Treatment Of Pain In Patients Research Articles

Is migraine a complicating factor for evidence-based therapy for masticatory myofascial pain? A case-control study

This study aimed to assess the response to conservative treatment of pain in patients diagnosed with masticatory myofascial pain (MMP) with or without migraine. A total of 61 patients were evaluated and divided into 2 groups: Group 1 (G1), patients with MMP (n = 34); Group 2 (G2), patients with MMP and migraine (n = 27). Pain was assessed subjectively by visual analog scale (VAS) and objectively through masticatory muscle palpation at baseline and after 3 treatment visits. Treatment included occlusal appliances, medication, and self-care exercises. G2 reported greater discomfort subjectively and objectively at all evaluation visits; however, significant difference between groups was noted objectively only at baseline (P = .0052). Regardless of group, pain levels decreased significantly over time as measured by VAS analyses (G1 P = .0033; G2 P = .0031) and muscle palpation (G1 P < .0001; G2 P < .0001). Evidence-based therapy improved pain scores over time in MMP patients regardless of the presence of migraine.

Effects of Metastasis on Pain Treatment in Patients with Cancer-Related Pain: A Retrospective Study.

The goal of this study was to investigate the effect of the presence of metastases on pain treatment in patients with cancer-related pain. Of the 1736 patients who were treated in Firat University, Faculty of Medicine, Department of Anaesthesiology and Reanimation, Algology Section, for cancer-related pain between January 1997 and December 2010, 1467 with complete medical records were evaluated. Patients were grouped as having no metastasis (Group I), a single organ metastasis (Group II), or multiple organ metastasis (Group III). There was no difference between the groups with regard to age. Visual Analog Pain (VAS) scores at admission were higher in Group III compared to the other groups, and significantly higher in Group I than in Group II. Analgesic ladder treatment was given to 85.5% of patients, and 14.5% were treated using additional minimally invasive analgesic intervention (MIAI) methods. In Group II and Group III, the rates of treatment in Step I and II were lower compared to Group I, while the rates of treatment in Step III were higher. Implementation of MIAI was higher in Group III than in the other groups, and higher in Group II than in Group I. The presence of metastases causes more severe pain, which becomes more difficult to treat, and increases the analgesia step and the consumption of opioids in patients with cancer-related pain.

Lateral Wedge Insoles as a Conservative Treatment for Pain in Patients With Medial Knee Osteoarthritis

There is no consensus regarding the efficacy of lateral wedge insoles as a treatment for pain in medial knee osteoarthritis. To evaluate whether lateral wedge insoles reduce pain in patients with medial knee osteoarthritis compared with an appropriate control. Databases searched include the Cochrane Central Register of Controlled Trials, EMBASE, AMED, MEDLINE, CINAHL Plus, ScienceDirect, SCOPUS, Web of Science, and BIOSIS from inception to May 2013, with no limits on study date or language. The metaRegister of Controlled Trials and the NHS Evidence website were also searched. Included were randomized trials comparing shoe-based treatments (lateral heel wedge insoles or shoes with variable stiffness soles) aimed at reducing medial knee load, with a neutral or no wedge control condition in patients with painful medial knee osteoarthritis. Studies must have included patient-reported pain as an outcome. Trial data were extracted independently by 2 researchers using a standardized form. Risk of bias was assessed using the Cochrane Risk of Bias tool by 2 observers. Eligible studies were pooled using a random-effects approach. Change in self-reported knee pain at follow-up. Twelve trials met inclusion criteria with a total of 885 participants of whom 502 received lateral wedge treatment. The pooled standardized mean difference (SMD) suggested a favorable association with lateral wedges compared with control (SMD, -0.47; 95% CI, -0.80 to -0.14); however, substantial heterogeneity was present (I2 = 82.7%). This effect size represents an effect of -2.12 points on the 20-point Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale. Larger trials with a lower risk of bias suggested a null association. Meta-regression analyses showed that higher effect sizes (unstandardized β, 1.07 [95% CI, 0.28 to 1.87] for trials using a no treatment control) were seen in trials using a no wedge treatment control group (n = 4 trials; SMD, -1.20 [95% CI, -2.09 to -0.30]) and lower effect sizes (unstandardized β, 0.26 [95% CI, 0.002 to 0.52] for each bias category deemed low risk) when the study method was deemed at low risk of bias. Among trials in which the control treatment was a neutral insole (n = 7), lateral wedges showed no association (SMD, -0.03 [95% CI, -0.18 to 0.12] on WOMAC; this represents an effect of -0.12 points), and results showed little heterogeneity (I2 = 7.1%). Although meta-analytic pooling of all studies showed a statistically significant association between use of lateral wedges and lower pain in medial knee osteoarthritis, restriction of studies to those using a neutral insole comparator did not show a significant or clinically important association. These findings do not support the use of lateral wedges for this indication.

