Haiko Sprott

Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes

OBJECTIVES To provide an overview of the effectiveness of multidisciplinary treatments of chronic pain and investigate about their differential effects on outcome in various pain conditions and of different multidisciplinary treatments, settings or durations. METHODS In this article, the authors performed a systematic review of all currently available randomized controlled trials (RCTs) fulfilling the inclusion criteria, by using a recently developed rating system aimed to assess the strength of evidence with regard to the methodological quality of the trials. RESULTS Compared with other non-disciplinary treatments, moderate evidence of higher effectiveness for multidisciplinary interventions was shown. In contrast to no treatment or standard medical treatment, strong evidence was detected in favour of multidisciplinary treatments. The evidence that comprehensive inpatient programmes were more beneficial that outpatient programmes was moderate. Fibromyalgia and chronic back pain patients tended to profit more substantially than patients with diverse origins or chronic pain diagnoses. No evidence was found that treatment variables, such as duration or programme components, were influential for the success of the intervention. CONCLUSION A standard of multidisciplinary programmes should be internationally established to guarantee generally good outcomes in the treatment of chronic pain. Our results highlight the lack of quality of design, execution or reporting of many of the RCTs included in this article. Future studies should more specifically focus on differential effects of treatment components and patient variables, allowing the identification of subgroups, which most probably would profit from multidisciplinary pain programmes.

Age- and Gender-Specific Normative Data of Grip and Pinch Strength in a Healthy Adult Swiss Population:

Assessment of hand strength is used in a wide range of clinical settings especially during treatment of diseases affecting the function of the hand. This investigation aimed to determine age- and gender-specific reference values for grip and pinch strength in a normal Swiss population with special regard to old and very old subjects as well as to different levels of occupational demand. Hand strength data were collected using a Jamar dynamometer and a pinch gauge with standard testing position, protocol and instructions. Analysis of the data from 1023 tested subjects between 18 and 96 years revealed a curvilinear relationship of grip and pinch strength to age, a correlation to height, weight and significant differences between occupational groups. Hand strength values differed significantly from those of other populations, confirming the thesis that applying normative data internationally is questionable. Age- and gender-specific reference values for grip and pinch strength are presented.

Cross-cultural adaptation, reliability, and validity of the German version of the Pain Catastrophizing Scale

OBJECTIVE In patients with chronic pain, catastrophizing is a significant determinant of self-rated pain intensity and disability. The Pain Catastrophizing Scale (PCS) was developed to assist with both treatment planning and outcome assessment; to date, no German version has been validated. METHODS A cross-cultural adaptation of the PCS into German was carried out, strictly according to recommended methods. A questionnaire booklet containing the PCS, visual analogue scales (numeric rating scale) for pain intensity and general health, the ZUNG self-rating depression scale, the Modified Somatic Perception Questionnaire (MSPQ), the Fear Avoidance Beliefs Questionnaire (FABQ), and the Roland-Morris (RM) disability questionnaire was completed by 111 patients with chronic low back pain (mean age, 49 years), 100 of which also completed it again 7 days later. RESULTS Cronbachs alpha (internal reliability) for the three subsections of the PCS--helplessness, magnification, rumination--and for the whole questionnaire (PCSwhole) were .89, .67, .88, and .92, respectively. The intraclass correlation coefficients of agreement for the reproducibility were .81, .67, .78, and .80, respectively. The PCSwhole scores correlated with the other scores as follows: pain intensity r=.26, general health r=-.29, ZUNG r=.52, MSPQ r=.53, FABQactivity r=.51, FABQwork r=.61 and RM r=.57. Factor analysis revealed three factors, with an almost identical factor structure to that reported in previous studies. CONCLUSION The psychometric properties of our German version of the PCS were comparable to those reported in previous studies for the original English version. It represents a valuable tool in the assessment of German-speaking chronic low back pain patients.

Abdominal muscle size and symmetry at rest and during abdominal hollowing exercises in healthy control subjects

The symmetry of, and physical characteristics influencing, the thickness of the lateral abdominal muscles at rest and during abdominal exercises were examined in 57 healthy subjects (20 men, 37 women; aged 22–62 years). M‐mode ultrasound images were recorded from the abdominal muscles at rest and during abdominal hollowing exercises in hook‐lying. The fascial lines bordering the transvs. abdominis, obliquus internus and obliquus externus were digitized and the absolute thickness, relative thickness (% of total lateral thickness) and contraction ratio (thickness during hollowing/thickness at rest), as well as the asymmetry (difference between sides expressed as a percent of the smallest value for the two sides) for each of these parameters were determined for each muscle. Both at rest and during hollowing, obliquus internus was the thickest and transvs. abdominis the thinnest muscle. There were no significant differences between left and right sides for group mean thicknesses of any muscle; however, individual asymmetries were evident, with mean values for the different muscles ranging from 11% to 26%; asymmetry was much less for the contraction ratios (mean % side differences, 5–14% depending on muscle). Body mass was the most significant positive predictor of absolute muscle thickness, for all muscles at rest and during hollowing, accounting for 30–44% variance. Body mass index explained 20–30% variance in transvs. abdominis contraction ratio (negative relationship). The influence of these confounders must be considered in comparative studies of healthy controls and back pain patients, unless groups are very carefully matched. Asymmetries observed in patients should be interpreted with caution, as they are also common in healthy subjects.

