Improvement In Self-reported Pain Research Articles

The Effects of Noxious Electrical Stimulation and Eccentric Exercise on Mechanical and Thermal Pain Sensitivity in Recreational Runners with Achilles Tendinopathy.

Achilles tendinopathy is a common overuse condition that can become persistent despite conservative treatment. Sensitization of both the peripheral and central nervous systems may contribute to the persistent pain. Both exercise and electrical stimulation have the potential to modulate the nervous system's sensitivity to painful stimuli. The purpose of this study was to describe the changes in pain sensitivity and self-reported function in runners with chronic Achilles tendon pain following sequential treatment with noxious electrical stimulation (NxES) and eccentric plantarflexion exercise. Single group, repeated measures design. Sixteen participants with chronic Achilles tendinopathy completed the Lower Extremity Functional Scale (LEFS) and the Victorian Institute of Sport Assessment-Achilles scale (VISA-A) and quantitative sensory tests (pressure pain threshold, heat temporal summation, and heat pain threshold) at baseline, one week, seven weeks, and then at a one month post intervention follow-up. The NxES was applied for one week, then followed by plantarflexion eccentric exercise for six weeks. Changes across timepoints were assessed using repeated measures ANOVA and post hoc analysis to describe differences. Hedges g effect sizes were also calculated. There was a significant improvement in LEFS (p < 0.001) and VISA-A (p < 0.001) from baseline to one month follow-up, with a mean change of 9.6 ± 7.7 and 19.4 ± 17.7 points respectively. Pressure pain threshold of the involved Achilles tendon increased over time (p < 0.001) with significant improvements after NxES application (p = 0.002) and after six weeks of eccentric exercise (p < 0.001). There were significant improvements from baseline to one month follow-up for heat temporal summation (p = 0.001) and heat pain threshold ( p < 0.001). For individuals with chronic Achilles tendinopathy, a sequential treatment of NxES followed by eccentric exercise resulted in a clinically significant improvement in self-reported pain and function. During the first week of treatment there was a reduction in mechanical hyperalgesia during the NxES-only phase, while a large reduction in primary heat hyperalgesia and additional desensitization to mechanical pain occurred during the eccentric training phase of treatment. 2b.

Effects of high frequency strengthening on pain sensitivity and function in female runners with chronic patellofemoral pain

ObjectiveTo investigate the effects of a high frequency strengthening program on function, pain, and pain sensitization in female runners with chronic patellofemoral pain (PFP). DesignCross-sectional study. SettingUniversity laboratory. ParticipantsThirty female runners (mean age 32 ± 8.1 years) with chronic PFP completed an 8-week home strengthening program. Main outcome measuresVariables assessed at baseline, 8-weeks, and 12 weeks included single leg step down test (SLSD), pain, Anterior Knee Pain Scale (AKPS), University of Wisconsin Running Injury and Recovery Index (UWRI), and quantitative sensory testing. ResultsThere was large and statistically significant improvement at 8 and 12 weeks for average knee pain (ηp2 = 0.334, p < 0.001), worst knee pain (ηp2 = 0.351, p < 0.001), SLSD (ηp2 = 0.161, p = 0.001), AKPS (ηp2 = 0.463, p < 0.001), and UWRI (ηp2 = 0.366, p < 0.001). A medium to large effect and statistically significant improvement in pressure pain threshold testing was found for all local and remote structures (ηp2 range, 0.110 to 0.293, range p < 0.001 to p = 0.009) at 8 and 12 weeks. ConclusionsThere was a significant decrease in local and remote hyperalgesia via mechanical and thermal pain sensitivity testing in female runners with chronic PFP. There was a large effect and significant improvement in self-reported pain and function.

Relationship between Nociplastic Pain Involvement and Medication use, Symptom Relief, and Adverse effects Among People using Medical Cannabis for Chronic Pain.

