Pain Medicine最新文献

Background: Difficult encounters represent an enormous burden and drain on resources in pain medicine, but their effect on outcome has not been studied.

Objective: To determine the effect of "difficult" encounters on chronic pain outcomes.

Methods: In this prospective study, new chronic pain visits were rated by an attending physician and trainee on a 6-point Likert scale and stratified into "difficult" and "non-difficult". The main outcome was successful treatment, defined as a ≥ 2-point reduction in average pain 4 weeks after initiating pharmacological, integrative or injection therapy or 12 weeks after invasive procedures. The secondary outcome was lost-to-follow-up.

Results: Among 428 patients seen for new-patient evaluations, 299 patients had follow-up, of which 127 (42.5%) experienced a positive outcome. Patients involved in difficult encounters were less likely to experience a positive outcome (28% vs. 46%; P = 0.02) than those not involved in difficult encounters. When stratified into quartiles, difficulty continued to be associated with an unsuccessful outcome, with the easiest encounters translating to a 53% success rate vs. 28% for patients involved in the most difficult encounters (P = 0.02). Difficult encounters were not associated with lost-to-follow-up. In multivariable analysis evaluating factors associated with difficultness, ≥10% missed appointments (OR 0.69, 95% CI 0.48 to 0.97; P = 04), nonorganic signs (OR 0.42, 95% CI 0.18 to 0.90; P = 0.03), visiting taking longer than expected (OR 0.49, 95% CI 0.25 to 0.96; P = 0.04) and refusal to try a treatment (OR 0.25, 95% CI 0.08 to 0.70; P = 0.01) were associated with poor outcome.

Conclusions: Difficult encounters can not only lead to administrative burdens, poor ratings and lost revenue, but are also associated with negative outcomes for chronic pain, a condition notoriously associated with difficult visits.

Trial registration: Clinicaltrials.gov (NCT05585619); https://clinicaltrials.gov/study/NCT05585619? id=NCT05585619&rank=1.

Objectives: To assess if implementing interventions to effectively manage preoperative chronic moderate to severe shoulder pain in patients undergoing rotator cuff repair (RCR) can improve shoulder surgery outcomes.

Methods: A systematic review was conducted following the PRISMA and SIGN guidelines. Randomized clinical trials (RCT), metanalysis, systematic revisions and cohort studies in Spanish/English, published within the last 10 years, evaluating interventions to control preoperative chronic moderate to severe shoulder pain in patients undergoing RCR and their impact in postoperative shoulder outcomes were included. Selected records were graded following the 2011 Oxford Centre for Evidence-Based Medicine levels of evidence (OCEBML). RCT were graded using the PEDro scale.

Results: Twenty-nine records were included in the analysis. Evidence suggests that preoperative chronic moderate to severe shoulder pain is the strongest risk factor for postoperative shoulder pain (OCEBML III). Patient-related factors and shoulder pain characteristics can also influence surgery outcomes (OCEBML II/III). Predictors of better shoulder function at 2 years after surgery include higher preoperative scores on the Western Ontario Rotator Cuff index and the Constant-Murley score in the contralateral shoulder (OCEBML III). Preoperative analgesia to control shoulder pain can improve postoperative pain (OCEBML I). Preoperative patient teaching and intensive postoperative follow-up also improve pain intensity and function (OCEBML II).

Discussion: Preoperative chronic shoulder pain together with patient-related factors are significant predictors of postoperative shoulder outcomes, emphasizing the need for proactive pain assessment and tailored therapeutic programs.

Design: Platelet-rich plasma (PRP) is a popular treatment option in managing chronic tendinopathies, although the literature is inconsistent, mainly because of significant heterogeneity in patient populations. Patients who failed conservative management may respond differently than those who have not undergone first-line treatment. This systematic review and meta-analysis aimed to evaluate the efficacy of PRP injections in reducing pain and improving function in patients with chronic tendinopathy who failed conservative treatment. A comprehensive search of Medline, Embase, Cochrane Library, Cinahl Complete and Dissertations & Theses Global was conducted to identify randomized controlled trials comparing the effect of PRP versus non-surgical treatments on pain and functional outcomes in adult non-responders to conservative management.

Results: A total of 9 RCTs involving 488 patients were included in the review. Of those, 6 studies at low risk of bias were included in the meta-analysis. PRP significantly reduced pain at both 6 and 12 months compared to control treatments (mean difference: -0.83 [95% CI: -1.61 to -0.04] at 6 months; and -1.11 [95% CI: -2.10 to -0.12] at 12 months). This effect was also seen at 24 months, although based on limited data. Subgroup analysis revealed no significant differences in pain reduction between upper and lower limb tendinopathies. Functional improvement was observed in some studies, though the heterogeneity in outcome measures precluded a pooled analysis. Heterogeneity was substantial across studies, likely due to differences in PRP preparation, site of tendinopathy, and study methodologies.

Conclusion: Despite these limitations, the findings suggest that PRP reduces pain in patients suffering from chronic tendinopathy who have not responded to first-line therapies. Further high-quality research with standardized protocols and longer follow-up is necessary to confirm PRP's long-term efficacy and safety.

