Christine Cedraschi

Pain measurement in patients with low back pain

Pain is a multidimensional experience that is a prominent feature of many musculoskeletal disorders. Despite its subjective nature, pain is a highly relevant complaint; hence, nothing should deter physicians from attempting to formally assess it. This Review summarizes the main aspects of pain measurement from a practical standpoint, with a specific focus on low back pain. On balance, for the assessment of pain intensity, categorical scales with verbal descriptors or numerical rating scales seem to be preferable to traditional visual analogue scales, although no single best measure can be recommended. Pain per se should be assessed, rather than surrogate measures such as analgesic use. Back and leg pain should be evaluated separately in patients in whom these conditions coexist. For assessing change, prospective measurements are preferable to retrospective reports. Pain is not synonymous with function or quality of life, and other tools covering these important outcome dimensions should complement the assessment of pain, especially in patients with chronic symptoms. Clinicians should be aware of the psychometric properties of the tool to be used, including its level of imprecision (random measurement error) and its minimum clinically important difference (score difference indicating meaningful change in clinical status).

A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines Research and Evaluation criteria

Clinical practice guidelines have been elaborated to summarize evidence related to the management of knee osteoarthritis and to facilitate uptake of evidence-based knowledge by clinicians. The objectives of the present review were summarizing the recommendations of existing guidelines on knee osteoarthritis, and assessing the quality of the guidelines using a standardized and validated instrument – the Appraisal of Guidelines Research and Evaluation (AGREE) tool. Internet medical literature databases from 2001 to 2006 were searched for guidelines, with six guidelines being identified. Thirteen clinician researchers participated in the review. Each reviewer was trained in the AGREE instrument. The guidelines were distributed to four groups of three or four reviewers, each group reviewing one guideline with the exception of one group that reviewed two guidelines. One independent evaluator reviewed all guidelines. All guidelines effectively addressed only a minority of AGREE domains. Clarity/presentation was effectively addressed in three out of six guidelines, scope/purpose and rigour of development in two guidelines, editorial independence in one guideline, and stakeholder involvement and applicability in none. The clinical management recommendation tended to be similar among guidelines, although interventions addressed varied. Acetaminophen was recommended for initial pain treatment, combined with exercise and education. Nonsteroidal anti-inflammatory drugs were recommended if acetaminophen failed to control pain, but cautiously because of gastrointestinal risks. Surgery was recommended in the presence of persistent pain and disability. Education and activity management interventions were superficially addressed in most guidelines. Guideline creators should use the AGREE criteria when developing guidelines. Innovative and effective methods of knowledge translation to health professionals are needed.

“Let’s Talk about OA Pain”: A Qualitative Analysis of the Perceptions of People Suffering from OA. Towards the Development of a Specific Pain OA-Related Questionnaire, the Osteoarthritis Symptom Inventory Scale (OASIS)

Introduction Pain is the primary outcome measurement in osteoarthritis, and its assessment is mostly based on its intensity. The management of this difficult chronic condition could be improved by using pain descriptors to improve analyses of painful sensations. This should help to define subgroups of patients based on pain phenotype, for more adapted treatment. This study draws upon patients’ descriptions of their pain, to identify and understand their perception of osteoarthritis pain and to categorize pain dimensions. Methods This qualitative study was conducted with representative types of patients suffering from osteoarthritis. Two focus groups were conducted with a sample of 14 participants, with either recent or chronic OA, at one or multiple sites. Focus groups were semi-structured and used open-ended questions addressing personal experiences to explore the experiences of patients with OA pain and the meanings they attributed to these pains. Results Two main points emerged from content analyses: -A major difficulty in getting patients to describe their osteoarthritis pain: perception that nobody wants to hear about it; necessity to preserve one’s self and social image; notion of self-imposed stoicism; and perception of osteoarthritis as a complex, changing, illogical disease associated with aging. -Osteoarthritis pains were numerous and differed in intensity, duration, depth, type of occurrence, impact and rhythm, but also in painful sensations and associated symptoms. Based on analyses of the verbatim interviews, seven dimensions of OA pain emerged: pain sensory description, OA-related symptoms, pain variability profile, pain-triggering factors, pain and physical activity, mood and image, general physical symptoms. Summary In osteoarthritis, pain analysis should not be restricted to intensity. Our qualitative study identified pain descriptors and defined seven dimensions of osteoarthritis pain. Based on these dimensions, we aim to develop a specific questionnaire on osteoarthritis pain quality for osteoarthritis pain phenotyping: the OsteoArthritis Symptom Inventory Scale (OASIS).