The Future of Topical Analgesics

Topically applied analgesic therapies have been used throughout history to treat a variety of patient conditions that present with pain. Before modern pharmaceuticals became readily available, mud-based emollients, salves, cold therapies, and other natural remedies were often used. Now we have effective therapies and are developing advanced topical analgesics as we learn more about the physiology and pathophysiology of pain. The use of topical analgesics may be associated with fewer patient systemic side effects than are seen with oral, parenteral, or transdermally administered agents, making the topical route of administration attractive to prescribers and patients. With further refinement of existing drugs and the development of novel agents, topical analgesics may offer relief for treating patient pain conditions that are currently challenging to treat, such as pain resulting from burns, wound debridement, and pressure ulcers. Recognizing the value of a multimodal approach, topical analgesics may offer a therapeutic option that can become part of a comprehensive treatment plan for the patient. With continued advancements in targeted drug–delivery systems, topical analgesics may be able to provide a method to prevent or reverse the phenomena of peripheral and central sensitization, or the neuroplastic changes believed to be responsible for the transition from acute to chronic pain states in patients. For those patients at risk for developing chronic pain states, such as complex regional pain syndrome, the combination of cutaneous stimulation (achieved through rubbing during application) and analgesic effects produced by the drug itself may prevent the disabling pain that often emerges during the subacute phase of disease. In summary, better utilization of currently available topical analgesics and continued research promise to ensure that topical analgesics are, and will continue to be, important tools in the treatment of patients with resistant pain.

The Response of Agitated Behavior to Pain Management in Persons with Dementia

Behavioral disturbances and pain are common in nursing home (NH) patients with dementia. An association between pain and increased agitation has been suggested, and recently a significant reduction of agitation has been demonstrated by pain treatment in patients with moderate to severe dementia. We now examined which specific agitated behaviors respond to individualized pain treatment. Cluster randomized clinical trial. 60 clusters (i.e., clusters defined as single independent NH units) in 18 NHs within five municipalities of Western Norway. 352 patients with moderate to severe dementia and clinically significant behavioral disturbances. The control group received usual treatment and care. According to a predefined scheme for 8 weeks, all patients in the intervention group received individual daily pain treatment with acetaminophen, extended release morphine, buprenorphine transdermal patch, and/or pregabaline. Cohen-Mansfield Agitation Inventory subscales and items. Analyses demonstrated that Factor 3 (Verbally agitated behaviors) showed the largest significant difference (DF = 1204.0, t = -4.308, p <0.001), followed by Factor 2 (Physically non-aggressive behaviors) (DF = 1198.0, t = -2.672, p = 0.008), and Factor 1 (Aggressive behaviors) (DF = 1196.0, t = -2.093, p = 0.037) after 8 weeks, by a linear random intercept mixed model in two-way repeated-measures configuration with adjustment for heteroscedasticity. We found that verbal agitation behaviors such as complaining, negativism, repetitious sentences and questions, constant request for attention, and cursing or verbal aggression responded to pain treatment. In addition, restlessness and pacing were sensible to analgesics. Such behaviors should therefore lead to an assessment of pain, and pain treatment. Further studies comparing how pain treatment should be balanced against other strategies including psychotropic drugs are needed.