Association between catastrophizing and self-rated pain and disability in patients with chronic low back pain.

BACKGROUND Catastrophizing plays an important role in models of pain chronicity, showing a consistent correlation with both pain intensity and disability. It is conceivable that these associations are mediated or confounded by other psychological attributes. OBJECTIVE To examine the relative influence of catastrophizing and other psychological variables on pain and disability in patients with chronic low back pain. METHODS Seventy-eight patients completed the Pain Catastrophizing Scale, Roland Morris Disability Questionnaire, Fear-Avoidance Beliefs Questionnaire (work/activity), Modified Somatic Perception Questionnaire, Modified Zung Depression Scale, and Pain Intensity scale. RESULTS Catastrophizing was significantly correlated with both Pain intensity and Roland and Morris Disability, and with all other psychological variables (all p < 0.001). However, multiple regression analyses showed that Catastrophizing explained no significant variance in Pain intensity beyond that explained by the unique contributions of Modified Somatic Perception and Fear-Avoidance Beliefs (work) and explained no further variance in Disability beyond that explained by the unique contributions of Fear-Avoidance Beliefs (work) and Depression. CONCLUSION These findings are consistent with previous models proposing that negative psychological attributes are associated with greater perceptions of pain and disability. Nonetheless, our study indicates that measures of catastrophizing show notable measurement overlap in multivariate models.

Microcirculation abnormalities in patients with fibromyalgia – measured by capillary microscopy and laser fluxmetry

This unblinded preliminary case-control study was done to demonstrate functional and structural changes in the microcirculation of patients with primary fibromyalgia (FM). We studied 10 women (54.0 ± 3.7 years of age) with FM diagnosed in accordance with the classification criteria of the American College of Rheumatology, and controls in three groups (n = 10 in each group) – age-matched women who were healthy or who had rheumatoid arthritis or systemic scleroderma (SSc). All 40 subjects were tested within a 5-week period by the same investigators, using two noninvasive methods, laser fluxmetry and capillary microscopy. The FM patients were compared with the healthy controls (negative controls) and with rheumatoid arthritis patients and SSc patients (positive controls). FM patients had fewer capillaries in the nail fold (P < 0.001) and significantly more capillary dilatations (P < 0.05) and irregular formations (P < 0.01) than the healthy controls. Interestingly, the peripheral blood flow in FM patients was much less (P < 0.001) than in healthy controls but did not differ from that of SSc patients (P = 0.73). The data suggest that functional disturbances of microcirculation are present in FM patients and that morphological abnormalities may also influence their microcirculation.

Prospective Epidemiological Observations on the Course of the Disease in Fibromyalgia Patients

ObjectivesThe aim of the study was to carry out a survey in patients with fibromyalgia (FM), to examine their general health status and work incapacity (disability-pension status), and their views on the effectiveness of therapy received, over a two-year observation period.Methods48 patients diagnosed with FM, according to the American College of Rheumatology (ACR) criteria, took part in the study. At baseline, and on average two years later, the patients underwent clinical investigation (dolorimetry, laboratory diagnostics, medical history taking) and completed the Fibromyalgia questionnaire (Dettmer and Chrostek [1]).Results27/48 (56%) patients participated in the two-year follow-up. In general, the patients showed no improvement in their symptoms over the observation period, regardless of the type of therapy they had received. General satisfaction with quality of life improved, as did satisfaction regarding health status and the family situation, although the degree of pain experienced remain unchanged. In comparison with the initial examination, there was no change in either work-capacity or disability-pension status.ConclusionsThe FM patients showed no improvement in pain, despite the many various treatments received over the two-year period. The increase in general satisfaction over the observation period was believed to be the result of patient instruction and education about the disease. To what extent a population of patients with FM would show similar outcomes if they did not receive any instruction/education about their disorder, cannot be ascertained from the present study; and, indeed, the undertaking of a study to investigate this would be ethically questionable. As present, no conclusions can be made regarding the influence of therapy on the primary and secondary costs associated with FM.