Cannabis is commonly used for chronic pain management, but cannabis' effects remain poorly characterized in chronic nociplastic pain (NPP), which is posited to be caused by disturbances in nervous system pain processing. In this cross-sectional study (n=1,213), we used the 2011 Fibromyalgia (FM) Survey Criteria as a surrogate measure for degree of NPP among individuals using medical cannabis for chronic pain. Using a quartile-split, we investigated associations between degree of NPP and medication use, cannabis use characteristics, and symptom relief. Continuous variables were assessed using one-way analysis of variance (ANOVA) and categorical variables with Pearson's Chi-square test (2) and binomial logistic regression for calculation of odds ratios (OR). Participants were predominately female (59%), with mean ±SD age 49.4±13.6 years. Higher FM scores were associated with less self-reported improvement in pain and health since initiating medical cannabis use, as well as more cannabis-related side effects. Paradoxically, higher FM scores were also associated with higher usage of concomitant medication use (including opioids and benzodiazepines) but also with substituting cannabis for significantly more medication classes, including opioids and benzodiazepines. This article presents evidence that individuals in higher NPP quartiles have higher analgesic intake, higher odds of substituting cannabis for medications, higher side effect burden, and lower therapeutic effect from cannabis. These seemingly contradictory findings may reflect higher symptom burden, polypharmacy at baseline, or that NPP may be challenging to treat with cannabis. Further research is necessary to further explain cannabinoid effects in NPP.

Cannabidiol Use, Substitution for Medications, and Perceptions of Effectiveness in Women with Chronic Pelvic Pain

<h3>Study Objective</h3> To describe the prevalence and patterns of cannabidiol (CBD) use in women with co-existing chronic pelvic pain (CPP) and fibromyalgia, and to evaluate characteristics associated with pain improvement. <h3>Design</h3> Cross-sectional, anonymous survey. <h3>Setting</h3> Web-based survey distributed by National Fibromyalgia Association in April-May 2020. <h3>Patients or Participants</h3> Female respondents with fibromyalgia who also self-reported diagnosis of CPP due to endometriosis, vulvodynia, interstitial cystitis or urinary chronic pelvic pain (IC/UCPP), and/or irritable bowel syndrome (IBS). <h3>Interventions</h3> Participants completed survey including self-reported CBD use patterns, substitution of CBD for medications, and self-reported improvement in pain due to CBD. <h3>Measurements and Main Results</h3> Our sample included 1382 women with ≥1 CPP diagnosis: 26.0% with endometriosis, 4.2% with vulvodynia, 14.0% with IC/UCPP, and 84.4% with IBS. Participants were classified by CBD use: current (n=477, 34.5%), past (n=404, 29.2%), or never (n=501, 36.3%). Of those who discontinued CBD, 61.6% did so because it did not improve symptoms. Participants who used CBD most commonly did so for pain (96.4%), sleep (48.8%) and anxiety (46.1%), with 80.9% reporting that CBD improved their pain. Side effects were minimal, with patients reporting an average of 1.0±1.3 side effects. The majority of participants (75.9%) reported substituting CBD for pain medications, including NSAIDs (45.3%), opioids (39.8%), gabapentinoids (27.7%), and benzodiazepines (19.3%). Compared to those who did not report pain improvement (n=91, 19.1%), those who reported improved pain had a higher proportion of substituting CBD for pain medications (p=0.003), reported greater improvements in other symptom domains (sleep, anxiety, depression, fatigue, and overall health, all p≤0.001). <h3>Conclusion</h3> Among women with FM and co-morbid CPP, over 60% reported past or current use of CBD. About half of participants who ever used CBD for pain reported improved pain, and many substitute CBD for pain medications including opioids and benzodiazepines.

A Randomized Controlled Trial Comparing a Medial Stabilized Total Knee Prosthesis to a Cruciate Retaining and Posterior Stabilized Design: A Report of the Clinical and Functional Outcomes Following Total Knee Replacement

BackgroundThe purpose of this randomized controlled trial was to compare the performance of 3 total knee joint replacement (TKJR) designs 6 months after the surgery. MethodsPatients were recruited between March 2015 and March 2018. Patients with osteoarthritis consented for TKJR were randomly allocated to a medial stabilized (MS), cruciate retaining (CR), or posterior stabilized (PS) design. Primary outcome measures were self-reported improvement in pain and function 6 months after TKJR, using the Oxford Knee Score. Secondary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index, Veterans RAND 12-item Health Survey, Knee Society Score 2011, Timed Up and Go test, and Six-Minute Walk Test. Twelve-month outcomes were also measured. ResultsNinety participants enrolled, 83 were randomized: PS (n = 26), CR (n = 28), and MS (n = 29) designs. One case withdrew before surgery: planned use of non-study implant; 7 did not complete all outcome measures. No 6-month between-group difference was observed for the primary outcome. A 6-month difference was observed in Knee Society Score 2011 Satisfaction: MS favored over CR and PS. Clinically meaningful 12-month differences in Western Ontario and McMaster Universities Osteoarthritis Index Pain, Function, and Global Subscales were observed: MS favored over CR. Twelve-month differences occurred in Veterans RAND 12-item Health Survey mental well-being, favoring MS and PS over CR. ConclusionMS prosthesis can be expected to yield similar clinical and functional outcomes to PS and CR designs 6 months after TKJR, and patients were more satisfied with their outcome. Compared with CR, patients with MS prosthesis also reported superior pain, function, and quality-of-life outcomes at 12 months.