Pain Treatment for Patients With Osteoarthritis and Central Sensitization

Osteoarthritis is one of the most frequent, disabling, and costly pathologies of modern society. Among the main aims of osteoarthritis management are pain control and functional ability improvement. The exact cause of osteoarthritis pain remains unclear. In addition to the pathological changes in articular structures, changes in central pain processing or central sensitization appear to be involved in osteoarthritis pain. The latter calls for a broader approach to the management of patients with osteoarthritis. Yet, the scientific literature offers scant information addressing the treatment of central sensitization, specifically in patients with osteoarthritis. Interventions such as cognitive-behavioral therapy and neuroscience education potentially target cognitive-emotional sensitization (and descending facilitation), and centrally acting drugs and exercise therapy can improve endogenous analgesia (descending inhibition) in patients with osteoarthritis. Future studies should assess these new treatment avenues.

An Unusual Complication after Shoulder Hemiarthroplasty

Hemiarthroplasty of the shoulder can be a safe and an effective treatment for pain in patients with rheumatoid arthritis. Many complications have been previously described in the literature; the most common of which are dislocation, loosening, periprosthetic fractures, and infection. We report a patient who presented with a discharging sinus over the tip of the acromium which was created by the displacement of the prosthesis and erosion of the AC joint and distal clavicle. The erosion of the distal clavicle and AC joint caused the remaining proximal clavicle to become mobile and displaced posteriorly; this spike of clavicle was then able to penetrate the trapezius muscle and eventually the skin causing an aseptic sinus. This was successfully treated with the exploration and excision of the distal 2 cm of the clavicle.

Pain and quality of life in patients undergoing radiotherapy for spinal metastatic disease treatment.

BackgroundRadiotherapy is an important tool in the control of pain in patients with spinal metastatic disease. We aimed to evaluate pain and of quality of life of patients with spinal metastatic disease undergoing radiotherapy with supportive treatment.MethodsThe study enrolled 30 patients. From January 2008 to January 2010, patients selection included those treated with a 20 Gy tumour dose in five fractions. Patients completed the visual analogue scale for pain assessment and the SF-36 questionnaire for quality of life assessment.ResultsThe most frequent primary sites were breast, multiple myeloma, prostate and lymphoma. It was found that 14 spinal metastatic disease patients (46.66%) had restricted involvement of three or fewer vertebrae, while 16 patients (53.33%) had cases involving more than three vertebrae. The data from the visual analogue scale evaluation of pain showed that the average initial score was 5.7 points, the value 30 days after the end of radiotherapy was 4.60 points and the average value 6 months after treatment was 4.25 points. Notably, this final value was 25.43% lower than the value from the initial analysis. With regard to the quality of life evaluation, only the values for the functional capability and social aspects categories of the questionnaire showed significant improvement.ConclusionRadiotherapy with supportive treatment appears to be an important tool for the treatment of pain in patients with spinal metastatic disease.

Outpatient Detoxification Completion and One-Month Outcomes for Opioid Dependence: A Preliminary Study of a Neuropsychoanalytic Treatment in Pain Patients and Addicted Patients

The current practice in the United States is to maintain patients with opioid dependence on opioids. A case series approach was used to investigate the results of outpatient detoxification/opioid-free treatment using a neuropsychoanalytic paradigm. Detoxification involved a single dose of buprenorphine, adjunctive medications, and intensive neuropsychoanalytic psychotherapy. Depression, attention deficit hyperactivity disorder (ADHD), and nicotine dependence were treated with bupropion. Low-dose naltrexone was used to remedy hypothesized low endogenous opioid tone. In the study, 92% of subjects completed one week of detoxification. By selfreport, 60% were still sober one month into treatment. When divided into a group who met the DSM–IV criteria for opioid dependence because of withdrawal, tolerance, and inability to cut down or stop opioid medications only (the “Pain Group”) and a group who met more than these three criteria (the “Addicted Group”), there were significant differences in maintaining abstinence. In addition, the Addicted Group were much more likely to be depressed and to have borderline personality disorder. All cases of ADHD and all drug dream reports were in the Addicted Group. The conclusion of the study was that neuropsychoanalytic treatment of addiction (including complete abstinence from opioids and neuropsychoanalytic interventions) may be a viable approach to opioid-use disorder. Current DSM criteria for diagnosis of addiction to opioids may incorrectly include a subgroup who are unable to stop the drug only because of inability to endure the withdrawal syndrome. With the neuropsychoanalytic approach, they appear to tolerate withdrawal and stay off opioids. Further investigation is required to compare this neuropsychoanalytic paradigm to other treatments.