Background: Identifying predictors for adherence and clinical response to psychological therapies is essential for improving individual treatment outcomes.

Objective: To explore predictors of adherence and clinical response among individuals with co-occurring chronic low back pain (CLBP) and depression receiving cognitive behavioral therapy (CBT).

Methods: This study employs a secondary analysis of data from a randomized controlled trial (NCT04140838), including 156 individuals with CLBP plus depressive symptoms who received CBT. Multiple linear regression analyses were conducted to assess the predictive power of sociodemographic, health status, pain-related, and therapy-related variables on adherence and clinical response. Adherence was measured by therapy progress (number of completed sessions) and therapy completion (attendance at least six out of eight sessions). Clinical response was assessed by a clinically relevant reduction in posttreatment pain interference.

Results: Older age, higher therapy credibility, and higher education level predicted greater therapy progress, while higher therapy credibility and lower baseline stress levels predicted greater therapy completion. In addition, higher opioid use, baseline pain interference, and baseline depression levels predicted lower clinical response; in contrast, higher behavioral activation levels, older age, and unemployment predicted higher clinical response.

Conclusion: Therapy credibility, age, and education level are key predictors of adherence, and baseline levels of pain interference, depression, and behavioral activation are key predictors of clinical response. These findings may inform opportunities to develop more effective personalized therapeutic plans for individuals with CLBP and depression.

Objective: This study aims to evaluate the effectiveness and tolerability of a phytotherapeutic topical gel (Douloff®) compared to oral paracetamol for acute pain resulting from minor limb soft tissue injuries.

Methods: A prospective, multicenter, randomized, double-blind study conducted over 13 months in three EDs. Patients aged 18 years and older, with minor limb soft tissue injuries, were randomized into Douloff® (n = 765) and paracetamol (n = 750) groups. The primary outcome was the pain resolution rate (reduction of at least 50% of pain intensity, measured by the numeric rating scale (NRS) on active motion at day-7compared to NRS at discharge). Secondary outcomes included time to pain resolution, rescue analgesia, patient satisfaction and adverse events.

Results: The groups were comparable in terms of baseline characteristics. On day-7, resolution of pain was observed in 641 patients (83.7%) in Douloff® group versus 535 patients (71.3%) in paracetamol group (OR 1.27; 95% CI 1.015-1.6; p = 0.02). Median time to reach pain resolution was 4.5 ± 2.9 days in Douloff® group compared with 5.6 ± 3.3 days in paracetamol group (p < 0.001). Patients in Douloff® group required less rescue analgesics (48.2%) compared to paracetamol group (59.1%) (-10.9%, 95% CI -15.89 to -5.9; p < 0.001). No major adverse events were observed in either group, and 89.4% of patients in Douloff® group were satisfied, compared to 92.5% in the paracetamol group (p < 0.001).

Conclusion: Douloff®, a topical herbal paste, is superior to oral paracetamol in the management of acute pain related to soft tissue injuries. It can be considered as an alternative to conventional analgesics.

Background: The National Institutes of Health (NIH) Pain Common Data Elements (CDEs) provide a standardized framework for pain research, but their implementation and interpretation present challenges.

Objectives: To review the NIH CDE Program's selected pain domains, provide best practices for implementing required questions, and offer a checklist for appropriate CDE use in clinical trials and secondary data analysis. This work analyzed the 10 core pain research domains selected by the NIH CDE Program and discuss their limitations and considerations for use.

Results: The manuscript provides an overview of the 10 core pain research domains, including pain intensity, interference, physical function, sleep, catastrophizing, depression, anxiety, global impression of change, substance use screening, and quality of life. It offers sample scenarios for implementing required questions and presents a checklist to guide researchers in using pain CDEs effectively for clinical trials and secondary data analysis.

Conclusion: Key challenges identified include contextual variability, lack of validation across all pain conditions and populations, and potential misuse or misinterpretation of measures. This work proposes solutions such as supplementary measures, context-specific guidance, comprehensive training programs, and ongoing refinement of the CDE framework. While NIH Pain CDEs are valuable tools for standardizing pain assessment in research, addressing challenges in their implementation and interpretation is crucial for improving the consistency, validity, and interpretability of pain research data, ultimately advancing the field and enhancing patient care.

Mentorship plays a vital role in pain medicine, guiding professionals from medical training through independent practice. This article explores how mentorship fosters research, enhances clinical competence, and promotes multidisciplinary collaboration. Drawing on insights from leading institutions, we propose a structured mentorship framework tailored to different career stages. Effective mentorship cultivates research skills, expands academic networks, and provides early exposure to the field, shaping long-term career trajectories. It also strengthens clinical expertise, encourages cross-disciplinary collaboration, and advances diversity, equity, and inclusion in medicine. Structured academic mentorship models offer longitudinal guidance for sustained professional development. By aligning mentor-mentee goals and ensuring consistent support, mentorship programs maximize professional growth and ultimately improve patient outcomes. This article outlines key strategies and tools for building effective mentorship programs, emphasizing their transformative impact on the field of pain medicine.