OBJECTIVE: To update knowledge on the effects of cryotherapy in reducing pain, increasing strength, and improving function in patients with knee osteoarthritis. METHODS: The databases used included PubMed, Embase, Cochra...OBJECTIVE: To update knowledge on the effects of cryotherapy in reducing pain, increasing strength, and improving function in patients with knee osteoarthritis. METHODS: The databases used included PubMed, Embase, Cochrane, Physiotherapy Evidence Database (PEDro), Scopus, Web of Science, and LILACS. In addition, gray literature was searched in Google Scholar, LIVIVO, Open Gray, and the CAPES Library of Theses and Dissertations. The risk of bias was assessed using the Cochrane tool, RoB 2, by two independent reviewers, with conflicts being resolved by consensus. The primary outcome was pain, while secondary outcomes included functionality and muscle strength. RESULTS: Five randomized controlled trials were selected from 2094 initial registrations. The meta-analysis included all five studies in the pain intensity outcome, resulting in a standardized mean difference (SMD) of -0.57 (95% CI: [-0.97, -0.18]; p = 0.004; I = 42%). In addition, four studies were included in the functionality outcome, with an SMD of -0.28 (95% CI: [-0.58, 0.02]; p = 0.07; I = 0%). Only one study assessed muscle strength. CONCLUSION: These findings indicate that cryotherapy can be useful as part of a comprehensive treatment for knee osteoarthritis, especially when combined with kinesiotherapy, but its effectiveness as a stand-alone treatment still requires further studies with a lower risk of bias.
INTRODUCTION: Cluster headache is a rare primary headache disorder characterized by excruciating unilateral pain around the eye, lasting between 15 and 180 min, accompanied by ipsilateral cranial autonomic symptoms. Clus...INTRODUCTION: Cluster headache is a rare primary headache disorder characterized by excruciating unilateral pain around the eye, lasting between 15 and 180 min, accompanied by ipsilateral cranial autonomic symptoms. Cluster headache is classified into two forms: episodic and chronic, with chronic cluster headache defined by pain-free intervals of less than 3 months between bouts. Both drug-based and invasive treatments are available for abortive and preventive purposes. Treatment selection depends on individual efficacy and tolerance, with invasive options considered when pharmacological treatments prove ineffective. METHODS: This narrative review summarizes the literature on common practice and the evidence in the treatment of cluster headache. RESULTS: Oxygen therapy and subcutaneous sumatriptan are the most effective abortive treatments for cluster headache. Oral corticosteroid tapering regimens can be used as bridging therapy. Verapamil, lithium, topiramate, and CGRP antagonists are potential preventive medication options. Greater occipital nerve (GON) injections and radiofrequency (RF) therapy can be used as preventive treatments, though their effects are often temporary. For refractory chronic cluster headache, occipital nerve stimulation (ONS) has proven to be effective. Deep brain stimulation (DBS) may also be considered if all other treatments have failed. CONCLUSIONS: The management of cluster headache is complex due to the variable efficacy of treatments across different patients and limited evidence.
OBJECTIVES: This study examined the feasibility of a research protocol for assessing psychological flexibility in patients with chronic pain to gain insight into the uniqueness of different phenotypes of psychological fl...OBJECTIVES: This study examined the feasibility of a research protocol for assessing psychological flexibility in patients with chronic pain to gain insight into the uniqueness of different phenotypes of psychological flexibility and to tentatively test whether psychological flexibility is associated with effective adaptation to chronic pain. METHODS: In a cross-sectional study, in twenty patients with chronic pain, different phenotypes of psychological flexibility and a variety of positive and negative health indicators were assessed. Correlations were explored to determine the unicity of the different phenotypes of psychological flexibility and to test their associations with chronic pain. RESULTS: All phenotypes of psychological flexibility could be assessed reliably in this patient group. Preliminary findings suggest that all phenotypes assess unique flexibility aspects (79% of the intercorrelations were less than moderate; > -0.30, < 0.30). Higher levels of different psychological flexibility phenotypes were generally associated with higher positive health indicators and lower negative health indicators (70% of the moderate correlations; ≤ -0.30 or ≥ 0.30 were in the expected direction). CONCLUSIONS: Results confirm that the protocol is feasible for large-scale research in patients with chronic pain and that it is useful to further investigate the different phenotypes of psychological flexibility in relation to optimal adaptation to chronic pain in a longitudinal study. PRACTICE IMPLICATIONS: Psychological flexibility is a potentially important future target in the treatment (e.g., biofeedback, cognitive behavioral therapy, mindfulness) of patients with chronic pain.