Individual Gait Features Are Associated with Clinical Improvement After Total Knee Arthroplasty.

Background:Over 20% of patients do not report clinically relevant pain relief or functional improvements after total knee arthroplasty (TKA). The aim of this study was to investigate the effect of demographics, pre-TKA knee-joint biomechanics, and postoperative changes in knee biomechanics on meaningful improvements in self-reported pain and function after TKA.Methods:Forty-six patients underwent 3-dimensional gait analysis and completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire before and 1 year after TKA. Response to treatment in terms of pain relief and functional improvement (“pain and function responders”) was defined as improvements in WOMAC scores that met minimal clinically important difference thresholds in the pain and function domains. Differences between responder and non-responder demographics, severity of the osteoarthritis as seen radiographically, and knee kinematics and kinetics before TKA were explored using the t test and Mann-Whitney U test. Correlations and regression models were used to examine demographics, baseline knee kinematics and kinetics, and post-TKA kinematic and kinetic improvements associated with being a pain responder and a function responder separately. Analyses were conducted using a hypothesis-driving approach.Results:Of the 46 patients, 34 were pain responders and 36 were function responders. Preoperatively, both responder groups had a higher radiographic severity (Kellgren-Lawrence) grade (p = 0.03) and pain responders were more symptomatic according to their WOMAC score (p < 0.04). Less preoperative stance-phase flexion-extension angle range (p ≤ 0.03), lower preoperative stance-phase adduction (varus) angle magnitude (p = 0.01), and less postoperative reduction in the adduction angle magnitude (p ≤ 0.009) were independently associated with more self-reported improvement in pain and function.Conclusions:Patients with a higher radiographic severity grade, with specific frontal and sagittal knee kinematic patterns during gait before TKA, and who demonstrated less reduction in frontal plane angles during gait after TKA had greater self-reported pain and function score improvements after standard TKA. Gait analysis may aid preoperative identification of kinematic subgroups associated with self-reported improvements after TKA, and provide evidence that may inform triaging, surgical planning, and expectation management strategies.Level of Evidence:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

RBTT-03. USE OF VIRTUAL REALITY ENVIRONMENTS TO IMPROVE SELF-REPORTED DISTRESS, MOOD DISTURBANCE AND OVERALL SYMPTOM BURDEN USING CORRELATIVE STRESS BIOMARKERS IN PRIMARY BRAIN TUMOR (PBT) PATIENTS

Abstract Approximately 20% of PBT patients experience moderate-severe distress at the time of neuroimaging &amp; diagnostic evaluation, which can adversely impact their psychological health and ability to tolerate oncologic therapies. Virtual reality (VR) technology is increasingly being utilized in clinical populations with demonstrated improvement in self-reported pain, anxiety, and distress, though little is known about the biological pathways involved. We hypothesize that VR can improve distress through a combination of distraction and promotion of the relaxation response, both of which could blunt activity of physiological stress pathways. The purpose of this study is to assess the effect of VR breathing and relaxation scenarios on self-reported acute and long-term distress incorporating correlative stress biomarkers, as well as assessing long-term effects on mood disturbance and overall symptom burden. This is a phase 2 experimental pre-post design with a sample size of 100 PBT patients, stratified into low and high distress groups. Self-reported measures include the Distress Thermometer, PROMIS Anxiety and Depression Short Forms, and the MD Anderson Symptom Inventory Brain Tumor instrument. Correlative stress biomarkers include salivary cortisol and dehydroepiandrosterone-sulfate (DHEA-S), representing hypothalamic-pituitary-adrenal (HPA) axis activity, and salivary alpha amylase (sAA) and heart rate, representing activity of the sympathetic-adrenal-medullary (SAM) system. Baseline and post-intervention assessments will be taken surrounding a 5 to 10 minute VR experience in clinic, with repeat assessments 1 week later and at the next clinic appointment. Anticipated outcomes include a decrease in self-reported acute and remote distress with correlative decrease in stress biomarkers, as well as improvement of mood disturbance and overall symptom burden. VR has the potential to help PBT patients improve self-management of their psychological symptoms, potentially enhancing their tolerance of oncologic therapies and overall quality of life. Additionally, the benefits of this intervention may have broad applicability to other cancer patient populations.

