8,0; 14,0] points against 8.0 [5,0; 11,0] points, p<0.01. Besides, this localization of pain in the arms, shoulders and back was related to higher levels of anxiety (r=0.22; p=0.03). Conclusion: Pain syndromes, anxiety, and depression are widespread among patients with MS and there is a relationship between them. MS patients with pain have higher levels of anxiety and depression than MS patients without pain. It is also noteworthy that among MS patients with pain syndromes, high levels of anxiety are detected. Anxiety and depression also have a pronounced relationship with a neuropathic component of pain in patients with MS. Besides this, the presence of more than one pain syndrome, high average pain intensity per month is associated with higher levels of anxiety and depression. The localization of pain in the arms, shoulders and back is related to higher anxiety levels. These discoveries, combined with modern neuroimaging technologies used in the next step of our study, will provide a better understanding of both pain and its structure, as well as anxiety and depression

Race, pain, and opioids among patients with chronic pain in a safety-net health system

BackgroundRecent changes in opioid prescribing practices in the US may exacerbate disparities in opioid access among Black compared to White patients. MethodsTo evaluate racial disparities in opioid prescribing and stewardship, we used baseline data collected from 2017 to 2019 for a longitudinal cohort of patients with chronic non-cancer pain and a history of illicit substance use. Sociodemographic characteristics, pain, psychological distress, substance use, and opioid prescription practices were compared between Black and White participants. We conducted multivariable logistic regression with race as the outcome. We also compared yellow flag events (opioid-related emergency department visits, illicit substances on urine drug screens, provider-documentation of concerning behaviors) by race. ResultsOver half of participants analyzed were Black (57%) and the remainder White (43%). Participants with worse average pain in the past three months (adjusted odds ratio [AOR]:1.29, 95%CI:1.08−1.55, p = 0.006) had higher odds of being Black. Past-year injection drug use (AOR:0.39, 95%CI:0.16−0.94, p = 0.04) and a higher past-year maximum opioid dose (AOR per 10 morphine milligram equivalents (MME):0.99, 95%CI:0.98−1.00, p = 0.006) were associated with lower odds of being Black. We found no differences by race in the use of opioid stewardship measures or discontinuation of opioids based on yellow flag events. ConclusionLower past-year maximum MME dose, despite higher average pain and less injection drug use, may represent bias away from prescribing opioids for chronic pain among Black patients. This could be due to unmeasured implicit provider bias or patient-level factors (e.g., utilizing non-opioid pain coping strategies or being less likely to request additional opioids).

Comparison of pain during intravitreal dexamethasone, ranibizumab and aflibercept injection

BackgroundThis study aimed to compare pain scores of patients during intravitreal aflibercept, ranibizumab or dexamethasone implant injection procedures.MethodsThis study included 162 eyes of 162 patients, who received intravitreal ranibizumab, aflibercept or dexamethasone implant injections at our clinic. Following the injection, patients were asked to rate their pain from 0 (no pain) to 10 (worst pain) using a visual analogue pain score survey (VAS). VAS was evaluated according to age, sex, indication for the injection, number of previous intravitreal injections, and lens status in the study eye.ResultsThe mean VAS in the ranibizumab, aflibercept or dexamethasone implant groups was 3.38 ± 2.31, 3.82 ± 2.46, and 3.61 ± 2.94, respectively. Female patients reported a higher average pain score than male patients (p = 0.02). Also, phakic patients reported a higher average pain score than pseudophakic patients (p = 0.01). Pain did not significantly correlate with indication for the injection, number of injections, and injection drugs (p > 0.05).ConclusionPain associated with intravitreal injection is generally mild and associated with sex, age, and lens status. There was no significant difference in pain between intravitreal injections of dexamethasone implant, ranibizumab or aflibercept.

