Long-term Pain Outcomes Research Articles

Estimating Risk of Chronic Pain and Disability Following Musculoskeletal Trauma in the United Kingdom

Serious traumatic injury is a leading cause of death and disability globally, with most survivors known to develop chronic pain. To describe early variables associated with poor long-term outcome for posttrauma pain and create a clinical screening tool for this purpose. This was a prospective cohort study at a major trauma center hospital in England. Recruitment commenced in December 2018 and ceased in March 2020. Participants were followed up for 12 months. Patients aged 16 years or older who were hospitalized because of acute musculoskeletal trauma within the preceding 14 days were included. Data were analyzed from March to December 2021. Acute musculoskeletal trauma requiring admittance to a major trauma center hospital. A poor outcome was defined as Chronic Pain Grade II or higher and measured at both 6 months (primary time point) and 12 months. A broad range of candidate variables potentially associated with outcomes were used, including surrogates for pain mechanisms, quantitative sensory testing, and psychosocial factors. Univariable models were used to identify the variables most likely to be associated with poor outcome, which were entered into multivariable models. A clinical screening tool (nomogram) was derived from 6-month results. In total, 1590 consecutive patients were assessed for eligibility, of whom 772 were deemed eligible and 124 (80 male [64.5%]; mean [SD] age, 48.9 [18.8] years) were recruited. At 6 months, 19 of 82 respondents (23.2%) reported a good outcome, whereas at 12 months 27 of 44 respondents (61.4%) reported a good outcome. At 6 months on univariable analysis, an increase in total posttraumatic stress symptoms (odds ratio [OR], 2.09; 95% CI, 1.33-3.28), pain intensity average (OR, 2.87; 95% CI, 1.37-6.00), number of fractures (OR, 2.79; 95% CI, 1.02-7.64), and pain extent (OR, 4.67; 95% CI, 1.57-13.87) were associated with worse outcomes. A multivariable model including those variables had a sensitivity of 0.93, a specificity of 0.54, and C-index of 0.92. A poor long-term pain outcome from musculoskeletal traumatic injuries may be estimated by measures recorded within days of injury. These findings suggest that posttraumatic stress symptoms, pain spatial distribution, perceived average pain intensity, and number of fractures are good candidates for a sensitive multivariable model and derived clinical screening tool.

Psychosocial Predictors of Chronic Pain 12Months After Surgical Fixation for Lower Extremity Fracture: A Prospective Study.

Pain is a common outcome after lower extremity fracture (LEF) requiring surgical fixation. Although psychosocial characteristics have meaningful associations with adverse outcomes, no studies have evaluated how psychosocial characteristics throughout recovery are associated with pain outcomes. The primary purpose of this study was to determine whether psychosocial characteristics are early risk factors for pain outcomes in patients following LEF who have no history of chronic pain. Participants, 122 patients with a LEF, consented to this single-center, prospective cohort study. Measurements of depression, pain self-efficacy, pain catastrophizing, and fear of movement were completed at 1week, 6weeks, 3months, 6months, and 12months after LEF. Chronic pain development and pain intensity were assessed at 12months. Univariate analyses assessing the difference between means and corresponding effect sizes were evaluated between those individuals with and without chronic pain at 12months. Separate logistic and linear regression models using psychosocial scores at each time point were used to determine the association with the development of chronic pain and pain intensity, respectively. Of 114 patients (93.4%) who completed the study, 51 (45%) reported chronic pain at 12months. In the univariate analysis, all psychosocial variables at 6weeks, 3months, 6months, and 12months were significantly different between those with and those without chronic pain at 12months (Cohen d range = 0.84 to 1.65). In the multivariate regression models, all psychosocial variables at 6weeks, 3months, and 6months were associated with chronic pain development (odds ratio range = 1.04 to 1.22) and pain intensity (β range = .05 to .14) at 12months. Psychosocial scores as early as 6weeks after surgery are associated with pain outcomes 12months after LEF. Physical therapists should consider adding psychosocial screening throughout recovery after LEF to identify patients at increased risk for long-term pain outcomes.