Effects of Scapular Stabilization Exercise Training on Scapular Kinematics, Disability, and Pain in Subacromial Impingement: A Randomized Controlled Trial

ObjectiveTo investigate the effects of 2 different exercise programs on 3-dimensional scapular kinematics, disability, and pain in participants with subacromial impingement syndrome (SIS). DesignRandomized controlled trial. SettingOutpatient clinic and research laboratory. ParticipantsParticipants who were diagnosed with SIS and who also exhibited scapular dyskinesis (N=30). InterventionsThe participants were randomized in 2 different exercise groups: (1) shoulder girdle stretching and strengthening with additional scapular stabilization exercises based on a kinetic chain approach (intervention group), and (2) shoulder girdle stretching and strengthening exercises only (control group). Main Outcome MeasuresThree-dimensional scapular kinematics, self-reported shoulder pain, and disability were evaluated at baseline, after 6 weeks of training, and after 12 weeks of training. ResultsSignificant differences were observed between the control and intervention groups in external rotation and posterior tilt after 6 weeks of training and in external rotation, posterior tilt, and upward rotation after 12 weeks of training. All groups showed improvement in self-reported pain and disability scores; however, there were no significant differences between the groups. ConclusionsProgressive exercise training independent from specific scapular stabilization exercises provides decreased disability and pain severity in impingement syndrome.

Botox combined with myofascial release physical therapy as a treatment for myofascial pelvic pain.

PurposeTo report the effects of combined onabotulinumtoxinA (Botox) injections and myofascial release physical therapy on myofascial pelvic pain (MFPP) by comparing pre- and posttreatment average pelvic pain scores, trigger points, and patient self-reported pelvic pain. Secondary outcomes were to examine posttreatment complications and determine demographic differences between patients with/without an improvement in pain.Materials and MethodsThis was an Institutional Review Board approved retrospective case series on women over 18 years with MFPP who received Botox and physical therapy between July 2006 and November 2014. Presence of trigger points and pelvic pain scores were determined by digital palpation of the iliococcygeus, puborectalis, obturator internus, and rectus muscles. Average pelvic pain scores (0–10) reflected an average of the scores obtained from palpation of each muscle. Self-reported improvement in pain was recorded as yes/no.ResultsFifty women met the inclusion/exclusion criteria. Posttreatment, patients had lower average pelvic pain scores (3.7±4.0 vs. 6.4±1.8, p=0.005), and fewer trigger points (44% vs. 100%, p<0.001). Fifty-eight percent of patients (95% confidence interval, 44–72) noted an improvement in self-reported pain. Patients most likely to report no improvement in pain had chronic bowel disorders, while those most likely to report an improvement in pain had a history of past incontinence sling (p=0.03). Posttreatment complications included: constipation (8%), worsening urinary retention (2%), and urinary tract infection (4%).ConclusionsBotox combined with soft tissue myofascial release physical therapy under anesthesia can be effective in treating women with chronic pelvic pain secondary to MFPP.

Mid-Treatment Sleep Duration Predicts Clinically Significant Knee Osteoarthritis Pain reduction at 6 months: Effects From a Behavioral Sleep Medicine Clinical Trial.