0829 Sleep, Chronic Pain, and Global Health in Adults Ages 65 or Older

Abstract Introduction Understanding the association of sleep and pain in older adults can help improve their global health. The purpose of the study was to describe the associations between sleep, chronic pain, and global health in adults ages 65 or older. Methods This study was a secondary analysis of data from adults over 65 years in the 2015 Sleep in America Poll - Sleep and Pain by the National Sleep Foundation (NSF). The survey included demographics (age, race, marital status, education), sleep (duration, quality, insomnia symptoms), and pain (type [none, chronic, fleeting], intensity, location). Global health derived from general health, physical health, mental health, and quality of life with a potential range of 4-20; higher score=better health. The survey also queried fatigue and stress. Results The sample (N=248) was 65-91 years (mean age=72.8±5.9), male (53.6%), White (82.7%), married (65.7%), and with post-highschool education (54.4%). Average sleep duration was 425±74 minutes. “No pain” was reported by 38.7% of the sample (n=96), “fleeting pain” by 32.7% (n= 81), and “chronic pain” by 28.6% (n=71). The most common locations for chronic pain were shoulder or neck (63.2%) and back (69.4%). Average global health score was 9.8±2.9. There was no significant difference in time in bed, sleep duration, bedtime, or wake-up time between groups. Persons with chronic pain had higher average pain intensity, worst pain intensity, and current pain; they reported significantly lower sleep quality with significantly more restlessness, trouble staying asleep, and worry about getting a good night sleep (all p-values<.02), there was no significant difference in difficulty falling asleep compared to persons with no pain. Persons with chronic pain had significantly worse general health, physical health, mental health, global health, fatigue, and stress (all p-values<.02); but no significant difference in quality of life compared to persons with no pain. Conclusion We conclude that chronic pain has a significant negative impact on sleep and global health in the sample of adults ages 65 or older from the 2015 Sleep in America Poll - Sleep and Pain by the NSF. Support Undergraduate Research Mentoring Program, University of Pittsburgh School of Nursing.

Clinical and Workplace Outcomes From a Virtually Delivered Cognitive Behavioral Therapy Program for Pain.

To evaluate clinical and workplace outcomes from an evidence-based virtual behavioral therapy program for individuals with pain and behavioral health issues. This was a retrospective de-identified data analysis among a cohort of 1,086 participants enrolled in a standardized, evidence-based telebehavioral therapy program between September 1, 2016, and August 31, 2017 (mean age 53±11.5years; 29% male). The program was delivered over approximately 8weeks by licensed therapists and behavior coaches by telephone or video, and tailored to the pain management and behavioral health goals of each participant. Structured measurements were documented in the electronic clinical record, including demographics, comorbidities, pain severity (Pain Intensity, Enjoyment of Life, General Activity tool), behavioral health symptoms (Depression, Anxiety and Stress Scale short form), and productivity (Work Productivity and Activity Impairment survey). At baseline, participants had high average pain severity (5.8/10 points), high frequencies of behavioral health symptoms (68%), and activity impairment (90%); absenteeism (34%) and presenteeism (75%) were observed among employed individuals. Pain severity and pain interference improved by 17% and 27%, respectively, over 8weeks (P<0.0001). Reductions in depression, anxiety, and stress symptoms were significant and associated with reductions in pain interference (P<0.0001). Absenteeism, presenteeism, and activity impairment ratings each improved by more than 25% (P<0.0001). Participants in a virtually delivered behavioral therapy program for pain experienced significant improvements in pain intensity, pain interference, behavioral health symptoms, and work productivity.

Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions.

Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

Genetic variability of tramadol pharmacokinetic genes and pain treatment outcome after breast cancer surgery.

e23133 Background: Tramadol is a treatment of choice for pain management after axillary lymph node dissection in breast cancer patients. Tramadol is metabolized via CYP2D6 and UGT2B7, while ABCB1, ABCC2 and SLC22A1 are involved in transport of tramadol metabolites. Genetic variability of metabolizing enzymes or drug transporters may therefore affect efficacy and adverse effects of tramadol. The aim of this study was to evaluate the association of genetic variability in tramadol pharmacokinetics pathway on long-term outcome of tramadol pain treatment after breast cancer surgery. Methods: The study included 102 breast cancer patients treated with either 75 or 37.5 mg of tramadol for pain relief after breast cancer surgery including axillary lymph node dissection as part of a randomized clinical trial KCT 04/2015-DORETAonko/si at Institute of Oncology Ljubljana. All patients were genotyped for 14 polymorphisms in ABCB1, ABCC2, CYP2D6, SLC22A1 and UGT2B7 genes, as well as for CYP2D6 duplication and deletion. CYP2D6 phenotype was predicted from the genotype data and patients were categorized as poor (PM), intermediate, extensive or ultrarapid metabolizers. The association of genetic factors with pain one year after treatment was evaluated using logistic regression and Mann-Whitney test. Results: One year after treatment, 21 (20.8%) patients were still experiencing chronic and 25 (24.8%) neuropathic pain. CYP2D6 PMs were significantly more likely to experience chronic and neuropathic pain after tramadol treatment (OR = 5.96, 95% CI = 1.22-29.13, p = 0.027 and OR = 9.31, 95% CI = 1.65-50.59, p = 0.011, respectively), even after adjustment for tramadol dose (p = 0.032 and p = 0.016, respectively). PMs also had higher average pain intensity compared to others regardless of tramadol dose (p = 0.042). In patients receiving lower tramadol dose, ABCB1 rs1128503, rs2032582 and rs1045642 were associated with more chronic pain in the dominant model (p = 0.004, p = 0.004 and p = 0.047, respectively). Conclusions: Genetic variability in tramadol pharmacokinetics pathway may be associated with pain treatment outcome in breast cancer patients, therefore pharmacogenetic testing could enable more effective tramadol treatment. Clinical trial information: EudraCT 2015-000992-28.