0632 Early sleep-disordered breathing in moderate-to-severe traumatic brain injury (TBI) is linked with chronic pain status at long-term follow-up: A TBI Model Systems study

Abstract Introduction Sleep disorders and chronic pain (pain of >3 months duration) are common after traumatic brain injury (TBI). A recently completed multi-center trial found that two-thirds of adults with moderate-to-severe TBI had sleep apnea diagnosed during polysomnography (PSG) completed during inpatient rehabilitation. Although a bidirectional relationship between sleep and pain exists, attention to sleep apnea as a specific diagnosis and its possible role in chronic pain following TBI has not been explored. We hypothesized that PSG-derived respiratory indices shortly following TBI would be worse among those reporting chronic pain at 1- to 2-year follow-up compared to those without chronic pain. Methods Sample (N=66) derived from overlapping cohorts across two separate multicenter studies. Participants with moderate to severe TBI underwent PSG during inpatient rehabilitation and completed a telephone follow-up interview to assess chronic pain status using standardized measures at 1-2 years post-TBI (610-day average). Pairwise comparisons across participants with and without chronic pain were made to determine the magnitude of clinically significant differences on respiratory indices including oxygen desaturation, central and obstructive apneas, and total apnea-hypopnea index (AHI). Results Presence of chronic pain at follow-up was associated with elevated central apnea events (2.6) and oxygen desaturation (19.6) relative to those without chronic pain (0.8 and 7.9, respectively). Important differences were also seen between obstructive and total apnea hypopnea index (AHI) using Centers for Medicaid and Medicare Services scoring criteria, with those in the chronic pain cohort being 6.5 and 8.7 points higher than their non-pain counterparts, respectively. Group differences on obstructive and total AHI were considered minor when using the American Academy of Sleep Medicine scoring criteria, although those with current pain experienced categorically worse sleep apnea (total AHI = 19 versus 12.4). Conclusion This is the first study to find an association between PSG-derived respiratory indices and long-term chronic pain status following moderate-to-severe TBI. Sleep apnea represents an important modifiable factor following injury that may contribute to long-term pain-related outcomes. Given the prominence of chronic pain several years post injury, future studies should investigate the role of sleep apnea and early intervention among those following moderate-to-severe TBI to determine impact on long-term rehabilitation and pain outcomes. Support (If Any) PCORI; CER-1511-33005); VA TBI Model Systems Program of Research; GDIT; NIDILRR 90DPTB0008. Clinicaltrial.gov Registration Number: NCT03033901.

Perioperative oxidative stress predicts subsequent pain-related outcomes in the 6 months after total knee arthroplasty.

Total knee arthroplasty (TKA) is effective for pain reduction in most patients, but 15% or more report unsatisfactory long-term pain outcomes. We tested whether oxidative stress (OS) related to extended tourniquet application during TKA and subsequent ischemic reperfusion (IR) contributed to adverse post-TKA pain outcomes. Blood samples were obtained in 91 patients with osteoarthritis (63% female) undergoing TKA before tourniquet placement (T1), 45 minutes after tourniquet inflation (T2), and 15 minutes after tourniquet removal (T3). Plasma levels of F 2 -isoprostanes and isofurans, the most specific measures of in vivo OS, were quantified. Pain intensity and function were assessed at baseline and again at 6 weeks and 6 months after TKA. Results indicated that higher Combined OS (F 2 -isoprostanes + isofurans/2) at T1 baseline and larger increases in Combined OS from T1 to T2 were associated with higher baseline-corrected past 24-hour worst and average pain intensity (numeric rating scale) and higher past week McGill Pain Questionnaire-2 total scores at 6-month follow-up ( P 's < 0.05). Increases in Combined OS from T1 to T3, which should most directly capture OS and IR injury related to tourniquet use, were not associated with short-term or long-term post-TKA pain outcomes. Longer ischemia duration was unexpectedly associated with lower baseline-corrected pain intensity at 6-month follow-up. Combined OS was not linked to functional outcomes at either follow-up. Elevated perioperative OS seems to exert small but significant adverse effects on long-term post-TKA pain outcomes, although this OS seems unrelated to IR injury associated with extended tourniquet use.

