Important Reductions In Pain Research Articles

An exploratory randomized controlled trial of virtual reality as a non-pharmacological adjunctive intervention for adults with chronic cancer-related pain

BackgroundThe growing popularity and affordability of immersive virtual reality (VR), as adjunctive non-pharmacological interventions (NPIs) for chronic pain, has resulted in increasing research, with mixed results of its effectiveness reported. This randomized controlled superiority trial explored the effects of a home-based adjunctive 3D VR NPI for chronic pain in cancer patients, compared to the same NPI experienced through a two-dimensional (2D) medium.MethodsThe NPI used four different applications experienced for 30 min for six days a week at home for four weeks using established cognitive distraction and mindfulness meditation techniques. Participants were randomly assigned (N = 110) into two arms: a VR group (n = 57) where the NPI was delivered through a VR system, and a control group (n = 53) which used a computer screen for delivery. Participants were blinded to which arm of the study they were in, and sequence of the NPI applications experienced was randomized. Primary outcomes of daily pre/post/during exposure, and weekly average pain scores were assessed via the Visual Analog Scale (VAS) and the Short Form McGill Pain Questionnaire (SF-MPQ), and secondary outcomes of weekly Quality of Life (SF-12), and sleep quality (Pittsburgh Sleep Quality Index) were measured.ResultsFindings indicate VR applications were not significantly superior to the 2D group, but both VR and control NPIs provided clinically important pain reduction for participants when experiencing significant daily pain of a VAS ≥ 4. No significant adverse effects were encountered, although many of the participants in the VR group reported some cybersickness in certain applications (VR group n = 46 vs 2D group n = 28).ConclusionsOverall, VR did not provide superiority as an NPI for pain relief compared to 2D computer-based applications. For those experiencing significant pain, cognitive distractive applications appeared superior for VR-based pain reduction during exposure, whilst meditative applications supplied better pain relief post-exposure. Findings from this trial support some clinical efficacy of home-based VR immersive experiences as NPIs for chronic cancer-related pain but in this context the 2D computer-based applications demonstrated similar value.Trial registrationClinicaltrials.gov, identifier NCT02995434, registered 2017–07-31.

Cannabis therapy in rheumatological diseases: A systematic review.

Cannabis has been used in rheumatic diseases as therapy for chronic pain or inflammatory conditions. Herein, the authors systematically review the rheumatological diseases in which cannabis has been studied: systemic sclerosis, fibromyalgia, osteoarthritis, rheumatoid arthritis, osteoporosis, polymyalgia rheumatica, gout, dermatomyositis, and psoriatic arthritis. We systematically searched PubMed for articles on cannabis and rheumatic diseases between 1966 and March 2023. Twenty-eight articles have been selected for review. Most of them (n=13) were on fibromyalgia and all of them but one showed important reduction in pain; sleep and mood also improved. On rheumatoid arthritis, two papers displayed decrease in pain and in one of them a reduction in inflammatory parameters was found. In scleroderma there was a case description with good results, one study on local use for digital ulcers also with good outcomes and a third one, that disclosed good results for skin fibrosis. In dermatomyositis a single study showed improvement of skin manifestations and in osteoarthritis (3 studies) this drug has demonstrated a good analgesic effect. Several surveys (n=5) on the general use of cannabis showed that rheumatological patients (mixed diseases) do use this drug even without medical supervision. The reported side effects were mild. In conclusion, cannabis treatment is an interesting option for the treatment of rheumatological diseases that should be further explored with more studies.

Custom-Made Implants in Ankle Bone Loss: A Retrospective Assessment of Reconstruction/Arthrodesis in Sequelae of Septic Non-Union of the Tibial Pilon.

Background and Objectives: Treating segmental tibial and ankle bone loss after radical surgery for chronic osteomyelitis is one of the most challenging problems encountered by orthopaedic surgeons. Open tibia and ankle fractures occur with an incidence of 3.4 per 100,000 and 1.6 per 100,000, respectively, and there is a high propensity of developing fracture-related infection with associated chronic osteomyelitis in patients. Segmental tibial and ankle bone loss have recently received new and improved treatments. Materials and Methods: Above all, 3D printing allows for the customization of implants based on the anatomy of each patient, using a personalized process through the layer-by-layer deposition of materials. Results: This article presents different cases from the authors' experience. Specifically, four patients suffered tibia and ankle fractures and after radical surgery for chronic osteomyelitis combined with high-performance antibiotic therapy underwent ankle reconstruction/arthrodesis with custom-made tibial spacers. Conclusions: Thanks to 3D-printed patient-specific devices, it is possible to perform surgical procedures that, for anatomical reasons, would have been impossible otherwise. Moreover, an improvement in overall functionality and an important reduction in pain were shown in the last follow-up in all patients.