To determine the relative influence of sleep continuity (sleep efficiency, sleep onset latency, total sleep time [TST], and wake after sleep onset) on clinical pain outcomes within a trial of cognitive behavioral therapy for insomnia (CBT-I) for patients with comorbid knee osteoarthritis and insomnia. Secondary analyses were performed on data from 74 patients with comorbid insomnia and knee osteoarthritis who completed a randomized clinical trial of 8-session multicomponent CBT-I versus an active behavioral desensitization control condition (BD), including a 6-month follow-up assessment. Data used herein include daily diaries of sleep parameters, actigraphy data, and self-report questionnaires administered at specific time points. Patients who reported at least 30% improvement in self-reported pain from baseline to 6-month follow-up were considered responders (N = 31). Pain responders and nonresponders did not differ significantly at baseline across any sleep continuity measures. At mid-treatment, only TST predicted pain response via t tests and logistic regression, whereas other measures of sleep continuity were nonsignificant. Recursive partitioning analyses identified a minimum cut-point of 382 min of TST achieved at mid-treatment in order to best predict pain improvements 6-month posttreatment. Actigraphy results followed the same pattern as daily diary-based results. Clinically significant pain reductions in response to both CBT-I and BD were optimally predicted by achieving approximately 6.5 hr sleep duration by mid-treatment. Thus, tailoring interventions to increase TST early in treatment may be an effective strategy to promote long-term pain reductions. More comprehensive research on components of behavioral sleep medicine treatments that contribute to pain response is warranted.

A Phase II Trial of Human Secretin Infusion for Refractory Type B Pain in Chronic Pancreatitis

We aimed to determine if intravenous synthetic human secretin (sHS) improves refractory type B pain in patients with chronic pancreatitis (CP). In a phase II dose escalation trial, patients with CP received sHS of varying doses (0.05-0.8 µg/kg) for 3 days. The primary outcomes were changes in the visual analogue pain score (VAS), short form (SF)-36, and opiate use from baseline at 30 days after infusion. Twelve patients (mean age, 42 years, 6 men) were included. Mean pain scores (VAS) were 5.79, 4.80, 4.72, and 4.90, at baseline, day 4, day 10, and day 30, respectively (P = 0.25, 0.19, and 0.27 when compared with baseline, respectively). Daily opiate use (oral morphine equivalents) decreased throughout the study from a baseline value of 136 to 111 mg on day 4 (P = 0.52) and to 104 mg on day 30 (P = 0.34). In subgroup analysis, women had the most improvement (VAS baseline, 5.42 vs. VAS day 30, 3.67; P = 0.07; baseline morphine equivalents, 107 mg vs. 84 mg; P = 0.21). In patients, especially women, with refractory type B pain from CP, intravenous sHS administration demonstrated a trend toward improvement in self-reported pain and opiate use at 30 days after infusion, although statistical significance was not achieved (clinicaltrials.gov registration number NCT01265875).

Validation of a consensus-based minimal clinically important difference (MCID) threshold using an objective functional external anchor

Background contextThe minimal clinically important difference (MCID) is defined as the smallest change in an outcome that a patient would perceive as meaningful. The Initiative on Methods, Measurement and Assessment in Clinical Trials (IMMPACT) group proposed defining the MCID as a 30% improvement in self-reported pain or function. However, this MCID threshold has not been validated against an objective physical measure. PurposeTo test the validity of the IMMPACT-based MCID threshold, using an objective physical measure as an external anchor. Study design/settingProspective study of chronic disabling occupational lumbar disorder (CDOLD) patients completing a functional restoration program. Patient sampleA consecutive cohort of 743 CDOLD patients. Outcome measuresSelf-report measures of pain-related function were compared with an objective lifting measure, the progressive isoinertial lifting evaluation (PILE), obtained after treatment. MethodsThe association between reporting 30% or greater improvement (the IMMPACT's MCID key criterion) and the PILE score after treatment was assessed. ResultsA 30% or greater improvement on the self-report measures was significantly associated with improvement in physical function on the PILE task. ConclusionsDespite extensive use of the MCID to evaluate effects of treatment in spinal disorders, this is the first empirical documentation of the validity of the IMMPACT's 30% change criterion compared with an objective physical anchor.