Multidata Analysis Based on an Artificial Neural Network Model for Long-Term Pain Outcome and Key Predictors of Microvascular Decompression in Trigeminal Neuralgia

To investigate use of multidata analysis based on an artificial neural network (ANN) to predict long-term pain outcomes after microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and to explore key predictors. Perioperative and long-term follow-up multidata of 1041 patients with TN who received MVD surgery at Hangzhou First People's Hospital from March 2013 to May 2018 were collected to construct an ANN model for prediction. The prediction results were compared with the actual follow-up outcomes, and the variables in each input layer were changed to test the effectiveness of ANN and explore the factors that had the greatest impact on prediction accuracy. The ANN model could predict the long-term pain outcomes after MVD in patients with TN with an accuracy rate of 95.2% and area under the curve of 0.862. Four factors contributed the most to the predictive performance of the ANN: whether the neurovascular offending site of the trigeminal nerve corresponded the region of facial pain, immediate postoperative pain remission after MVD, degree of nerve compression by culprit vessels, and the type of culprit vessels. After these factors were sequentially removed, the accuracy of the ANN model decreased to 74.5%, 78.6%, 87.2%, and 90.1%, while the area under the curve was 0.705, 0.761, 0.793, and 0.810. The ANN model, constructed using multiple data, predicted long-term pain prognosis after MVD in patients with TN objectively and accurately. The model was able to assess the importance of each factor in the prediction of pain outcome.

Comparison of Spinal Cord Stimulation Trial Reporting Protocols and Long-Term Pain Relief Outcomes Following Implantation

ObjectivesAppropriate spinal cord stimulation (SCS) candidates are required to undergo an SCS trial before implant, typically with ≥50% pain relief deemed “successful.” However, SCS trialing protocols can vary substantially. The primary aim of this retrospective study is to investigate the associations between SCS trial results and long-term SCS pain outcomes. Materials and MethodsThis study was a retrospective single-center review of successful SCS trials from January 1, 2017, to July 1, 2019. A total of 115 patients were included. Group differences in continuous variables were evaluated using t-tests, and group differences in categorical variables were evaluated using the χ2 test. The percentage improvement in long-term pain intensity was analyzed as a binary variable, where long-term success was defined as ≥50% improvement in numeric rating scale pain scores. The level of significance for all tests was set at p < 0.05. ResultsThe mean age was 64.9 years, and 52% of patients were men. The mean pain score at long-term follow-up was 4.7 ± 2.6, and the median time from implantation to follow-up was 13 months (25th–75th interquartile range; 4–22). In the logistic regression analysis adjusted for age, sex, and follow-up time, greater patient-reported percentage improvement in pain scale during the trial was significantly associated with greater odds of experiencing ≥50% improvement in pain scores (p = 0.048; 95% CI 1.00–1.70). All other assessed trial metrics were not significantly associated with greater odds of experiencing >50% improvement in pain scores at last follow-up. ConclusionsGiven the variability in current assessment techniques, we recommend the patient-reported percentage improvement in pain scale as the posttrial assessment method of choice instead of a calculated percentage improvement. However, our results indicate that current trial assessment methods are generally poor, and improved trial reporting protocols must be sought.

The effectiveness and safety of neurosurgical treatment via retrosigmoid approach in elderly patients with trigeminal neuralgia

ObjectiveThe purpose of this study was to evaluate the effectiveness and safety of retrosigmoid approach in treating older patients with trigeminal neuralgia (TN). MethodsIn this retrospective study, 49patients (65 and over, elderly group) and 85 patients (under 65, young group) underwent MVD, MVD + PSR or PSR for idiopathic TN from July 2009 to December 2018. The two groups were compared for immediate, long-term pain outcome and postoperative complications. All perioperative data were collected from medical records and telephone interviews. The pain outcomes were assessed with the Barrow Neurological Institute (BNI) pain score. ResultsThe length of follow-up was 13.2 to 124.8 months. 91.8% of the elderly patients and 89.4% of the young patients achieve “Good” immediate pain outcome (BNI I-II), the proportion were 73.5% and 60.0%, respectively, in long-term pain outcome. No statistically significant differences existed in the immediate and long-term pain outcome between the elderly and young patients (P = 0.768 and P = 0.116, respectively). In the grouping analysis, whether in the pure MVD group or the PSR-related group, the immediate and long-term pain outcomes of elderly patients were not significantly different from those of younger patients. Meanwhile, there was no significant difference in the incidence of neurological and non-neurological complications between two groups. ConclusionsCompared with young patients, the treatment for TN in elderly patients via retrosigmoid approach has the same favorable pain outcome. The safety of this procedure for elderly TN patients is similar to that in young patients.

