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Anesthesiology 2001 Dec;95(6):1531-3
Publication Types:
PMID: 11780176, UI: 21617880
Ann Intern Med 2001 Dec 18;135(12):S-65
PMID: 11785472, UI: 21618882
Ann Intern Med 2001 Dec 18;135(12):S-64
PMID: 11785471, UI: 21618879
Ann Intern Med 2001 Dec 18;135(12):1047-51
Hematology-Oncology Section, Department of Medicine, University of Oklahoma Health Sciences Center, Box 26901, Oklahoma City, OK 73190, USA.
BACKGROUND: Quinine-associated thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is thought to be uncommon and to have a good prognosis. OBJECTIVE: To describe the frequency, clinical features, and long-term outcomes of quinine-associated TTP-HUS. DESIGN: Case series. SETTING: Hospitals in central-western Oklahoma. PATIENTS: 225 consecutive patients with TTP-HUS, 1989-2000. MEASUREMENTS: Presenting features and clinical outcomes. RESULTS: Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome was associated with quinine in 17 patients. Four patients died, and 7 survivors currently have chronic renal failure. Since 1 July 1995, 132 patients with clinically suspected TTP-HUS were explicitly asked about drug exposure. Fourteen (11%) had taken quinine, and 7 had taken other drugs associated with TTP-HUS. Neurologic abnormalities were as severe in patients with quinine-associated TTP-HUS as in the 118 patients who had not taken quinine. CONCLUSIONS: Quinine is a common cause of drug-associated TTP-HUS and can cause death and chronic renal failure. When the disorder is described as TTP-HUS rather than only as HUS, the severity of neurologic abnormalities and the occasional absence of renal failure are emphasized. If recurrent disease is to be prevented, clinicians must recognize quinine as a possible cause.
PMID: 11747383, UI: 21614301
Cancer 2001 Nov 15;92(10):2609-22
Psycho-Oncology Division, National Cancer Center Research Institute East, Chiba, Japan.
BACKGROUND: Few longitudinal studies have investigated psychiatric disorders in patients with unresectable nonsmall cell lung carcinoma (NSCLC). This study addressed three questions: 1) Which psychiatric disorders are prevalent among patients with unresectable NSCLC? 2) What is the clinical course of psychological distress? 3) Which factors are associated with this distress, and do any antecedent variables predict subsequent psychological distress? METHODS: A series of 129 consecutive patients with newly diagnosed, unresectable NSCLC participated. Psychiatric assessments were conducted by using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition revised between the time of diagnosis and initial treatment for NSCLC (baseline) and 6 months after diagnosis (follow-up). Potential associated and predictive variables, including sociodemographic, biomedical, and psychosocial factors, were explored. RESULTS: The most common psychiatric disorder at baseline was nicotine dependence (67%), followed by adjustment disorders (14%), alcohol dependence (13%), and major depression (5%). At follow-up, adjustment disorders were diagnosed in 16% of patients, and major depression was diagnosed in 3% of patients. Thirty-five percent of patients who experienced depressive disorders (adjustment disorders and/or major depression) at baseline continued to experience the same disorders at follow-up. Multivariate analysis revealed that relatively younger age and pain were associated significantly with psychological distress at baseline. Only self-reported anxiety and depression at baseline could predict subsequent psychological distress. CONCLUSIONS: Substance dependence and depressive disorders are common psychiatric disorders in patients with unresectable NSCLC. Although this form of malignant disease often is progressive, depressive disorders do not seem to increase during its clinical course. Pain management is essential for alleviating patients' depressive disorders, and self-rating depression and anxiety seems to be an indicator of subsequent depressive disorders. Copyright 2001 American Cancer Society.
PMID: 11745196, UI: 21610138
Clin J Pain 2001 Dec;17(4 Suppl):S94-104
Family Medicine Centre, Elizabeth Bruyere Health Centre, Ottawa, Ontario, Canada. rmbernst@uottawa.ca
[Medline record in process]
OBJECTIVE: The purpose of this review was to determine how effective surgery and injection therapy are in the management of chronic pain. METHODOLOGY: A standardized literature search identified seven systematic reviews of the literature and six randomized controlled trials to provide evidence about surgery and injection therapy for chronic pain. RESULTS: Some study subjects had highly specific diagnoses, whereas other study subject groups had nonspecific pain, including multiple conditions. The timing of treatment interventions was generally unclear, and few studies analyzed subgroups. Overall, there was a lack of methodologically sound studies of surgery and injection therapies. CONCLUSIONS: Standard discectomy compared with conservative treatment for proven disc herniation (< or = 1 year) and local triamcinolone injection for lateral epicondylitis (< or = 12 weeks) are both effective for pain relief (level 2). There was limited evidence of effectiveness (level 3) of intraoperative steroid at discectomy, epidural steroid injection for sciatica with low back pain, caudal steroid injection for low back pain, local glycosaminoglycan polyphosphate injection for lateral epicondylitis, intraarticular steroid injection for shoulder arthritis, subacromial steroid injections for rotator cuff tendinitis, nonspecific injections for painful shoulder, systemic growth hormone for fibromyalgia, and intravenous adenosine for fibromyalgia. There was limited evidence (level 3) that there is no additional benefit of adding steroid to local anesthetic in caudal epidural injections. There is limited evidence (level 3) that intravenous adenosine is ineffective for fibromyalgia. The remaining evidence was inadequate (level 4a) or contradictory (level 4b).