Is volition the missing link in the management of low back pain

Patients with nonspecific chronic low back pain are typically prescribed a regimen of regular physical exercises to improve pain and function, increase workability, and prevent pain recurrence. However, adherence to home exercise programs is often partial at best. Patients often fail to translate their intention to exercise (motivation) into action (implementation). Volition is the mental activity by which intentions are implemented. In this review, we argue that volition may be crucial to the successful rehabilitation of patients with low back pain. Obstacles to the implementation of intentions are described, as well as factors that promote implementation, most notably the conscious formation of implementation intentions.

The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities

PurposeThe purpose of this review was to develop recommendations for the management of spinal disorders in low-income communities, with a focus on non-invasive pharmacological and non-pharmacological therapies for non-specific low back and neck pain.MethodsWe synthesized two evidence-based clinical practice guidelines for the management of low back and neck pain. Our recommendations considered benefits, harms, quality of evidence, and costs, with attention to feasibility in medically underserved areas and low- and middle-income countries.ResultsClinicians should provide education and reassurance, advise patients to remain active, and provide information about self-care options. For acute low back and neck pain without serious pathology, primary conservative treatment options are exercise, manual therapy, superficial heat, and nonsteroidal anti-inflammatory drugs (NSAIDs). For patients with chronic low back and neck pain without serious pathology, primary treatment options are exercise, yoga, cognitive behavioral therapies, acupuncture, biofeedback, progressive relaxation, massage, manual therapy, interdisciplinary rehabilitation, NSAIDs, acetaminophen, and antidepressants. For patients with spinal pain with radiculopathy, clinicians may consider exercise, spinal manipulation, or NSAIDs; use of other interventions requires extrapolation from evidence regarding effectiveness for non-radicular spinal pain. Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction.ConclusionGuidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Characteristics of elderly patients with fibromyalgia: a pilot retrospective study

Background and aims: Very little informations are available about the characteristics of fibromyalgia (FM) in older patients. The objective of the study was to know better what are some of their specificities in order to tailor the management of elderly patients with FM. Methods: Retrospective chart review of all patients with a diagnosis of FM addressed to the pain consultation of a geriatric hospital, have been analysed. Results: Forty patients (38 women and 2 men) were included. Mean age at the moment of diagnosis of FM was 75±9.1 years. Patients were hospitalized with a mean of 6±5.2 years after onset of FM. Median pain intensity measured by a visual or numerical pain scale was 6 at rest and 9 during mobilisation. Seventeen patients were isolated at home because of pain. Symptoms associated with FM were depression (n=25), fatigue and poor sleep quality (n=24), anxiety (n=15), irritable bowel syndrome (n=10), restless leg syndrome (n=3) and tension-type headache (n=2). Traumatic events, such as the death of a relative or nursing home admission were frequent. Twenty-four patients were discharged home, 13 patients in a nursing home and 3 patients died during the hospitalisation. Discussion: Although elderly patients with FM constituted a small proportion of elderly patient’s addressed to a pain consultation, these patients have some particular features that must be taken into account. Further prospective studies should be conducted in this population.

The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities

PurposeThe purpose of this systematic literature review was to develop recommendations for the assessment of spine-related complaints in medically underserved areas with limited resources.MethodsWe conducted a systematic review and best evidence synthesis of guidelines on the assessment of spine-related complaints. Independent reviewers critically appraised eligible guidelines using the Appraisal of Guidelines for Research and Evaluation-II criteria. Low risk of bias clinical practice guidelines was used to develop recommendations. In accordance with the mandate of the Global Spinal Care Initiative (GSCI), recommendations were selected that could be applied to medically underserved areas and low- and middle-income countries by considering the limited access and costs of diagnostic technologies.ResultsWe screened 3069 citations; 20 guidelines were eligible for critical appraisal. We used 13 that had a low risk of bias that targeted neck and back pain.ConclusionsWhen assessing patients with spine-related complaints in medically underserved areas and low- and middle-income countries, we recommend that clinicians should: (1) take a clinical history to determine signs or symptoms suggesting serious pathology (red flags) and psychological factors (yellow flags); (2) perform a physical examination (musculoskeletal and neurological); (3) do not routinely obtain diagnostic imaging; (4) obtain diagnostic imaging and/or laboratory tests when serious pathologies are suspected, and/or presence of progressive neurologic deficits, and/or disabling persistent pain; (5) do not perform electromyography or nerve conduction studies for diagnosis of intervertebral disc disease with radiculopathy; and (6) do not perform discography for the assessment of spinal disorders. This information can be used to inform the GSCI care pathway and model of care.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Cognitive-behavioral Treatment for Subacute and Chronic Neck Pain: A Cochrane Review