Factors Associated With Acute Pain Estimation, Postoperative Pain Resolution, Opioid Cessation, and Recovery

Acute postoperative pain is associated with the development of persistent postsurgical pain, but it is unclear which aspect is most estimable. To identify patient clusters based on acute pain trajectories, preoperative psychosocial characteristics associated with the high-risk cluster, and the best acute pain predictor of remote outcomes. A secondary analysis of the Stanford Accelerated Recovery Trial randomized, double-blind clinical trial was conducted at a single-center, tertiary, referral teaching hospital. A total of 422 participants scheduled for thoracotomy, video-assisted thoracoscopic surgery, total hip replacement, total knee replacement, mastectomy, breast lumpectomy, hand surgery, carpal tunnel surgery, knee arthroscopy, shoulder arthroplasty, or shoulder arthroscopy were enrolled between May 25, 2010, and July 25, 2014. Data analysis was performed from January 1 to August 1, 2018. Patients were randomized to receive gabapentin (1200 mg, preoperatively, and 600 mg, 3 times a day postoperatively) or active placebo (lorazepam, 0.5 mg preoperatively, inactive placebo postoperatively) for 72 hours. A modified Brief Pain Inventory prospectively captured 3 surgical site pain outcomes: average pain and worst pain intensity over the past 24 hours, and current pain intensity. Within each category, acute pain trajectories (first 10 postoperative pain scores) were compared using a k-means clustering algorithm. Fifteen descriptors of acute pain were compared as predictors of remote postoperative pain resolution, opioid cessation, and full recovery. Of the 422 patients enrolled, 371 patients (≤10% missing pain scores) were included in the analysis. Of these, 146 (39.4%) were men; mean (SD) age was 56.67 (11.70) years. Two clusters were identified within each trajectory category. The high pain cluster of the average pain trajectory significantly predicted prolonged pain (hazard ratio [HR], 0.63; 95% CI, 0.50-0.80; P < .001) and delayed opioid cessation (HR, 0.52; 95% CI, 0.41-0.67; P < .001) but was not a predictor of time to recovery in Cox proportional hazards regression (HR, 0.89; 95% CI, 0.69-1.14; P = .89). Preoperative risk factors for categorization to the high average pain cluster included female sex (adjusted relative risk [ARR], 1.36; 95% CI, 1.08-1.70; P = .008), elevated preoperative pain (ARR, 1.11; 95% CI, 1.07-1.15; P < .001), a history of alcohol or drug abuse treatment (ARR, 1.90; 95% CI, 1.42-2.53; P < .001), and receiving active placebo (ARR, 1.27; 95% CI, 1.03-1.56; P = .03). Worst pain reported on postoperative day 10 was the best predictor of time to pain resolution (HR, 0.83; 95% CI, 0.78-0.87; P < .001), opioid cessation (HR, 0.84; 95% CI, 0.80-0.89; P < .001), and complete surgical recovery (HR, 0.91; 95% CI, 0.86-0.96; P < .001). This study has shown a possible uniform predictor of remote postoperative pain, opioid use, and recovery that can be easily assessed. Future work is needed to replicate these findings. ClinicalTrials.gov Identifier: NCT01067144.