PMID: 11783838, UI: 21641288
Clin J Pain 2001 Dec;17(4 Suppl):S86-93
Department of Clinical Neurological Sciences/Oncology, University of Western Ontario, London, Canada. dwight.moulin@lhsc.on.ca
OBJECTIVE: The purpose of this review was to determine how effective different classes of analgesic agents are in the management of chronic pain. METHODOLOGY: The literature search identified five systematic reviews and 18 randomized controlled trials to provide evidence about systemic drug treatment for chronic pain. RESULTS: Studies in the systematic reviews were mainly of low back pain, and studies in the randomized controlled trials were mainly of fibromyalgia. Other studies investigated of rheumatic pain, musculoskeletal pain, chronic low back pain, and temporomandibular pain. Classes of analgesic agents reviewed were antidepressants, nonsteroidal anti-inflammatory drugs, muscle relaxants, opioid analgesics, and a number of miscellaneous agents. CONCLUSIONS: For chronic pain, opioid analgesics provide benefit for up to 9 weeks (level 2). For chronic low back pain, the evidence shows that various types of nonsteroidal antiinflammatory drugs are equally effective or ineffective, and that antidepressants provide no benefit in the short to intermediate term (level 2). Muscle relaxants showed limited effectiveness (level 3) for chronic neck pain and for chronic low back pain for up to 4 weeks. For fibromyalgia, there is limited evidence (level 3) of the effectiveness of amitryptiline, ondansetron, zoldipem, or growth hormone, and evidence of no effectiveness for nonsteroidal anti-inflammatory drugs, malic acid with magnesium, calcitonin injections, or s-adenyl-L-methionine. For temporomandibular pain, oral sumatriptan is not effective (level 2). The remaining evidence was inadequate (level 4a) or contradictory (level 4b).
PMID: 11783837, UI: 21641287
Clin J Pain 2001 Dec;17(4 Suppl):S8-9
Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Canada. robert.teasell@lhsc.on.ca
PMID: 11783836, UI: 21641276
Clin J Pain 2001 Dec;17(4 Suppl):S77-85
Department of Graduate Studies and Research, Canadian Memorial Chiropractic College, Toronto, Ontario. smior@cmcc.ca
OBJECTIVE: The purpose of this review was to determine how effective exercise is in the treatment of chronic pain. METHODOLOGY: The literature search identified three systematic reviews and three randomized controlled trials addressing the effectiveness of exercise for the management of chronic low back pain, one systematic review and one randomized controlled trial addressing chronic neck pain, two systematic reviews and three randomized controlled trials addressing upper extremity pain, and three randomized controlled trials addressing fibromyalgia. RESULTS: Randomized controlled trials were better than systematic reviews for providing details of patient subgroups and of exercise programs, but there was a general lack of evaluation of the different subgroups. The studies also failed to assess the different duration and frequency of exercise programs. For chronic low back pain, a systematic review and two of the three randomized controlled trials found exercise to be effective: other findings were uncertain. For chronic neck pain, both the systematic review and the randomized controlled trial provided generally uncertain results, with only one positive-result study in the systematic review. For upper extremity, positive effects of exercise were shown for chronic lateral epicondylitis and for specific soft tissue shoulder disorders. For fibromyalgia, two of the three randomized controlled trials showed effectiveness of exercise. CONCLUSIONS: Exercise is effective for the management of chronic low back pain for up to 1 year after treatment and for fibromyalgia syndrome for up to 6 months (level 2). There is conflicting evidence (level 4b) about which exercise program is effective for chronic low back pain. For chronic neck pain and for chronic soft tissue shoulder disorders and chronic lateral epicondylitis, evidence of effectiveness of exercise is limited (level 3).
PMID: 11783835, UI: 21641286
Clin J Pain 2001 Dec;17(4 Suppl):S70-6
OBJECTIVE: The purpose of this review was to determine how effective manipulation and mobilization are in the treatment of chronic pain. METHODOLOGY: The literature search identified three systematic reviews addressing the effectiveness of manipulation and mobilization for low back pain, two systematic reviews addressing chronic neck pain, three randomized controlled trials addressing post-traumatic headache and neck pain, and one systematic review and one randomized controlled trial addressing upper limb (including shoulder) disorders. RESULTS: Most studies lacked details of the specific interventions, which were often combined with other interventions, and this could have enhanced or masked effectiveness. Subject groups were heterogeneous, and investigators did not indicate effectiveness for subgroups. Systematic reviews of chronic low back pain found evidence of effectiveness compared with placebo and with usual care. Evidence from the systematic reviews for chronic neck pain and from the systematic review and randomized controlled trial for chronic soft tissue shoulder disorders was contradictory. For post-traumatic headache, the randomized controlled trials reported a time-limited positive benefit or no different effects than comparison treatment. CONCLUSIONS: Manipulation and mobilization are more effective for chronic low back pain than placebos or usual care for up to 6 months (level 2). For chronic post-traumatic headache, evidence of effectiveness of manipulation and mobilization is limited (level 3). Manipulation and mobilization may or may not be effective for either chronic neck pain or chronic soft tissue shoulder disorders (level 4b).
PMID: 11783834, UI: 21641285
Clin J Pain 2001 Dec;17(4 Suppl):S68-9
Department of Medicine, University of Western Ontario, London, Canada. warren.nielson@sjhc.london.on.ca
PMID: 11783833, UI: 21641284
Clin J Pain 2001 Dec;17(4 Suppl):S5-7
PMID: 11783832, UI: 21641275
Clin J Pain 2001 Dec;17(4 Suppl):S46-64
BACKGROUND: The literature contains many different viewpoints on the impact of compensation on recovery from chronic pain. OBJECTIVE: What is the role of compensation in chronic pain and/or chronic pain disability? METHODOLOGY: The literature search identified 11 observational studies to provide evidence about this question. RESULTS: There is a paucity of high-quality data on the subject of the impact of compensation on chronic pain. This subject was reviewed under the headings of (1) injury claim rate and duration; (2) recovery; and (3) rehabilitation treatment programs. The studies were of subjects with musculoskeletal pain, mainly low back pain. CONCLUSIONS: Filing a compensation claim for costs, retaining a lawyer, or higher pain intensities were limited predictors of longer claims (level 3). As the ratio of compensation to preinjury wage increases, there is moderate evidence (level 2) that the duration of the claim increases and that disability is more likely. Compensation status, particularly combined with higher pain intensities, is associated with poorer prognosis after rehabilitation treatment programs (level 3).