Pain catastrophising in the oro-facial pain population.

Pain catastrophising is a maladaptive cognitive response characterised by an exaggerated negative interpretation of pain experiences. It has been associated with greater disability and poorer outcomes in chronic pain, to include several specific oro-facial pain conditions. The goal of this study was to examine pain catastrophising at a military oro-facial pain specialty clinic. This retrospective chart review (RCR) examined information collected at initial examination from 699 new patients seen between September 2016 and August 2019 at the Orofacial Pain Center at the Naval Postgraduate Dental School (Bethesda, MD). Pain catastrophising, pain characteristics, psychosocial factors and sleep were assessed using standardised scales. Linear regression was used to evaluate associations of patient characteristics and pain intensity with pain catastrophising. Mediation analyses were done to characterise the extent to which the relationship between pain intensity and pain catastrophising may be explained by anxiety, depression and insomnia. Higher pain intensity, depression, anxiety, insomnia and younger age were each associated with higher pain catastrophising (all p<.05). A primary diagnosis of neuropathic pain was the strongest independent predictor of higher pain catastrophising. The relationship between pain intensity and pain catastrophising was partially mediated by anxiety, depression and insomnia. In this RCR of a population of oro-facial pain patients, those diagnosed with neuropathic pain were most likely to display high levels of pain catastrophising, a characteristic which is associated with poor long-term pain outcomes. This is the first study to show that, independent of other patient characteristics, those suffering from neuropathic pains displayed the highest levels of pain catastrophising. This highlights the importance of also addressing psychosocial factors in the treatment of neuropathic pain conditions, which are commonly treated using a predominantly biomedical approach. Additionally, anxiety, depression and insomnia each partially explains the relationship between pain intensity and pain catastrophising.

STarT-Lower Extremity Screening Tool at Six-weeks Predicts Pain and Physical Function 12-months after Traumatic Lower Extremity Fracture

BackgroundPatients with lower extremity fracture requiring surgical fixation often have poor long-term pain and disability outcomes. This indicates the need for a risk stratification tool that can inform patient prognosis early in recovery. The purpose of this study was to determine the predictive validity of the STarT-Lower Extremity Screening Tool (STarT-LE) in patients with lower extremity fracture requiring surgical fixation. Materials and MethodsOne-hundred and twenty-two patients (41.7 ± 14.7 years, 54% male) with lower extremity fracture and no history of chronic pain were enrolled in this prospective cohort study. Patients completed the STarT-LE Screening Tool six-weeks after definitive fixation. Validated measures of chronic pain development, pain interference, and physical function were collected at 12-months. STarT-LE low, medium, and high risk subgroups were compared against each outcome measure with chi-square, one-way analysis of variance, and sensitivity and specificity analyses. Multivariable linear regression analyses determined if STarT-LE risk subgroups at six weeks were associated with each outcome at 12 months when controlling for important baseline demographics. ResultsTwelve-month follow-up was completed by 114 patients (93.4%). Increase in STarT-LE risk subgroup at six-weeks was associated with higher frequency of chronic pain (Low: 14.7%, Medium: 48.3%, High: 85.0%), worse pain interference (Low: 48.6 ± 8.88, Medium: 56.33 ± 8.79, High: 61.65 ± 7.74), and worse physical function (Low: 50.77 ± 9.89, Medium: 42.52 ± 6.47, High: 37.44 ± 7.46) at 12-months. The low risk subgroup had high sensitivity (range: 84.9%-93.9%) and the high risk subgroup had high specificity (range: 87.7%-95.2%) for dichotomized 12-month outcomes. The multivariable results showed that medium and high STarT-LE risk categories were associated with chronic pain development (Medium odds ratio: 3.90, 95%CI: 1.11 to 13.66; High odds ratio: 13.14, 95%CI: 2.25 to 76.86), worse pain interference (Medium: β:4.37, 95%CI: 0.17 to 8.58; High: β:7.01, 95%CI: 1.21 to 12.81), and worse physical function (Medium: β:-3.76, 95%CI: -7.41 to -0.11; β:-7.44, 95%CI:-12.47 to -2.41), respectively, when controlling for important baseline variables. ConclusionThe STarT-LE has the potential to identify patients at-risk for poor pain and functional outcomes, and may help inform the post-surgical management of patients with traumatic LE injury.