Measuring biopsychosocial risk for back pain disability in chiropractic patients using the STarT back screening tool: a cross-sectional survey

BackgroundThe Keele STarT Back Screening Tool (SBT), a 9-item questionnaire, screens for pain, physical functioning, fear-avoidance beliefs, catastrophizing, anxious thoughts, low mood, and bothersomeness in persons with back pain. SBT scores designate low, medium, or high risk for developing persistent disabling back pain. The primary study aim was to report the prevalence of SBT-calculated risk for back pain disability in US patients seeking chiropractic care.MethodsThe SBT questionnaire was administered to patients ≥18 years in 3 Chiropractic College outpatient teaching clinics in Iowa and Illinois (May 2017). Descriptive statistics were used to analyze respondent characteristics and prevalence of SBT-calculated risk subgroups. Binary logistic regression analysis was used to examine the relationship between respondent characteristics and SBT scores (including psychological subscores).ResultsOf 550 respondents, 496 completed the SBT; 392 (79%) scored low-risk, 81 (16%) medium-risk, and 23 (5%) high-risk. Mean (SD) age was 44.8 (15.9), 56.9% were female, 88.2% white, 62.6% employed, mean current pain was 2.9 (2.1) out of 10, and 62% reported symptom duration > 3 months. Eighteen percent of respondents reported anxious thoughts, 32% low mood, 41% ≥ 1 and 21% ≥ 3 SBT psychological risk factors. Respondents reporting higher average pain (OR = 1.8 [1.4, 2.3]) and pain severity (OR = 1.3 [1.0 to 1.6]) were more likely to score with medium or high risk. Respondents reporting mid back versus low back pain (OR = 0.2 [0.1, 0.7]), and those employed less than full-time versus full-time (0.2 [01, 0.5]) were less likely to score with medium or high risk. Respondents reporting higher average pain were more likely to report ≥1 psychological factor (OR = 1.8 [1.5, 2.0]). Respondents employed part-time were less likely to report ≥1 psychological factor than those employed full-time (OR = 0.4 [0.2, 0.7]).ConclusionThe sample surveyed was less likely to score with medium or high risk for back pain disability than previous samples studied, perhaps due to differences in study design and sample characteristics. Rates of low mood and anxious thoughts indicate a need for future research to explore psychological factors among persons seeking chiropractic care.

Pain, psychological distress and motor pattern in women with provoked vestibulodynia (PVD) - symptom characteristics and therapy suggestions.

Provoked vestibulodynia (PVD) represent a longstanding pain syndrome that affects large numbers of women worldwide. However, no standardized guidelines for PVD treatment exist. In a cross-sectional pilot study we examined 30 PVD patients on multidimensional parameters including pain, psychological distress and quality of movement, in order to obtain a broader understanding of the somatic and psychological symptoms in PVD, and for the future to develop better interventions. Additionally, we compare the findings to previously published results regarding the same parameters in women with chronic pelvic pain (CPP). Thirty women with PVD recruited from a tertiary care university clinic of gynecology were assessed for demographic data, pain intensity (VAS), psychological distress (GHQ-30 and Tampa scale of Kinesophobia) and quality of movement (standardized Mensendieck test, SMT). Average age of the PVD women was 24.7±3.60 years, 60% of them were in permanent relationships, all were nulliparous, none had been subjected to surgical procedures, 100% were working full or part time and 90% were educated to at least undergraduate level. Mean VAS score was 7.77±1.97 (mean±SD), kinesiophobia 24.4±3.95 and anxiety domain of GHQ-30 9.73±4.06. SMT scores were particularly low for the domains of respiration and gait (less than 50% of optimal scores). PVD women display reduced quality of movement, especially for gait and respiration patterns, increased level of anxiety and high average pain scores. These findings are similar to what we have previously reported in CPP patients. However, in contrast to CPP group, PVD women are on average younger, have higher work participation, higher education level and have not been subjected to surgical procedures. Since PVD women display similar, although somewhat less severe, symptom profile than CPP, we suggest that a multidimensional approach to treatment, such as "somatocognitive therapy" should be investigated in this group as it has previously been shown to be promising in treatment of CPP.

Differentiating lipedema and Dercum's disease.