PMID: 11783831, UI: 21641283
Clin J Pain 2001 Dec;17(4 Suppl):S39-45
BACKGROUND: Disability is a multifactorial phenomenon. Social scientists suggest that nonclinical factors, including age, education, and job status, correlate with disability. OBJECTIVE: Do employment-related factors predict chronic pain and/or chronic pain disability? METHODOLOGY: The literature search identified 15 observational studies to provide the evidence about this question. RESULTS: Review topics included job satisfaction, type of work, modified work and work autonomy, other employment-related factors, and socioeconomic status. Most subjects in the studies had low back pain. The studies used return to work as an outcome predicting chronic pain disability. CONCLUSIONS: Lack of modified work and lack of work autonomy predicted chronic pain disability (level 2). There was limited evidence (level 3) that lack of job satisfaction, perception of difficult job conditions and demands, heavy physical demands of the job, private rather than public employment, and lower socioeconomic group predict chronic pain disability. The number of years employed varied as a predictor in different studies (level 4b).
PMID: 11783830, UI: 21641282
Clin J Pain 2001 Dec;17(4 Suppl):S33-8
Department of Psychiatry, University of Toronto, Ontario, Canada. klaus.kuch@sympatico.ca
OBJECTIVE: What is the role of psychological factors in chronic pain and chronic pain disability? METHODOLOGY: The literature search identified 20 observational studies to provide evidence about this question. RESULTS: Most studies evaluated psychological variables as predictors of return to work. Most studies were prospective cohort studies, including those providing the most data about etiology. In some studies, weak methods and analyses limited the conclusions. In addition, the methodologic criteria of the literature search excluded some well-known reports about this subject. CONCLUSIONS: Because of the small number of studies, there was inadequate evidence that chronic pain results from a prior psychiatric disorder (level 4a). The studies provided limited evidence (level 3) that chronic depression plays a role in the development of new pain locations (although not for low back pain); that prior nervousness and past negative life events predict work disability; and that depression, anxiety, and a sense that control rests outside of one's own self may predict slower recovery from pain and disability. These findings do not prove that psychological factors have a role in the development of chronic pain. Psychological impairment may precede the onset of pain. Based on current knowledge, it may also arise as a complication of chronic pain.
PMID: 11783829, UI: 21641281
Clin J Pain 2001 Dec;17(4 Suppl):S26-32
Department of Physical Therapy, Faculty of Medicine, University of Toronto, Ontario, Canada. judith.hunter@utoronto.ca
OBJECTIVE: Do physical findings that are used to indicate location and extent of tissue damage and a measure of the severity of initial pain predict subsequent reports of pain and of disability? METHODOLOGY: A standardized literature search identified one systematic review and 12 observational studies (9 low back pain, 2 neck pain, and 1 carpal tunnel syndrome) to provide evidence about these questions. RESULTS: Most studies were of specific populations. These studies were useful studies of predictors, but they have limited generalizability. Exclusions and loss of subjects at follow-up in some studies also limited generalizability. Conclusions were made cautiously, because some factors with statistical correlations with chronic pain were not plausible predictors. CONCLUSIONS: The studies provide moderate evidence (level 2) that reports of the intensity of pain in acute musculoskeletal injury predict subsequent reports of pain. There is limited evidence (level 3) that the location and extent of injury predict reports of pain and poor functional activity outcomes. There is moderate evidence (level 2) that physical symptoms and signs cannot be considered individual predictors of chronic pain disability as measured by participation outcomes. Instead, in the transition from subacute to chronic pain disability, functional disability and psychological distress play a more important role than pain intensity.
PMID: 11783828, UI: 21641280
Clin J Pain 2001 Dec;17(4 Suppl):S20-5
OBJECTIVE: Can either a history of previous similar injury, including recurrence of injury, or an individual's symptoms, including time off work, predict chronic pain and/or chronic pain disability? METHODOLOGY: The literature search identified one systematic review and six observational studies (5 low back pain and 1 chronic shoulder pain) to provide evidence about these questions. RESULTS: Only one study evaluated subjects before a painful event. Other studies evaluated subjects over a range of time from onset of pain, including some selected for clinic treatment. This variability as well as the use of different outcome measures without blinding limited the quality of the evidence. CONCLUSIONS: The studies provide moderate evidence (level 2) that a history of previous similar pain predicts subsequent reports of pain and limited evidence (level 3) that a history of similar pain predicts poorer outcomes after recurrent injury. The studies also provide moderate evidence (level 2) that longer duration of pain predicts the occurrence of subsequent reports of pain and limited evidence (level 3) that longer time off work before treatment predicts poorer activity and poorer participation outcomes after recurrent injury.
PMID: 11783827, UI: 21641279
Clin J Pain 2001 Dec;17(4 Suppl):S14-9
OBJECTIVE: Are demographic variables (age, gender, sex, and marital status) predictors of chronic pain and chronic pain disability? METHODOLOGY: The literature search identified one systematic review plus 12 observational studies (11 back or spinal pain and 1 whiplash) to provide evidence about this question. RESULTS: The role of predictive factors varied with different patient groups, settings, and interventions. Analytic methods also varied. Most studies evaluated age, sex, and marital status with other nondemographic variables. CONCLUSIONS: The studies provided limited and conflicting evidence (level 4b) that either increasing age or sex correlates with chronic pain and chronic pain disability. Marital status and education both showed conflicting evidence (level 4b) of a correlation with chronic pain. Age and sex express different risks for disease, severity of injury, and occupational opportunities and choices. Demographic factors can modify the effect of other factors with which they interact. Future identification of predictors of chronic pain should include control for age and gender (level 3).
