J. Scheman

Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis

Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis

The Role of Exercise and Types of Exercise in the Rehabilitation of Chronic Pain: Specific or Nonspecific Benefits

Chronic pain is one of the most common complaints seen in general practitioners’ offices, and it contributes to social, emotional, physical, and economical losses. The management of this problem poses challenges for health care providers when the current treatment of choice for chronic pain is pharmacological management, which may not be a sufficient and/or holistic approach to the management of chronic pain. Our goal is to increase awareness of the significance of physical activity, as well as examine additional cost-effective, integrated approaches to help manage the complex and debilitating effects of this condition. This article summarizes the types of exercise in the rehabilitation of chronic pain patients and provides practical recommendations for the clinician based on empirical and clinical experience. This safe, cost-free, nonpharmacologic way of managing pain has been found to reduce anxiety and depression, improve physical capacity, increase functioning and independence, and reduce morbidity and mortality.

The impact of preoperative depression on quality of life outcomes after posterior cervical fusion.

BACKGROUND CONTEXT Posterior cervical fusion (PCF) has been shown to be an effective treatment for cervical spondylosis, but is associated with a 9% complication rate and high costs. To limit such complications and costs, it is imperative that proper selection of surgical candidates occur for those most likely to do well with the surgery. Affective disorders, such as depression, are associated with worsened outcomes after lumbar surgery; however, this effect has not been evaluated in patients undergoing cervical spine surgery. PURPOSE To assess the predictive value of preoperative depression and the health state on 1-year quality of life (QOL) outcomes after PCF. STUDY DESIGN A retrospective cohort analysis. PATIENT SAMPLE Eighty-eight patients who underwent PCF for cervical spondylosis were reviewed. OUTCOME MEASURES Preoperative and 1-year postoperative health outcomes were assessed based on the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire-9 (PHQ-9), and the EuroQol five-dimensions (EQ-5D) questionnaire. METHODS Univariable and multivariable regression analyses were performed to assess for preoperative predictors of 1-year change in health status. RESULTS Compared with preoperative health states, the PCF cohort showed statistically significant improved PDQ (87.8 vs. 73.6), PHQ-9 (7.7 vs. 6.6), and EQ-5D (0.50 vs. 0.60) scores at 1 year postoperatively. Only 10/88 (11%) patients achieved or surpassed the minimum clinically important difference for the PHQ-9 (5). Multiple linear and logistic regression analyses showed that increasing PHQ-9 and EQ-5D preoperative scores were associated with reduced 1-year postoperative improvement in health status (EQ-5D index). CONCLUSIONS Of patients who undergo PCF, those with a greater degree of preoperative depression have lower improvements in postoperative QOL compared with those with less depression. Additionally, patients with better preoperative health states also attain lower 1-year QOL improvements.

Pain Psychology: A Global Needs Assessment and National Call to Action

Objective. The Institute of Medicine and the draft National Pain Strategy recently called for better training for health care clinicians. This was the first high-level needs assessment for pain psychology services and resources in the United States. Design. Prospective, observational, cross-sectional. Methods. Brief surveys were administered online to six stakeholder groups (psychologists/therapists, individuals with chronic pain, pain physicians, primary care physicians/physician assistants, nurse practitioners, and the directors of graduate and postgraduate psychology training programs). Results. 1,991 responses were received. Results revealed low confidence and low perceived competency to address physical pain among psychologists/therapists, and high levels of interest and need for pain education. We found broad support for pain psychology across stakeholder groups, and global support for a national initiative to increase pain training and competency in U.S. therapists. Among directors of graduate and postgraduate psychology training programs, we found unanimous interest for a no-cost pain psychology curriculum that could be integrated into existing programs. Primary barriers to pain psychology include lack of a system to identify qualified therapists, paucity of therapists with pain training, limited awareness of the psychological treatment modality, and poor insurance coverage. Conclusions. This report calls for transformation within psychology predoctoral and postdoctoral education and training and psychology continuing education to include and emphasize pain and pain management. A system for certification is needed to facilitate quality control and appropriate reimbursement. There is a need for systems to facilitate identification and access to practicing psychologists and therapists skilled in the treatment of pain.

Opioid Use 12 Months Following Interdisciplinary Pain Rehabilitation with Weaning

OBJECTIVES To examine the frequency of and factors predicting opioid resumption among patients with chronic non-cancer pain (CNCP) and therapeutic opioid addiction (TOA) treated in an interdisciplinary chronic pain rehabilitation program (CPRP) incorporating opioid weaning. DESIGN Longitudinal retrospective treatment outcome study. Only those with addiction were counseled to avoid opioids for non-acute pain. SETTING Large academic medical center. PARTICIPANTS One hundred twenty patients, 32.5% with TOA. Participants were predominately married (77.5%), females (66.7%). Mean age was 49.5 (±13.7). 29.2% had lifetime histories of non-opioid substance use disorders. METHODS TOA was diagnosed using consensus definitions developed by American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine to supplement Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) criteria. Non-opioid substance use disorders were diagnosed using DSM-IV-TR. Data, including pain severity, depression and anxiety, were collected at admission, discharge and 12 months. Opioid use during treatment was based on medical records and use at 12 months was based on self-report. RESULTS Only 22.5% reported resuming use at 12 months. Neither patients with TOA nor patients with non-opioid substance use disorders were more likely to resume use than those without substance use disorders. Only posttreatment depression increased the probability of resumption. CONCLUSIONS CNCP and co-occurring TOA can be successfully treated within a CPRP. Patients report low rates of resumption regardless of addiction status. This is in marked contrast to reported outcomes of non-medically induced opioid addictions. Prolonged abstinence may depend upon the successful treatment of depression.