Study Design. Systematic review of randomized-controlled trials (RCTs). Objective. To assess the effects of cognitive-behavioral therapy (CBT) on neck pain (NP). Summary of Background Data. Although research on nonpharmacological and nonsurgical treatments for NP is progressing, there remains uncertainty about the efficacy of CBT. Methods. We searched electronic databases for RCTs. We included RCTs assessing the use of CBT on adults with subacute and chronic NP. 2 independent reviewers extracted data on pain (primary outcome), disability, psychological indicator, and quality of life. We calculated standardized mean differences and 95% confidence intervals. We used the Cochrane Collaborations tool to assess risk of bias and the GRADE approach to evaluate the quality of evidence and summarize conclusions. Results. We included 10 studies (836 participants), 4 at low risk of bias. With regard to chronic NP, there was low quality evidence that CBT was better than no treatment for improving pain, disability, and quality of life, whereas no effect was found on kinesiophobia. The clinical importance of these benefits is uncertain. When comparing both CBT to other interventions and CBT in addition to another intervention to the other intervention alone, no difference was found for pain and disability, whereas a positive effect was achieved for kinesiophobia only when comparing CBT with other interventions. On subacute NP, CBT was found to be better than other interventions for pain, whereas no difference was found for secondary outcomes. Conclusion. CBT was shown to induce changes on pain and disability for chronic NP only when compared with no treatment. On subacute NP, benefit was found on pain relief but not on disability when comparing CBT with other interventions. However, none of these effects were clinically meaningful. Due to the low quality of the evidence, our conclusions might change over time whereas new data are available. Level of Evidence: 1

Validity of the French version of the Core Outcome Measures Index for low back pain patients: a prospective cohort study

PurposeAmong the many questionnaires available to evaluate low back pain (LBP) patients, the Core Outcome Measures Index (COMI) has the unique advantage to investigate five dimensions using seven short questions. The aim of this study was to explore additional properties of the questionnaire in a French-speaking non-surgical population.MethodsThis study was conducted on 168 patients suffering from subacute or chronic LBP and followed up for 6xa0months in three French-speaking countries. In addition to basic psychometric properties (e.g., construct validity, floor and ceiling effect, reproducibility), internal validity was analyzed by a factor analysis using Cronbach’s alpha. Responsiveness and sensitivity to change were assessed through minimal detectable change (MDC), effect size, and Minimal Clinically Important Improvement (MCII). We used an anchor-based method with receiver operating characteristic (ROC) curve analysis to assess MCII and the Patient Acceptable Symptom State.ResultsConstruct validity, reliability (Cronbach’s alphaxa0=xa00.87), reproducibility and the absence of floor and ceiling effects were confirmed. Factor analysis indicated a one-dimensional construct that validates the use of a sum score. The MDC (2.1) was inferior to the MCII (2.3). The limit below which the patient claims to be in a fair condition (Patient Acceptable Symptom State) was set at 3.ConclusionsThe COMI is a self-report questionnaire with the capacity to easily and quickly explore several dimensions in patients with LBP that can be then summarized in a meaningful sum score. Additional knowledge provided by our study should encourage the widespread use of the COMI among the spine community.

Representations of Symptom History in Women with Fibromyalgia vs Chronic Low Back Pain: A Qualitative Study

OBJECTIVEnTo compare fibromyalgia (FM) and chronic non-specific low back pain (LBP) patients narratives about symptom onset. This investigation aimed to better understand how patients with FM relate to their pain problem and the physicians in charge of making the diagnosis.nnnDESIGNnQualitative study.nnnSUBJECTS AND METHODSnWe included 56 female patients with FM and 29 with LBP. Semi-structured interviews were conducted, eliciting patients representations of symptom onset. Interviews were tape-recorded and transcribed, and content analysis was performed.nnnRESULTSnPatients with FM and LBP were comparable for socio-demographic characteristics and pain duration. Content analysis identified five dimensions: psychological issues, somatic concerns, occupational problems, diagnostic issues, and issues related to chronicity. FM patients emphasized psychological issues, as single events and long-lasting distress. Regarding somatic concerns, gynecological events were prominent in FM while LBP patients emphasized accidents, awkward movements, and physical work conditions. Both groups expressed pessimistic views about pain evolution. FM patients reported diagnosis as an area of major uncertainty in an illness perceived as spreading all over the body.nnnCONCLUSIONSnThe narratives of patients with FM expressed high psychological loads and dramatic connotations and emphasized legitimacy issues. In contrast, patients with LBP stressed overload, wear and tear, and treatment inefficacy. The combination of chronicity and lack of specificity may render FM and LBP prone to raise skepticism in the therapists. Investigating and discussing patients perceptions allows overcoming the apparent uniformity of patients complaints. It contributes defining realistic and shared treatment goals and help therapists cope with pain chronicity.