PMID: 11783826, UI: 21641278
Clin J Pain 2001 Dec;17(4 Suppl):S114-27
BACKGROUND: Biopsychosocial treatments address the range of physical, psychological, and social components of chronic pain. OBJECTIVE: This review sought to determine how effective unimodal and multimodal biopsychosocial approaches are in the treatment of chronic pain. METHODOLOGY: The literature search identified three systematic reviews of the literature and 21 randomized controlled trials to provide the evidence for this review. RESULTS: The systematic reviews and 12 randomized controlled trials reported on chronic low back pain. Other randomized controlled trials studied fibromyalgia (three trials) and back or other musculoskeletal disorders (five trials). Biopsychosocial components reviewed were electromyogram feedback and hypnosis as unimodal approaches, and behavioral and cognitive-behavioral treatments and back school, or group education, as multimodal approaches for chronic low back pain. For other chronic pain disorders, cognitive-behavioral treatments were reviewed. Comparisons were hindered by studies with heterogeneous subjects, varied comparison groups, different cointerventions and follow-up times, variable outcomes, and a range of analytic methods. CONCLUSIONS: Multimodal biopsychosocial treatments that include cognitive-behavioral and/or behavioral components are effective for chronic low back pain and other musculoskeletal pain for up to 12 months (level 2). There is limited evidence (level 3) that electromyogram feedback is effective for chronic low back pain for up to 3 months. The remaining evidence of longer-term effectiveness and of effectiveness of other interventions was inadequate (level 4a) or contradictory (level 4b). Future studies of cognitive-behavioral treatments should be condition specific, rather than include patients with different pain conditions.
PMID: 11783824, UI: 21641290
Clin J Pain 2001 Dec;17(4 Suppl):S105-13
Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada. babjaka@mcmaster.ca
OBJECTIVE: The purpose of this review was to determine how effective acupuncture, transcutaneous electrical nerve stimulation, acupuncture-like transcutaneous nerve stimulation, laser therapy, electrical nerve stimulation, and neuroreflexotherapy are in the management of chronic pain. METHODOLOGY: The literature search identified six systematic reviews of the literature and four randomized controlled trials to provide evidence for this review. RESULTS: The systematic reviews included different methodologies and heterogeneity of study groups, but studies were generally of poor methodology. Although sham acupuncture may have analgesic effects, it was used as a control in many studies. CONCLUSIONS: In general, the evidence was contradictory or inadequate, reflecting poor study methodologies. No positive conclusion could be reached for acupuncture, transcutaneous electrical nerve stimulation, acupuncture-like transcutaneous nerve stimulation, laser therapy, or neuroreflexotherapy. A single randomized controlled trial provided limited evidence (level 3) that electrical nerve stimulation is effective for pain relief in myofascial pain syndrome for up to 4 weeks, but further study in humans is needed. Future randomized controlled trials and systematic reviews should include subgroup analyses of sham acupuncture and inert placebos as controls.
PMID: 11783823, UI: 21641289
Clin J Pain 2001 Dec;17(4 Suppl):S10-1
PMID: 11783822, UI: 21641277
Clin J Pain 2001 Dec;17(4 Suppl):S1-4
Chronic Pain Expert Advisory Panel, Work-place Safety and Insurance Board, Toronto, Ontario, Canada. brock_smith@wsib.on.ca
PMID: 11783821, UI: 21641274
Clin J Pain 2001 Dec;17(4):378-9
PMID: 11783820, UI: 21641273
Clin J Pain 2001 Dec;17(4):365-74
Department of Farmacologia, de Terapeutica i de Toxicologia, Universitat Autonoma de Barcelona, Bellaterra, Spain.
OBJECTIVE: Versions of the McGill Pain Questionnaire are available in a several languages and are used in clinical studies and sociocultural or ethnic comparisons of pain issues. However, there is a lack of studies that compare the validity and reliability of the instrument in the countries where it is used. The current study investigates the psychometric properties of a Spanish version of the McGill Pain Questionnaire in five Spanish-speaking countries. DESIGN: The authors conducted a multicenter and transnational study with one investigator in each center. Patients were evaluated once with a Spanish version of the McGill Pain Questionnaire, a visual analog scale, and a verbal rating scale. SETTING: The study was performed in pain clinics and acute pain units of four Latin American countries (Argentina, Costa Rica, Mexico, and Panama) and Spain. PATIENTS: The study included 205 patients (84 with acute pain, 121 with chronic pain) from Latin America. Their data were compared with those of 282 Spanish patients. INTERVENTIONS: The McGill Pain Questionnaire, visual analog scale, and verbal rating scale were administered once to all patients. The McGill Pain Questionnaire was administered again to patients from Latin America countries to ascertain descriptor comprehension. OUTCOME MEASURES: Demographic data, McGill Pain Questionnaire parameters, and visual analog scale and a verbal rating scale scores were obtained from patients with chronic and acute pain. Psychometric properties of the Spanish version of the McGill Pain Questionnaire were established for each country by calculating the ordinal consistency by means of rank-scale correlation (Spearman test), intercategory correlation, and interparameter correlation (Pearson test). Concurrent validity was also calculated by comparing scores from the visual analog scale (Pearson test) and verbal rating scale (Spearman test) with questionnaire parameters (qualitative-to-quantitative comparisons). RESULTS: The Spanish version of the McGill Pain Questionnaire maintained a high internal validity when tested in different countries. Ordinal consistency, intercategory, interparameter, and qualitative-to-quantitative parameter correlations were similar in all countries. Few descriptors were considered to be inappropriate or difficult to understand. CONCLUSIONS: The psychometric properties of the Spanish version of the McGill Pain Questionnaire assessed in different Latin-American countries suggest that the questionnaire may be used to evaluate Spanish-speaking patients. The validity of this test should be extended with reliability studies to further establish its usefulness in the evaluation of pain.
