Clinical Journal of Pain最新文献

Objectives: To assess the effect of perineural dexamethasone on analgesia duration and opioid consumption when used as an adjuvant to the iPACK (infiltration between the popliteal artery and capsule of the knee) block and adductor canal block in patients undergoing total knee arthroplasty.

Methods: In this double-blind, randomized controlled trial, 60 patients aged 65 years or older undergoing total knee arthroplasty under spinal anesthesia were assigned to one of two groups. The Control group received iPACK and adductor canal block with 0.2% ropivacaine alone, while the Dexamethasone group received the same blocks with the addition of perineural dexamethasone. The primary outcome was time to first opioid rescue analgesia. Secondary outcomes included total opioid consumption over 48 hours, postoperative pain scores at defined time points, quadriceps muscle strength, and adverse effects including neurological complications and hyperglycemia.

Results: Patients receiving dexamethasone experienced a significantly longer duration of analgesia (15.9±1.2 h vs. 8.8±1.6 h), lower total opioid consumption over 48 hours (1.2±1.3 mg vs. 2.3±1.4 mg morphine equivalents), and fewer patients required opioids (20% vs. 50%). Pain scores were significantly lower at 8 and 12 hours postoperatively. No differences were observed in motor function or adverse event rates.

Discussion: Perineural dexamethasone enhances the duration and quality of postoperative analgesia without compromising motor function. Its inclusion in regional analgesia protocols for total knee arthroplasty may contribute to improved recovery and reduced opioid use.

Objective: Acute musculoskeletal (MSK) injuries are common in youth and prior research has identified somatosensory experiences such as conditioned pain modulation (CPM) as a predictor of the transition from acute to chronic pain. Prior pediatric studies are limited by small samples, single quantitative sensory testing (QST) modalities, and short-term follow-up, so the utility of QST in predicting longer-term pain outcomes following acute injury is unknown. To fill this gap, we examined somatosensory function in the acute pain period as a predictor of pain outcomes over 12 months.

Methods: Participants were 226 youth (and a caregiver) taking part in a prospective longitudinal study. Youth completed a QST battery (pain threshold, pain tolerance, temporal summation, and CPM) at baseline (post-injury), and questionnaires assessing pain (average pain, movement-evoked pain; MEP) at three timepoints over 12 months.

Results: A subset of youth developed persistent pain (≥3/0-10 NRS) at 3 months (15-21% depending on pain measure). Regression models indicated CPM was the sole QST measure that predicted pain intensity and persistence at 3 months (both average and MEP). No QST measures predicted pain outcomes at 12 months. Female sex was associated with pain persistence in multiple models.

Discussion: CPM in the acute pain period is a potential marker for short-term pain outcomes. Future research can examine the utility of using QST in predicting pain outcomes in other pediatric pain samples (e.g., non-MSK locations, more severe injuries) and can expand assessment of MEP using standardized performance tasks.

Objective: To compare the relative efficacy of common non-pharmacological treatments for migraine and to determine the optimal dosage for physical exercise.

Methods: We searched four databases up to January 2025 for randomized controlled trials of non-pharmacological interventions for migraine. A multilevel network meta-analysis, integrated with a dose-response analysis, was conducted to compare intervention efficacy and determine the optimal exercise dosage. Treatments were ranked by the Surface Under the Cumulative Ranking curve. Two independent reviewers extracted data and assessed the risk of bias.

Results: Fifty-nine randomized controlled trials involving 10,020 participants (78.1%, female) were included. Neuromodulation techniques were most effective (Hedges'g=-0.61, 95% Credible Interval: -0.89 to -0.33), followed by physical exercise (Hedges'g=-0.42, 95% Credible Interval: -0.67 to -0.18) and mindfulness meditation (Hedges'g=-0.38, 95% Credible Interval: -0.63 to -0.12). The dose-response analysis for exercise indicated that while 100 metabolic equivalent (MET)-minutes per session was statistically effective, a minimum of 110 MET-minutes per session was required to achieve the Minimal Clinically Important Difference. Efficacy reached an optimal therapeutic plateau at 250-300 MET-minutes per session, achievable with 3-5 weekly sessions of 30-40 minutes.

Discussion: Neuromodulation, physical exercise, and mindfulness meditation are promising non-pharmacological therapies for migraine. For physical exercise, a minimum dose of 110 MET-minutes per session is needed for clinically significant effects, with an optimal therapeutic window at 250-300 MET-minutes per session. Due to the low quality of primary evidence, these findings warrant cautious interpretation and require future validation.

Objectives: The average level of outcomes is the most used index for assessing the efficacy of psychological therapies; however, emerging evidence suggests that it may not fully capture the complexity of treatment effects. This study compared the effects of third-wave cognitive behavioral therapy (CBT) on pain-related outcomes (pain intensity, pain interference, sleep disturbance, and depressed mood) using six indices: average level, variability, maximum level, minimum level, frequency in high, and frequency in low.

Methods: Ecological momentary assessment (EMA) data were collected within a randomized controlled trial (RCT) that evaluated the addition of remote-delivered third-wave CBT to treatment-as-usual (TAU) in individuals with chronic low back pain plus depressive symptoms. A total of 82 participants (CBT = 50 and TAU = 32) provided 4,595 EMA data points over 10 weeks (70 days).