Comparison of Face-to-Face vs Digital Delivery of an Osteoarthritis Treatment Program for Hip or Knee Osteoarthritis

Digital care platforms have been introduced, but there is limited evidence for their efficacy compared with traditional face-to-face treatment modalities. To compare mean pain reduction among individuals with osteoarthritis (OA) of the knee or hip who underwent face-to-face vs digital first-line intervention. This registry-based cohort study included all persons with knee or hip osteoarthritis who participated in structured first-line treatment for osteoarthritis in a primary care setting in Sweden. Inclusion criteria were as follows: the treatment was delivered face-to-face or digitally between April 1, 2018, and December 31, 2019; patients provided 3-month follow-up data for pain; and patients had program adherence of at least 80%. Data analysis was conducted in March 2021. Participants completed a 3-month intervention, including education and exercise for hip or knee osteoarthritis, with program adherence of 80% or higher, delivered face-to-face or by a digital application. Difference in change in joint pain (11-point numeric rating scale, with 0 indicating no pain and 10, the worst possible pain) between baseline and 3-month follow-up between the 2 intervention modalities. A minimal clinically important difference in pain change between groups was predefined as 1 point. Secondary outcomes were walking difficulties, health-related quality of life, willingness to undergo joint surgery, and fear avoidance behavior. A total of 6946 participants (mean [SD] age, 67 [9] years; 4952 [71%] women; 4424 [64%] knee OA; 2504 [36%] hip OA) were included, with 4237 (61%) receiving face-to-face treatment and 2709 (39%) receiving digital treatment. Both the face-to-face (mean change, -1.10 [95% CI -1.17 to -1.02] points) and digital interventions (mean change, -1.87 [95% CI, -1.94 to -1.79] points) resulted in a clinically important pain reduction at 3 months. Participants in the digitally delivered intervention experienced a larger estimated improvement at 3 months (adjusted mean difference, -0.93 [95% CI, -1.04 to -0.81] points). Results of secondary outcomes were broadly consistent with main outcome. This Swedish national registry-based cohort study showed that people with knee or hip OA participating in first-line intervention experienced clinically relevant improvements in pain, whether delivered face-to-face or digitally. The increased benefit of digital delivery compared with face-to-face delivery was of uncertain clinical importance.

Efficacy and safety of colchicine for the treatment of osteoarthritis: a systematic review and meta-analysis of intervention trials

ObjectiveColchicine, an approved treatment for gout, has been trialed in many diseases including osteoarthritis (OA) due to its anti-inflammatory effects. However, its efficacy and safety remain unclear in OA. This systematic review and meta-analysis evaluated the efficacy and safety of colchicine for the treatment of OA.MethodsPubMed, Web of Science, Scopus, and Cochrane Central were searched from inception through September 2022. Two reviewers independently screened for randomized controlled trials (RCTs) comparing colchicine with placebo or other active comparators for the treatment of OA (knee, hand, or hip OA), extracted data, and performed Cochrane risk of bias assessments.ResultNine RCTs for the knee OA and one for the hand OA were identified, consisting of 847 patients (429 in colchicine arms, 409 in control arms). The studies were conducted between 2002 and 2021 with follow-up periods ranging from 2 to 12 months, in India, Iran, Turkey, Australia, Singapore, and Iraq. Moderate-quality evidence showed no clinically important pain reduction with colchicine compared to control (standardized mean difference [SMD], 0.17; 95% confidence interval [CI], − 0.55, 0.22). Moderate-quality evidence showed no improvement in function with colchicine compared to control in knee OA patients (SMD, − 0.37; 95% CI, − 0.87, 0.13). Colchicine showed an acceptable safety profile with AEs/SAEs comparable to control.ConclusionCurrent evidence does not suggest a benefit of colchicine in reducing pain and improving physical function in the overall cohort of hand/knee OA patients. Future trials should focus on the subgroups of OA patients with local or systemic inflammation and/or mineralization who might benefit from colchicine.Graphical abstractKey Points•Colchicine is an approved treatment for gout that has been trialed in many diseases including osteoarthritis (OA) due to its anti-inflammatory effects. However, the benefit and harms of colchicine in OA remain unclear.• Current evidence from randomized control trials does not suggest a benefit of colchicine in reducing pain and improving physical function for the treatment of OA patients.• Future trials of colchicine in OA should focus on the subgroups of OA patients with local or systemic inflammation and/or mineralization who might benefit from colchicine.