PMID: 11783818, UI: 21641271
Clin J Pain 2001 Dec;17(4):359-64
Department of Anesthesiology, Multidisciplinary Pain Center, University of Michigan Medical Center, Ann Arbor 48109-0048, USA. carmeng@umich.edu
OBJECTIVE: This study investigated the association between repeated childhood and adulthood abuse and somatic symptom reporting, mental health care use, and substance use among women with chronic pain. DESIGN: A survey of a consecutive sample. PATIENTS: Ninety consecutive women patients presenting for chronic pain management at a multidisciplinary pain management center. OUTCOME MEASURES: The authors assessed the presence or absence of physical or sexual abuse (using the Drossman Physical-Sexual Abuse Survey), period of abuse, demographics, mental health care use, drug or alcohol use and substance abuse, and the presence or absence of physical, pain, and anxiety (somatic) symptoms. RESULTS: The response rate among patients surveyed was 64%. Of the 43 respondents (48%) who reported abuse, 17 (40%) cited childhood abuse, 12 (28%) cited adulthood abuse, and 14 (33%) cited repeated abuse. Women describing long-term abuse reported a significantly greater number of physical, pain, and anxiety symptoms and were more likely to report a history of substance abuse than women reporting abuse during childhood or adulthood alone. CONCLUSIONS: These data indicate a significant association between health status and reported abuse among women presenting to a multidisciplinary pain center for pain management. This finding is consistent with those of previous investigators, and emphasizes the importance of routine evaluation of the presence of long-term abuse as a possible predictor of the onset of chronic pain states.
PMID: 11783817, UI: 21641270
Clin J Pain 2001 Dec;17(4):350-8
Center for Community Health and Health Evaluation Research, British Columbia Research Institute For Children's and Women's Health, Vancouver, Canada. smorison@cw.bc.ca
OBJECTIVE: The purpose of this study was to assess relations and concordance between behavioral and physiologic reactivity to pain in preterm neonates at 32 weeks postconceptional age as a function of gestational age at birth. SETTING: Level III neonatal intensive care unit. DESIGN/PATIENTS: The study group comprised 136 preterm neonates (mean [range] birthweight, 1,020 g [445-1,500 g]: gestational age at birth, 28 weeks [23-32 weeks]) separated into three groups according to gestational age at birth as follows: 23 to 26 weeks (n = 48), 27 to 29 weeks (n = 52), and 30 to 32 weeks (n = 36). OUTCOME MEASURES: Reactivity to routine blood collection at 32 weeks postconceptional age was assessed using bedside-recorded behavioral and autonomic measures. Coders who were blinded to the study design scored behavioral responses (facial activity using the Neonatal Facial Coding System, sleep/waking state, and finger splay). Autonomic reactivity was assessed by change in heart rate and spectral analysis of heart rate variability (change in low-frequency and high-frequency power, and the ratio of low-frequency to high-frequency power during blood collection). RESULTS: Facial activity and state correlated moderately with change in heart rate across gestational age groups (r = 0.41-0.62). Facial activity and state did not correlate significantly with change in low-frequency and high-frequency power, or the ratio of low-frequency to high-frequency power (r = 0.00-0.31). Finger splay did not correlate with any autonomic recording (r = 0.03-0.41). Concordance between established biobehavioral measures of pain revealed individual differences. Although some neonates showed high behavioral but low physiologic reactivity, other neonates displayed the opposite reaction; however, the majority displayed concordant reactions. CONCLUSIONS: The study findings confirm the value of measuring domains independently, especially in neonates born at a very young gestational age.
PMID: 11783816, UI: 21641269
Clin J Pain 2001 Dec;17(4):341-9
Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Ohio 45229, USA.
OBJECTIVES: The primary aim of this study was to describe pain characteristics, coping strategies, depression, and functional disability in children and adolescents with chronic pain and to examine potential factors that are associated with functional disability in a pediatric pain population. The secondary aim of this study was to compare functional disability in two chronic pain conditions: localized musculoskeletal pain and chronic daily headaches. SUBJECTS: The participants in this study were 73 pediatric pain patients with a variety of chronic pain conditions. Subjects in the second part of the study were a subset of patients (N = 44) from the pain clinic sample with chronic localized musculoskeletal pain and a subset of patients (N = 38) from the headache center of the same hospital who had chronic daily headaches. DESIGN: Patients completed self-report measures of pain intensity, depression, coping strategies, coping efficacy, and functional disability. RESULTS: Results indicated that chronic pain had a substantial impact on the children's lives and that depression was strongly associated with functional disability. Maladaptive coping was correlated with depression and disability; however, maladaptive coping was not independently associated with functional disability. A comparison between the two groups found significant differences in pain intensity and functional disability. The localized musculoskeletal pain group reported higher levels of disability and more difficulty coping than the chronic daily headache group. CONCLUSIONS: The implications for treatment of chronic pain in children are discussed with an emphasis on greater attention to developmental issues and their relation to coping, emotional functioning, and disability in pediatric pain. Further research examining differences in coping and disability between different pediatric pain groups is also warranted.
PMID: 11783815, UI: 21641268
Clin J Pain 2001 Dec;17(4):327-36
Comprehensive Pain Program, The Toronto Western Hospital, and Institute for Work & Health, Ontario, Canada.