Results: Compared to TAU, third-wave CBT was generally associated with greater improvement across the pain-related outcomes. Frequency in low emerged as the most sensitive index for change in pain interference and depressed mood; in contrast, the average level showed limited sensitivity. The maximum level also captured some between-group differences for sleep disturbance and depressed mood. The remaining indices (variability, minimum, and frequency in high) did not consistently provide additional value.

Discussion: These findings suggest that the frequency in low may be a sensitive and clinically informative index for detecting treatment effects in RCTs using EMA. Nevertheless, further research is needed to establish its reliability and generalizability across clinical contexts and clinical trial designs.

Objective: Individuals receiving opioids for pain management are at risk for negative outcomes. However, it is not clear whether social determinants of health (SDOH) predict outcomes a year after starting a prescription opioid. The purpose was to examine associations between SDOH with psychiatric-related, pain-related, and opioid-related outcomes at a 12-month follow-up.

Methods: Participants (N=783) with a new period of 30 to 90-day opioid use completed baseline and 12-month follow-up questionnaires regarding SDOH, depressive symptoms, pain severity, pain interference, and opioid use. Multivariate adjusted models estimated the association between SDOH and outcomes.

Results: Participants had a mean age of 53.4 years (SD=11.9), 71.2% White race, and 69.9% women. Older age (OR=0.97; 0.95, 0.99) and Black race (OR=0.45; 0.27, 0.76) were inversely associated with depression, while being widowed/divorced/separated (OR=1.72; 1.01, 2.91) and lacking a college education (OR=2.43; 1.25, 4.73) were positively associated with depression. Women (OR=1.56; 1.12, 2.18) and lower income (OR=2.09; 1.14, 3.85) were associated with greater odds of opioid use, while unemployment was associated with lower odds of opioid use at 12 months (OR=0.55; 0.34, 0.89). Older age (OR=0.95; 0.91, 0.99) was inversely associated with opioid use concerns while disability (OR=4.59; 1.60, 13.11) was positively associated.

Discussion: Several SDOH variables were associated with poorer functioning at baseline and 12 months after individuals were prescribed an opioid. It may be useful for clinicians to screen for SDOH to identify higher-risk individuals.

Objectives: To identify evidence for pain assessment during acute procedures in hospitalized neonates at risk of neonatal opioid withdrawal syndrome (NOWS).

Methods: This scoping review was conducted using the JBI scoping review methodology. The search strategy focused on identifying in-patient neonates undergoing acute painful procedures. Databases searched are MEDLINE, CINAHL, Embase, PsycInfo, and Scopus. The relevant data were extracted by 2 reviewers and the results were summarized in a narrative description and presented in a tabular format, including the components of participants, concept, and context.

Results: A total of 22,731 unique studies were screened, with 5 studies ultimately included. Of these studies, 2 included neonates at risk of NOWS but did not report pain responses separately. The 3 remaining studies observed procedural pain in opioid-exposed neonates compared with neonates without opioid exposure during heel lance. Pain assessment methods included physiological responses and validated composite pain scores. When using composite pain tools, 1 study showed higher pain response in opioid-exposed neonates, while the other 2 studies showed the same or lower pain response. For skin conductance, the findings from 2 studies were discrepant, with 1 study reporting higher pain response in opioid-exposed neonates and the other showing no statistically significant difference.

Discussion: There is a need for more studies designed to examine the influence of opioid exposure and withdrawal on pain responding and management in neonates. As there is currently limited evidence to guide clinical care, clinicians should continue to use validated composite pain assessment tools and pain management strategies.

Objective: Mindfulness-based interventions (MBIs) show promise in managing chronic pain but often require substantial time commitments, leading to high attrition and concerns about acceptability. This meta-analysis evaluated attrition rates in MBIs for chronic pain and examined moderators contributing to participant withdrawal.

Methods: Following PRISMA guidelines, we searched relevant databases for studies of MBIs for pain. Eligible studies included randomised controlled trials, controlled trials, and quasi-experimental designs that reported attrition data for adults (≥18 y) with chronic pain lasting over 3 months. Data extraction covered attrition metrics, program characteristics, and participant demographics. Statistical analyses included random-effects meta-analyses of proportions, sensitivity analyses, meta-regression, and publication bias assessments.

Results: Forty-four studies (45 intervention conditions) were included. The pooled attrition rate was 30.1% (95% CI: 24.5% to 37.3%) with substantial heterogeneity (I²=89.0%). Attrition increased with stricter completion thresholds (minimum sessions required for programme completion status) (P<0.001, R²=28.1%): 18.0% (≥3-4 sessions), 31.6% (≥5-6 sessions), and 49.7% (>6 sessions). Online delivery showed higher attrition (51.0%) than in-person delivery (25.6%, P=0.002, R²=17.1%). Individually delivered MBIs were also associated with higher attrition than group formats (β=0.216, P=0.039, R²=5.5%). Publication bias analyses suggested minor influence on the pooled effect, which remained robust after adjustment.

Discussion: Attrition rates for MBIs in chronic pain vary widely. Higher attrition is associated with stricter completion criteria, online delivery, and individual formats. These findings highlight the need to optimise MBI programme structure for management of pain.