INTRODUCTION: Chronic back/neck pain costs the United States around 250 billion dollars annually. Treatment strategies include medication, physical therapy, and specialized procedures. This study aimed to investigate the...INTRODUCTION: Chronic back/neck pain costs the United States around 250 billion dollars annually. Treatment strategies include medication, physical therapy, and specialized procedures. This study aimed to investigate the trends in procedural frequency and Medicare reimbursement rates for common back pain procedures. METHODS: Data from 2000 to 2020 were extracted from Medicare Part B National Summary Data files, using Current Procedural Terminology (CPT) codes to identify reimbursement for cervical/thoracic and lumbar/sacral epidural injections, radiofrequency ablation, facet joint injections, and spinal cord stimulators (both percutaneous and paddle). Key metrics included annual total physician charges, reimbursements, and the number of procedures performed. RESULTS: From 2000 to 2020, 53,208,205 pain procedures were performed. The most common was lumbar/sacral epidural injections, followed by facet joint injections and radiofrequency ablations. Paddle SCS placement was the least common. Percutaneous SCS had the greatest volume growth, increasing from 3595 to 111,172 [+2992%], followed by lumbar/sacral epidural injections with 118,884 to 1,965,445 [+1553%], and cervical/thoracic epidural injections, 22,480-348,642 [+1451%]. All procedures saw a significant increase in volume except for facet joint injections. Inflation-adjusted reimbursement per service also increased, with paddle SCS demonstrating the largest increase ($618-$2960 [+379.0%]), followed by percutaneous SCS ($353-$1428 [+304.5%]) and cervical/thoracic epidural injections ($128-$153 [+19.5%]). CONCLUSIONS: Pain management procedures have increased in volume and reimbursement over the last 20 years. This increased reimbursement may allow for broader access to these procedures compared to prior decades and support a shift from traditional and more invasive surgical procedures to minimally invasive treatments for chronic pain patients.
BACKGROUND: The development of liposomal bupivacaine (LB) as an anesthetic was widely lauded due to the potential benefits this drug claimed to carry. This systematic review and meta-analysis aimed to assess the efficacy...BACKGROUND: The development of liposomal bupivacaine (LB) as an anesthetic was widely lauded due to the potential benefits this drug claimed to carry. This systematic review and meta-analysis aimed to assess the efficacy of LB versus standard bupivacaine (SB) in improving postoperative outcomes, including pain scores and morphine use. METHODS: PubMed, Cochrane CENTRAL, Web of Science, and MedLine databases were searched until April 2024. All trials evaluating the efficacy of LB versus SB in abdominal surgeries like colorectal procedures, bariatric surgeries, and hemorrhoidectomy were included. Data analysis was conducted in Review Manager employing a random-effects model. RESULTS: Eight clinical trials with 810 patients were included. No statistically or clinically significant result was obtained on using LB over SB in reducing postoperative pain score on postoperative day 0 (POD0) (mean difference (MD) = -0.19, [95% confidence interval (CI): -0.91, 0.53]; p = 0.60), POD1 (MD = -0.11 [95% CI: -1.12, 0.91]; p = 0.84), POD2 (MD = -0.18 [95% CI: -0.57, 0.22]; p = 0.22), and POD3 (MD = 0.01 [95% CI: -0.55, 0.22]; p = 0.57). Additionally, there was no reduction in morphine use in PODs 0-3, time to ambulation, hours to postoperative flatus, or length of hospital stay between the groups. CONCLUSION: Our findings showed that LB is not superior to SB in the surgical plane for individuals undergoing abdominal procedures.
INTRODUCTION: Trigeminal neuralgia (TN) is a disorder characterized by recurrent, unilateral brief electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more branches of the tr...INTRODUCTION: Trigeminal neuralgia (TN) is a disorder characterized by recurrent, unilateral brief electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more branches of the trigeminal nerve, and triggered by innocuous stimuli. METHODS: The literature on the diagnosis and treatment of TN was retrieved and summarized. RESULTS: The diagnosis is made almost entirely based on the patient's history. In classical TN, the neurological examination is typically normal, whereas the exam in secondary TN is focused on surveilling for signs of multiple sclerosis (MS) or a cerebellopontine tumor. The appropriate imaging technique is magnetic resonance imaging (MRI) with contrast of the trigeminal ganglion, which is recommended prior to interventional procedures. The treatment of a patient with TN is a team effort and should always be multidisciplinary, addressing all dimensions of pain. Carbamazepine or oxcarbazepine are first-line medical treatments. Microvascular decompression (MVD) is the technique of choice for patients without or with minor comorbidities. Percutaneous procedures for TN are mainly radiofrequency thermocoagulation of the branches of the trigeminal nerve introduced by Sweet and Wepsic in 1965, retrogasserian glycerol injection introduced by Hakanson in 1981, and balloon compression introduced by Mullan and Lichtor in 1983. Radiofrequency treatment is recommended in elderly patients or those with major comorbidities. Other techniques such as stereotactic radiosurgery and pulsed radiofrequency treatment are also discussed. CONCLUSIONS: Recommendations are based on very low-quality evidence. MVD and radiofrequency are the preferred invasive treatments, although higher-quality evidence is necessary to better assess the risk-benefit ratios.