Evaluation of implementation and effectiveness of neck-specific exercise for persistent disability and pain after whiplash injury: study protocol for a randomized controlled study using a hybrid 2 design

BackgroundPersistent pain and disability in whiplash-associated disorders (WAD) grades II and III are common. In two randomized controlled trials (RCTs) of neck-specific exercises (NSE), we have seen promising results in chronic WAD, with a sustained clinically important reduction in pain and disability. NSE can also be delivered through internet support (NSEIT) and a few visits to a physiotherapist, saving time and cost for both patients and providers. NSE have been shown to have positive effects in other neck pain disorders and we will evaluate the diffusion of the exercises to other patients. The aims of the proposed study are to evaluate an implementation strategy for NSEIT and NSE in primary health care and to evaluate the effectiveness of NSEIT and NSE in clinical practice.MethodsThe proposed study is a prospective cluster-randomized mixed-design study with hybrid 2 trial design. Reg. physiotherapists working in twenty physiotherapy clinics will be included. The primary implementation outcome is proportion of patients with neck pain receiving neck-specific exercise. Secondary outcomes are; physiotherapists attitudes to implementation of evidence-based practice, their self-efficacy and confidence in performing NSEIT/NSE, number of patients visits, and use of additional or other exercises or treatment. To further evaluate the implementation strategy, two qualitative studies will be performed with a sample of the physiotherapists. The primary outcome in the patient effectiveness evaluation is self-reported neck disability according to the Neck Disability Index (NDI). Secondary outcomes are pain intensity in the neck, arm, and head; dizziness; work- and health-related issues; and patient’s improvement or deterioration over time. All measurements will be conducted at baseline and at 3 and 12 months. Physiotherapists´ self-efficacy and confidence in diagnosing and treating patients with neck pain will also be evaluated directly after their instruction in NSEIT/NSE.DiscussionThis trial will evaluate the implementation strategy in terms of adoption of and adherence to NSEIT and NSE in clinical primary health care, and measure diffusion of the method to other patients. In parallel, the effectiveness of the method will be evaluated. The results may guide physiotherapists and health care providers to sustainable and effective implementation of effective exercise programs.Trial registrationThe randomized trial is registered on ClinicalTrials.gov, NCT05198258, initial release date January 20, 2022.

Targeting neurotrophic factors for low back pain and sciatica: a systematic review and meta-analysis.

This meta-analysis aims to investigate the efficacy and safety of medicines that target neurotrophic factors for low back pain (LBP) or sciatica. We searched published and trial registry reports of randomized controlled trials evaluating the effect of medicines that target neurotrophic factors to LBP or sciatica in seven databases from inception to December 2020. Two reviewers independently identified studies, extracted data, and assessed the risk of bias and certainty in the evidence. Nine studies (3370 participants) were included in the meta-analyses. Low certainty evidence showed that anti-nerve growth factor (NGF) may reduce pain at 4 weeks (mean difference [MD] -6.75, 95% CI: -8.61, -4.90) and 12 weeks (MD -6.16, 95% CI: -8.38, -3.94), and may increase adverse effects for chronic LBP (odds ratio [OR] 1.18, 95% CI: 1.01, 1.38). Higher doses of anti-NGF may offer a clinically important reduction in pain at the cost of increased adverse effects for chronic LBP. Very low certainty evidence showed that anti-NGF and glial cell line-derived neurotrophic factor (pro-GDNF) may not reduce pain for sciatica at 4 weeks (MD -1.40, 95% CI: -8.26, 5.46), at 12 weeks (MD -2.91, 95% CI: -13.69, 7.67) and may increase adverse effects for sciatica (OR 3.27, 95% CI: 1.78, 6.00). Anti-NGF may offer small reductions in pain intensity for chronic LBP. The effect may depend on the dose and types of medicines. For sciatica, anti-NGF or pro-GDNF may not reduce pain. Medicines that target neurotrophic factors for LBP or sciatica are associated with different adverse effects compared to those observed in commonly prescribed medicines for these conditions.

To Combine or Not to Combine Physical Therapy With tDCS for Stroke With Shoulder Pain? Analysis From a Combination Randomized Clinical Trial for Rehabilitation of Painful Shoulder in Stroke.

Purpose: Transcranial Direct Current Stimulation (tDCS) is an intervention that seems to be an ideal tool to enhance the effects of rehabilitation therapies given it facilitates generation of plasticity in the stimulated brain area. In stroke this strategy has been highly utilized; however, the results have been mixed. In this trial we have evaluated the analgesic and functional effects of Transcranial Direct Current Stimulation (tDCS) combined with physiotherapy in stroke survivors with shoulder pain.Methods: Twenty-six stroke surviving adults with shoulder pain received 10 sessions of passive mobilization and performed upper limb exercises using a cycle ergometer, combined with active or sham tDCS. The intensity of pain in the hemiplegic shoulder was measured using the Visual Analog Scale (VAS); secondary outcomes were the level of motor impairment, handgrip strength, range of motion, motor function of the upper limbs, and quality of life (QOL) assessed before and after 10 sessions and 1 month after the end of the treatment.Results: A clinically important pain reduction (3 points) was found in both groups and was maintained at follow-up; there was no significant difference between groups (p = 0.3). Similarly, the shoulder range of motion improved, motor function and quality of life improved showed no significant differences between groups. One result that needs to be underscored is that both groups had a significant effect size toward improvement in all of these outcomes.Conclusions: We discuss in this study that tDCS is not a useful combination strategy when the physical therapy has a large effect by itself and we also review other negative trials of combined therapy under this framework of ceiling effect of the main physical therapy.Trial registry: Trial registration: Brazilian Registry of Clinical Trials, RBR-8F5MNY (http://www.ensaiosclinicos.gov.br/rg/RBR-8f5mny/). Registered on June 2, 2017.Beginning of the recruitment of the volunteers: august, 2017.