Preoperative sleep quality and adverse pain outcomes after total hip arthroplasty.

Sleep disturbance is thought to aggravate acute postoperative pain. The influence of preoperative sleep problems on pain control in the long-term and development of chronic postsurgical pain is largely unknown. This prospective, observational study aimed to examine the links between preoperative sleep disturbance (Pittsburgh Sleep Quality Index, PSQI) and pain severity (Brief Pain Inventory, BPI) 6months postoperative (primary outcome), objective measures of pain and postoperative pain control variables (secondary outcomes). Patients (n=52) with disabling osteoarthritis (OA) pain undergoing total hip arthroplasty (THA) were included. Quantitative sensory testing (QST) was performed preoperatively on the day of surgery to evaluate pain objectively. Clinical data, as well as measures of sleep quality and pain, were obtained preoperatively and longitudinally over a 6-month period. Preoperatively, sleep disturbance (i.e., PSQI score >5) occurred in 73.1% (n=38) of THA patients, and pain severity was high (BPI pain severity 5.4±1.3). Regression models, adjusting for relevant covariates, showed that preoperative PSQI score predicted pain severity 6months postoperative (β=0.091 (95% CI 0.001-0.181), p=.048, R2 =0.35). Poor sleep quality was associated with increased pressure pain sensitivity and impaired endogenous pain inhibitory capacity (R2 range 0.14-0.33, all p's<0.04). Moreover, preoperative sleep disturbance predicted increased opioid treatment during the first 24hr after surgery (unadjusted β=0.009 (95% CI 0.002-0.015)mg/kg, p=.007, R2 =0.15). Preoperative sleep disturbance is prevalent in THA patients, is associated with objective measures of pain severity, and independently predicts immediate postoperative opioid treatment and poorer long-term pain control in patients who have undergone THA. Poor sleep quality and impaired sleep continuity are associated with heightened pain sensitivity, but previous work has not evaluated whether preoperative sleep problems impact long-term postoperative pain outcomes. Here, we show that sleep difficulties prior to total hip arthroplasty adversely predict postoperative pain control 6months after surgery. Given sleep difficulties robustly predict pain outcomes, targeting and improving sleep may have salutary effects on postoperative pain reports and management.

Outcomes of Occipital Nerve Stimulation for Craniofacial Pain Syndromes.

Occipital nerve regional stimulation (ONS) is reported to improve pain in several studies. We examined long-term pain and functional outcomes of ONS in an open-label prospective study. Patients with medically refractory and disabling craniofacial pain were prospectively selected for ONS. Primary outcome was a change in mean daily pain intensity on the numeric pain rating scale (NPRS) at 6 months. Secondary outcomes included changes in NPRS, Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), Pain Disability Index (PDI), Center for Epidemiologic Studies Depression Scale - Revised (CESD-R), and Short Form-36 version 2 (SF36) at last follow-up. Thirteen patients (mean age 49.7 ± 8.4) diagnosed with occipital neuralgia (6), hemicrania continua (2), persistent idiopathic facial pain (2), post-traumatic facial pain (1), cluster headache (1), and chronic migraine (1) were enrolled. Mean NPRS improved by 2.1 ± 2.1 at 6 months and 2.1 ± 1.9 at last follow-up (23.5 ± 18.1 months). HIT-6 decreased by 8.7 ± 8.8, MIDAS decreased by 61.3 ± 71.6, and PDI decreased by 17.9 ± 18. SF36 physical functioning, bodily pain, and social functioning improved by 16.4 ± 19.6, 18.0 ± 31.6, and 26.1 ± 37.3, respectively. Moderate to severe headache days (defined as ≥50% of baseline mean NPRS) were reduced by 8.9 ± 10.2 days per month with ONS. ONS reduced the long-term NPRS and moderate-severe monthly headache days by 30% and improved functional outcomes and quality of life. A prospective registry for ONS would be helpful in accumulating a larger cohort with longer follow-up in order to improve the use of ONS.

The relationship between parental factors, child symptom profile, and persistent postoperative pain interference and analgesic use in children.

