Clinical Journal of Pain最新文献

Objectives: Complex regional pain syndrome remains a challenging condition characterized by severe, persistent pain and a variety of inflammatory and trophic symptoms. This study aimed to analyze the current literature to evaluate hyperbaric oxygen therapy (HBOT)'s efficacy in treating complex regional pain syndrome (CRPS), focusing on both sympathetically maintained pain (SMP) and sympathetically independent pain (SIP) subtypes.

Methods: A comprehensive literature search was conducted in PubMed Clinical Queries using the MeSH term "Complex Regional Pain Syndromes" OR the keyword "CRPS" AND "Hyperbaric Oxygen Therapy" OR the keyword "HBOT." The selected publication types included a randomized controlled trial, a retrospective observational study, a comparative study, a retrospective case series, and case reports. The search was restricted to articles published in English between January 1994 and October 2024. The results from the search were used to compile this review. Patients were categorized into SMP, SIP, or indeterminate groups based on the presence of prior sympathetic nerve block history or disease duration.

Results: Thirteen studies involving 280 participants were reviewed. Of the patients, 42.5% were categorized as SMP, 48.2% as SIP, and 9.3% as indeterminate. HBOT treatment ranged from 3 to 63 sessions, typically using 2.4 atmospheres absolute for 90 minutes. The results indicated significant symptom relief and functional improvement across both SMP and SIP subtypes, suggesting the broad efficacy of HBOT for CRPS management.

Discussion: This review of the current literature suggests that HBOT may offer significant symptom relief, regardless of CRPS subtype or disease duration. HBOT's anti-inflammatory and neuroplasticity promoting properties make it a valuable noninvasive option for CRPS patients, potentially improving outcomes when combined with other therapeutic modalities. Further research is necessary to refine patient selection and optimize treatment protocols.

Objective: School refusal is a longstanding difficulty for youth with chronic pain. Yet, research is hindered by a lack of adequate measurement tools to assess and describe the complex interpersonal and system-level factors contributing to school refusal. This study investigates the utility of the SChool REfusal EvaluatioN (SCREEN) measure and its psychometric properties in a sample of youth with chronic pain.

Materials and methods: Youth undergoing multidisciplinary evaluation at outpatient pain clinics completed self and parent-report questionnaires. Descriptive data examined school refusal. Internal consistency and construct validity were tested. Multiple regressions examined the parent and child factors related to school refusal.

Results: In all, 698 youth with chronic pain participated. Two-thirds reported symptoms suggesting at-risk or clinically significant symptoms of school refusal. Cronbach alpha scores were in the acceptable to good range on the SCREEN. Convergent validity for the interpersonal discomfort subscale of the SCREEN was established. The child's fear of pain, stress, peer relationships, and parent protective behaviors significantly correlated with SCREEN total scores. Participants enrolled in fully in-person school during the study period reported significantly higher scores on the interpersonal discomfort scale than those enrolled in remote learning.

Discussion: Our results provide evidence that youth with chronic pain experience significant challenges with school functioning and offer some support for the reliability and validity of the SCREEN in a sample of youth with chronic pain, a population for which few appropriate measures of school functioning have been established. The SCREEN measure may aid in assessing school refusal, with good clinical potential to quantify risk and identify modifiable factors.

Background: Emergency delirium (ED) is a common and serious postoperative complication, especially after pediatric surgery. Quadratus lumborum block (QLB) is a critical component of the multimodal, opioid-sparing analgesia regimens, which provide effective analgesia, reduce opioid consumption, and attenuate surgical stress response. Therefore, this trial was designed to validate the hypothesis that the adjunctive use of QLB reduces the incidence of ED after laparoscopic surgery in children.