The efficacy of platelet rich plasma on anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Anterior cruciate ligament (ACL) rupture is a common musculoskeletal injury, most frequently affecting young and physically active patients. Platelet-rich plasma (PRP) has been widely used in ACL reconstruction to augment the graft healing. However, high-level studies addressing its clinical efficacy could not reach a consensus. In this study, we assess the efficacy of PRP on pain relief, functional improvement along with radiological changes in patients who underwent ACL reconstruction. We performed comprehensive literature search and included 17 RCTs containing 970 participants who underwent ACL reconstruction. The combined data showed significant difference between PRP and control with regard to VAS score (MD: −1.12, 95% CI −1.92, −0.31; P = .007), subjective IKDC score (MD: 6.08, 95% CI 4.39, 7.77; P < .00001) and Lysholm score (MD: 8.49, 95% CI 1.63, 15.36; P = .02) by postoperative 6 months, but only pain reduction was deemed clinically important. At the end of one year’s follow-up, no clinically meaningful improvement in VAS (MD: −0.47, P = .04), subjective IKDC score (MD: 3.99, P = .03), Lysholm score (MD: 2.30, P = .32), objective IKDC score (RR: 1.03, P = .09) and knee joint laxity (MD: 0.17, P = .28) was seen. In terms of radiological findings, about one-third of the studies favored PRP to facilitate the graft healing, improve the harvest site morbidity and prevent tunnel widening. In summary, moderate quality of evidence suggested that PRP could provide short-term but not long-term clinically important pain reduction.

Efficacy and safety of a single intra-articular injection of 6\u2009ml Hylan G-F 20 compared to placebo in Chinese\xa0patients with symptomatic knee osteoarthritis

BackgroundSingle 6 ml Hylan G-F 20 injection, is indicated for knee osteoarthritis patients who have failed to respond to non-pharmacologic therapy and/or simple analgesics. To obtain more thorough understanding of the clinical efficacy and safety, a randomized clinical trial was conducted comparing intra-articular (IA) administration of single 6 ml Hylan G-F 20 injection versus placebo in knee OA patients of Chinese ethnicity.MethodsThis was a randomized, multi-center, double-blind, placebo-controlled clinical trial conducted in 21 centers across China. Four hundred forty adults with knee OA received a single 6 ml Hylan G-F 20 or placebo injection and were evaluated for clinical efficacy and safety outcomes over 26 weeks. Western Ontario and McMaster Universities OA (WOMAC) A1 index, treatment-emergent adverse events (TEAEs) and standard safety parameters were measured at pre-injection, and at weeks 1, 4, 8, 12, 16, 20 and 26 post-injection.ResultsFour hundred forty patients (male: 98 [22.3%]; female: 342 [77.7%]) were randomized. The mean age [standard deviation (SD)] was 61.5 (7.9) years. All patients were of East Asian ethnicity. Mean WOMAC A1 score at baseline was 5.3 (1.2) and 5.2 (1.3) in single 6 ml Hylan G-F 20 injection and placebo groups, respectively. Significant reductions of WOMAC A1 score were observed in both treatment groups when compared to baseline at 26 weeks post-injection, with the mean reduction of [standard error (SE)/percentage] -2.146 (0.108)/− 40.5% and − 2.271 (0.110) /− 43.7% in the single 6 ml Hylan G-F 20 injection and the placebo groups, respectively. Additionally, clinically important reductions in pain at 26 weeks was reported in 67.0 and 68.2% in single 6 ml Hylan G-F 20 injection and placebo groups (p = 0.36). Regarding safety, TEAEs were similar between the two treatment groups (hylan G-F 20 single: 61.5%; placebo: 64.5%).ConclusionsWhile the magnitude of the effect of a single 6 ml Hylan G-F 20 injection in this study is consistent with previously published literature with respect to the efficacy and safety of the drug, the current study shows a strong IA placebo effect and did not established superiority of single 6 ml Hylan G-F 20 injection over IA placebo in Chinese knee OA patients.Trial registrationProspectively registered Jun 16, 2017 at www.clinicaltrials.gov (NCT03190369).

Efficacy and safety of hydroxychloroquine in osteoarthritis: a systematic review and meta-analysis of randomized controlled trials.