Immediate Benefits of a Brief 10-Minute Exercise Protocol in a Chronic Pain Population: A Pilot Study

OBJECTIVE Determining the acute effects of a brief, 10-minute exercise protocol on pain, mood, and perceived exertion. PATIENTS Twenty-eight subjects who were admitted to the Cleveland Clinic Chronic Pain Rehabilitation Program (CPRP), and who were capable of completing an experimenter-designed and controlled treadmill protocol were included in this pilot study. METHODS A within-group repeated measure analysis was used to compare 28 subjects admitted to the Cleveland Clinic CPRP. Measures of heart rate were obtained using the Nellcor Oximax, pulse oximeter; measures of mood and pain were obtained using a 0-10 Likert scale, and perceived exertion measured with a visual analog scale. Each measure was taken pre- and post-10-minute exercise protocol. RESULTS The brief exercise protocol was associated with self-report of immediate antidepressant and anxiolytic effects. Additionally, after the 3-week CPRP, self-reports in perceived exertion decreased. Brief exercise was not found to have an acute analgesic effect. CONCLUSION This preliminary research revealed a temporal association of improvement in self-rated anxiety and depression, following a brief exercise protocol, and over the course of 3 weeks leads to decreased perceived exertion. Therefore suggesting that brief exercise is a safe, nonpharmacologic strategy for immediately improving mood, and has further implications for mortality risk.

Reliability and validity of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in evaluations of chronic low back pain patients.

The purpose of the current study was to investigate the reliability and concurrent validity of Minnesota Multiphasic Personality Inventory (MMPI)-2-Restructured Form (2-RF) (Ben-Porath & Tellegen, 2008/2011) scores in a sample of 811 chronic low back pain patients (346 males, 529 females) beginning treatment in a short-term interdisciplinary pain rehabilitation program. We calculated internal consistency coefficients, mean-item correlations, and SEM for all substantive scales, as well as zero-order correlations with collateral medical record information and self-report testing. Results indicated reliability and validity for most of the MMPI-2-RF substantive scales. Implications of these findings and limitations of this study are discussed.

Sustained improvements in pain, mood, function and opioid use post interdisciplinary pain rehabilitation in patients weaned from high and low dose chronic opioid therapy.

Abstract Increased prescribing of opioids for chronic noncancer pain is associated with significant social costs, including overdose and addiction. In this context, there is interest in interdisciplinary chronic pain rehabilitation programs focusing on self-management and minimizing opioid use. This study examined outcomes of patients weaned from opioids in an ICPRP from 2007 to 2012. Participants included 413 patients on high dose chronic opioid therapy (COT; >100 mg), 528 on low dose COT, and 516 not on opioids (NO). Outcomes were assessed at discharge, 6, and 12 months posttreatment through self-report and chart review. One thousand one hundred ninety-four participants completed treatment (81.95%); 86.74% of those on opioids were weaned. High doses were less likely to complete (78.45%) than NO participants (85.27%; P < 0.05). Results showed immediate (P < 0.01) and sustained improvements (P < 0.05) in pain severity, depression, anxiety, and functional impairment with no group differences. Effect sizes ranged from medium to large (Cohen d values 0.57-1.96). Longitudinal medication use data were available for 319 no dose and 417 weaned participants; opioid resumption rates were 10.51% and 30.70% respectively. There were no differences in resumption between the high dose and low dose groups. Logistic regression analyses determined that opioid dose predicted neither treatment completion nor opioid resumption. Anxiety predicted completion, and functional impairment predicted opioid resumption within 1 year of discharge. Results suggest that patients on COT can be successfully weaned with long-term benefits in pain, mood, and function. Targeting anxiety and functional restoration may increase success rates.

Interdisciplinary treatment of patients with multiple sclerosis and chronic pain: a descriptive study.

The objective of this study was to examine the efficacy of an interdisciplinary pain rehabilitation program in a multiple sclerosis (MS) population by evaluating changes in mood, pain, and functioning. This descriptive study examined 20 patients with chronic pain and MS who were admitted to the Cleveland Clinics Chronic Pain Rehabilitation Program (CPRP) between 2000 and 2009. At both admission to and discharge from the CPRP, measures of pain, depression, and functioning were obtained using a pain visual analogue scale (VAS), the Beck Depression Inventory (BDI), the Depression Anxiety Stress Scale (DASS), and the Pain Disability Index (PDI). Outcomes for the MS patients were compared with those of patients without MS who had participated in the same program. The results showed that MS patients who completed the CPRP reported dramatic decreases in pain and depression and an increase in daily functioning. The benefits received by MS patients from the program were similar to those received by patients without MS. Thus programs like the CPRP can result in significant improvements in pain, depression, and functioning among people with MS.

Flashback and nightmares after surgery under neuraxial anesthesia: A report of two cases

Recall, awareness, flashback, and nightmares are reported complications of general anesthesia, but flashback and nightmares after regional anesthesia have not been described. Two patients underwent vascular and orthopedic surgery under spinal and epidural anesthesia, respectively. Local anesthetic consisted of bupivacaine, and sedation was achieved with the combination of fentanyl, midazolam, and diphenhydramine. In both patients the anesthetic course was uneventful, but the recovery process was complicated by flashbacks and nightmares leading to depression, physical complaints, and lengthy convalescence. Flashback and nightmares after neuraxial anesthesia are unreported and, therefore, their incidence is unknown.