Both parental and child factors have been previously associated with persistent or recurrent postoperative pain in children. Yet, little is known about the relative contribution of parent factors or whether child symptom factors might impact the association between parent factors and long-term pain. The aim of this study was to explore the associations between parent factors, child symptomology, and the child's long-term pain outcomes after surgery. This prospective, longitudinal study included parents and their children who were scheduled to undergo spinal fusion for underlying scoliosis. Parents completed baseline surveys about their pain history, pain relief preferences (ie, preference to relieve their child's pain vs avoid analgesic risks), and pain catastrophizing (ie, beliefs about their child's pain). Children were classified previously into high vs low symptom profiles at baseline based on their self-reported pain, catastrophizing, fatigue, depression, and anxiety. Children were assessed 1-year after surgery for their long-term pain interference scores and analgesic use. Serial regression modeling was used to explore whether associations between parent factors and the outcomes were changed when accounting for child factors. Seventy-six parent/child dyads completed all surveys. Parental preferences and catastrophizing were atemporally associated with the child's baseline psychological-somatic symptom profile. Though parent and child factors were both associated with the long-term pain outcomes, when all three factors were accounted for, the associations between parent factors and long-term pain was fully attenuated by the child's profile. These findings suggest that the relationship between parent factors and long-term postoperative pain outcomes may be dependent on the child's symptom profile at baseline. Since there may be bidirectional relationships between parent and child factors, interventions to mitigate long-term pain should address child symptoms as well as parental factors.

Long-term pain outcomes in elderly patients with trigeminal neuralgia: comparison of first-time microvascular decompression and stereotactic radiosurgery.

Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD) and stereotactic radiosurgery (SRS). The use of MVD in elderly patients has been described but has yet to be prospectively compared to SRS, which is well-tolerated and noninvasive. The authors aimed to directly compare long-term pain control and adverse event rates for first-time surgical treatments for idiopathic TN in the elderly. A prospectively collected database was reviewed for TN patients who had undergone treatment between 1997 and 2017 at a single institution. Standardized collection of preoperative demographics, surgical procedure, and postoperative outcomes was performed. Data analysis was limited to patients over the age of 65 years who had undergone a first-time procedure for the treatment of idiopathic TN with at least 1 year of follow-up. One hundred ninety-three patients meeting the study inclusion criteria underwent surgical procedures for TN during the study period (54 MVD, 24 MVD+Rhiz, 115 SRS). In patients in whom an artery was not compressing the trigeminal nerve during MVD, a partial sensory rhizotomy (MVD+Rhiz) was performed. Patients in the SRS cohort were older than those in the MVD and MVD+Rhiz cohorts (mean ± SD, 79.2 ± 7.8 vs 72.9 ± 5.7 and 70.9 ± 4.8 years, respectively; p < 0.0001) and had a higher mean Charlson Comorbidity Index (3.8 ± 1.1 vs 3.0 ± 0.9 and 2.9 ± 1.0, respectively; p < 0.0001). Immediate or short-term postoperative pain-free rates (Barrow Neurological Institute [BNI] pain intensity score I) were 98.1% for MVD, 95.8% for MVD+Rhiz, and 78.3% for SRS (p = 0.0008). At the last follow-up, 72.2% of MVD patients had a favorable outcome (BNI score I-IIIa) compared to 54.2% and 49.6% of MVD+Rhiz and SRS patients, respectively (p = 0.02). In total, 0 (0%) SRS, 5 (9.3%) MVD, and 1 (4.2%) MVD+Rhiz patients developed any adverse event. Multivariate Cox proportional hazards analysis demonstrated that procedure type (p = 0.001) and postprocedure sensory change (p = 0.003) were statistically significantly associated with pain control. In this study cohort, patients who had undergone MVD had a statistically significantly longer duration of pain freedom than those who had undergone MVD+Rhiz or SRS as their first procedure. Fewer adverse events were seen after SRS, though the MVD-associated complication rate was comparable to published rates in younger patients. Overall, the results suggest that both MVD and SRS are effective options for the elderly, despite their advanced age. Treatment choice can be tailored to a patient's unique condition and wishes.

Pain prevention and management must begin in childhood: the key role of psychological interventions.