OBJECTIVES: Awareness about the role of micronutrients in the development of chronic pain has drastically increased. We investigated how serum micronutrient levels differ in subjects with chronic pain compared to pain-fr...OBJECTIVES: Awareness about the role of micronutrients in the development of chronic pain has drastically increased. We investigated how serum micronutrient levels differ in subjects with chronic pain compared to pain-free subjects. METHODS: A cross-sectional study was conducted with subjects from the All of Us database, divided into cohorts of no, mild/moderate, and severe pain based on numeric rating scale scores. We examined serum levels of vitamins D (25OH-D), C, B12, folate, and magnesium-micronutrients found to be involved in chronic pain (38,006; 656; 62,110; 25,937, and 93,445 subjects, respectively) and defined them as normal, deficient, or borderline deficient based on reference ranges. We examined the variation of these findings based on sex and race/ethnicity. RESULTS: Subjects with severe pain had lower 25OH-D, B12, and folate levels than those with mild/moderate pain and/or without pain (p < 0.001). We found a higher incidence of 25OH-D, vitamin C (males), and magnesium deficiency in subjects with severe pain (p < 0.05). Black and White subjects with severe pain had lower levels of 25OH-D and folate (p < 0.05 for 25OH-D, NS for folate in Black males, and p < 0.001 for the other groups), but lower vitamin B12 only in Whites (p < 0.001 for females and p < 0.05 for males). Asian and Hispanic females also had lower folate (p < 0.01 and p < 0.001, respectively). DISCUSSION: We found lower 25OH-D, B12, and folate, and a higher incidence of 25OH-D, vitamin C (males), and magnesium deficiency at subjects with chronic pain, more consistent in Blacks and Whites than in Asians and Hispanics. Micronutrient repletion may influence chronic pain.
INTRODUCTION: Greater occipital nerve block (GON-B) may still represent a valuable strategy in migraine prophylaxis despite the development of newer drugs. The absence of a standardized method leads to variable outcomes...INTRODUCTION: Greater occipital nerve block (GON-B) may still represent a valuable strategy in migraine prophylaxis despite the development of newer drugs. The absence of a standardized method leads to variable outcomes and limits its use. In this light, we investigated GON-B effects in a migraine population trying to define its duration and response predictors. METHODS: In this real-world study, we recruited patients with migraine who underwent bilateral GON-B. They were clinically evaluated at baseline and then monthly for the next 3 months, using a 30-day headache diary. The potential role of baseline headache characteristics in predicting treatment response was thoroughly analyzed. RESULTS: A total of 73 patients were enrolled: 50 (68%) were affected by chronic migraine while 38 (52%) by medication overuse headache (MOH). The greatest clinical benefit due to GON-B was reported during the first month, although the therapeutic response was substantially maintained during follow-up. Notably, similar outcomes were recorded in patients with and without MOH. The mean duration of effect was 55.3 ± 72.0 days, with no clinical variables significantly influencing this parameter. The therapeutic response seemed to be stronger in patients with migraine with aura. CONCLUSIONS: GON-B appears an effective option in migraine prophylaxis, even in difficult-to-treat patients. Its rapid effect, high tolerability, and cost-effectiveness represent indisputable advantages. A prolonged duration of action, which could be favored by the combination of anesthetic and steroid and needs to be confirmed in future studies, may further optimize patient management.
