Meredith C.B. Adams

Musculoskeletal pain, fear avoidance behaviors, and functional decline in obesity: potential interventions to manage pain and maintain function.

Abstract Individuals with musculoskeletal pain exhibit abnormal movement patterns, including antalgic gait, postural dysfunction, increased thoracolumbar stiffness, decreased proprioception, and altered activation of abdominal and extensor muscles. Additionally, aberrant or increased biomechanical forces over time produce joint or structural damage that results in pain. A large body habitus resulting from excessive weight can accelerate these musculoskeletal complaints. Irrespective of age, obesity contributes to chronic musculoskeletal pain, impairment of mobility, and eventual physical disability. Potential mechanisms that may mediate the relationships between obesity-related pain and functional decline include skeletal muscle strength deterioration, systemic inflammation, and psychosocial characteristics (eg, pain catastrophizing, kinesiophobia, and depression). Treatment considerations for obese patients with musculoskeletal pain include assessment of kinesiophobia levels, biomechanical analysis, and pain medication use. Ideally, a multidisciplinary team of physicians, psychologists, and physical therapists should optimize the design of interventions specific to the patient. In some cases, the use of appropriate pain medications or intra-articular injectable agents may help control pain, fostering sustained activity, caloric expenditure, and weight loss. Morbid obesity is a medical condition that alters biomechanical forces on the tissues of the body. This condition provides the opportunity to examine accelerated development of musculoskeletal pain syndromes and etiology. The proposed therapeutic interventions can have multiple benefits in the obese population including weight loss, improved psychological outlook and self-efficacy, reduced kinesiophobia levels, reduced risk of functional dependence, and improved quality of life.

Neuropathic pain: Treatment guidelines and updates

Purpose of review The purpose of this review is to provide an update on the diagnosis, treatment, and prevention of neuropathic pain. Recent findings Neuropathic pain can be debilitating, leading to poor quality of life and functional status. Neuropathic pain results from numerous mechanisms of nerve injury including infectious diseases, complication of medical diseases, and mechanical damage. As a result of the lack of class I evidence for the treatment of numerous neuropathic pain conditions, those diseases without such evidence are often managed, as though neuropathic pain is a singular condition. In diseases such as diabetes, HIV, and herpes infections, the resultant neuropathic pain is often modifiable with prevention strategies. In one of the more prevalent neuropathic pain conditions, radiculopathy, the commonly used treatments lack sufficient evidence to explain their widespread use. Summary The literature reveals that neuropathic pain is underdiagnosed and often undertreated or treated with ineffective or untested modalities. Evolving definitions of neuropathic pain has broadened the range of therapeutic approaches and brought current treatment paradigms under increased scrutiny. The lack of a mechanism-based approach to treatment may be responsible for the lackluster responses seen in most neuropathic pain conditions.

Perioperative Pain Management

In the previous two installments we reviewed the basic adva ntages of effective perioperative, multimodal pain control. Analgesics coupled with sedative/tranquiliz ers provide a more comfortable patient experience, reduce induction and maintenance agent requirements, and gene rally improve patient morbidity and mortality. Multimodal techniques reduce the dose of each i ndividual drug which, in turn, reduces the potential for adverse drug effects. Intervening before the pai n system becomes sensitized is an absolute necessity when your goal is optimal patient benefit. I n Part III, we will continue our review of the various drug families and individual agents that may contribute to our perioperative patient analgesic management.

Central and Peripheral Neurolysis

Abstract Intrathecal neurolysis is considered when the patient’s cancer pain is intractable and refractory to medical and interventional therapies. The pain should be unilateral, located in the thorax and abdomen, and restricted to 1–4 dermatomes. In intrathecal neurolysis, the needle tip is placed at the vertebral level where the target dorsal root leaves the spinal cord and not where it passes the intervertebral foramen. The physician should observe all the recommended precautions to prevent spillage of the alcohol or phenol to unintended nerve roots. In epidural neurolysis, the needle or catheter tip lies closer to the vertebral level that corresponds to the dermatomal level of pain. An epidural catheter is usually inserted, and repeated injections are done over a few days. Complications include extremity weakness or bowel/bladder paresis. Peripheral neurolysis is rarely performed; it is usually done in the trunk (e.g., intercostal nerves) to avoid weakness of the extremities.

Re-assessing the Validity of the Opioid Risk Tool in a Tertiary Academic Pain Management Center Population

Objective To analyze the validity of the Opioid Risk Tool (ORT) in a large. diverse population. Design A cross-sectional descriptive study. Setting Academic tertiary pain management center. Subjects A total of 225 consecutive new patients, aged 18 years or older. Methods Data collection included demographics, ORT scores, aberrant behaviors, pain intensity scores, opioid type and dose, smoking status, employment, and marital status. Results In this population, we were not able to replicate the findings of the initial ORT study. Self-report was no better than chance in predicting those who would have an opioid aberrant behavior. The ORT risk variables did not predict aberrant behaviors in either gender group. There was significant disparity in the scores between self-reported ORT and the ORT supplemented with medical record data (enhanced ORT). Using the enhanced ORT, high-risk patients were 2.5 times more likely to have an aberrant behavior than the low-risk group. The only risk variable associated with aberrant behavior was personal history of prescription drug misuse. Conclusions The self-report ORT was not a valid test for the prediction of future aberrant behaviors in this academic pain management population. The original risk categories (low, medium, high) were not supported in the either the self-reported version or the enhanced version; however, the enhanced data were able to differentiate between high- and low-risk patients. Unfortunately, without technological automation, the enhanced ORT suffers from practical limitations. The self-report ORT may not be a valid tool in current pain populations; however, modification into a binary (high/low) score system needs further study.