People with lipedema or Dercum's disease (DD) can have a similar distribution of excess painful nodular subcutaneous adipose tissue (SAT), making them difficult to differentiate. Case series of 94 patients with DD, 160 with lipedema and 18 with both diagnoses (Lip+DD) from a single clinic in an academic medical center to improve identification and differentiation of these disorders by comparison of clinical findings, prevalence of type 2 diabetes (DM2), hypermobility by the Beighton score and assessment of a marker of inflammation, Total complement activity (CH50). Differences between groups were by Student's t-test with α of 0.05. The Lipedema Group had significantly greater weight, body mass index (BMI), gynoid distributed nodular SAT and fibrotic and heavy tissue than the DD Group. Hypermobility was significantly higher in the Lipedema (58±0.5%) than DD Group (23±0.4%; P<0.0001). DM2 was significantly greater in the DD (16±0.2%; P=0.0007) than the Lipedema Group (6±0.2%). Average pain by an analog scale was significantly higher in the DD (6±2.5%) than the Lipedema Group (4±2.1%; P<0.0001). Fatigue and swelling were common in both groups. Easy bruising was more common in the Lipedema Group, whereas abdominal pain, shortness of breath, fibromyalgia, migraines and lipomas were more prevalent in the DD Group. The percentage of patients with elevated CH50 was significantly positive in both groups. The significantly lower prevalence of DM2 in people with lipedema compared with DD may be due to the greater amount of gynoid fat known to be protective against metabolic disorders. The high percentage of hypermobility in lipedema patients indicates that it may be a comorbid condition. The location of fat, high average daily pain, presence of lipomas and comorbid painful disorders in DD patients may help differentiate from lipedema.

Occurrence, Characteristics, and Predictors of Pain in Patients with Chronic Obstructive Pulmonary Disease

Few studies have provided a detailed characterization of pain in patients with chronic obstructive pulmonary disease (COPD). The aims of this cross-sectional study were to describe the occurrence, intensity, locations, and level of interference associated with pain, as well as pain relief; to identify differences in demographic, clinical, and symptom characteristics between COPD patients with and without pain; and to determine which demographic, clinical, and symptom characteristics were associated with average pain, worst pain, and pain interference. A total of 258 patients with COPD provided information on demographic characteristics; comorbidities; respiratory parameters including dyspnea; body mass index; and symptom characteristics (i.e., anxiety, depression, sleep disturbance, and fatigue). Pain was measured using the Brief Pain Inventory. Of these 258 COPD patients, 157 (61%) reported pain. Multiple linear regression analyses were performed to determine which demographic, clinical, and symptom characteristics were associated with average pain severity, worst pain severity, and mean pain interference. Lower stages of COPD were associated with higher worst pain and higher pain interference scores. Higher depression scores were associated with higher average pain and higher pain interference scores. In addition, higher number of pain locations was associated with higher average and higher worst pain severity scores. Findings from this study confirm that pain is a significant problem and highlights the need for specific pain management interventions for patients with COPD. More research is needed about specific pain characteristics and symptoms to gain an increased knowledge about the causes of pain in these patients.

The Association of Pain With Smoking and Quit Attempts in an Electronic Diary Study of Cancer Patients Trying to Quit.

The purpose of this electronic daily diary study was to examine the relation of pain to smoking and quit attempts among 34 cancer patients with pain enrolled in a smoking cessation program. Electronic daily diary assessments of pain and smoking were collected at the end of each day for a 2-week period during smoking cessation treatment. Pain experienced throughout the day was measured on a scale from 1 to 5, from "no pain" to "pain as bad as you can imagine." Smoking was defined as the number of cigarettes smoked per day. Linear multilevel modeling was used in examining associations between pain and smoking. A within-person pain and smoking association was found, such that greater daily pain was linked to greater daily smoking within individuals, controlling for baseline symptoms, nicotine dependence, smoking urge, age, and gender. No between-person pain and smoking association was observed. Additionally, cancer patients with higher average pain across the 2-week assessment period were less likely to make a quit attempt (defined as a day on which participants smoked no cigarettes) during the study period. The findings of this study add to a nascent literature on pain and smoking by providing initial evidence that pain may be a barrier to quitting among cancer patients who smoke and have pain. Future research examining the effectiveness of integrated pain and smoking cessation treatment in this population may be warranted.