Pain conditions in childhood often continue into adulthood. Childhood chronic pain is related to a range of vulnerabilities that may have contributed to the onset of childhood pain or that may co-occur as a consequence of childhood pain. These vulnerabilities have been shown to maintain pain and disability during childhood but may also contribute to long-term developmental and health impairments that affect adult life. If progress is to be made in reducing the impact of pain and disability through the lifespan, greater efforts need to be directed toward understanding why, for whom, and how pain occurring in childhood affects subsequent adult pain and health. In this review, a developmental framework is applied to link childhood pain to adult pain highlighting childhood vulnerabilities (emotional, health behavior, social/family, and neurobiological) that may represent pathways for interventions in childhood to interrupt this trajectory. Psychological interventions can play a key role in addressing childhood pain and vulnerabilities associated with risk for maladaptive adult outcomes. The review summarizes the evidence base for the effectiveness of psychological interventions for childhood chronic pain and identifies gaps and opportunities to further develop and test early targeted interventions in childhood to reduce childhood chronic pain as well as build resiliency to promote positive adult outcomes. A future research agenda is delineated including the need for longitudinal cohort studies from childhood into adulthood and testing of both targeted early intervention to reduce risk and build resiliency to enhance long-term adult pain, health, developmental, and social outcomes.

Improving osteoarthritis care by digital means - Effects of a digital self-management program after 24- or 48-weeks of treatment.

Osteoarthritis (OA) is highly prevalent in older adults and a growing cause of disability. Easily accessible first-line treatment of OA is increasingly important. Digital self-management programs have in recent years become available. Evidence of short-term effects of such programs are abundant, yet reports on long-term benefits and adherence to treatment are scarce. The current study's objective was to investigate the long-term pain and function outcomes of people with hip or knee OA participating in a digital self-management programme. In this longitudinal cohort study, individuals with hip and knee OA, from the register of a digital self-management program and with 0-24-week (n = 499) or 0-48-week adherence (n = 138), were included. The treatment effect in terms of monthly pain (NRS, 0-10 worst to best) and physical function (30-second chair stand test (30CST), number of repetitions) change were investigated using a mixed model, controlling for the effect of age, body mass index (BMI), gender and index joint. For the 24-week sub-sample, pain NRS decreased monthly by -0.43 units (95% CI -0.51, -0.35, mean knee pain from 5.6 to 3.1, and hip pain from 5.9 to 3.8) and 30CST repetitions increased monthly by 0.76 repetitions (95% CI 0.64, 0.89 mean for knee from 10.0 to 14.3, and for hip from 10.9 to 14.8). For the 48-week sub-sample, pain decreased monthly by -0.39 units (95% CI -0.43, -0.36, mean knee pain from 5.7 to 3.2, and hip pain from 5.8 to 3.8), and repetitions increased by 0.72 repetitions (95% CI 0.65, 0.79, mean repetitions for knee from 10.3 to 14.4, and for hip from 11.1 to 14.9). There were no clinically relevant effects on the improvement of pain or function by any covariate (age, sex, index joint). The lack of a control group and randomization limit our ability to explain the mechanisms of the observed results. Continuously participating in a digital OA treatment program for 6 or 12 months was associated with a clinically important decrease in joint pain and increased physical function, in hip and knee OA. Future research should follow OA-related outcomes in participants that end their treatment to explore when and why that decision was made.

Risk Factors for Outcomes After Microvascular Decompression for Trigeminal Neuralgia

Microvascular decompression (MVD) has been the most effective long-term surgical treatment of trigeminal neuralgia (TN). However, the risk factors for poor pain control after MVD are not fully understood. A total of 184 patients with typical TN who had undergone MVD at our institution from January 3, 2008 to January 3, 2016 were enrolled in the present study. The data were collected from the electronic operative records and case notes and retrospectively analyzed. Patients were followed up at the outpatient department or by telephone at a minimum of 3 months and a maximum of 48 months postoperatively. Of the 184 patients enrolled in the present study, 72.3% had had freedom from pain after MVD and 27.7% had experienced poor pain control at the follow-up examinations (minimum, 3 months; maximum, 48 months). The risk factors for poor pain control after MVD using binary logistic regression and receiver operating characteristic curve analysis included younger age (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.82-0.99; P=0.028; area under the curve [AUC], 0.774), poor preoperative pain control (Barrow Neurological Institute score >IV; OR, 52.03; 95% CI, 6.44-420.16; P < 0.001; AUC, 0.858), intraoperatively detected multivessel compression (OR,2.49; 95% CI, 3.10-46.59, P < 0.001; AUC, 0.871). Furthermore, combined compression of the superior cerebellar artery and petrosal vein was an independent risk factor predicting a poor outcome after MVD (OR, 5.69; 95%CI, 33.78-2579.03; P < 0.001; AUC, 0.812). Younger patients with TN had worse long-term pain outcomes after MVD. The additional factors associated with postoperative recurrence included poor preoperative pain control (Barrow Neurological Institute score >IV) and multivessel compression. Furthermore, combined compression of the superior cerebellar artery and petrosal vein was associated with worse outcomes.