Materials and methods: Children aged 1 to 6 years who underwent laparoscopic surgery under general anesthesia were randomly divided into general anesthesia combined with QLB group (Group G+Q) or general anesthesia group (Group G). The primary outcome was the incidence of ED in the postanesthesia care unit (PACU), the incidence of delirium 24 hours postoperatively, extubation time, length of stay in PACU, opioid consumption, and pain score were recorded. From July 2020 to October 2022, 292 children were randomized and 287 completed the study.

Results: The incidence of delirium in Group G+Q was significantly lower than that in Group G in PACU (16.1% vs. 47.9%, P <0.001) and 24 hours postoperatively (3.4% vs. 11.1%; P <0.05). The time of extubation time (21.2±11.4 vs. 18.2±11.8 min; P <0.05) and PACU stay in Group G were significantly longer than Group G+Q (57.2±20.3 vs. 48.9±20.4 min, P <0.01) compared with Group G.

Discussion: General anesthesia combined with QLB can significantly reduce the incidence of ED, shorten the extubation time and PACU residence time, and improve the quality of resuscitation.

Objectives: An emerging concept in the chronic pain literature, high-impact chronic pain (HICP), refers to pain that occurs very frequently and results in major disruption of daily life. Previous epidemiologic investigations have noted that lower educational attainment, age, and race appear to be associated with the frequency of HICP, but condition-specific investigations of HICP have been less common.

Materials and methods: Here we investigate HICP status and its clinical/demographic correlates in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network symptom pattern study.

Results: Participants were 476 urologic pelvic pain syndrome (UCPPS) patients, 64% of whom were female. Of these, 22% were classified as having HICP based on responses to several questions about pain interference in daily life. We confirmed that African American individuals and those with lower educational attainment were more likely to experience HICP (both P <0.05). In addition, those with HICP demonstrated much greater levels of disability, genitourinary pain, urinary symptoms, widespread pain, and pelvic floor tenderness and were more likely to experience pain in response to consuming standardized amounts of water (all P <0.05). Binary logistics regression showed that genitourinary pain, widespread pain, and race were the strongest predictors of pain in multivariate models. Furthermore, HICP status was associated with more self-reported health care utilization over the subsequent 18 months ( P <0.05).

Discussion: These findings suggest that HICP affects more than 1 of 5 UCPPS patients, with significant associated morbidity. Demographic and clinical characteristics associated with HICP may be useful for identifying at-risk UCPPS patients.

Objectives: After cesarean, optimal analgesia is important for early mobilization, mitigating thromboembolic risks, and mother-infant communication. Our study compared the postoperative analgesic effects of intrathecal morphine (ITM) and erector spinae plane block (ESPB) in elective cesarean section under spinal anesthesia.

Methods: Eighty-two patients were randomized into ESPB and ITM groups. Both groups received spinal anesthesia with 10 mg of heavy bupivacaine. In the ITM group, ITM (100 mcg) was added. The ESPB group received bilateral T10 level ESPB with 20 mL 0.25% bupivacaine postoperatively. Postoperative pain control included intravenous paracetamol 4x1 g, intravenous patient-controlled analgesia with tramadol, and diclofenac 75 mg for rescue analgesia when Numeric Rating Scale (NRS) >4. NRS, tramadol consumption, and side effects were recorded 24 hours postoperatively. The primary outcome of this study is to compare 24-hour postoperative opioid consumption after cesarean sections. Secondary outcomes include postoperative pain scores, rescue analgesia needs, and side effects.

Results: NRS scores ≤4 at all time intervals and were comparable among groups. The total 24-hour tramadol consumption was significantly higher in the ESPB group (median: 75; Q1, Q3 [40, 140]) compared with ITM (50 [27.5, 60], P = 0.008). Tramadol consumption was similar among groups during 0 to 6 and 6 to 12 hours. In the 12 to 24 hours, tramadol consumption was significantly higher in the ESPB group (22.5 [15, 57.5]) compared with ITM (15 [12.5, 25], P = 0.005). In the ITM group, nausea and vomiting were observed in 3 patients and itching in 1 patient; no adverse effects were observed in the patients in the ESPB group.