The relationships between pain, disability, and health-related quality of life: an 8-year follow-up study of female home care personnel

Purpose: To investigate the development of pain conditions, disability, and health-related quality of life over an 8-year period in home care personnel. Method: In earlier studies of 607 women, we reported baseline data concerning home care personnel. This study reports the results from an 8-year follow-up using a postal questionnaire. Results: The questionnaire was completed by 87%. Prevalences of pain in upper back, lower back, and knees as well as pain intensity of the low back had decreased. Participants with the highest pain intensities of the low back at baseline had relatively lower pain intensities at follow-up. Anatomical spreading of pain was associated with higher average pain intensity. Disability had increased significantly during the time period. In the regression of disability at follow-up, average pain intensity together with disability rating index at baseline were the most important regressors; a similar pattern was found for quality of life. Conclusions: The development of disability differed from that of low-back pain intensity. Spreading of pain and pain intensity across the anatomical regions influenced disability and quality of life over 8 years. When assessing pain, it seems important to determine the spread of pain rather than just focusing on the area with intense pain.Implications for RehabilitationSpreading of pain and the average intensity of pain across the involved anatomical regions have importance for future pain and disability and quality of life.The clinical assessment of subjects with chronic pain prior to rehabilitation interventions has to determine the spreading of pain rather than just focusing on the area with the most intense pain.The different developments over time for pain intensity and disability indicate the need for applying a bio-psycho-social view of pain both when assessing the patient with pain and when discussing the prognosis and course of the actual pain condition with the patient.

Feasibility of collecting vulvar pain variability and its correlates using prospective collection with smartphones.

Context. Vulvar pain level may fluctuate in women with vulvodynia even in the absence of therapy; however, there is little evidence suggesting which factors may be associated with variability. Objective. Determine the feasibility of using smartphones to collect prospective data on vulvar pain and factors that may influence vulvar pain level. Methods. 24 clinically confirmed women were enrolled from a population-based study and asked to answer five questions using their smartphones each week for one month. Questions assessed vulvar pain level (0–10), presence of pain upon wakening, pain elsewhere in their body, treatment use, and intercourse. Results. Women completed 100% of their scheduled surveys, with acceptability measures highly endorsed. Vulvar pain ratings had a standard deviation within women of 1.6, with greater variation on average among those with higher average pain levels (P < 0.001). On the weeks when a woman reported waking with pain, her vulvar pain level was higher by 1.82 on average (P < 0.001). Overall, average vulvar pain level was not significantly associated with the frequency of reporting other body pains (P = 0.64). Conclusion. Our smartphone tracking system promoted excellent compliance with weekly tracking of factors that are otherwise difficult to recall, some of which were highly associated with vulvar pain level.

Higher pain scores, similar opioid doses and side effects associated with antipyretic analgesics in specialised tertiary pain care

To evaluate whether non-opioid antipyretic analgesics are associated with lower pain scores, opioid doses and side effects in pain patients in tertiary care. In a cross-sectional observational study, data from 519 Caucasians (197 men, 322 women; mean age 55.6 ± 15 years) who had undertaken pain therapy for various causes for 77.5 ± 90.8 months, obtained in three separate study centres, was analysed for actual 24-h pain scores, daily opioid doses and the occurrence of side effects. Of the 519 patients, 352 received opioids and 260 antipyretic analgesics, from whom 154 received both classes and 304 only either class. The administration of non-opioid antipyretic analgesics was associated with higher average pain scores (4.6 ± 2.5 vs 3.9 ± 2.6; P = 0.01), tendentially higher average oral morphine equivalent doses (121.8 ± 162.2 vs 146.7 ± 242.4 mg/d; P = 0.25) and a similar incidence of side effects (P = 0.21). These results were correspondingly seen when analysing the three study centres separately as independent cohorts. With the caution advised for cross-sectional data, the results dispute a clinical benefit of non-opioid antipyretic analgesics for most chronic pain patients in tertiary care and draw attention towards prospectively re-evaluating the utility of non-opioid antipyretic analgesics in tertiary pain care in a randomised placebo controlled trial.