Background/AimsConventional disease-modifying anti-rheumatic drugs have been trialed in osteoarthritis (OA). Hydroxychloroquine (HCQ), which has shown its effectiveness in rheumatoid arthritis, has been trialed for the treatment of OA; however, its efficacy and safety remain unclear. This systematic review and meta-analysis evaluate efficacy and safety of HCQ for the treatment of OA.MethodsMEDLINE, EMBASE, and Cochrane Central were searched from inception through June 2020. Two reviewers independently screened for randomized controlled trials (RCTs) comparing HCQ with placebo or other active-comparators for the treatment of knee, hand, or hip OA, extracted data, and performed Cochrane risk of bias assessments.ResultsSix RCTs, four in hand OA, two in knee OA, consisting of 842 patients (436 in HCQ arm, 406 in control arm) were included. RCTs were conducted between 2012 and 2020, one each at UK, Netherlands, Germany, Italy, Iran, and Egypt; follow-up period ranged 24 to 52 weeks. High-quality evidence showed no clinically important pain reduction with HCQ compared to placebo/active-control in hand OA (standardized mean difference [SMD], 0.14; 95% confidence interval [CI], –0.20 to 0.48). Effect on pain reduction in knee and hand OA was small and non-significant (SMD, –0.09; 95% CI, –0.44 to 0.25). High-quality evidence showed no improvement in dysfunction with HCQ compared to placebo in hand OA patients (SMD, 0.08; 95% CI, –0.23 to 0.40). Effect on dysfunction improvement in knee and hand OA was modest and statistically non-significant (SMD, –0.20; 95% CI,–0.57 to 0.18). No improvement in quality of life was observed in hand OA.ConclusionsHCQ has no benefit in reducing pain and improving physical function in hand or knee OA patients.

Effect of media distraction (audio-visual and music) for pain and anxiety control in patients undergoing shock-wave lithotripsy: A systematic review and meta-analysis.

Audio-visual (AV) or music distraction may be used to reduce pain during several healthcare procedures. The present manuscript is a systematic review and meta-analysis to assess the effectiveness of media distraction in reducing pain and anxiety in extracorporeal shock wave lithotripsy (ESWL) patients. The PubMed, Embase, Scopus, BioMed Central, Ovoid and CENTRAL (Cochrane Central Register of Controlled Trials) databases were screened for studies assessing the role of media distraction (music/AV media) in reducing pain and anxiety of ESWL patients. Data were summarized using the mean difference (MD) with 95% confidence intervals (CI). A total of 11 randomized controlled trials were included. Pooled analysis indicated a statistically significant difference in pain outcomes with media distraction [mean difference (MD): -1.18; 95% CI: -2.35, -0.01; I2=96.8%)]. Subgroup analysis indicated that both AV media (MD: -2.94; 95% CI: -4.70, -1.17; I2=79.2%) and music (MD: -0.86; 95% CI: -1.37, -0.35; I2=62.5%), led to significant reduction in pain outcomes. Pooled analysis indicated a statistically significant reduction of anxiety scores with the use of media distraction (MD: -3.91; 95% CI: -6.44, -1.38; I2=77.7%). To conclude, the present review suggests that media distraction in the form of AV media or music may be beneficial in reducing the pain and anxiety of patients undergoing ESWL. Evidence is, however, weak considering the small effect size, confidence intervals being close to zero, and instability of the results on sensitivity analysis. In clinical practice, media distraction may be used during ESWL as a nursing intervention, but a clinically important reduction of pain and anxiety may not be expected.

Efficacy of a combination of hypnosis and transcutaneous electrical nerve stimulation for chronic non-cancer pain: A randomized controlled trial.

BackgroundChronic non‐cancer pain, which persists for at least three months, seriously affects quality of life. Chronic non‐cancer pain patients are usually managed by a multidisciplinary team using pharmacological and non‐pharmacological strategies. Nurses perform transcutaneous electrical nerve stimulation (TENS) and hypnosis, which are widely used in France for the treatment of chronic pain in pain departments.ObjectiveTo assess pain relief at three months, comparing a simultaneous combination of hypnosis and TENS (intervention) with TENS alone (control).DesignRandomized controlled trial.MethodsPatients aged 18–80 years, suffering from chronic peripheral neuropathic and/or nociceptive non‐cancer pain were included (September 2013 to May 2017) and followed for six months. The primary outcome was the pain intensity difference (by visual analog scale score) between month 3 and baseline. The secondary outcomes, assessed at months 3 and 6, were SF36 score, analgesics consumption and number of TENS sessions performed at home (last seven days).ResultsSeventy‐two patients were included, suffering from a combination of chronic non‐cancer nociceptive and neuropathic pain, with a mean pain intensity of about sixty out of a hundred. The results show an important pain reduction (forty percent) in both groups at 3 months. No significant difference was observed between the control and intervention groups. Similarly, SF36 score, change in analgesic intake and patient compliance did not differ significantly between groups.ConclusionsThis is the first randomized controlled study showing a decrease of pain intensity and a high level of compliance with transcutaneous electrical nerve stimulation alone or associated to hypnosis. The combination does not seem to be more efficient than transcutaneous electrical nerve stimulation alone. Chronic non‐cancer pain remains a major issue and a substantial proportion of patients do not appear to benefit from interventions.ImpactThis study increases our understanding of the combination of two non‐pharmacological methods in chronic non‐cancer pain patients. The combination of the two non‐pharmacological strategies did not appear to be more efficient than one alone. Further research on non‐pharmacological treatments targeting to patient's characteristics are needed to find appropriate strategies in patients with complex multidimensional pain conditions. Clinical Trial Number: NCT01944150 (Sept. 17, 2013).