Effect and treatment of chronic pain in inflammatory arthritis.

Pain is the most common reason patients with inflammatory arthritis see a rheumatologist. Patients consistently rate pain as one of their highest priorities, and pain is the single most important determinant of patient global assessment of disease activity. Although pain is commonly interpreted as a marker of inflammation, the correlation between pain intensity and measures of peripheral inflammation is imperfect. The prevalence of chronic, non-inflammatory pain syndromes such as fibromyalgia is higher among patients with inflammatory arthritis than in the general population. Inflammatory arthritis patients with fibromyalgia have higher measures of disease activity and lower quality of life than inflammatory patients who do not have fibromyalgia. This review article focuses on current literature involving the effects of pain on disease assessment and quality of life for patients with inflammatory arthritis. It also reviews non-pharmacologic and pharmacologic options for treatment of pain for patients with inflammatory arthritis, focusing on the implications of comorbidities and concurrent disease-modifying antirheumatic drug therapy. Although several studies have examined the effects of reducing inflammation for patients with inflammatory arthritis, very few clinical trials have examined the safety and efficacy of treatment directed specifically towards pain pathways. Most studies have been small, have focused on rheumatoid arthritis or mixed populations (e.g., rheumatoid arthritis plus osteoarthritis), and have been at high risk of bias. Larger, longitudinal studies are needed to examine the mechanisms of pain in inflammatory arthritis and to determine the safety and efficacy of analgesic medications in this specific patient population.

Treatment of Pain in Patients With Complicating Disorders: Case Report From Norway, With Commentaries From Germany and Belgium

ABSTRACTA 70-year-old male with a history of bipolar disorder, alcohol misuse, and polyneuropathy is presented. His treatment was complicated by multiple drugs, and by instability and falls. The advantages and disadvantages and dosing considerations with short- and long-acting analgesics are discussed.

1531 Drugs Administered in Sickle Cell Disease Vaso-Oclusive Crisis

Background and AimsThe vascular occlusion of small vessels with blood cells in sickle cell disease leads to clinical manifestation such as pain crisis and organs’ chronic damage.ObjectiveTo study the drugs...

How Do Gastrointestinal or Liver Comorbidities Influence the Choice of Pain Treatment in Inflammatory Arthritis? A Cochrane Systematic Review

To assess efficacy and safety of pharmacological pain treatment in patients with inflammatory arthritis (IA) and gastrointestinal (GI) or liver comorbidities. A systematic literature search was performed using Medline, Embase, and Cochrane Controlled Trial Register up to June 2010, as well as American College of Rheumatology and European League Against Rheumatism meeting abstracts (2007-2010). The population investigated was defined as patients with IA and existing or prior reported GI or liver disease treated with nonsteroidal antiinflammatory drugs (NSAID), opioids or opioid-like drugs, paracetamol, antidepressants, neuromodulators, or muscle relaxants. Outcomes of interest were defined as efficacy evaluated by common pain measures and safety evaluated by withdrawals due to adverse events, worsening of comorbidity, and mortality. Out of 2869 identified studies only a single open-arm trial fulfilled inclusion criteria assessing the safety and efficacy of naproxen in 58 patients with active rheumatoid arthritis and GI comorbidities. The presence of fecal occult blood was reported in 1/58 participants tested between Weeks 1 to 26 and 2/32 participants tested between Weeks 27 to 52. Over the course of the study, 7 participants (12.1%) withdrew due to adverse events; no serious adverse events were reported. Among the 14 studies excluded due to inclusion of a mixed population (osteoarthritis or other rheumatic conditions) or an intervention that was already withdrawn, 5 trials reported a higher risk of developing GI events in patients with prior GI events when treated with NSAID. Very little evidence regarding safety and efficacy of pain treatment in patients with IA and GI or hepatic comorbidities was found. In patients with a history of GI events, extrapolating from other studies, NSAID should be used cautiously since there is evidence that these patients are at a higher risk of developing adverse events.

Surgical treatment of pain in patients with chronic pancreatitis.