OBJECTIVE: To determine if chemical sympathectomy successfully reduces limb neuropathic pain. DESIGN: Systematic literature review of the effectiveness of phenol or alcohol sympathectomy for extremity neuropathic pain. PATIENT: A 29-year-old female with complex regional pain syndrome of both lower extremities after back surgery who was submitted to bilateral lumbar chemical sympathectomy. SEARCH STRATEGY: The Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register, Medline, and EMBASE were systematically searched. OUTCOME MEASURES: (1) For the patient in question: spontaneous pain, allodynia, pinprick hyperalgesia, pressure evoked pain; (2) For the literature review: meaningful versus nonmeaningful pain relief based on degree and duration (>2 weeks) of pain relief. RESULTS: (1) The case reported experienced partial temporary relief of pain primarily related to selective modulation of allodynia, but not deep pain or pinprick hyperalgesia; (2) 44% of 66 patients in 13 studies that met the authors' inclusion criteria experienced meaningful pain relief. Whereas 19% experienced no meaningful relief, for the remaining 37% of the patients no conclusions regarding duration and degree of relief could be drawn due to poor reporting of outcomes. CONCLUSIONS: Based on the case reported and systematic literature review, chemical sympathectomy seems to have at best a temporary effect, limited to cutaneous allodynia. Despite the popularity of chemical sympatholysis, only few patients and poorly defined outcomes are reported in the literature, substantiating the need for well-designed studies on the effectiveness of the procedure.
PMID: 11783813, UI: 21641266
Clin J Pain 2001 Dec;17(4):306-15
Department of Anesthesiology, University Hospital of Bern, Inselspital, Switzerland. michele.curatolo@insel.ch
OBJECTIVE: The mechanisms underlying chronic pain after whiplash injury are usually unclear. Injuries may cause sensitization of spinal cord neurons in animals (central hypersensitivity), which results in increased responsiveness to peripheral stimuli. In humans, the responsiveness of the central nervous system to peripheral stimulation may be explored by applying sensory tests to healthy tissues. The hypotheses of this study were: (1) chronic whiplash pain is associated with central hypersensitivity; (2) central hypersensitivity is maintained by nociception arising from the painful or tender muscles in the neck. DESIGN: Comparison of patients with healthy controls. SETTING: Pain clinic and laboratory for pain research, university hospital. PATIENTS: Fourteen patients with chronic neck pain after whiplash injury (car accident) and 14 healthy volunteers. OUTCOME MEASURES: Pain thresholds to: single electrical stimulus (intramuscular), repeated electrical stimulation (intramuscular and transcutaneous), and heat (transcutaneous). Each threshold was measured at neck and lower limb, before and after local anesthesia of the painful and tender muscles of the neck. RESULTS: The whiplash group had significantly lower pain thresholds for all tests. except heat, at both neck and lower limb. Local anesthesia of the painful and tender points affected neither intensity of neck pain nor pain thresholds. CONCLUSIONS: The authors found a hypersensitivity to peripheral stimulation in whiplash patients. Hypersensitivity was observed after cutaneous and muscular stimulation, at both neck and lower limb. Because hypersensitivity was observed in healthy tissues, it resulted from alterations in the central processing of sensory stimuli (central hypersensitivity). Central hypersensitivity was not dependent on a nociceptive input arising from the painful and tender muscles.
PMID: 11783810, UI: 21641263
Clin J Pain 2001 Dec;17(4):296-305
Department of Rehabilitation, Lund University Hospital, Sweden. akusyd@swipnet.se
OBJECTIVE: The authors sought to determine whether a series of needle acupuncture treatments produced long-term relief of chronic low back pain. DESIGN: A blinded placebo-controlled study with an independent observer. The patients were randomized to receive manual acupuncture, electroacupuncture, or active placebo (mock transcutaneous electrical nerve stimulation). Subjects were examined and monitored by an investigator who was blinded to the treatment given. SETTING: A tertiary-level pain clinic at a Swedish university hospital. PATIENTS: Fifty consecutive patients (33 women, 17 men; mean age, 49.8 years) with chronic low back pain (mean pain duration, 9.5 years) and without rhizopathy or history of acupuncture treatment were included in the study. INTERVENTIONS: Treatments were given once per week for 8 weeks. Two further treatments were given during the follow-up assessment period of 6 months or longer. OUTCOME MEASURES: The independent observer made a global assessment of the patients 1, 3, and 6 months after treatment. The patients kept pain diaries to score pain intensity twice daily, analgesic intake, and quality of sleep daily, and activity level weekly. RESULTS: At the 1-month independent assessment, 16 of 34 patients in the acupuncture groups and 2 of 16 patients in the placebo group showed improvement (p <0.05). At the 6-month follow-up assessment, 14 of 34 patients in the acupuncture groups and 2 of 16 patients in the placebo group showed improvement (p <0.05). A significant decrease in pain intensities occurred at 1 and 3 months in the acupuncture groups compared with the placebo group. There was a significant improvement in return to work, quality of sleep, and analgesic intake in subjects treated with acupuncture. CONCLUSIONS: The authors found a long-term pain-relieving effect of needle acupuncture compared with true placebo in some patients with chronic nociceptive low back pain.
PMID: 11783809, UI: 21641262
Clin J Pain 2001 Dec;17(4):284-95
University of Maastricht, The Netherlands.
OBJECTIVE: To assess the efficacy/effectiveness and side effects of gabapentin for the treatment of neuropathic pain. DESIGN: Systematic review of the literature. METHODS: Extensive search of several electronic databases located both controlled and uncontrolled studies. Efficacy was assessed through meta-analysis of randomized controlled trials (RCTs), whereas the effectiveness of gabapentin in uncontrolled studies was assessed via a novel system of dichotomous classification of "bad" versus "good" results. FINDINGS: Thirty-five papers involving 727 patients with multiple neuropathic pain conditions met the inclusion criteria. The meta-analysis of the 2 high-quality, placebo-controlled RCTs showed positive effect of gabapentin in diabetic neuropathy and post-herpetic neuralgia. The addition of 2 low-quality, placebo-controlled RCTs did not alter the magnitude or direction of observed effect. The uncontrolled studies demonstrated positive effect on pain in different neuropathic syndromes, as well as benefit on different types of neuropathic pain; highest dose administered and rate-of-dose escalation showed wide variability between prescribers. Fewer and less severe side effects were reported in the uncontrolled studies. CONCLUSIONS: Gabapentin seems to be effective in multiple painful neuropathic conditions. The variable prescribing patterns of the uncontrolled studies raise the suspicion that effectiveness may be reduced if one limits administration of the drug to very low doses, whereas rapid dose escalation may be associated with increased central nervous system side effects. Well-designed controlled trials may provide insight into differential symptom sensitivity to the drug.