Distance Between Periapical Lesion and Mandibular Canal as a Factor in Periapical Surgery in Mandibular Molars

Mandibular molars with a periapical pathology that remains unresolved by endodontic treatment may be considered for periapical surgery (PS); even for those situated in close proximity to the mandibular canal. Our objective was to compare PS in mandibular molars situated close to the mandibular canal, and those at a greater distance, and to study the postoperative morbidity and prognosis of both groups. A follow-up study was made on PS carried out using the ultrasound technique. The cases were classified into 2 different groups in function of the proximity of the periapical lesion to the mandibular canal; group A when the distance was less than 2 mm and group B when it was equal to 2 mm. Only patients undergoing PS in mandibular molars were included in this study; minimum follow-up was set at 12 months. The postoperative morbidity was evaluated, as well as the mid- and long-term overall success. SPSS 12 (SPSS Inc, Chicago, IL) was used for statistical analysis. All estimated association measures were then tested for statistical significance, and declared significant for P values less than .05. PS was carried out on 79 patients, with 98 lesions, involving 88 mandibular molars. Group A was made up of 22 patients with 27 periapical lesions in close proximity to the mandibular canal, involving 23 mandibular molars; and group B comprised 57 patients with 71 lesions not in close proximity to the mandibular canal, involving 65 molars. Sixty percent of the patients presented between no pain and mild pain on the second postoperative day and two thirds of the patients between mild and moderate swelling. Group A had higher average pain than group B (P < .05), peaking at 2 days, whereas in group B maximum pain was reached at 2 hours of the intervention. The success at 12 months in the mandibular molars was 66.6% with no statistically significant differences between the 2 groups (P > .05). The success obtained in mandibular molars shows that periapical surgery is a valid treatment option, even in molars situated in close proximity to the mandibular canal.

Breakthrough pain in opioid-treated chronic non-malignant pain patients referred to a multidisciplinary pain centre: a preliminary study

Breakthrough pain (BTP) has not formerly been discussed as such in chronic non-malignant pain patients referred to pain centres and clinics. The purpose of the study was to investigate the prevalence, characteristics and mechanisms of BTP in opioid-treated chronic non-malignant pain patients referred to a pain centre and to assess the short-term effects of pain treatment. Patients were assessed at referral (T(0)) and after a treatment period of 3 months (T(3)) using the visual analogue scale (VAS) of the brief pain inventory (BPI) within somatic nociceptive, neuropathic and/or visceral pain conditions, the mini mental state examination (MMSE) and the hospital anxiety and depression scale (HADS). The main treatment intervention from T(0) to T(3) was to convert short-acting oral opioids to long-acting oral opioids and to discontinue on demand and parenteral use of opioids. Thirty-three patients were assessed at T(0) and 27 at T(3). The prevalence of BTP declined significantly from T(0) (90%) to T(3) (70.4%). Worst, least, average and current pain intensities as well as duration of BTP were significantly reduced from T(0) to T(3.) The majority of BTPs were exacerbation of background pain assumed to be of the same pain mechanisms. High average pain intensity (BPI) was significantly associated with high scores for both anxiety and depression (HADS). BTP in chronic non-malignant pain patients seems to be surprisingly frequent and severe. Stabilizing the opioid regimen seems to reduce pain intensity in general as well as the intensity and duration of BTP. Average pain intensity was associated with anxiety and depression.

Development of a metric for a day of manageable pain control: derivation of pain severity cut-points for low back pain and osteoarthritis

The objective of this study was to adapt the concept of ‘episode-free day’, a metric for measuring symptom relief in daily units, to the clinical outcome literature for persistent pain. The episode-free day metric is widely used in other medical literature, but no analogous measure exists in pain literature. Prior focus groups with this population suggested that a ‘Day of Manageable Pain Control’ was an appropriate name for the metric. In the present study, in order to derive a statistical criterion for ‘Manageable Day’, we used Serlin et al.’s (Pain 61 (1995) 277) cut-point derivation method to derive a single cut-point on a 0–10 scale of average pain that divided groups with significant persistent pain optimally on pain-related functional interference. Participants were 194 patients with moderate-severe low back pain ( n=96) or osteoarthritis ( n=98). For both patient samples, ‘5’ was the cut-point that optimally distinguished groups on pain-related interference. ‘5–8’ and ‘5–7’ were double cut-point solutions that optimally divided LBP and OA samples into three categories (e.g. lowest, medium and highest average pain), respectively. Derived cut-points were confirmed using a variety of measures of functional disability. Together with research that showed that average pain ratings of approximately 5 and below permit increased function and quality of life in patients with moderate to severe low back pain and osteoarthritis, our findings provide support for the use of 0–5 on a 0–10 numeric average pain severity scale as one possible criterion for a Manageable Day.