When to perform vertebroplasty? A retrospective analysis from a single center and a review of the literature.

Background and aim:To establish an optimal timing for vertebroplasty in order to obtain a clinically important pain reduction and improving quality of live in patients with osteoporotic or traumatic vertebral fractures.Methods:This study includes 22 vertebroplasty procedures performed from October 2018 to July 2020 in 21 patients with traumatic or osteoporotic vertebral fractures (19 female, two men; age between 53 and 89 years). All treatments were executed under fluoroscopic guidance using 11 or 13 G needle through transpedicular or costovertebral unilateral approach. Each patient underwent conscious sedation, continuously monitored by an anesthesiologist. Preoperative MRI images, obtained by 3T or 1.5T MRI scanner, always showed bone marrow edema. The VAS scale and Roland Morris disability questionnaire (RMdq) were administered to patients before and after the treatment to evaluate pain and life quality.Results:7 patients were treated in the first month after the injury, one was treated twice; 8 patients in the second month, 6 in the third. We observed a reduction of: 5.5 points in the vas scale, 10.3 in the RMdq in the first month; 5.6 points vas, 11.6 points RMdq in the second month; 4 points vas and 9.75 points RMdq in the third month.Conclusions:This study demostrated that, in our preliminary experience, vertebroplasty has the best outcome if performed at 2 months from injury.

Hyoscine butylbromide versus acetaminophen for nonspecific colicky abdominal pain in children: a randomized controlled trial.

Less than two-thirds of children with abdominal pain in the emergency department receive analgesia. We sought to determine whether hyoscine butylbromide was superior to acetaminophen for children with nonspecific colicky abdominal pain. We randomly allocated children aged 8-17 years with nonspecific colicky abdominal pain who presented to the pediatric emergency department of London Health Sciences Centre, London, Ontario to receive hyoscine butylbromide, 10 mg given orally, or acetaminophen, 15 mg/kg given orally (maximum 975 mg). We considered the minimal clinically important difference for the primary outcome (self-reported pain at 80 min) to be 13 mm on a 100 mm visual analogue scale. Secondary outcomes included administration of rescue analgesia, adverse effects and pain score less than 30 mm at 80 minutes. A total of 236 participants (120 in the hyoscine butylbromide group and 116 in the acetaminophen group) were included in the trial. The mean visual analogue scale scores at 80 minutes were 29 mm (standard deviation [SD] 26 mm) and 30 mm (SD 29 mm) with hyoscine butylbromide and acetaminophen, respectively (adjusted difference 1, 95% confidence interval -7 to 7). Rescue analgesia was administered to 4 participants (3.3%) in the hyoscine butylbromide group and 1 participant (0.9%) in the acetaminophen groups (p = 0.2). We found no significant differences in rates of adverse effects between hyoscine butylbromide (32/116 [27.6%]) and acetaminophen (28/115 [24.3]) (p = 0.5); no serious adverse effects were observed. The proportion with a pain score less than 30 mm at 80 minutes was 66 (55.0%) with hyoscine butylbromide and 63 (54.3%) with acetaminophen (p = 0.9). Hyoscine butylbromide was not superior to acetaminophen in this setting. Both agents were associated with clinically important pain reduction, and either can be considered for children presenting to the emergency department with nonspecific colicky abdominal pain. Trial registration: Clinicaltrials.gov, no. NCT02582307.

No Difference in Pain After Spine Surgery with Local Wound Filtration of Morphine and Ketorolac: A Randomized Controlled Trial.