PMID: 11783808, UI: 21641261
Clin J Pain 2001 Dec;17(4):281-3
PMID: 11783807, UI: 21641260
Eur J Anaesthesiol 2001 Dec;18(12):829-32
First Department of Anaesthesiology, Dokkyo University School of Medicine, Tochigi, 321-0293, Japan. y-okuda@dokkyomed.ac.jp
Occipital nerve block is usually considered to be a very simple and safe regional anaesthetic technique. We describe a case of sudden unconsciousness during a lesser occipital nerve block in a patient with an occipital bone defect. A 63-year-old man complained of headache, which was localized to the right occipital region. A right lesser occipital nerve block with a local anaesthetic was performed for treatment. During the lesser occipital nerve block, the patient suddenly became disturbed and lost consciousness. Two hours after the incident, the patient was fully awake without neurological sequelae. He had previously undergone a microvascular decompression for right trigeminal neuralgia. The patient had a bone defect following craniotomy. We believed that the loss of consciousness during lesser nerve block may be due to a subarachnoid injection. Occipital nerve block is relatively contraindicated in the presence of a bone defect.
PMID: 11737183, UI: 21600895
J Pain Symptom Manage 2002 Jan;23(1):84-5
PMID: 11779680, UI: 21638582
J Pain Symptom Manage 2002 Jan;23(1):80-1
PMID: 11779676, UI: 21638578
J Pain Symptom Manage 2002 Jan;23(1):78-9
PMID: 11779674, UI: 21638576
J Pain Symptom Manage 2002 Jan;23(1):77
PMID: 11779673, UI: 21638575
J Pain Symptom Manage 2002 Jan;23(1):60-5
Department of Anesthesiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
To evaluate the role of oral ketamine as an adjuvant to oral morphine in cancer patients experiencing neuropathic pain, 9 cancer patients (5 men, 4 women) taking maximally tolerated doses of either morphine, amitriptyline, sodium valporate, or a combination of these drugs for intractable neuropathic pain, and reporting a pain score of >6 on a 0-10 scale, were studied prospectively to evaluate analgesia and adverse effects. Ketamine in the dose of 0.5 mg/kg body weight three times daily was added to the existing drug regimen. Patients were taught to maintain a pain diary wherein they daily recorded their pain, sedation, and vomiting scores, and other side effects. A decrease of more than 3 from the baseline in the average pain score, or a score of </=3 was taken as a successful response. Seven patients exhibited a decrease of more than 3. Four patients experienced nausea, of which one had vomiting. Two developed loss of appetite. Eight patients reported drowsiness during the first two weeks of therapy (P = 0.001), and this gradually improved over the next two weeks in 5 of these 8 patients. Three patients withdrew from the study, two owing to excessive sedation and another due to a "feeling of unreality." None of the patients reported visual or auditory hallucinations. This experience suggests that low dose oral ketamine is beneficial and effective in the management of intractable neuropathic pain in patients with advanced cancer. However, its utility is limited in some patients by the adverse effects that accompany its use.
PMID: 11779670, UI: 21638572
J Pain Symptom Manage 2002 Jan;23(1):39-47
Center for Bioethics, Clinical Research Institute of Montreal and McGill University, Montreal, Quebec, Canada
We report the results of a cancer pain survey mailed to Quebec hematologist-oncologists and palliative care physicians in 1999. The survey was designed to sample views on the current status of pain management and on obstacles to the provision of adequate pain relief for patients. The survey, formulated by an ethics network centered at the Clinical Research Institute of Montreal, was distributed to all members of the Association of Hematologist-Oncologists of Quebec and to all physician members of the Quebec Palliative Care Association. Responses were obtained from 138 Palliative Care Association members (response rate 61%) and 76 hematologist-oncologists (response rate 45%). Major obstacles reported included inadequate assessment of both contributory psychosocial issues and severity of pain, patient reluctance to take opioids, and inadequate access to non-drug techniques for pain relief. Access to opioids was not regarded as a problem. Both groups felt generally competent in their ability to manage various aspects of cancer pain therapy. They gave little credit to their formal medical school or residency training. Fifty-six percent of the palliative care group and 57% of the hemato-oncologists rated their medical school experience as only "poor" or "fair" on a 4-point scale. Residency ratings were modestly better. We conclude that medical faculties should assign a high priority to teaching health professionals patient assessment techniques. Simple symptom assessment scales should be routinely used in oncology/palliative care practice. Medical school training in pain management is not highly regarded and should be enhanced. We also note that, based on response to the scenario of a patient presenting with severe pain, many physicians, while feeling competent in the use of opioids, may be overly conservative in their initial use.
PMID: 11779667, UI: 21638569
J Pain Symptom Manage 2002 Jan;23(1):31-8
University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
This study identified factors associated with inaccurate family caregiver assessments of patient pain. Participants were 31 caregiver-patient dyads receiving hospice home care. All patients had a primary diagnosis of end-stage cancer. As expected, caregivers overestimated patient pain. The degree of disparity for each dyad was calculated by subtracting the patient's pain rating from the caregiver's rating of patient pain. Caregiver knowledge of cancer pain management was not related to the degree of disparity in pain ratings, but caregivers' experience of patient pain was significantly related to accuracy of caregivers' pain ratings. Those caregivers who 1) perceived their loved one to be in a great deal of distress secondary to pain, 2) associated greater efforts at pain relief (i.e., more medication) with greater levels of pain, and 3) were themselves distressed by the patient's pain had the most inaccurate estimates of patient pain. There was a trend for greater disparity in pain estimates to be related to poorer existential quality of life for patients. Overall, the findings suggest that health care providers need to take into consideration family members' interpretation of patient pain when providing pain management education services.