BACKGROUND: Post-traumatic stress disorder (PTSD) is a significant psychiatric comorbidity in individuals with chronic pain. To date, the link between PTSD and chronic pain has mostly been described using the outdated DS...BACKGROUND: Post-traumatic stress disorder (PTSD) is a significant psychiatric comorbidity in individuals with chronic pain. To date, the link between PTSD and chronic pain has mostly been described using the outdated DSM-IV PTSD criteria. Stronger evidence utilizing the updated DSM-5 criteria is needed to ensure comparability with earlier prevalence rates. METHODS: This observational study reported the percentage of individuals who had experienced at least one traumatic event and fulfilled the DSM-5 PTSD criteria, based on self-report, at a tertiary pain clinic in Sweden. The study also investigated the associations between PTSD symptom severity and sociodemographic characteristics, trauma-related factors, and pain-related factors, using regression analysis in the trauma-affected subsample. RESULTS: A large proportion of the sample (76.8%) reported having experienced at least one traumatic event, with the prevalence of self-reported PTSD being 23.0% for the sample. Female sex, being born outside of Sweden, anxiety, and multiple traumatic events were identified as significant predictors of more severe PTSD symptoms. The most common trauma types were accidents, life-threatening illness or injury, sudden accidental or violent death, and multiple traumas. CONCLUSIONS: Based on the results from this study, it seems important to integrate PTSD assessment in clinical settings focused on chronic pain. The findings align with the broader literature on the impact of sex, migration, and cumulative traumas as predictors of PTSD symptomatology. Furthermore, the results highlight the complex interconnection between PTSD and chronic pain, underscoring the importance of considering sociodemographic and trauma-related factors in the clinical assessment and treatment of chronic pain populations.
BACKGROUND: Understanding longitudinal trajectories of prescription opioid use, and associated risk factors, can inform clinical practice. However, little is known regarding trajectories of opioid use for patients with l...BACKGROUND: Understanding longitudinal trajectories of prescription opioid use, and associated risk factors, can inform clinical practice. However, little is known regarding trajectories of opioid use for patients with low back pain, a prevalent health condition in the United States. OBJECTIVE: The objective of this study was to identify opioid prescribing trajectories for patients with low back pain and describe the resulting trajectory classes. METHODS: We used group-based trajectory modeling of electronic health records from 2011 to 2018 to identify latent trajectory classes of prescribed opioids (milligram morphine equivalent or MME) before and after index visits for low back pain in six annual cohorts. We characterized class demographics, health status, and utilization histories. RESULTS: Our sample included 74,181 index outpatient visits. Modeling identified four latent trajectory classes among patients with opioid prescriptions, in addition to a fifth zero-prescription class. Most visits were associated with no prescribed MME (65%-79% of visits, depending on the annual cohort) or low prescribed MME (18%-30%). Additionally, there were small but notable trajectory classes with persistent high (1%-2%), increasing (1%-5%), and decreasing (0%-1%) prescribed MME. Patients with persistent high prescribed opioid doses had a high prevalence of psychiatric diagnoses and benzodiazepine use, whereas patients with increasing opioid doses had varying characteristics depending on the annual cohort. CONCLUSIONS: A small proportion of low back pain patients had concerning patterns of persistent high or increasing prescribed opioids. However, the overall number of patients with persistently high or increasing use may be large nationally due to the high prevalence of low back pain. Interventions may be warranted for patients with profiles like the persistent high use trajectory class. More research is needed to understand risk factors for the increasing use trajectory class.
BACKGROUND: Pain self-management (PSM) programs have demonstrated effectiveness as a pain management strategy, yet evidence remains scarce for patients with chronic pain treated with medical cannabis. We aimed to explore...BACKGROUND: Pain self-management (PSM) programs have demonstrated effectiveness as a pain management strategy, yet evidence remains scarce for patients with chronic pain treated with medical cannabis. We aimed to explore feasibility aspects and practical applications of developing and implementing a group-based PSM intervention in this context. METHODS: Twenty-two semi-structured qualitative interviews were conducted with 10 chronic pain patients treated with cannabis and 12 clinicians from a range of expertise. RESULTS: Overall, the interviewees believed that the proposed intervention is feasible; yet it is essential to consider the following aspects during program planning and implementation. Inductive thematic analysis of interview transcripts identified five major themes. The first is that the program enablers include the intrinsic benefits of therapeutic group dynamics, aligning expectations, and setting individual goals at program initiation. The second theme is the program barriers. These include expected challenges for participants due to behavioral and mental changes that necessitate high commitment, the challenge for the group leader in delivering an appropriate response to each participant's emotional narrative; and managing logistical issues. The third theme is the psychological experience of living with pain, with an emphasis on addressing patients' emotional perspectives within the program's framework, namely, their perceptions of pain, fear of pain, and the relations of such to past experiences. The fourth theme is the psychoeducation on pain and cannabis use, including the brain-pain connection and informed guidance regarding cannabis use. The fifth theme is the integration of guided movement and relaxation techniques in pain management, thus underscoring the importance of practice during the group sessions. CONCLUSIONS: Our findings suggest key elements that may inform planning PSM-approach therapy groups, tailored to the particular needs of patients with chronic pain using medical cannabis.