Conclusion: For patients undergoing cesarean section under spinal anesthesia, ITM reduced opioid consumption more effectively than ESPB. ESPB is not recommended as a primary analgesic option for cesarean sections.

Objective: To determine whether psychosocial factors such as resilience, perceived stress, catastrophizing, anxiety, depression, pain self-efficacy, and social support, explain the persistence of pain and disability in individuals with RCRSP following an education program.

Methods: One hundred forty-three individuals with persistent RCRSP were included in this prospective cohort study. At baseline, participants completed self-reported questionnaires related to pain, disability, and psychosocial constructs, including resilience, stress, catastrophizing, anxiety and depressive symptoms, pain self-efficacy, and social support. Thereafter, participants took part in an educational program aimed at promoting self-management of RCRSP that included two meetings with a physiotherapist. After 12 and 24-weeks, participants filled only pain and disability questionnaires and based on their scores, were classified as having persistent shoulder pain or as recovered.

Results: A univariable modified Poisson regression showed that higher perceived stress (RRadjusted: 1.02; 95%CI: 1.01-1.04), catastrophizing (RRadjusted: 1.01; 95%CI: 1.01-1.02), symptoms of depression (RRadjusted: 1.03; 95%CI: 1.01-1.06) and anxiety (RRadjusted: 1.03; 95%CI: 1.01-1.06), along with lower resilience (RRadjusted: 0.90; 95%CI: 0.81-1.00), were associated with ongoing RCRSP at 12 weeks. Additionally, reduced pain self-efficacy was associated with persistent pain at both 12 weeks (RRadjusted: 0.98; 95%CI: 0.97-0.99) and 24 weeks (RRadjusted: 0.99; 95%CI: 0.98-1.00). Multivariable regression indicated that only pain self-efficacy served as a protective factor against persistent RCRSP (RRadjusted: 0.98; 95%CI: 0.97-0.99).

Discussion: This study sheds light on the impact of psychosocial factors on persistent RCRSP, underscoring the importance of positive beliefs in pain management. Importantly, pain self-efficacy emerges as a key factor in recovery.

Objectives: Postoperative pain, nausea, and vomiting (PONV) adversely affect postoperative rehabilitation after total knee arthroplasty (TKA). We aimed to identify factors associated with postoperative pain trajectory and PONV and evaluated the effects of different analgesic modalities.

Methods: We retrospectively reviewed patients undergoing unilateral primary TKA from 2017 to 2022. Patients received either general or spinal anesthesia. Patient-controlled analgesia (PCA) included patient-controlled epidural analgesia (PCEA) and intravenous analgesia (PCIA). Outcome variables included maximal pain intensity at certain times (before surgery, and 24 h and 48 h after surgery); and incidence of PONV. A generalized estimating equation was used to determine the correlation between PCA usage and longitudinal pain score at 48 hours follow-up after surgery. Multivariable logistic regression analyses were used to evaluate PONV after adjusting for potential confounders.

Results: In total, 2510 patients were included in the analyses. Patients without PCA intervention and with higher BMI reported greater acute postoperative pain. Furthermore, women and lower BMI were associated with higher rates of PONV. After adjusting for confounding factors, the PCEA group had a lower pain score than both the no PCA group (β estimate =-0.443, 95% CI= [-0.561 to -0.324], P <0.001) and the PCIA group (mean difference=-0.227, 95% CI = [-0.328 to -0.126], P <0.001).

Conclusion: General anesthesia and PCA had no effect on the PONV incidence after TKA. Greater BMI correlated with higher pain scores but a lower likelihood of PONV. Epidural PCA provided superior acute postoperative analgesia without increasing the incidence of PONV.

Objective: Posterior cervical spine surgery can result in significant discomfort in the postoperative period. Postoperative pain management presents a challenge, particularly in the elderly population that is more sensitive to adverse effects from analgesia. We compared outcomes after perioperative posterior cervical muscle plane blocks versus patients who received general anesthesia only.