The Quantified Lumbar Flexion-Relaxation Phenomenon Is a Useful Measurement of Improvement in a Functional Restoration Program

A prospective cohort study evaluating the quantitative lumbar flexion-relaxation phenomenon (QLFRP), measured with surface electromyographic (SEMG) signals from the erector spinae during trunk flexion pre- and postrehabilitation, in patients with chronic disabling occupational lumbar disorders (CDOLD). To assess the responsiveness of the QLFRP in documenting change in functional performance during a functional restoration program for CDOLD patients. A recent theoretical construct suggests that QLFRP is responsive to change in lumbar range of motion (ROM) during rehabilitation, with high sensitivity and specificity for abnormal QLFRP predicting ROM. A cohort of normal subjects was tested for QLFRP correlated to inclinometric lumbar ROM measures. The cutoff score was applied to a group of CDOLD patients entering a functional restoration program (N = 135), and to program completers (N = 104). Pain and functional self-report scores were compared with SEMG and ROM measures. The CDOLD group averaged 23.7 months off work. Surgical treatment was provided prerehabilitation to 51% of patients, with 29% receiving lumbar fusions. From pre- to post-treatment, achievement of QLFRP rose from 31% to 74% of patients, while normal ROM rose from 8% to 63% of patients. Compared to the 16% of patients still demonstrating both abnormal QLFRP and ROM, the other groups showed significantly greater improvement in self-reported pain and function, with the best improvements occurring in patients showing normal ROM and QLFRP. The QLFRP showed high sensitivity, but only modest predictive validity and specificity for predicting ROM postrehabilitation. Improvement in sensitivity and predictive validity occur when surgical cases were excluded from the analysis. A majority of patients in an interdisciplinary functional restoration program failed to demonstrate either the QLFRP or normal ROM on admission to the program. A majority of program completers, however, achieved both normal ROM and QLFRP and another 30% demonstrated either normal QLFRP or normal ROM. Both QLFRP and ROM measures were responsive to relevant self-report scales.

Cost-Effectiveness of Exercise and Diet in Overweight and Obese Adults with Knee Osteoarthritis

The purpose of this study was to compare the cost-effectiveness of dietary and exercise interventions in overweight or obese elderly patients with knee osteoarthritis (OA) enrolled in the Arthritis, Diet, and Physical Activity Promotion Trial (ADAPT). ADAPT was a single-blinded, controlled trial of 316 adults with knee OA, randomized to one of four groups: Healthy Lifestyle Control group, Diet group, Exercise group, or Exercise and Diet group. A cost analysis was performed from a payer perspective, incorporating those costs and benefits that would be realized by a managed care organization interested in maintaining the health and satisfaction of its enrollees while reducing unnecessary utilization of health care services. The Diet intervention was most cost-effective for reducing weight, at $35 for each percentage point reduction in baseline body weight. The Exercise intervention was most cost-effective for improving mobility, costing $10 for each percentage point improvement in a 6-min walking distance and $9 for each percentage point improvement in the timed stair climbing task. The Exercise and Diet intervention was most cost-effective for improving self-reported function and symptoms of arthritis, costing $24 for each percentage point improvement in subjective function, $20 for each percentage point improvement in self-reported pain, and $56 for each percentage point improvement in self-reported stiffness. The Exercise and Diet intervention consistently yielded the greatest improvements in weight, physical performance, and symptoms of knee OA. However, it was also the most expensive and was the most cost-effective approach only for the subjective outcomes of knee OA (self-reported function, pain, and stiffness). Perceived function and symptoms of knee OA are likely to be stronger drivers of downstream health service utilization than weight, or objective performance measures and may be the most cost-effective in the long term.

Time to response for duloxetine 60 mg once daily versus placebo in elderly patients with major depressive disorder

Rapid response to antidepressant therapy is desirable and may be particularly critical in elderly patients with major depressive disorder (MDD). Findings are based on post-hoc analyses from a double-blind trial of elderly patients with MDD > or = 65 years, randomly assigned 2:1 to duloxetine 60 mg QD (N = 207) or placebo (N = 104) for 8 weeks. Depression and pain measures included the Geriatric Depression Scale (GDS), 17-item Hamilton Depression Scale (HAMD17), CGI-Severity, and Visual Analog Scale (VAS) for overall pain. The time to response and remission for duloxetine compared with placebo was evaluated using Cox proportional hazards (PH) modeling, Kaplan-Meier estimation, and categorical repeated measures analysis. Significant improvements of estimated HAMD17 response and remission rates for duloxetine started at week 2 (P = 0.022 and P = 0.033, respectively). Time to HAMD17 response and remission were significantly shorter for duloxetine versus placebo (P 0.10 for all PH treatment-by-age interactions). The placebo-referenced duloxetine HR for time to 50% reduction in overall pain was 1.75 (P = 0.024) for patients with moderate to severe pain. Duloxetine demonstrated a faster time to antidepressant response and improvement in self-reported pain as compared with placebo. CLINICAL TRIAL REGISTRY NUMBER FOR THIS STUDY: NCT00062673, at www.clinicaltrials.gov.