Ultrasound Tissue Doppler Imaging Reveals No Delay in Abdominal Muscle Feed-Forward Activity During Rapid Arm Movements in Patients With Chronic Low Back Pain

Study Design. Cross-sectional study. Objective. Comparison of the timing of onset of lateral abdominal muscle activity during rapid arm movements in patients with nonspecific chronic low back pain (cLBP) and back-pain-free controls. Summary of Background Data. Rapid movements of the arm are normally associated with prior activation of trunk-stabilizing muscles in readiness for the impending postural perturbation. Using invasive intramuscular electromyography techniques, studies have shown that this feed-forward function is delayed in some patients with low back pain (LBP). Ultrasound tissue Doppler imaging (TDI) provides an ultrasound method for quantifying muscle activation in a noninvasive manner, allowing investigation of larger groups of patients and controls. Methods. Ninety-six individuals participated (48 patients with cLBP and 48 matched LBP-free controls). During rapid shoulder flexion, abduction, and extension, surface electromyographic signals from the deltoid and motion-mode TDI images from the contralateral lateral abdominal muscles were recorded simultaneously. The onset of muscle activity was given by changes in the tissue velocity of the abdominal muscles, as measured with TDI. Pain and disability in the patients were assessed using standardized questionnaires. Data were analyzed using repeated measures analysis of variance. Results. In both groups, feed-forward activity of the lateral abdominal muscles was recorded during arm movements in all directions. The main effect of “group membership” revealed no significant difference between the groups for the earliest onset of abdominal muscle activity (P = 0.398). However, a significant “group × body side” interaction (P = 0.015) was observed, and this was the result of earlier onsets in the cLBP group than controls for the abdominal muscles on the right (but not left) body side. No relationship was found between the time of onset of the earliest abdominal muscle activity and pain intensity, pain frequency, pain medication usage, or Roland Morris disability scores. Conclusion. Patients with cLBP did not show a delayed onset of feed-forward activation of the lateral abdominal muscles during rapid arm movements. Earlier activation was observed for one body side compared with the controls. However, the clinical relevance of this finding remains obscure, especially because there was no relationship between the onset of activation and any clinical parameters.

Chronic nonmalignant pain: a challenge for patients and clinicians

Chronic pain is widely regarded as a condition that is triggered by various factors, including physical, socio-cultural and psychological deficiencies (that is, maladaptive beliefs). These factors are important in the development and maintenance of this unpleasant experience, which consequently requires a biopsychosocial treatment approach. Pain is a multifaceted sense, the perception of which is personal. Pain also depends on various circumstances, and therefore represents a challenge for the patient, as well for the treating physicians. Patients who suffer from long-lasting pain with a predominantly psychosocial component should be referred to specialized pain clinics for further diagnostic assessment and possible allocation to multidisciplinary pain programs. High-quality randomized controlled trials indicate that multidisciplinary pain programs represent the best therapeutic option for the management of patients with complaints associated with complex chronic pain. The prevalence and the costs—both direct and indirect—that are attributed to chronic pain are increasing; however, not enough is being done to sufficiently and effectively treat chronic pain. There is, therefore, a need for well-designed, interdisciplinary, internationally comparable, and widely distributed pain programs, both in outpatient and inpatient settings, to contribute to the prevention of some future pain diseases.

DREAM is reduced in synovial fibroblasts of patients with chronic arthritic pain: is it a suitable target for peripheral pain management?

IntroductionThe endogenous pain-relieving system depends in part on the regulation of nociceptive signals through binding of opioids to the corresponding opioid receptor. Interfering with the trans-repression effect of downstream regulatory element antagonist modulator (DREAM) on the transcription of the opioid dynorphin-encoding prodynorphin (pdyn) gene might enhance pain relief in the periphery.MethodsExpression levels were measured in osteoarthritis (OA) synovial fibroblast-like cells (SFLCs) (n = 8) and in peripheral blood mononuclear cells (PBMCs) from OA patients (n = 53) and healthy controls (n = 26) by real-time polymerase chain reaction. Lysed OA SFLCs were analyzed by immunoprecipitation. Translation of DREAM mRNA was inhibited by small interfering RNAs (siRNAs). Expressions of DREAM, pdyn, and c-fos mRNAs were measured at 24, 48, and 72 hours after transfection.ResultsThe expression of DREAM mRNA was shown in both healthy and OA SFLCs as well as PBMCs. Inhibiting transcription using siRNAs led to a marked reduction in DREAM expression after 24, 48, and 72 hours. However, no significant changes in c-fos and pdyn expression occurred. In addition, DREAM mRNA expression was significantly reduced in OA patients with chronic pain (pain intensity as measured by a visual analog scale scale of greater than 40), but no pdyn expression was detectable.ConclusionTo our knowledge, this is the first report showing the expression of DREAM in SFLCs and PBMCs on the mRNA level. However, DREAM protein was not detectable. Since repression of pdyn transcription persists after inhibiting DREAM translation, DREAM appears to play no functional role in the kappa opioid receptor system in OA SFLCs. Therefore, our data suggest that DREAM appears not to qualify as a target in peripheral pain management.