The objectives of the research were to compare the outcomes of pancreatoduodenectomy (PD) (Kausch-Whipple or Traverso-Longmire) and resection with drainage operations (RDO) (Frey or Partingtone-Rochelle) in patients suffering from chronic pancreatitis (CP), in management of pain syndrome and quality of life provided by these kinds of surgical procedures. From 2002 to 2008 sixteen patients suffering from CP underwent PD and 16 underwent RDO. Treatment results for the two groups were analyzed with respect to postoperative complications and results of the questionnaire MOS SF-36 v.2(TM). In the immediate postoperative period more complications were observed in the PD group (a<0.05). In both groups a positive effect on removing the painful syndrome and improvement of the quality of life (p<0.01) were observed. In the PD group there were the best results of management by General Health difference criterion (a<0.01). A greater improvement of Physical Functiong value (a<0.01) was noticed in patients who underwent RDO. Both PD and RDO adequately remove pain syndrome and improve the quality of life in patients suffering from CP. Under equal conditions the preference should be given to RDO, as improvement in life quality of operated patients is greater.

Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction #221

Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction #221

Fractal characteristics of the functional state of the brain in patients with anxiuos phobic disorders

The task of estimation of the functional state of the human brain during psychotherapeutic treatment of psychogenic pain in patients with anxious phobic disorders is examined. For solving the task the methods of spectral and multifractal analyses of EEG fragments are applied during the perception of psychogenic pain and its removal by the psychorelaxation technique. Contrary to power spectra singularity spectra allow to distinguish EEGs quanitatively in the examined functional states of the human brain. The pain suppression in patients with anxious phobic disorders during psychorelaxation is accompanied by changing the width of the singularity spectrum and approximation of this multifractal partameter to the value corresponding to a healthy subject.

Konzepte der Frührehabilitation und Sekundär-Prävention bei osteoporotischen Wirbelfrakturen

Due to the aging population the number of vertebral fractures will increase in the next years. In the acute care setting the pain treatment of patients with acute vertebral fractures is highly important. Part of the acute pain treatment is the early rehabilitative intervention of the treating team consisting of physicians, nurses and physiotherapists. In the acute care setting mostly rheumatologists, orthopaedic surgeons and physical therapy physicians are the treating physicians. Individual physiotherapy and patient communication and instruction are most important in this acute care setting. Special techniques of mobilisation and positioning are instructed. The guidelines of pain therapy in elderly geriatric patients have to be observed. In the last decade opioid therapy is one of the cornerstones of pharmacotherapy. For posture training and stabilization individual corselets have to be adapted. The aim is to stabilize the vertebral column and to avoid further anterior or posterior compression of the vertebral body. In the secondary prevention novel therapy programs are discussed.

Is there a potential role for attention bias modification in pain patients? Results of 2 randomised, controlled trials

Potential applications of attention bias modification (ABM) for acute and chronic pain patients are investigated. In study 1, 54 acute back pain patients (46 of whom completed the study) were recruited at their initial physiotherapy session and randomised to receive 1 session of ABM or placebo. Patients were followed up 3months later. Participants who were randomised to receive ABM reported less average (P=0.001) and current pain (P=0.008) and experienced pain for fewer days (P=0.01) than those who received placebo. In study 2, 34 chronic pain patients were recruited and randomly assigned to receive either 4 sessions of ABM (n=22) or placebo (n=12), followed by 8 sessions of cognitive behavioural treatment (CBT). After ABM, there was a significant group-by-time effect for disability. By 6-month follow-up, differences had emerged between the 2 training groups, such that the ABM group had shown greater reductions in anxiety sensitivity and disability than the placebo group. Although the results of these studies show that there is potential in the application of ABM to pain conditions, the mechanisms of treatment could not be established. Neither group showed an initial bias towards the word stimuli or a training effect, and only in the acute pain group were changes in biases related to outcome. Nonetheless, the fact that 2 independent samples showed a positive effect of ABM on clinical outcomes suggests that ABM is worthy of future study as an intervention for pain patients.

Pain management for inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and other spondylarthritis) and gastrointestinal or liver comorbidity.