Controlling postoperative pain after spinal surgery is important for rehabilitation and patient satisfaction. Wound infiltration with local anesthetics may improve postoperative pain, but true multimodal approaches for achieving analgesia after spinal surgery remain unknown. In this randomized, controlled, double-blind trial after lumbar interbody fusion, we asked: (1) Does multimodal analgesia reduce VAS pain scores by a clinically important amount? (2) Does this analgesic approach reduce the amount of morphine patients consume after surgery? (3) Is this approach associated with fewer opioid-related side effects after surgery? This study included 80 adult patients undergoing lumbar interbody fusion who were randomized into two groups: A control group (n = 40) who received infiltration of the surgical incision at the end of the procedure with an injection of 0.5% bupivacaine 100 mg (20 mL) and epinephrine 0.5 mg (0.5 mL), and the multimodal group (n = 40), who received wound infiltration with the same approach but with different medications: 0.5% bupivacaine 92.5 mg (18.5 mL), ketorolac 30 mg (1 mL), morphine 5 mg (0.5 mL), and epinephrine 0.5 mg (0.5 mL). There were no between-group differences in the proportion of patients who were male, nor in the mean age, height, weight, preoperative pain score, or surgical time. All treatments were administered by one surgeon. All patients, the surgeon, and the researchers were blinded to the allocation of patients to each group. Pain at rest was recorded using the VAS. Postoperative morphine consumption (administered using a patient-controlled analgesia pump) and opiod-associated side effects including nausea/vomiting, pruritus, urinary retention, and respiratory depression were assessed; this study was analyzed according to intention-to-treat principles. No loss to follow-up or protocol deviations were noted. We considered a 2-cm change on a 10-cm scale on the VAS as the minimum clinically important difference (MCID). Differences smaller than this were considered unlikely to be important. At no point were there between-group differences in the VAS scores that exceeded the MCID, indicating no clinically important reductions in pain associated with administering multimodal injections. The highest treatment effect was observed at 3 hours that showed only a -1.3 cm mean difference between the multimodal and the control groups (3.2 ± 1.8 versus 4.5 ± 1.9 [95% CI -1.3 to -0.3]; p < 0.001), which was below the MCID. Morphine consumption was very slightly higher in the control group than in the multimodal group (2.8 ± 2.8 versus 0.3 ± 1.0, mean difference 2.47; p < 0.001). The percentage of patients reporting opioid-related side effects was lower in the multimodal group than in the control group. The proportions of nausea and vomiting were higher in the control group (30% [12 of 40] than in the multimodal group (3% [1 of 40]; p = 0.001). All of these side effects were transient and none was severe. Multimodal wound infiltration with an NSAID and morphine did not yield any clinically important reduction in pain or opioid consumption. Since no substantial benefit of adding these drugs to a patient's aftercare regimen was achieved, and considering the potential risks of administering opioids and NSAIDs (such as, polypharmacy in older patients, serious adverse effects of NSAIDs), we recommend against routine use of this approach in clinical practice. Level I, therapeutic study.

Outcomes of amputation due to long-standing therapy-resistant complex regional pain syndrome type I.

To assess long-term outcomes of amputation in patients with long-standing therapy-resistant complex regional pain syndrome type I (CRPS-I). Partly cross-sectional, partly longitudinal study. Patients who had amputation of a limb due to long-standing, therapy-resistant CRPS-I, at the University Medical Centre Groningen, The Netherlands, between May 2000 and September 2015 (n = 53) were invited to participate. Participants were interviewed in a semi-structured way regarding mobility, pain, recurrence of CRPS-I, quality of life, and prosthesis use. Those who reported recurrence of CRPS-I underwent physical examination. A total of 47 patients (median age at time of amputation, 41.0 years; 40 women) participated. Longitudinal evaluation was possible in 17 participants. Thirty-seven participants (77%) reported an important improvement in mobility (95% confidence interval (95% CI) 63; 87%). An important reduction in pain was reported by 35 participants (73%; 95% CI 59; 83%). CRPS-I recurred in 4 of 47 participants (9%; 95% CI 3; 20%), once in the residual limb and 3 times in another limb. At the end of the study of the 35 participants fitted with a lower limb prosthesis, 24 were still using the prosthesis. Longitudinal evaluation showed no significant deteriorations. Amputation can be considered as a treatment for patients with long-standing, therapy-resistant CRPS-I. Amputation can increase mobility and reduce pain, thereby improving the quality of patients' lives. However, approximately one-quarter of participants reported deteriorations in intimacy and self-confidence after the amputation.

Patients undergoing surgery for lumbar spinal stenosis experience unique courses of pain and disability: A group-based trajectory analysis.

ObjectiveIdentify patient subgroups defined by trajectories of pain and disability following surgery for degenerative lumbar spinal stenosis, and investigate the construct validity of the subgroups by evaluating for meaningful differences in clinical outcomes.MethodsWe recruited patients with degenerative lumbar spinal stenosis from 13 surgical spine centers who were deemed to be surgical candidates. Study outcomes (leg and back pain numeric rating scales, modified Oswestry disability index) were measured before surgery, and after 3, 12, and 24 months. Group-based trajectory models were developed to identify trajectory subgroups for leg pain, back pain, and pain-related disability. We examined for differences in the proportion of patients achieving minimum clinically important change in pain and disability (30%) and clinical success (50% reduction in disability or Oswestry score ≤22) 12 months from surgery.ResultsData from 548 patients (mean[SD] age = 66.7[9.1] years; 46% female) were included. The models estimated 3 unique trajectories for leg pain (excellent outcome = 14.4%, good outcome = 49.5%, poor outcome = 36.1%), back pain (excellent outcome = 13.1%, good outcome = 45.0%, poor outcome = 41.9%), and disability (excellent outcome = 30.8%, fair outcome = 40.1%, poor outcome = 29.1%). The construct validity of the trajectory subgroups was confirmed by between-trajectory group differences in the proportion of patients meeting thresholds for minimum clinically important change and clinical success after 12 postoperative months (p < .001).ConclusionSubgroups of patients with degenerative lumbar spinal stenosis can be identified by their trajectories of pain and disability following surgery. Although most patients experienced important reductions in pain and disability, 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery. These findings may inform appropriate expectation setting for patients and clinicians and highlight the need for better methods of treatment selection for patients with degenerative lumbar spinal stenosis.