Association between clinician-assessed lifting ability and workplace tolerance and patient self-reported pain and disability following work conditioning

Objective: We investigated the association between clinician-assessed performance-based measures of improvement in lifting ability and workplace tolerance and patient self-reported improvement in pain and perceived disability following work conditioning (WC). Methods: A sample of 76 patients (42 ± 9 yrs, 21 to 60 yrs, 74% male) was selected from a retrospective database because they had lumbar spine impairments and received treatment in a WC program. Patients completed self-report surveys for perceived disability (Oswestry), pain intensity (visual analog pain scale – VAS), and pain concerns (McGill short form) before initial functional capacity evaluation (FCE) and after termination of the WC program. During the FCE and during the WC, therapists assessed patient workplace tolerance (WT) and ability to lift from floor to waist (PDL). Results: Over the WC program that averaged 19 (6 SD) days, Oswestry and VAS scores improved (P&lt; 0.05), but the McGill scores did not (P=0.334). 72% of patients improved their PDL, and 64% met their WT goals. None of the associations between patient self-report scores and performance-based measures were significant (P&gt;0.05). Conclusions: In spite of continuing pain complaints, patients decreased their perceived disability and pain intensity, increased their lifting ability, and improved their workplace tolerance while participating in a work-conditioning program.

A Pilot Study of Low-Power Laser Therapy in the Management of Chronic Neck Pain

Objective: This pilot study was undertaken to test techniques of application of laser therapy, appropriate outcome measures and to determine effect sizes in order to facilitate the performance of a larger, clinical trial of laser therapy in chronic neck pain.Methods: We conducted a randomized double-blind, placebo-controlled study of low level laser therapy in 20 patients with chronic neck pain. The primary outcome measure was change in a 10 cm Visual Analogue Scale [VAS] for pain. Other measures used included a Self-Reported Improvement in pain [SRI], measured by a VAS, Short-Form 36 Quality-of-Life questionnaire [SF-36], Northwick Park Neck Pain Questionnaire [NPNPQ] and the McGill Pain Questionnaire [MPQ]. Measurements were taken at baseline, at the end of 7 weeks treatment and at 12 weeks from baseline.Results: We found a positive, pain-relieving effect in the treated group compared with those given placebo using the VAS [P < 0.039], SRI [P < 0.001], NPNPQ [P < 0.002] and the MPQ [P < 0.009]. The resu...

Chiropractic management of ehlers-danlos syndrome: a report of two cases

Objective To discuss 2 patients with Ehlers-Danlos syndrome seeking chiropractic evaluation and management of their disabling musculoskeletal pain and associated disorders. Clinical features Two disabled patients diagnosed with Ehlers-Danlos syndrome had spinal pain, including neck and back pain, headache, and extremity pain. Commonalities among these 2 cases included abnormal spinal curvatures (kyphosis and scoliosis), joint hypermobility, and tissue fragility. One patient had postsurgical thoracolumbar spinal fusion (T11-sacrum) for scoliosis and osteoporosis. The other patient had moderate anterior head translation. Intervention and outcome Both patients were treated with mechanical force and manually assisted spinal adjustments delivered to various spinal segments and extremities utilizing an Activator II Adjusting Instrument and Activator Methods Chiropractic Technique. Patients were also given postural advice, stabilization exercises, and postural corrective exercises, as indicated in Chiropractic BioPhysics Technique protocols. Both patients were able to reduce pain and anti-inflammatory medication usage in association with chiropractic care. Significant improvement in self-reported pain and disability as measured by visual analog score, Oswestry Low-Back Disability Index, and Neck Pain Disability Index were reported, and objective improvements in physical examination and spinal alignment were also observed following chiropractic care. Despite these improvements, work disability status remained unchanged in both patients. Conclusion Chiropractic care may be of benefit to some patients with connective tissue disorders, including Ehlers-Danlos syndrome. Low-force chiropractic adjusting techniques may be a preferred technique of choice in patients with tissue fragility, offering clinicians a viable alternative to traditional chiropractic care in attempting to minimize risks and/or side effects associated with spinal manipulation. Psychosocial issues, including patient desire to return to work, were important factors in work disability status and perceived outcome.