Effects of presurgical interventions on chronic pain after total knee replacement: a systematic review and meta-analysis of randomised controlled trials

ObjectiveNearly 100 000 primary total knee replacements (TKR) are performed in the UK annually. The primary aim of TKR is pain relief, but 10%–34% of patients report chronic pain. The...

Are within and/or between session improvements in pain and function prognostic of medium and long-term improvements in musculoskeletal problems? A systematic review

BackgroundInitial or between session improvements in pain and/or function are often considered to be predictive of ultimate outcomes in musculoskeletal problems. ObjectiveTo determine the long-term prognostic value of within and between session improvements to pain and function. DesignSystematic review of relevant literature. MethodA search was made of multiple databases (Pubmed/Medline, Cochrane, Cinahl, and AMed) using relevant search terms. Titles, abstracts, and then full texts were filtered to find articles that met the strict inclusion/exclusion criteria. Searching, data extraction, and quality assessment, using GRADE, were done independently by two authors. Disagreements were resolved by consensus. ResultsOnly 13 articles met the criteria for inclusion. For the effect of pain location or pain intensity changes in the first treatment session on medium or long-term pain, disability, return-to-work, or global outcomes nine outcomes were available. Findings were mostly inconclusive (5) or negative (3). There was only one study evaluating between session improvements with ambiguous results. There were no studies evaluating the prognostic value of early improvements in function. ConclusionsThere is no conclusive evidence to support the concept that early changes in pain location or pain intensity offer a good longer-term prognosis on a variety of outcomes; and no evidence relating to early improvements in function. The idea that patients who appear to improve in the first treatment session will do well longer term is not supported by the literature.

Effectiveness and reporting standards of psychological interventions for improving short-term and long-term pain outcomes after total knee replacement: a systematic review

ObjectivesTo assess the effectiveness and reporting standards of psychological interventions for improving outcomes after total knee replacement (TKR).DesignMedline, Embase, and PsycINFO were searched from inception to up to 9 May...

Metabolomics Signature for Non‐Responders to Total Joint Replacement Surgery in Primary Osteoarthritis Patients: The Newfoundland Osteoarthritis Study

Although total joint replacement (TJR) surgery is considered as the most effective treatment for advanced osteoarthritis (OA) patients, up to one-third of patients reported unfavorable long-term post-operative pain outcomes. We aimed to identify metabolic biomarkers to predict non-responders to TJR using a metabolomics approach. TJR patients were recruited and followed-up at least 1-year post-surgery; TJR outcomes were assessed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function subscales. Targeted metabolomic profiling was performed on plasma samples collected pre-surgery and pairwise metabolite ratios, as proxies for enzymatic reactions, were calculated. Association tests were performed between each metabolite ratio and non-responders. The metabolome-wide significance was defined as p < 2 × 10-5 . A total of 461 TJR patients due to primary OA were included in the analysis. Fifteen percent of patients were classified as pain non-responders; 16% were classified as function non-responders. Lower baseline WOMAC pain and function scores were significantly associated with pain and function non-responders, respectively (both p < 0.03). Two metabolite ratios were significantly associated with pain non-responders; acetylcarnitine (C2) to phosphatidylcholine acyl-alkyl C40:1 (PC ae C40:1) was five times higher in pain non-responders whereas phosphatidylcholine diacyl C36:4 (PC aa C36:4) to isoleucine was twenty one times lower in pain non-responders than responders (all p ≤ 1.93 × 10-5 ). One metabolite ratio, glutamine to isoleucine, was significantly lower in function non-responders than responders (eight times lower; p = 1.08 × 10-5 ). Three metabolite ratios (C2 to PC ae C40:1, PC aa C36:4, and glutamine to isoleucine) related to inflammation and muscle breakdown could be considered as novel plasma markers for predicting non-responders to TJR and warrant further investigation. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:793-802, 2020.