Effects of eccentric exercise in patients with subacromial impingement syndrome: a systematic review and meta-analysis

BackgroundSubacromial impingement syndrome is a common problem in primary healthcare. It often include tendinopathy. While exercise therapy is effective for this condition, it is not clear which type of exercise is the most effective. Eccentric exercises has proven effective for treating similar tendinopathies in the lower extremities. The aim of this systematic review was therefore to investigate the effects of eccentric exercise on pain and function in patients with subacromial impingement syndrome compared with other exercise regimens or interventions. A secondary aim was to describe the included components of the various eccentric exercise regimens that have been studied.MethodsSystematic searches of PubMed, Cochrane Library and PEDro by two independent authors. Included studies were assessed using the PEDro scale for quality and the Cochrane scale for clinical relevance by two independent authors. Data were combined in meta-analyses. GRADE was applied to assess the certainty of evidence.ResultsSixty-eight records were identified. Seven studies (eight articles) were included, six were meta-analysed (n = 281). Included studies were of moderate quality (median PEDro score 7, range 5–8). Post-treatment pain was significantly lower after eccentric exercise compared with other exercise: MD -12.3 (95% CI − 17.8 to − 6.8, I2 = 7%, p < 0.001), but this difference was not clinically important. Eccentric exercise provided no significant post-treatment improvement in function compared with other exercise: SMD -0.10 (95% CI − 0.79 to 0.58, I2 = 85%, p = 0.76). Painful eccentric exercise showed no significant difference compared to pain-free eccentric exercise. Eccentric training regimes showed both similarities and diversity. Intervention duration of 6–8 weeks was almost as effective as 12 weeks.ConclusionsEvidence of low certainty suggests that eccentric exercise may provide a small but likely not clinically important reduction in pain compared with other types of exercise in patients with subacromial impingement syndrome. It is uncertain whether eccentric exercise improves function more than other types of exercise (very low certainty of evidence). Methodological limitations of existing studies make these findings susceptible to change in the future.Trial registrationPROSPERO CRD42019126917, date of registration: 29-03-2019.

179. Predictors of clinical outcome following surgery for lumbar spinal stenosis: a study of postoperative pain and disability trajectories

BACKGROUND CONTEXT On average, patients experience important reductions in pain and disability following surgery for degenerative lumbar spinal stenosis (LSS). However, variability in the postoperative course of symptoms suggests many patients do not fit the average symptom trajectory. PURPOSE To identify patient subgroups defined by trajectories of pain and disability following surgery for LSS and investigate the construct validity of the subgroups by evaluating meaningful differences in clinical outcomes. Identify predictors of belonging to the poor outcomes subgroup for disability, leg pain and back pain. STUDY DESIGN/SETTING Retrospective analysis of prospectively collected data. PATIENT SAMPLE Patients with LSS were recruited from 13 surgical spine centers participating in the Canadian Spine Outcomes and Research Network registry. OUTCOME MEASURES Leg and back pain numeric rating scales and the modified Oswestry disability index were measured before surgery and at 3, 12, and 24 months following surgery. METHODS Patients were fit into pain and disability trajectory subgroups with group-based trajectory modeling. Differences in the proportion of patients achieving minimum clinically important change in pain and disability (30%) and clinical success (50% reduction in disability or Oswestry score ≤22) were examined. Generalized linear mixed models adjusted for age and sex, were used to identify associations between subgroup membership and preoperative demographic, clinical history, health status and surgical factors. The subgroup with excellent outcomes was used as the reference group; associations were reported with relative risk ratios (RR). RESULTS The group-based trajectory models identified 3 unique pain trajectories each (excellent, fair and poor) for leg pain, back pain and disability. Depending on outcome 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery. The construct validity of the trajectory subgroups was supported by differences in the proportion of patients meeting thresholds for minimum clinically important change and clinical success (p CONCLUSIONS The percentage of patients with poor outcomes highlights the need for better methods of treatment selection for patients with LSS. The predictors of having poor outcomes suggests it is time to look beyond pathology/surgical factors only and include mental health variables as an integral part of the surgical decision-making process in an effort to avoid patients at increased risk for surgical failure. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.