Methods: MEDLINE, EMBASE, and the Cochrane Library were searched for articles concerning the use of blocks in posterior cervical spinal surgery from January 1, 1974 to December 11, 2023. Data from studies meeting inclusion criteria were analyzed. Fixed-effect and random-effect models were used to establish odds ratios and mean differences with 95% CIs for each outcome.

Results: The results of the pooled analysis showed that in patients undergoing elective posterior cervical spine surgery, a perioperative posterior cervical muscle plane block resulted in a statistically significant decrease in numerical pain rating scores at 2 hours postoperatively, 12 hours postoperatively, adverse events, and postoperative nausea/vomiting. A preoperative posterior cervical block resulted in a decrease in the duration of surgery, and numerical pain rating scores at 24 hours postoperatively, though not to a level of statistical significance.

Conclusion: These meta-analyses suggest that perioperative posterior cervical muscle plane blocks are safe and result in improved postoperative analgesic efficacy when compared with controls. More robust prospective, randomized studies are necessary to help inform the safety and efficacy of perioperative posterior cervical blocks for elective posterior cervical spine surgery.

Objectives: Historically in medicine and beyond, the understanding of and treatment of pain is based on finding tissue injury. The fact that for chronic pain, there often is no (longer) any traceable tissue injury, in combination with the fact that pain essentially is a private experience, poses a challenge for clinical communication. This paper therefore examines how pain is linguistically and interactionally constructed as invisible.

Materials and methods: The qualitative approach of interactional sociolinguistic analysis is used to analyze 37 consultations and 11 semistructured interviews with patients with chronic pain, collected at a Belgian pain clinic. This fine-grained approach to studying communication provides an in-depth empirical understanding of the phenomenon under scrutiny.

Results: The data show that pain is constructed as invisible on several levels: (1) on the biomechanical and clinical level, in terms of its lack of visible or traceable tissue injury, (2) on the level of interaction, as pain needs to be made apparent to other people through pain displays, and (3) on the social level, as chronic pain often is not visible or apparent in society more broadly.

Conclusion: The discussion explores how on these 3 levels, notions of the abnormal or deviant body come into play, in which patients and health professionals complexly construct pain both as not normal (i.e., not a neutral or desirable state of being), whereas, at the same time, the lack of traceable tissue injury is constructed as medically normal for chronic pain. This also relates to how patients and health care providers often orient to the stigma around chronic pain.

Objectives: Chronic pain is a leading cause of morbidity in children and adolescents globally but can be managed with a combination of traditional Western medicine and integrative medicine (IM) practices. This combination has improved various critical health outcomes, such as quality of life, sleep, pain, anxiety, and health care utilization. These IM practices include acupuncture, yoga, biofeedback, massage, mindfulness, or any combination of these modalities. The current article developed a budget impact model to estimate the institutional costs of implementing these practices among adolescents.

Methods: A decision tree was used to estimate the reduction in hospitalizations and emergency department (ED) use based on a previously published retrospective analysis of children receiving IM practices comparing utilization rates 1-year pre-implementation and post-implementation of IM services (Figure 1). Costs associated with implementing each modality were based on hourly compensation rates for licensed professionals administering each service and equipment associated with delivery (eg, acupuncture needles, biofeedback equipment, and sensors). The cost of each hospitalization and ED visit was derived from the literature. In addition, cost savings were estimated based on government-contracted and commercial-contracted reimbursement rates for each service.

Results: Cost savings were approximated to range from $1344 to $3439 per patient, with even greater cost savings of up to $6000 and $4132 when accounting for governmental and commercial payer reimbursement, respectively.

Discussion: IM leads to improved pain relief when combined with traditional medicine and yields significant cost savings, thus supporting the routine implementation of IM alongside traditional medicine in health care settings.