Even with optimal disease-modifying treatment and good control of disease activity, persistent pain due to structural damage is common in people with inflammatory arthritis and therefore additional treatment for pain might be required. Because comorbidity is highly prevalent in people with inflammatory arthritis, it is important to consider comorbidities such as gastrointestinal or liver diseases in deciding upon optimal pharmacologic pain therapy. To assess the efficacy and safety of pharmacological pain treatment in patients with inflammatory arthritis who have gastrointestinal or liver comorbidities, or both. We searched MEDLINE, EMBASE and Cochrane CENTRAL for studies to June 2010. We also searched the 2007-2010 ACR and EULAR abstracts and performed a hand search of reference lists of articles. All randomised or quasi-randomised controlled trials (RCTs or CCTs) were considered for inclusion for assessment of efficacy. For safety we also considered single arm trials, controlled before-after studies, interrupted time series, cohort and case-control studies, and case series of 10 or more consecutive cases. Pain therapy comprised paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, opioid-like drugs (tramadol) and neuromodulators (anti-depressants, anticonvulsants and muscle relaxants). The study population comprised adults (>18 years) with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis or other spondyloarthritis who had gastrointestinal and/or hepatic comorbid conditions. Outcomes of interest were pain, adverse effects, function and quality of life. Studies that included a mixed population of inflammatory arthritis and other conditions were included only if results for inflammatory arthritis were reported separately. Two review authors independently selected trials for inclusion, assessed risk of bias and extracted data. Out of 2869 articles only one single arm open trial was identified that fulfilled our inclusion criteria. This trial assessed the safety and efficacy of naproxen (dosage not specified) in 58 patients with active rheumatoid arthritis and gastrointestinal comorbidities for up to 52 weeks. Thirteen participants (22%) remained on gold therapy, four participants (10%) remained on hydroxychloroquine, 27 (47%) remained on corticosteroids, 12 (21%) remained on salicylates and all participants continued on antacids and bland diet. The presence of faecal occult blood was reported in 1/58 participants tested between weeks 1 to 26 and 2/32 participants tested between weeks 27 to 52. Over the course of the study, seven participants (12.1%) withdrew due to adverse events but of these, only two participants withdrew due to gastrointestinal side effects (abdominal pain n=1, nausea n=1) and no serious adverse events were reported. Noteable, out of 14 studies excluded due to inclusion of mixed population (osteoarthritis or other rheumatic conditions) or intervention already withdrawn, five trials reported higher risk of developing gastrointestinal events in patients with prior gastrointestinal events when treated with NSAIDs. On the basis of the current review, there is scant evidence to guide clinicians about how gastrointestinal or liver comorbidities should influence the choice of pain treatment in patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis or other spondylarthritis. Based upon additional studies that included a mixed population of participants with a range of rheumatic conditions, NSAIDs should be used cautiously in patients with inflammatory arthritis and a history of gastrointestinaI comorbidity as there is consistent evidence that they may be at increased risk.

The Efficacy and Safety of Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis for Treatment of Pain in Patients with Pancreatic Cancer

Introduction. Celiac plexus neurolysis is used in pain management of patients with advanced and unresectable pancreatic cancer. We retrospectively analyzed efficacy and safety of endoscopic ultrasound- (EUS-) guided celiac plexus neurolysis in patients treated in our unit. Methods. Twenty nine subjects with unresectable pancreatic cancer and severe pain despite pharmacological treatment underwent EUS-guided celiac plexus neurolysis with 98% ethanol. Patients scored their pain according to a 0–10 point scale and were interviewed 1-2 weeks and 2-3 months after the procedure. Results. Twenty five (86%) patients reported improvement in their pain at 1-2 weeks following the procedure. Of these, 7 (24%) reported substantial improvement (decrease in pain by more than 50%) and 4 (14%) complete disappearance of pain. Pain relief was still present in 76% of patients after 2-3 months. Treatment-related side effects included hypotonia in 1 patient, severe pain immediately postprocedure in 2 patients, and short episodes of diarrhea in 3 patients. Conclusion. Endoscopic ultrasound- (EUS-) guided celiac plexus neurolysis is a safe and effective treatment of severe pain from advanced pancreatic cancer.