Background: Total knee arthroplasties are the second most common surgery in Canada. Most patients recover well, but 20% or more still suffer from persistent pain and opioid use. Though opioids are an important part of perioperative pain management, their potential for long-term adverse effects is well recognized. Limiting opioids may be insufficient to overcome the issue of opioid overuse. Pain and opioid use are highly linked, so an effective alternative needs to address both issues.
Objectives: The principal objective of this pilot trial is to assess the feasibility. The clinical objectives are to determine the effects of a multicomponent care pathway on opioid-free pain control, persisting pain and opioid use, functional knee outcomes, quality of life, and return to function.
Methods: We will include adult patients scheduled for primary elective total knee arthroplasty. Patients in the intervention group will undergo a multicomponent intervention pathway that will be facilitated by an intervention coordinator linking each patient and their surgical/ perioperative team. The interventional pathway will include (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation using cognitive behavioral skills, (3) personalized postdischarge analgesic prescriptions, and (4) continued support for pain control and recovery up to 8 weeks. Patients in the control group will receive the usual care at their institution.
Discussion: The overarching goal is to implement and evaluate a coordinated approach to clinical care to improve pain control and reduce harms, with an emphasis on patient-centered care and shared decision making.Trial Registration Number: NCT04968132 (informed consent/ research ethics board statement).
Background: The Canadian Pain Task Force recently advanced an action plan calling for improved entry-level health professional pain education. However, there is little research to inform the collaboration and coordination across stakeholders that is needed for its implementation.
Aims: This article reports on the development of a stakeholder-generated strategic plan to improve pain education across all Canadian physiotherapy (PT) programs.
Methods: Participants included representatives from the following stakeholder groups: people living with pain (n = 1), PT students and recent graduates (n = 2), educators and directors from every Canadian PT program (n = 24), and leaders of Canada's national PT professional association (n = 2). Strategic priorities were developed through three steps: (1) stakeholder-generated data were collected and analyzed, (2) a draft strategic plan was developed and refined, and (3) stakeholder endorsement of the final plan was assessed. The project was primarily implemented online between 2016 and 2018.
Results: The plan was developed through five iterative versions. Stakeholders unanimously endorsed a plan that included five priorities focusing on uptake of best evidence across (1) national PT governance groups and (2) within individual PT programs; (3) partnering with people living with pain in pain education; (4) advocacy for the PT role in pain management; and (5) advancing pain education research.
Conclusion: This plan is expected to help Canadian stakeholders work toward national improvements in PT pain education and to serve as a useful template for informing collaboration on entry-level pain education within other professions and across different geographic regions.
Memory biases for previous pain experiences are known to be strong predictors of postsurgical pain outcomes in children. Until recently, much research on the subject in youth has assessed the sensory and affective components of recall using single-item self-report pain ratings. However, a newly emerging focus in the field has been on the episodic specificity of autobiographical pain memories. Still in its infancy, cross-sectional work has identified the presence of various memory biases in adults living with chronic pain, one of which concerns the lack of spatiotemporal specificity. Moreover, a recent prospective longitudinal study found that adults scheduled for major surgery who produced fewer specific pain memories before surgery were at greater risk of developing chronic postsurgical pain up to 12 months later. The present review draws on this research to highlight the timely need for a similar line of investigation into autobiographical pain memories in pediatric surgical populations. We (1) provide an overview of the literature on children's pain memories and underscore the need for further research pertaining to memory specificity and related neurobiological factors in chronic pain and an overview of the (2) important role of parent (and sibling) psychosocial characteristics in influencing children's pain development, (3) cognitive mechanisms underlying overgeneral memory, and (4) interplay between memory and other psychological factors in its contributions to chronic pain and (5) conclude with a discussion of the implications this research has for novel interventions that target memory biases to attenuate, and possibly eliminate, the risk that acute pain after pediatric surgery becomes chronic.
Background: Chronic postsurgical pain (CPSP) in children remains an important problem with no effective preventive or therapeutic strategies. Recently, genomic underpinnings explaining additional interindividual risk beyond psychological factors have been proposed.
Aims: We present a comprehensive review of current preclinical and clinical evidence for genetic and epigenetic mechanisms relevant to pediatric CPSP.
Methods: Narrative review.
Results: Animal models are relevant to translational research for unraveling genomic mechanisms. For example, Cacng2, p2rx7, and bdnf mutant mice show altered mechanical hypersensitivity to injury, and variants of the same genes have been associated with CPSP susceptibility in humans; similarly, differential DNA methylation (H1SP) and miRNAs (miR-96/7a) have shown translational implications. Animal studies also suggest that crosstalk between neurons and immune cells may be involved in nociceptive priming observed in neonates. In children, differential DNA methylation in regulatory genomic regions enriching GABAergic, dopaminergic, and immune pathways, as well as polygenic risk scores for enhanced prediction of CPSP, have been described. Genome-wide studies in pediatric CPSP are scarce, but pathways identified by adult gene association studies point to potential common mechanisms.
Conclusions: Bench-to-bedside genomics research in pediatric CPSP is currently limited. Reverse translational approaches, use of other -omics, and inclusion of pediatric/CPSP endophenotypes in large-scale biobanks may be potential solutions. Time of developmental vulnerability and longitudinal genomic changes after surgery warrant further investigation. Emergence of promising precision pain management strategies based on gene editing and epigenetic programing emphasize need for further research in pediatric CPSP-related genomics.
Chronic postsurgical pain (CPSP) results from a cascade of events in the peripheral and central nervous systems following surgery. Several clinical predictors, including the prior pain state, premorbid psychological state (e.g., anxiety, catastrophizing), intraoperative surgical load (establishment of peripheral and central sensitization), and acute postoperative pain management, may contribute to the patient's risk of developing CPSP. However, research on the neurobiological and biobehavioral mechanisms contributing to pediatric CPSP and effective preemptive/treatment strategies are still lacking. Here we evaluate the perisurgical process by identifying key problems and propose potential solutions for the pre-, intra-, and postoperative pain states to both prevent and manage the transition of acute to chronic pain. We propose an eight-step process involving preemptive and preventative analgesia, behavioral interventions, and the use of biomarkers (brain-based, inflammatory, or genetic) to facilitate timely evaluation and treatment of premorbid psychological factors, ongoing surgical pain, and postoperative pain to provide an overall improved outcome. By achieving this, we can begin to establish personalized precision medicine for children and adolescents presenting to surgery and subsequent treatment selection.
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