BACKGROUND: Chronic low back pain (CLBP) is a common and harmful medical condition, and in many cases, no specific radiographic cause is identified. Many cases of CLBP are refractory to treatment and will recur after the...BACKGROUND: Chronic low back pain (CLBP) is a common and harmful medical condition, and in many cases, no specific radiographic cause is identified. Many cases of CLBP are refractory to treatment and will recur after the initial episode. Dysfunction of the lumbar multifidus muscle (LMM) has been increasingly identified as a possible cause of non-specific CLBP (NSCLP). METHODS: A review was conducted on the multifidus anatomy, dysfunction, diagnosis, and treatment literature. RESULTS: Multifidus dysfunction has been increasingly recognized as a potential contributor to the pathogenesis of non-specific chronic low back pain. Multifidus dysfunction is thought to arise from reflex inhibition stemming from an initial insult, which decreases spinal stability and predisposes patients to further injury. Therapeutic approaches aimed at addressing multifidus dysfunction include traditional conservative management, such as patient education, non-steroidal anti-inflammatory drugs, spinal manipulation, and physical therapy. These therapies aim mainly to achieve pain relief. Treatments that restore natural multifidus function include motor control exercises and restorative neurostimulation. CONCLUSION: Non-specific chronic low back pain is correlated with multifidus atrophy, fatty infiltration, and abnormal lumbar multifidus muscle function. This finding highlights the need for further research and clinical trials on targeted therapeutic approaches. Existing treatments on the lumbar multifidus muscle include motor control exercises and restorative neurostimulation. Unlike many conventional treatments that primarily provide symptom relief, these therapies aim to restore natural multifidus function, offering a rehabilitative rather than purely palliative approach. Motor control exercises have been shown to improve symptoms in cases of CLBP, but there is mixed evidence of their effectiveness relative to standard physical therapy. Restorative neurostimulation is a promising intervention that has been shown to provide significant, durable improvements to disability and pain. Further research on restorative therapies should be conducted using rigorous control protocols and comparative analyses with other CLBP treatment modalities.
INTRODUCTION: DISTINCT is a randomized controlled trial evaluating passive recharge burst SCS compared with CMM in improving pain and pain-related physical function in patients suffering from chronic back pain without pr...INTRODUCTION: DISTINCT is a randomized controlled trial evaluating passive recharge burst SCS compared with CMM in improving pain and pain-related physical function in patients suffering from chronic back pain without prior lumbar surgery, and for whom corrective surgery is not an option. Sub-analyses of outcome measures are presented for a subset implanted with paddle leads at both 6 and 12 months. OBJECTIVE: To investigate the treatment effect of using BurstDR-capable SCS in nonsurgical low back pain (NSLBP) patients with paddle leads. METHODS: An independent board-certified spine surgeon reviewed each case, confirming a lack of corrective surgical options. Out of 29 sites and 115 implants, 10 sites implanted 50 patients with paddle leads. Primary and secondary endpoints assessed improvements in low back pain intensity (NRS), low back pain-related disability (ODI), pain catastrophizing (PCS), and patient global impression of change (PGIC). RESULTS: Data for patients with NSLBP and implanted with paddle leads are available for 47 and 44 patients at 6 and 12 months, respectively. Patients reported significant reductions in pain relief at 6 and 12 months, decreasing from 7.8 ± 1.2 at baseline to 2.0 ± 1.6 and 2.2 ± 2.2, respectively (p < 0.0001). Disability was substantially reduced (> 20 points) from severe to mild at 6 and 12 months; ODI reduced from 54.4 ± 15.0 at baseline to 19.9 ± 14.1 and 22.1 ± 13.6, respectively (p < 0.0001). Pain catastrophizing improved to reflect the average of a non-chronic pain population; decreased from 27.6 ± 13.1 at baseline to 8.1 ± 8.2 and 7.8 ± 9.9 (p < 0.0001). 93.2% of patients reported a moderately better-much-improved outcome on PGIC. Ten complications occurred in 9 patients, 3 being severe device-related events. Two explants were required; one due to infection and one due to persistent pain at the IPG site, and one lead-related event was resolved by surgical repositioning. CONCLUSIONS: Passive recharge burst using paddle leads provides substantial relief to patients suffering from severe, debilitating, NSLBP. Patients report significant improvements in pain, function, and pain-related emotional distress. In addition, the rate of adverse events is low, supporting a favorable safety profile.