PMID: 11779666, UI: 21638568
J Pain Symptom Manage 2002 Jan;23(1):26-30
University Hospital, Kragujevac, Yugoslavia
To investigate the efficacy of the second 4 Gy given as a single fraction radiotherapy (RT) for patients with painful bone metastasis who had already twice received single fraction RT (4, 6, or 8 Gy plus 4 Gy), a total of 25 patients were assessed before and after re-irradiation. The patients included 19 responders and 6 nonresponders to two prior single fraction RT, the latter one being 4 Gy. The overall response rate was 80%, with both complete response (CR) and partial response (PR) being 40%. No difference was found between the previous responders and previous nonresponders regarding both CR (P = 0.70) and overall response rate (P = 0.35). Response duration was longer in the previous responders (P = 0.0041), but the time to pain relief was similar between the two treatment groups. No acute or late high-grade toxicity was observed during this study and no pathological fractures or spinal cord compressions were seen. In this small and highly selected series of patients, the third single fraction RT of 4 Gy was effective and not toxic in the treatment of painful bone metastasis.
PMID: 11779665, UI: 21638567
J Pain Symptom Manage 2002 Jan;23(1):3-5
Department of Anesthesiology University of Cologne, Cologne, Germany
PMID: 11779660, UI: 21638562
J Pain Symptom Manage 2002 Jan;23(1):1
[Record supplied by publisher]
PMID: 11779658
J Pain Symptom Manage 2001 Dec;22(6):1042-7
Medtronic, Inc., Minneapolis, MN 55432-5604, USA.
With the exception of morphine, hydromorphone is the most commonly used intrathecal opioid for the treatment of intractable pain. The purpose of this study was to evaluate the stability and compatibility of hydromorphone in the implantable infusion system that is most commonly used in these patients. Hydromorphone solution was incubated at 37 degrees C in infusion system reservoirs and with individual materials which comprise the fluid pathway of the infusion system. Stability was analyzed using high performance liquid chromatography; mechanical integrity of device materials was evaluated after drug exposure. After 4 months of exposure to device materials or intact devices, hydromorphone concentration remained greater than 95% of starting material. All device materials retained acceptable mechanical performance. These results demonstrate that hydromorphone is stable at physiological temperatures for at least 4 months in an implantable infusion system and that current clinical practice of refilling the pump every 3 months is appropriate.
PMID: 11738167, UI: 21602374
J Pain Symptom Manage 2001 Dec;22(6):1027-34
Department of Clinical Affairs, Ortho McNeil Pharmaceutical, Inc., O'Fallon, IL 62269, USA.
In hospice organizations, continuous subcutaneous infusion (CSI) is a common medication delivery modality for pain management. Nonetheless, little is known regarding the practices of hospice organizations in their utilization of this technique. We surveyed 3,930 hospice organizations to describe indication, diluents, medications, and other variable factors associated with CSI utilization. Of the 3,930 surveys sent, 907 were returned, yielding a response rate of 24%. Seventy-three percent of hospice organizations surveyed indicated they utilized CSI. The average daily census (ADC) of these hospices was 38.6 +/- 61.0. The most common indication for CSI use was palliative management (95%). The most common medication used in CSI was morphine sulfate (97%). These results indicate that CSI utilization may be widespread in hospices and further study regarding this delivery system is warranted.
PMID: 11738165, UI: 21602372
Lancet 2001 Dec;358 Suppl:49
Centre Francais des Porphyries, INSERM U409, CHU, Louis Mourier-Bichat, 92700, Colombes, France
PMID: 11784598, UI: 21644323
Pain 2001 Nov;94(2):215-24
Pain Research Group, Department of Anaesthetics, Imperial College School of Medicine, Chelsea and Westminster Hospital Campus, 369 Fulham Road, London SW10 9NH, UK. a.rice@ic.ac.uk
A multicentre double blind, randomised, placebo controlled 7-week study evaluated the efficacy and safety of gabapentin 1800 or 2400 mg/day in treating postherpetic neuralgia. Three hundred and thirty-four men and women aged at least 18 years (mean 73) received gabapentin 1800 or 2400 mg daily or placebo in three divided doses with a forced titration schedule. The primary outcome measure was change in average daily pain diary score (baseline week v final week). Secondary outcomes included mean weekly sleep interference score; Short Form-McGill Pain Questionnaire (SF-MPQ); Clinician and Patient Global Impression of Change (CGIC/PGIC); Short Form-36 Health Survey (SF-36). From week 1, pain scores showed a significantly greater improvement with gabapentin: the final difference v baseline was -34.5% for the 1800 mg dose, -34.4% for the 2400 mg dose compared with -15.7% for the placebo group. The difference vs. placebo was 18.8% for the 1800 mg dose (95% confidence interval 10.9-26.8%; P<0.01) and 18.7% for the 2400 mg dose (10.7-26.7%; P<0.01). Sleep interference diaries showed a similar pattern. There were significant differences in favour of gabapentin for number of patients reporting >50% reduction in their pain intensity, in the CGIC and PGIC, in the sensory and total scores of the SF-MPQ (both doses), in the visual analogue scale of pain of the SF-MPQ (2400 mg only) and in the vitality, bodily pain and mental health domains of the SF-36. Overall gabapentin was well tolerated. The most common adverse events were dizziness and somnolence, particularly during the titration phase. Thus, this study confirms the role of gabapentin as an efficacious and well-tolerated treatment for postherpetic neuralgia.
PMID: 11690735, UI: 21550166
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